Exam

Soft-Tissue Examination in the Dental Office

Russell E. Christensen, DDS, MS

Copyright 2001 Journal of the California Dental Association.

This article describes in detail all features of the head and neck soft-tissue examination as performed routinely in a dental office. The ongoing thought process while performing the exam is described, and examples of findings are given.

The head and neck soft-tissue examination given routinely in the dental office provides general information on the health of the patient, screens for potential or overt malignancies, and detects other conditions that may require dental or medical attention. The term "cancer screening" is limited, potentially misleading, and should be avoided except when included as one item in a description of a comprehensive examination or in advertising for a health fair. An appropriate medical history is usually obtained or updated prior to beginning the examination. Prompt attention to the patient’s chief complaint is, of course, important, so the soft-tissue examination may take place at any time during the appointment. After the routine examination, supplementary examinations may be warranted, such as a cranial nerve exam or detailed examination of the temporomandibular joint and masticatory muscles.

The Examination Process

Step One: General Assessment

Step one in every patient examination begins the moment the patient is seen. Whether the patient is first encountered as he or she is walking into the treatment area or once already seated in the dental chair, a broad array of data can be collected instantly with practiced observation. General information such as sex; approximate age; general body type; gait; asymmetries; swollen ankles; large facial or skin lesions; and whether the patient is well-groomed or disheveled, confident or frightened, or using walking aids, glasses, hearing aids, etc. is easily obtained in one head-to-toe glance. A moment of reflection on these observations can lead to other findings. This is particularly the case if there has been a change since the previous appointment. Weight loss could be from successful dieting or from malignancy, depression, hyperthyroidism, or other illness. Grooming may also reflect health status. Untied or loosely tied shoes could indicate edema; unkempt appearance may indicate depression; a copper bracelet might indicate arthritis; overly warm clothing could be a clue to the cold intolerance of hypothyroidism. Distinctive facial findings include the elongated head and bony prominence of the forehead in acromegaly, the moon face of Cushing syndrome, the mask-like face of Parkinson’s or systemic sclerosis, and parotid enlargement from a wide variety of etiologic factors. Facial expressions may reveal pain, anxiety, anger, or depression. Use of accessory breathing muscles, exhaling through pursed lips, or too many sighs may be a clue to lung disease or hyperventilation. Patients who appear older than their stated ages may be intentionally misreporting their ages or perhaps have prolonged histories of cigarette smoking or sun exposure; others might be suffering from a chronic illness such as malignancy or widespread arterial disease.¹ A younger appearance is less likely from misreporting of age and may be due to cosmetic surgery. Any of these findings could significantly influence treatment planning. Vital signs, if taken at this appointment, may also yield important information.

Step Two: Examination of the Skin

Step two in most cases is an inspection of the facial skin. The patient should be informed that an examination is about to begin. The dentist might say, "Let’s begin with an examination of your mouth. First on the outside …" Then, a few seconds, the dentist later might say, "Now on the inside ..." as a cue for the patient to open his or her mouth. The examination of the facial skin in the dental office is done to distinguish lesions of potential significance that need referral from a background of minor blemishes with no medical importance. The dental office is a particularly good environment for such an examination because of the good lighting and ready access to magnification. Inspection is the only necessary technique in the dental screening; palpation may help a more experienced clinician. A basic array of common skin disorders is included in dental school curricula, and dentists can find numerous sources to update their knowledge of common skin conditions.^2,3 Habitually looking up skin lesions in an illustrated dermatology text can rapidly improve one’s skills in screening them.

The skin examination began in step one; now deliberate attention is given to the facial skin. Color, moisture, temperature, and lesions can be assessed simultaneously when the examination is limited to the face. The eyes are a good place to start. Although the conjunctiva is not particularly good for assessing cyanosis, examination of this area may reveal jaundice. Before inspection of the eyes is finished, ptosis, exophthalmos, ectropion, xanthelasma, corneal arcus, pinguecula, pterygium, cataracts and other lesions of eyes and adjacent tissues may be seen. Routine, organized observation increases the knowledge and experience of the clinician. Although some of these conditions (e.g. pinguecula) are probably irrelevant to dental treatment planning, others reflect potentially serious conditions that require medical attention. Corneal arcus in a young patient or xanthelasma is suggestive of hyperlipidemia; jaundice and exophthalmos should be investigated promptly.

