The primary objectives of an oral cavity examination are to distinguish between health and disease and to recognize normal anatomic structures and their variations. Therefore knowledge of normal oral mucous membranes is crucial to the recognition of oral diseases. This is best accomplished by a careful and methodic inspection of all of the oral structures, complemented by a complete medical and dental history. Because the great majority of lesions in the oral cavity represent reactive processes to either trauma or infections rather than neoplasms, the precise etiology can often be uncovered by a meticulous history and clinical examination.
Because medications often result in oral side effects, a detailed drg history should be routinely obtained. Oral habits and use of dentrifices and mouthwashes should also be recorded because these ay also precipitate oral mucosal reactions.
When the diagnosis of an oral abnormality cannot be confirmed on the basis of clinical features, the examination may be supplemented by an excisional or incisional biopsy of the oral mucosa. The microscopic findings correlated with the clinical examination are usually sufficient to confirm the diagnosis.
Clinicians should be encouraged to use photography to document oral diseases and to monitor progress during therapy. Most 33-mm, single lens cameras can be easily adapted for intraoral use. In fact, photographic systems have been designed exclusively for intraoral use.
EXTRAORAL EXAMINATION
The initial clinical evalution of a patient with an oral complaint should begin with an extraoral head and neck examination, which may reveal additional pertinent data. The skin should be inspected for the presence of neoplasms. For example, in patients with multiple hamartoma syndrome, the recognition of cutaneous tricholemmomas on the face is necessary to establish the diagnosis because histopathologic examiation of the oral mucosal papillomatosis does not reveal any ditinctive histologic properties that would indicate the presence of the syndrome. Changes in color of the facial skin may result from medications such as minocycline or sytemic conditions such as Addison's disease, both of which may produce similar changes in the oral mucosa.
All facial structures should be palpated for the presence of masses. Parotid gland tumors ay cause intraoral abnormalities, but they are best detected by palpation of the skin overlying the preauricular region. All of the lymph nodes of the neck should be routinely palpated, especially the anterior cervical chain.
The lips should be inspected for color and surface abnormalities, which may indicate actinic damage. Healthy lips are smooth and pliable and do not demonstrate any areas of induration.
INTRAORAL EXAMINATON
The examination of the oral cavity is an acquired skill that improves with repetition. Adequate lighting is an invaluable aid that is essential for maximum intraoral visualization. Although present in dental offices, bright overhead lighting is usually absent in medical offices. For those practitioners who do not normally use a fixed or head-mounted examination light, a hand-held flashlight or pen light may be sufficient to supplement ambient room lighting.
The color of all oral mucous membranes should be evaluated because it varies greatly among ethnic groups. Changes in the color of the oral mucosa.
DIAGNOSTIC TESTS
After a thorough patient history and examination, the diagnosis of an oral condition may remain uncertain. Diagnostic tests provide supplemental information that may be invaluable in establishing a definitive diagnosis. The selection of a diagnostic test or procedure should be based on its value in confirming or excluding a disease process or condition, the attendant risks(e.g.,morbidity), and the relative expense to the patient.
ORAL BIOPSY
Accurate diagnosis of oral disease is often delayed or postpones because of a hesitation to perform intraoral biopsies. Consequently, treatment of oral diseases is often delayed, resulting in less desirable outcomes. Provided that the clinician is familiar with the normal anatomy of the biopsy site and the basic tenets of good surgical technique, intraoral biopsies can be accomplished with great success.
IMMUNOFLOURESCENCE TESTS
The deposition of immunoglobulins and complement components in the oral mucosa is a common feature of autoimmune and other immunologically mediated diseases and conditions. The presence of such substances is ascertained by direct immunoflourescence staining of appropriately fixed biopsy specimens.
When biopsy specimens for direct immunoflourescence studies are obtained, intact perilesional tissue should be selected and ulcerated mucosa should avoided. When multiple mucosal sites are involved, the selection of an appropriate biopsy site should be governed by the level of disease present and the ease of procuring an appropriate tissue sample.
Indirect immunoflourescence, a method of detecting circulating antibodies by reacting patients' sera with an appropriate mucosal substrate, is an invaluable method used not only for diagnosing vesiculoerosive disorders, but also for monitoring patients' response to therapy. Indirect immunoflourescence has its great use in the diagnosis and management of pemphigus vulgaris and paraneoplastic pemphigus.
VIRAL DIAGNOSTIC TESTS
Viral culturing is not equally effective for all viral infections. Cultures of herpes simplex infections become positive usually within 3 days, whereas varicella zoster virus is difficult to isolate from oral lesions.
Immunologic and immunohistochemical testing for the presence of specific viral antigens can be accomplished by a variety of mechanisms including immunoflourescence, immunoperoxidase, in situ hybridization, specific molecular probes, and polymerase chain reacton-based techniques. All of these mechanisms require an appropriately submitted biopsy specimen. Although these diagnostic technique tests were once used exclusively for investigational purposes, they ahev in recent years become commercially available.
FUNGAL DIANOSTIC TESTS
With the exceptional of dental caries and periodontal disease, oral candidiasis remains the most common infection of the oral cavity. Accurate diagnosis of the infection is essential for the timely institution of appropriate therapy.
The classic method of diagnosing oral candidiasis involves potassium hydroxide digestion of a mucosal smear. The remaining fungalv oranisms that resist such digestion can be viewed by dark-field or phase contrast microscopy. Oral candidiasis may also be diagnosed with flourescent microscopy using calcoflour white(an industrial whitening substance used in the paper industry), which binds to fungal cell walls and flouresces when exposed to the appropriate excitatory wavelength of light. Although this method is extremely rapid, it requires the use of a flourescent microscope, which is not routinely found in medical and dental offices.
