Diagnosis

A careful history will often lead to a provisional diagnosis but a careful full clinical examination is always indicated, not least because an unsuspected lesion may be present in addition to the patient’s main complaint. The clinician is often then in a position to formulate the diagnosis, or at least a list of differential diagnoses. In the latter case, the diagnosis is provisional, and investigations or another opinion (e.g. specialist referral) may be necessary to reach a firm diagnosis.

Bearing in mind the fact that the whole orofacial tissues and cervical nodes must be examined in every patient, this chapter details diagnosis of disorders in the various sub-sites.

Diagnosis of mucosal disorders

Mucosal disorders are diagnosed mainly from history and examination findings. All mucosae should be examined, in order to detect early lesions. Begin away from the focus of complaint or known lesions. Labial, buccal, floor of the mouth, ventrum of tongue, dorsal surface of tongue, hard and soft palate mucosae, gingivae and teeth should be examined in sequence, recording lesions on a diagram.

Mucosal lesions are not always readily seen and, among attempts to help improve visualisation, are:

• toluidine blue (vital) staining

• chemiluminescent illumination

• fluorescence spectroscopy and imaging.

These are discussed in Chapter 7.

Investigations that may be diagnostically helpful can include biopsy examination, blood tests and microbiological investigations. Informed consent and confidentiality is required for all investigations.

Biopsy is the removal of tissue for diagnosis by histopathological and often immunological examination. Indications for biopsy include mucosal lesions that:

• have malignant or potentially malignant features

• are enlarging

• persist > 3 weeks

• are of uncertain aetiology

• fail to respond to treatment

• cause concern.

Blood tests, microbiology tests and other investigations are discussed in Chapter 7. Testing for infections can be a very sensitive issue, especially in the case of human immunodeficiency virus (HIV) and other sexually shared infections and tuberculosis. HIV testing in particular remains voluntary and confidential, and patients must be counselled properly beforehand.

Diagnosis of salivary disease

Salivary disorders are diagnosed mainly from history and examination findings. The salivary glands should be examined by inspecting:

• symmetry

• evidence of enlargement glands

• ducts for salivary flow

and by palpating the parotid glands in front of the ears, to detect pain, or swelling, and the submandibular glands by bimanual palpation between fingers inside the mouth and extraorally.

It is also important to examine the eyes for dryness, redness or discharge, and the oral mucosa; note particularly angular cheilitis, dryness and lingual depapillation or erythema.

Investigations required may include:

• plasma viscosity or erythrocyte sedimentation rate (ESR) or C reactive protein (CRP)

• antibodies