Lesions of the facial skin are discovered by a swift scalp-to-neck examination that also includes inspection from the sides. Depending on the age of the patient, an array of lesions will be present, ranging from normal to innocuous to concerning to obviously serious alterations. Nevi, seborrheic keratoses, dermatosis papulosa nigra, comedones, angiomas, melasma (mask of pregnancy), and other common lesions are often seen on a daily basis in a dental practice. Routine examinations provide the practitioner with experience to know the range of appearance of these completely benign conditions.

Actinic keratosis is also very common but often ignored by patients who do not realize that these lesions are a precursor to squamous cell carcinoma. Referral to the patient’s physician can prevent serious trouble later. Basal cell carcinoma may have a variety of clinical presentations, but the classic presentation of a raised, rolled border with a depressed, often ulcerated center is easily identified in a dental examination. Any lesion suspicious for basal cell carcinoma requires referral to a dermatologist for evaluation. Basal cell carcinoma may be the most frequently discovered malignancy in the dental office. Pigmented lesions should be checked for the A, B, C, D characteristics: Asymmetry, Border irregularities, Color variation, and Diameter enlargement. These findings can be suggestive of malignancy in a pigmented lesion of the skin. Early, "thin" melanomas have an excellent prognosis compared with more advanced lesions. This is a classic example of a life-saving early detection.

Step Three: The Intraoral Examination

Step three begins when the patient opens his or her mouth. When the skin examination is completed, the patient might appreciate an opportunity to remove lipstick if this has not been done previously. The "Now on the inside …" cue informs the patient that the intraoral examination is beginning. Dentures, retainers, or any other appliances should be removed at this time. During the examination, the dentist should keep risk factors in mind and pay particular attention to the "horseshoe area" of lateral tongue and floor of mouth in patients who have a history of smoking. However, all areas must be inspected regardless of risk factors.

The intraoral soft-tissue examination should be done in the same order and in the same way on every patient.

The sequence of examination is a matter of individual preference. The author proceeds in the following order:

* The dentist begins in the buccal vestibule near tooth #1 and inspects the buccal gingivae, vestibular mucosa, and inner surface of the lip following the maxillary teeth across to the left side, using a mouth mirror as necessary (Figure 1).

* The dentist then similarly inspects the lower vestibule, buccal mucosae, buccal gingivae, and lip. The coloration of oral tissues may be the first observable finding. Lack of oxyhemoglobin is best reflected in a bluish coloration of the lips, tongue, and buccal mucosa. Cyanosis may indicate anemia, congenital heart disease, and advanced lung disease among others.

* Next, the dentist inspects the palate and palatal gingivae. The patient is allowed to briefly close and swallow.

* When the patient opens, the tonsils, peritonsilar areas, and posterior pharynx can be inspected. If the tongue obscures these structures, the patient can be asked to "pant like a puppy." Alternatively, with a mirror or tongue blade placed in the mid-tongue area, not so far back as to cause gagging, the patient is asked to yawn or say "aah." The dentist should note the symmetry of the rising soft palate; asymmetry may indicate a 10th nerve defect. The patient is allowed to close and swallow once again while the dentist obtains a gauze.

* The dentist requests that the patient protrude his or her tongue and notes size, coloration, and whether the protrusion is symmetrical (asymmetry may indicate malignancy or a 12th nerve defect).

* The dentist then gently grasps the tip of the tongue and inspects the dorsum and reflects the tongue to one side, carefully inspecting the lateral and ventral surfaces, particularly the base. Then the dentist palpates the extended surface with the other hand (Figure 2), switches hands and repeats on the other side. If the dentist plans to lift the soft palate to better inspect the pharynx or perform indirect laryngoscopy, it can be done at this time. Having the patient tip his or her head slightly backward while the dentist gently grasps the tongue may allow better visualization. The patient should then swallow again.

* Upon opening again, the dentist should dry the parotid duct orifices and express saliva from the ducts by stroking the skin from the parotid area toward the cheek opposite the duct. Then, the dentist should dry the submandibular gland orifices and, if necessary, stroke the skin of the chin from the area posterior to the submandibular gland forward. After stimulation from the examination, the saliva should be clear and copious.

* The next focus is palpation. The dentist begins by gently placing one finger under the ventral tongue along the floor of the mouth; the dentist may have to pause just a moment to get the patient more relaxed. Then, with the other hand under the chin, the dentist bimanually palpates the floor of the mouth for masses or tenderness (Figure 3) and repeats on the contralateral side. With the floor of mouth depressed and the soft tissues of the chin moved laterally, submandibular nodes can often be palpated against the inferior border of the mandible as the skin and subcutaneous tissues of the chin are allowed to return to place. Palpation is then continued in an organized manner including buccal mucosae, lips, vestibules, alveolar mucosa, then hard and soft palate. Dryness as well as lumps or tenderness should be noted.

