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OXTORD
Max Robinson
Keith Hunter
Michael Pemberton
Philip Sloan
Soames ’ and Southam’s
Oral Pathology
'X
Max Robinson
Senior Lecturer in Oral Pathology
School of Dental Sciences
Newcastle University
UK
Keith Hunter
Professor of Head and Neck Pathology
Department of Oral Pathology
School of Clinical Dentistry
University of Sheffield
UK
Michael Pemberton
Professor in Oral Medicine
University Dental Hospital of Manchester
Manchester University Hospitals NHS Foundation Trust
UK
Philip Sloan
Professor of OraI Pathology
School of Dental Sciences
Newcastle University
UK
OXFORD
UNIVERSITY PRESS
OXFORD
UNIVERSITY PRESS
Abbreviations XIII
3 Oral cancer 59
Chapter contents
Introduction 2
Obtaining an accurate history 2
A systematic approach to patient examination 3
Thinking about the differential diagnosis 5
Choosing and ordering investigations 5
Referring a patient to a specialist 9
Documenting clinical information 10
Diagnosis of oral disease
Introduction
The most common oral diseases are dental caries and periodontal dis- must obtain an accurate patient history and undertake a systematic
ease (Fig. 1.1). The diagnosis and treatment of these diseases are the clinical examination. These key clinical skills underpin both medicine
focus of the majority of dentists, dental therapists, and dental hygien- and dentistry, and are an absolute requirement to formulate a differ-
ists. Nevertheless, it is the responsibility of the dental healthcare profes- ential diagnosis. The use of imaging modalities and laboratory tests are
sional to provide a holistic approach to management that ensures both often required to reach a definitive diagnosis, and it is the justification
good oral and general health for their patients. A broad knowledge of and informed choice of these additional investigations that will facilitate
the range of diseases that affect the oral cavity is essential and also an a timely and accurate diagnosis. Following diagnosis, appropriate treat-
appreciation that oral disease may be the first sign of an underlying ment can be instituted, the ideal outcome being a return to health or
systemic disease. Before this knowledge can be applied, the clinician control of the patient’s symptoms in recalcitrant chronic diseases.
Table 1.2 Establishing the history of a lesion Box 1.1 The medical history
System
Features Descriptors
• Cardiovascular system (CVS)
Site Anatomical location, single, multiple
• Respiratory system ( RS)
Size Estimate of size, increasing in size ( slowly,
rapidly), decreasing in size, fluctuates in size
• Haematological diseases
Onset Recent, longstanding, days, weeks, months,
• Bleeding disorders
years • Central nervous system (CNS)
Initiating factors Trauma, dentoalveolar infection • Eyes
Associated features Pain, bleeding, malaise, fever,
• Ear, nose, and throat
lymphadenopathy • Gastrointestinal tract (GIT)
• Liver
( Chapter 10) and highlight any issues relating to proposed medical or
• Genitourinary tract (GUT)
surgical interventions.
• Kidneys
• Musculoskeletal system
Family history • Endocrine disease
Some diseases are heritable and have a characteristic pedigree that • Medications
can be mapped over multiple generations, e.g. haemophilia. Other dis- • Allergies
eases show a preponderance to affect individuals within family groups,
but it is difficult to predict which individuals will be affected and rela-
• Pregnancy
tives may suffer to a greater or lesser extent. These familial traits may
• Hospitalization
be heritable with variable genetic penetrance and expressivity, or may • History of cancer
reflect exposure to similar environmental and social factors. • Blood-borne infectious diseases
Social history
The social history may be of direct relevance to oral disease and general
Dental history
health. For example , tobacco consumption and alcohol abuse are risk
factors for the development of oral cancer, as well as other systemic The previous dental history will help to build a picture of the patient’s
diseases, e.g. cardiovascular disease and liver disease. Factors such as current state of oral health and their previous engagement with dental
occupation and personal status provide additional information and may health services. The dental history may inform the acceptability of any
influence the care plan. proposed treatment.
the neck, which include the larynx, trachea, and thyroid gland, should neurological deficit over the distribution of the trigeminal nerve should
be examined. The presentation of lumps in the neck is covered in be documented and mapped out.
Chapter 9. Any lumps, e.g. enlarged lymph nodes, are described by The intra-oral, soft-tissue examination should include inspection of the
anatomical site, size, consistency (cystic, soft, rubbery, or hard), rela- vermillion border of the lips, labial and buccal mucosae, hard palate, soft
tionship to underlying tissues ( fixed or mobile), and whether palpation palate, fauces and tonsils, the floor of the mouth, oral tongue, alveolar
elicits pain. The parotid glands are also examined and palpated for any mucosa, gingivae, and teeth. The clinician should be aware of the regional
abnormalities. variation of the mucosa within the oral cavity and recognize the normal
The examination then focuses on assessment of the temporoman- anatomical structures that occasionally are mistaken for disease: Fordyce
dibular joints and the muscles of mastication to assess functional spots (intra- oral sebaceous glands), sublingual varices, lingual tonsil, and
abnormalities and any muscle tenderness. The muscles of facial expres- fissured tongue (Fig. 1.3). Documentation of lesions (lumps, ulcers, and
sion are also assessed, to establish facial nerve function. Any sensory patches) follows the schemes outlined in Tables 1.3 and 1.4.
.
Fig 1.3 Fordyce spots on the buccal and labial mucosa (A), sublingual varices (B), lingual tonsil (C), and fissured tongue (D).
Consistency Soft, firm, fluctuant, pulsatile, rubbery, Consistency Soft, firm, rubbery, indurated (hard)
indurated (hard)
Colour Yellow, red, grey, black
Colour Pink, red, white, yellow, brown, purple, black
Edge Well defined, ragged, rolled margin
Edge Well defined, irregular, poorly defined
Attachment to adjacent Mobile, tethered, fixed
Attachment to Mobile, tethered, fixed structures
adjacent structures
Choosing and ordering investigations
Inherited Congenital disease an oro-facial swelling in a patient with a neglected dentition is most
likely to be a dentoalveolar infection. If the clinical assessment indi-
Iatrogenic Dental or medical intervention
cates that the lesion is benign, then the differential diagnosis should
Idiopathic Unknown cause focus on infective causes, hyperplastic lesions, and benign neoplasms.
Conversely, clinical signs and symptoms of a destructive lesion suggest
Systemic disease Oral manifestation of systemic disease
malignancy.
5 avril.
Courtrai, 5 avril.
Claude à Marie.
Arras, 8 avril.
Même jour.