Case 2
Head and Neck Examination
Medical History
Review of the patient’s medical history revealed allergies to most animals, dust, and mites. The patient takes one capsule Benadryl (Diphenhydramine HCL) 25 mg every four to six hours at least four days per week for allergies. Her vital signs are within normal limits.
Dental History
The patient grew up in the Kingston, New York area without fluoride. She brushes twice daily and uses toothpaste without fluoride. The patient states she flosses once daily. Minor occlusal restorations were placed during college.
Social History
The patient teaches at a residential institution for children with emotional and academic problems. Also, she plays the violin with a local symphony orchestra. She drinks several bottles of sweetened ice tea daily and snacks on candy before, during, and after work.
Head and Neck Examination
The extraoral exam revealed hyperpigmented areas under the patient’s left mandible and erythematous plaques on the left lower neck and no enlarged or palpable lymph nodes (Figure 1.2.1). The patient states that she practices violin one hour on weekdays and two hours on weekends and holds the violin against her chin and collar bone. The three lesions are slightly raised, erythematous, broad, and rough in appearance and conform to the placement position of the violin. Each lesion measures 5 × 5 mm, 3 × 7 mm, 7 × 3 mm. The patient states violinists stabilize their instrument with the sternocleidomastoid muscle (Figure 1.2.2). It is the muscle that passes diagonally across the front and side of the neck beginning at the top of the sternum and ending behind the ear. The lesions known as “fiddlers neck” are a common skin problem found on violinists (Jue et al. 2010) and conform to the performance position of the violin as described by the patient.
Figure 1.2.1: Extraoral image of neck with erythematous areas.
Figure 1.2.2: Sternocleidomastoid muscle.
Intraorally, visual examination and transillumination of teeth revealed noncavitated white spot lesions on the proximal surfaces of teeth #8, #9, and #10. There is localized slight supragingival biofilm on affected tooth surfaces. Supplemental oral findings indicate the patient is a mouth breather. Class I malocclusion with anterior open bite present.
Radiographic Examination
Caries lesions are visible radiographically but confined to the enamel. Partially erupted third molars are visible.
Dental Hygiene Diagnosis
| Problems | Related to Risks and Etiology |
| Increased caries | Localized slight supragingival biofilm, frequent sugar intake, nonexistent use of fluoridated dentifrice or fluoride rinses and xerostomia (side effect of medication and mouth breathing). |
| Three red callus‐like areas below the chin and along the neck | Violin placement, frequency of violin practice, possible allergy to varnish |
Planned Interventions
| Planned Interventions (to arrest or control disease and regenerate, restore, or maintain health) |
||
| Clinical | Education/Counseling | Oral Hygiene Instruction |
| Initial exam, radiographs, and adult prophylaxis 5% NaF fluoride varnish with a synthetic form of colophony (to reduce risk of allergy) every 3 to 4 months Sealants Referral to dermatologist for red lesions on neck Referral to primary care physician to evaluate allergy symptoms |
The importance of regular dental visits. Increased risk for caries. The role of fluoride in remineralization of noncavitated lesions. Reduction of bacterial infection through daily biofilm removal and antimicrobial therapy. Food diary for analysis of sugar exposures. Use of chamois cloth to protect exposed skin while practicing violin |
Modified Bass brushing technique Recommend use of 1.1% NaF toothpaste and 0.05% NaF rinse 2X daily 10 ml 0.12%Chlorhexidine rinse one minute daily for 1 week each month for short term (evaluate at 3 months recall until risk reduced). Recommend frequent sips of water during the day and xylitol gum or candy four times daily if mouth feels dry. |
Progress Notes
The patient arrived for her appointment on time. A complete medical, social, and dental history was taken. Initial exam and FMS were performed. Three atypical callus‐like red lesions on the neck were noted during the head and neck exam. Noncavitated white spot lesions were charted, and bacterial infection reduction methods were explained according to patient caries risk assessment. A food diary for analysis of sugar intake was reviewed and given to the patient. The patient was instructed to return in one week for dietary analysis and counseling. The patient was advised to see a dermatologist for a differential diagnosis and treatment of neck lesions and her primary care physician for symptoms of allergies. Three to four months recall recommended for high caries risk.