* The dentist should recall any lesions he or she has encountered and return to these for a closer examination, if necessary, before leaving the oral cavity. Step four may be momentarily postponed and step five completed at this time if the dentist is performing this examination.

Step Four: Examination of the Neck

* The dentist begins with an examination of lymph nodes. He or she palpates pre-auricular and posterior auricular nodes along with the parotid region. Occipital nodes are at the base of the skull posteriorly. The posterior cervical chain lies along the anterior margin of the trapezius muscle. The superficial cervical nodes are superficial to the sternocleidomastoid. The deep cervical nodes require grasping around the muscle with thumb and fingers (Figure 4). If the patient turns to the opposite side, the muscle may be grasped more easily and then isolated as the patient returns to a forward gaze. This should be continued to the supraclavicular nodes found deep in the angle formed by the back of the sternocleidomastoid and the clavicle. The dentist palpates the region of the tonsillar nodes at the angle of the mandible then forward to submandibular and submental nodes. The hyoid bone lies high in the neck and should not be mistaken for a pathologic condition. Lymph nodes generally will be moveable to some degree in all directions. Blood vessels and muscles will not move up and down. With practice and experience, both sides may be examined at once.

* Finally, the dentist inspects the midline neck. The patient should tilt his or her head slightly backward. The trachea should be in the midline. The dentist then notes scars and obvious masses, particularly below the cricoid cartilage in the area of the thyroid gland. The patient is then asked to swallow; a sip of water may be necessary. Swallowing will cause the thyroid gland, along with the cricoid and thyroid cartilage, to rise and fall. Masses that rise with swallowing are likely to be thyroid in origin; bulky neck tissue that fails to rise with swallowing is usually fat and muscle. Palpation of the thyroid gland requires practice; usually the thyroid is not palpable in adults. Palpation of the thyroid is not a necessary part of the dental head and neck examination and is not covered here. Textbooks of physical diagnosis have a complete description of this procedure. ⁴

Steps one through four should generally be completed within two minutes.

Step Five: Generate a Differential Diagnosis

Step five begins with a re-examination by the dentist of any lesions or abnormalities discovered. Many aspects of the first four steps can be adequately performed by the hygienist during visits for scaling and prophylaxis. However, a complete examination by the dentist should be performed at least once per year on every patient and more often in high-risk patients or patients with lesions that are being "watched." When lesions are discovered, treatment planning, and even simple referral, requires a differential diagnosis by the dentist. Generating a differential diagnosis requires the clinician to categorize the lesion, in other words to ask, "Basically, what sort of lesion is this?" Categorization as a white lesion, papillary lesion, red lesion, pigmented lesion, mass, ulcer, or vesiculobullous lesion comes first. Then some subcategorization will help.

Lumps in particular locations carry their own set of common conditions. Lateral neck masses most commonly arise in lymph nodes. Therefore, infections, lymphomas, metastatic carcinomas, and branchial cleft cysts are of primary consideration. Midline neck lumps are often thyroid-related. Generalized gingival hyperplasias may result from medications, metabolic conditions, leukemia, and even heritable syndromes. Localized gingival masses are often pyogenic granulomas and related reactive lesions. Lumps of the lips and buccal mucosae can arise from any normal tissue present in that location, particularly salivary glands. Long-term ulcers are usually due to chronic trauma, major aphthae, squamous cell carcinomas, or specific infections. Papillary lesions are often warts, but may be verrucous carcinomas or papillary squamous cell carcinomas. White lesions that rub off may be materia alba or chemical burns, etc. The dentist should be well-aware of the typical presentations of a wide variety of oral lesions so that an appropriate differential diagnosis can be generated. No differential is ever "complete"; there is always something that is rare or presenting in an unusual way that could be added to the list. Narrowing the list of possibilities too swiftly can result in a grievous oversight. On the other hand, generation of a huge list of conditions may be good as an academic exercise, but a more compact list over a broad variety of etiologic factors is a more efficient way to "cover the bases." See Table 1 for an example.

