Oral health and disease are intimately related to general health status. Clinicians understand that the oral cavity does not exist in isolation, but as an integral component of the human body. The oral cavity and peri-oral region consist of various tissues that are not unlike other organ systems, including mucous membranes, nerves, muscles, ligaments, and bone. The oral cavity is perhaps more intricate than other areas because, in addition to those tissues, there is a complex dentition with its supporting structures. In addition, the oral cavity harbors saliva produced by major and minor exocrine glands, which has a profound impact on both health and disease. Diseases that affect various tissues and organs are now well-understood to potentially affect and/or manifest in the oral and/or peri-oral areas. To think of the oral cavity as only consisting of teeth and supporting structures is to suggest that the intimate, bidirectional relationship of systemic and oral health does not exist. The oral cavity may be a potential source of inflammation or infection, which could have a significant impact on systemic health. For example, an injured or diseased oral cavity may hinder an individual’s ability to acquire proper nutrition, which may lead to poor wound healing or other ailments.
Moreover, the oral cavity often mirrors systemic health and may be the initial site of presentation of an underlying disease process. That disease may simply manifest in the oral cavity (eg, localized oral lichen planus) or may include the oral cavity in its manifestation (eg, glossitis related to malabsorption). The oral cavity may even provide a more accessible location for diagnosis of certain conditions (eg, Sjögren’s syndrome). When a practitioner evaluates the oral cavity, he/she must be cognizant that local oral disease may be present or the oral condition may be a result of an underlying disorder.
Lesions affecting the oral cavity usually have a similar clinical appearance and there is often no single characteristic that differentiates oral soft tissue diseases. It is often extremely difficult to diagnose oral diseases based solely on clinical appearances. This diagnostic dilemma often precludes appropriate diagnosis and management of local disease and delays investigation of a possible systemic etiology. A detailed medical evaluation is essential for all complaints related to the oral cavity and peri-oral structures. The medical evaluation should include the history of the present condition, the patient’s past medical and surgical history, and any symptomatology (usually acquired through a thorough review of systems) that the patient may be experiencing. A family history is an important aspect of medical evaluation and may gain additional importance in patient care, as we now know that some oral conditions have a genetic predisposition. In the age of personalized medicine, it is only a matter of time before routine clinical practice will incorporate a genetic basis for oral disease diagnosis, which will help drive customized therapeutics. In addition, medication usage, documentation of allergies, and a social history are all critical components of a thorough medical evaluation.
When querying a patient about oral lesions, it is imperative for clinicians to understand the various aspects of the condition. Asking patients if lesions developed recently or are of long-standing duration, the number of lesions present, if this is the first episode of lesions or if they recur, and if there are lesions elsewhere on the body will help clinicians categorize the disease process as being acute or chronic, single or multiple, primary or recurrent, or if the oral condition is a local manifestation of a systemic process, respectively. A detailed series of questions regarding the present illness includes appropriate symptom development.
In conjunction with developing a detailed history, it is equally important to perform an accurate and expanded physical examination, which should be viewed in the context of a regional examination. This must include thorough inspection and palpation of the dentition, supporting dental structures, oral mucosa, and tongue, as well as evaluation of the visible posterior tongue and oropharynx. Additional clinical information may be necessary to aid in formulating a differential diagnosis and is often obtained from examination of the cranial nerves and the temporomandibular joint system. Evaluation of the patient’s facial skin, with particular attention to the peri-oral area, is also extremely important. A thorough examination of the regional lymph nodes and palpation of the thyroid gland are indicated and can aid in developing the appropriate clinical algorithm. Finally, an evaluation and assessment of the salivary glands, including palpation of structures and assessment of salivary flow, are extremely important to aid in the diagnosis of salivary gland disorders, which may otherwise be overlooked, but can have significant impact on the patient’s overall health status.
It is from this wealth of information that the clinician will begin to formulate a differential diagnosis, which is, in part, based on prior fundamental knowledge and experience. It can be difficult to reach a final diagnosis without the use of adjunctive diagnostics and it is often necessary to order appropriate laboratory tests for comprehensive evaluation. These tests might include hematologic assays and/or obtaining samples of tissue or other specimens, for laboratory analysis, such as cultures/smears.
A “final” diagnosis may need to be modified by the clinician as the patient is being managed for the presumed disorder. For example, a patient may be placed on a medication known to modify a specific disease. If the patient has been on a treatment regimen and is unresponsive to therapy, a review of the differential diagnosis and final diagnosis is required. Sometimes it is during this clinical scenario that an underlying systemic condition is identified as the etiology of the disease manifesting locally in the oral cavity.
Understanding appropriate patient evaluation, formulating a differential diagnosis, obtaining adjunctive diagnostic testing, and rendering a final diagnosis are all expected of today’s modern dentist. It is of paramount importance to diagnose an oral condition, which may save a patient’s life or may significantly decrease any disease-related morbidity. It is incumbent upon the clinician “to get it right.” Following the diagnostic approach as outlined gives the clinician the greatest chance of accurately diagnosing oral disease.
In this series of Dental Clinics of North America , most of the common oral disorders are reviewed, including those that have an acute presentation and those that are of a chronic nature. All of our contributing authors have been carefully selected and are experts in their fields. Authors have provided general information, including epidemiology regarding a specific disorder, the known etiologies, and the presumed pathophysiology of that disorder. To focus on the clinical aspects of patient management, authors describe the clinical presentation and how clinicians should formulate a differential and/or final diagnosis. Finally, authors discuss treatment and management strategies, which may aid in providing comfort and/or cure to the patient’s ailment.
We anticipate that you will find these editions helpful in enhancing your fundamental knowledge and ability to diagnose and treat oral and peri-oral mucosal disorders. It is our hope that these collected works underscore the oral cavity as a functional unit of the whole and as a window to overall health.
I dedicate these works to my wife, Carolyn, and my children, Elizabeth, Peter, and Katharine, who are always present with love and encouragement. I also wish to acknowledge the many colleagues and residents with whom I’ve been associated. They continue to challenge and inspire me with their many contributions to the profession.
Thomas P. Sollecito, DMD, FDS RCSEd
I dedicate these works to my wife, Melanie, and my children, Ryan and Ethan, for their unconditional love, encouragement and support of my academic endeavors. I also thank my parents, Francine and Stanley, for their love and guidance through the years.
Eric T. Stoopler, DMD, FDS RCSEd