Discussion: The Head and Neck Examination
Dental hygienists see patients for well‐check visits more often than physicians and are at the frontline for recognizing early illness and for educating patients about their risk factors. The head and neck and intraoral examinations – often referred to as an oral cancer examination or oral cancer screening – are an important part of comprehensive dental hygiene care and can be completed in around five minutes. However, approximately half of practicing hygienists (51%) performs a head and neck exam routinely during dental visits (Forrest et al. 2001; Horowitz et al. 2002). The head and neck exam is emphasized during hygiene education as a standard of care to detect manifestations of systemic illness, early skin cancer, and lymphadenopathy. Demands on patient scheduling, working time, knowledge, and perceived risk of cancer in the United States often prevent hygienists from performing the service (Forrest et al. 2001; Horowitz et al. 2002; Cotter et al. 2011). However, failure to include this exam routinely has profound consequences such as late‐stage diagnosis, more extensive surgery and therapies such as radiation and chemotherapy, and a decreased quality of life and health.
Hygienists should perform the head and neck and intraoral assessments the same way at every visit to maintain efficiency and high levels of accuracy. The head and neck exam includes checking symmetry and profile of the face, the skin, eyes, lips, lymph nodes, salivary, and thyroid glands as well as a temporomandibular joint examination (see Figure 1.2.3). If possible, clinicians visually examine each area before performing a thorough palpation. Additionally, it is important to ask permission to do the exam and to tell patients exactly what is being done and why. For example, ask your patients if you may perform an extra‐ and intraoral examination to look for abnormalities that affect oral and general health. Tell patients that palpation will include the clavicle area.
Figure 1.2.3: Steps in the head and neck examination.
If a problem is identified, ask the patient about its history (onset, duration, and possible causes). As in this case, when deviations from normal are detected, patients are referred to a physician for differential diagnosis and treatment. Finally, educating patients about known risk factors for cancer such as age, genetic predisposition, sun exposure, alcohol, tobacco, viruses such as HPV and HIV, chronic inflammation and inadequate nutrition and host immunity is essential to decreasing the rate of cancer (Sciubba 2001; Neild‐Gehrig 2018).
Take‐Home Hints
- The American Cancer Society and the American Dental Association recommend oral cancer examinations as an essential element of routine dental examinations (Smith et al. 2013; Walsh et al. 2013).
- The Objectives of the Head and Neck and Intraoral Exam are:
- To determine general wellness and ability to continue dental treatment.
- To provide and/or to compare to a baseline of assessment information.
- To determine need for additional diagnostic procedures and medical or other consultations.
- To enable early diagnosis of pathology.
- Findings from the Head and Neck and Oral Examinations fall into one of three categories:
- Normal – found in most individuals.
- Atypical – a variant of normal found in some individuals but within normal limits.
- Pathologic– indicative of infection, trauma, neoplasms, development errors causing functional issues, inadequate nutrition and immunity, and more.
- Include the following in your description of findings:
- History – Onset, duration, and possible causes.
- Description – Location and extent, size, surface texture, consistency, and color.
- Morphology –elevated, depressed, or flat.
- Oral cavity and oropharyngeal cancers are considered to be the sixth most common cancers worldwide (Warnakulasurlya 2009), there will be an estimated 51,540 new cases in the United States in 2016, and an estimated 10,030 people will die of this disease (SEER Cancer Statistics 2017).
- The most common malignancy of the head and neck, oral cavity squamous cell carcinoma (OC‐SCC), is preceded often by white or red mucosal changes known as leukoplakia or erythroplakia. “Some lesions will show a combination of red and white features, termed erythroleukoplakia, speckled leukoplakia, or speckled erythroplakia” (Chi et al. 2015).
- Although oral cancer is associated with aging, studies indicate a rise in the disease in adults below the age of 40 and that squamous cell carcinoma in tongues of young adults has increased sharply (Schantz and Yu 2002; Chaturvedi et al. 2011).
- Alarmingly, cancers in younger people are more aggressive and associated with a poorer prognosis than those found in older adults (Warnakulasurlya 2009). A new study found that the human papillomavirus (HPV) may be causally linked to 70% of oropharyngeal squamous cell carcinomas in white males in the United States, and found that by 2020 the number of oropharyngeal cancers in this population will surpass the annual number of cervical cancers (Chaturvedi et al. 2011).
- Primary areas for the development of oral cancer in the (wet) oral tissues are:
- Lateral borders of tongue (Figure 1.2.4)
- Lips
- Floor of the mouth
- Soft tissue complex: includes “the posterior mouth such as the tonsils, tonsillar pillar and crypt, the base of the tongue, and the oropharynx” (SEER Cancer Statistics 2017).
- Primary areas for the development of oral cancer in the (wet) oral tissues are:
Figure 1.2.4: Lateral borders of the tongue.
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