A differential diagnosis that includes a spectrum of specific conditions allows the clinician to ask appropriate, specific follow-up questions, to seek specific information from the medical history, or to perform specific supplemental examinations such as inspection of exposed skin. This process allows conditions in a differential diagnosis to be emphasized, diminished in likelihood, or eliminated from consideration while the dentist forms a concise working diagnosis. The differential diagnosis makes treatment planning much easier; if the patient is to be referred for a second opinion or biopsy, it provides clear information to the referral doctor who may see the lesion differently on a different day. Perhaps the most important reason for a differential diagnosis becomes apparent when the patient returns to the general practice for follow-up. The general practitioner’s assessment of whether the pathologic diagnosis rendered matches her or his own findings is more critical than usually realized. This is the last and best protection for the patient. Occasionally, the biopsy was not taken at a representative site, or the pathology may even be misinterpreted, particularly by a pathologist unfamiliar with oral lesions. The general practitioner may have the last chance to notice a discrepancy before a tragic delay in diagnosis. Without an appropriate differential in mind, the practitioner may miss this critical opportunity. Many, if not most, medicolegal cases in soft-tissue diagnosis occur in this way rather than as a failure to detect the lesion in the first place.

Adjunctive techniques marketed to assist "screening" are no substitute for the techniques of inspection, palpation, and differential diagnosis.

Step Six: Documentation in the Dental Record

Step six is the recording of all places inspected and/or palpated, whether normal or not, along with a description of abnormal findings. Should a lesion arise in the future on any head or neck site, records of previous negative findings are not only helpful diagnostically, but they conform to accepted clinical guidelines.⁵ One simple method is a checklist that can be part of a separate sheet in the chart or stamped onto the progress notes. Simple drawings of lesions with measured dimensions and brief descriptions can be invaluable in recalling lesions from one visit to another. Documentation with intraoral cameras is extremely helpful. Surgeons and pathologists will appreciate a photograph of any lesion as it appeared upon discovery.

Step Seven: Treatment Planning

Step seven is the treatment planning phase. A differential diagnosis for the lesion has been generated; specific examinations or questioning have eliminated some possibilities and strengthened others. Choices for treatment or additional diagnostic procedures depend upon the working diagnosis. A decision to "watch" a particular lesion should result in re-evaluation at specific times and with particular features in mind.

Step Eight: Informing the Patient

The dentist should inform the patient of the extent of the examination. For example: "a soft-tissue examination including a screening for oral cancer." Then the dentist must summarize his or her findings, describe any recommended diagnostic procedures, and possibly discuss treatment options. When the dentist has a specific working diagnosis in mind, the appropriate level of concern is communicated; and the patient is more likely to feel confident of the dentist’s recommendations.

Step Nine: Examination of the Teeth and Periodontium

Step nine comprises the examination of teeth and periodontium. Sometimes this may have begun earlier when focusing on the patient’s chief complaint. This evaluation usually requires correlation with radiographs and is beyond the scope of this paper. Dental and radiographic findings also require differential diagnosis and treatment planning. Clear documentation of those findings is obviously important.

Conclusions

* The protection of patients necessitates a routine periodic head and neck soft-tissue examination performed by the dentist as part of standard comprehensive care.

* A sequence for the intraoral exam must be followed consistently on every patient.

* Areas examined will always include:

* Inspection of general features of the patient, facial skin, and midline neck and

* Inspection and palpation of the major salivary glands, lips, buccal mucosa, palate, tongue, floor of mouth, and regional nodes.

* Documentation of the examination must include normal findings as well as notation of lesions and abnormal findings.

* Development of an appropriate differential diagnosis is essential for treatment planning or proper referral.

* The patient must be informed of the examination itself and about any specific findings.

Author

Russell E. Christensen, DDS, MS, is an associate professor of oral and maxillofacial pathology at the University of California at Los Angeles School of Dentistry.

References

1. Lahmann C, Bergemann J, Harrison G, and Young AR, Matrix metalloproteinase-1 and skin ageing in smokers. Lancet 357:935-6, 2001.

2. Habif TP, Clinical Dermatology, 3rd ed. CV Mosby, St Louis, 1996.

3. Fitzpatrick TB, Johnson RA, Wolff K, Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases, 4th ed. McGraw-Hill, New York, 2001.

4. Seidel HM, Ball JW, et al, Mosby’s Guide to Physical Examination. Mosby, St Louis, 1999.

5. California Dental Association. Guidelines for the Assessment of Clinical Quality and Professional Performance, 3rd ed. California Dental Association, Sacramento, Calif, 1995.

Legends

Figure 1. Mirror examination in #16 area.

Figure 2. Inspection and palpation of the tongue.

Figure 3. Bimanual palpation of floor of mouth and submandibular region.

Figure 4. Palpation of deep cervical nodes.

To request a printed copy of this article, please contact/Russell E. Christensen, DDS, MS, UCLA School of Dentistry, 53-058 Center for the Health Sciences, Los Angeles CA 90095-1668 or at rchriste@dent.ucla.edu.

Table 1. Differential for a White Lesion That Does Not Rub off