SAVVY SUCCESS

Chapter 21: Oral Pathology in Private Practice

By Olga A. C. Ibsen, RDH, MS, FAADH

Learning Objectives

 The student dental hygienist and dental hygiene professional will learn the following key objectives from this chapter:

1. Describe some of the types of lesions and conditions seen in patients in the private practice setting as discussed.

 2. Learn the definitions, descriptions and questions that should be asked of the patient to assist in the documentation process.

3. Describe the eight features of the diagnostic process, which includes: Clinical, Radiographic, Historical, Laboratory, Microscopic, Surgical, Therapeutic and Differential and give examples for each process.

4. Determine the outcome of each type of lesion and condition and the pathogenesis of it.

5. Define leukoplakia and erythroplakia, what causes angular cheilitis, which symptoms appear first in primary herpetic stomatitis and describe the difference between hematoma and hemangioma.

Overview

One of the most challenging aspects in the clinical practice of dental hygiene is the identification and description of oral lesions and conditions. In the private practice setting, dental hygienists are often the first professionals to see a new patient. After reviewing the medical history, the intra and extra oral examination is paramount to any other procedure because it can save a patient’s life. One person dies every hour of every day from oral cancer. Clearly a careful and thorough oral examination is of significant importance to the optimal care of the patient. Although the dentist ultimately makes the final diagnosis, the dental hygienists’ role in data collection is a critical component to the diagnostic process.

This chapter will describe some lesions seen in patients in the private practice setting. Emphasis will be placed on definitions, descriptions and questions that should be asked of the patient to assist in the documentation process. What are the lesions or conditions most often observed? How are they described? What questions should be asked of the patient? Which one or two of the diagnostic categories contributes the most information to the final diagnosis? Several lesions and conditions will be discussed. Once clinicians have a clinical impression, we shall refer to this impression as a “you suspect” topic, then they can review pertinent questions that should be asked of the patient. This data collection will assist in the diagnosis or the decision to refer the patient to another specialist. The summary will discuss the answers to many of the questions asked of the patient.

In addition to the intra and extra oral examination, data collection involves reviewing the patient’s personal, family and medical/dental history, providing documentation of all findings, describing the clinical features of the lesion or condition in question and taking quality radiographs. The patient should also be asked a series of questions relevant to the pathologic lesion present.

Methods for Diagnosing Oral Lesions and Conditions

 Diagnosis is a process which involves one or several aspects of a lesion or condition. The diagnostic process includes the following eight features: clinical, radiographic, historical, laboratory, microscopic, surgical, therapeutic and differential. A diagnosis is made based upon one or several of these features applied to the lesion in question. A review of these features will help the clinician in documenting what is observed. In discussing lesions and conditions later in the chapter, the clinician will be referred to the diagnostic aspects that contribute to the diagnosis.

Clinical diagnosis means the strength of the diagnosis comes from the clinical appearance alone. A few examples of disease that can be diagnosed using a clinical method include: fordyce granules, tori and linea alba.

 Radiographic diagnosis is applied when the radiograph provides significant evidence to establish a diagnosis in bone or tooth structure. Sometimes the radiograph alone is sufficient to identify caries, calcified pulp or unerupted teeth. In some cases, additional aspects of the diagnostic process must be used in conjunction with the radiograph to make a diagnosis (i.e., Paget disease, cysts and other radiolucent or radiopaque lesions).

Historical diagnosis uses information which includes: personal history (age, sex, race, occupation), family history, history of the presenting condition, drug history, medical/dental history and combines one or several of these features with the clinical aspect. For example: if a patient presents with enlarged gingiva, a review of the medical and drug history may indicate that the patient is taking a calcium channel blocker. Periapical cemento-osseous dysplasia is most often diagnosed in African American females in their 30s. Thus the age, sex and race of the patient combined with specific radiographic features contribute significantly to the diagnosis. Family history contributes to the diagnosis of genetic conditions. Patients who are diabetic are more likely to develop infections including periapical pathosis. Information obtained through historical diagnosis can be most helpful to the data collection process.

Laboratory diagnosis can require blood, urine analysis or laboratory cultures. Paget disease can have some unique radiographic features including hypercementosis, loss of the lamina dura and the “cotton-wool” appearance of the affected bone. However, laboratory diagnosis contributes significantly to the diagnosis of Paget disease. Although radiographs are of value to the diagnosis, the significantly elevated serum alkaline phosphatase levels in the blood confirm the final diagnosis.

Microscopic diagnosis is a major feature in the diagnostic process. Microscopic evaluation of the specimen taken in the biopsy is most often the most significant factor in the final diagnosis of many lesions. Leukoplakia is a clinical term for a white lesion which has no histologic features of its own. Biopsy and microscopic analysis must be performed to make the diagnosis.

Surgical diagnosis would apply to a procedure requiring surgical intervention. Stafne bone cyst and traumatic bone cyst are examples.

 Therapeutic diagnosis is used to determine conditions such as candidiasis. If the clinician suspects angular cheilitis, an antifungal agent is prescribed by the dentist. If the condition resolves, the diagnosis is made based upon therapeutic diagnosis.

Differential diagnosis is used to rule out one or more suspected lesions and make a final diagnosis. Usually additional tests or procedures are performed. This information combined with all data collection helps to determine the final diagnosis.

Common Pathologic Lesions and Conditions

The format for describing some of the most common pathologic lesions and conditions seen in the oral cavity will be followed by dividing the mouth into the following areas: lips, tongue, floor of the mouth, buccal mucosa, palate and gingiva. Always review the patient’s medical history prior to the intra or extra oral examination.