The oral medicine specialist and oral pathologist are the disciplined subspecialists in dentistry who deal with oral disease and related systemic conditions. Dental colleagues are an invaluable resource for the diagnosis and treatment of diseases unfamiliar to the otolaryngologist. This article reviews the process of history taking, the physical examination, head and neck examination, oral soft tissue anatomy, the oral examination, and screening and diagnostic testing.
Introduction
Oral diseases often reflect systemic health as well as local reactions to irritation. It is the role of the oral health professional to understand these disease processes for a timely diagnosis and treatment of potentially life threatening conditions. A precise history and physical examination and appropriate screening and diagnostic testing are at the center this process. This paper reviews this process and discusses the accuracy of screening and diagnostic testing for the patient with oral pathology. Newer oral cancer screening technology like salivary biomarkers and optical detection techniques are exciting developments in oral cancer detection and are discussed here. A more complete review should include the many excellent resources in oral medicine and oral pathology including Burket’s Oral Medicine 11th edition, 2008, and Oral & Maxillofacial Pathology by Brad Neville DDS, 3rd edition, 2008.
History
A detailed patient history is the foundation for an accurate diagnosis. An incomplete history leads to a flawed diagnosis, unnecessary testing, a delay in disease management, and possibly a misdiagnosis. The surgeon has the responsibility to minimize patient risk by defining the patient’s comorbidities and instituting appropriate measures and treatments. Previous medical records, including operative reports, radiographic and laboratory information pertaining to the patient’s problem are important sources of information and should be used whenever possible to supplement an accurate history.
The chief complaint should be evaluated by determining onset, location, duration, intensity, frequency, progression, character, severity, triggers, factors that improve or worsen the condition, effect on function, and results of previous treatments. The symptoms of pain, burning, dry mouth, paresthesia, hypesthesia, swelling, texture, and visual abnormality evaluated with the patient’s pertinent medical history gives the surgeon an initial level of concern regarding the urgency of the complaint.
The past medical and surgical history can often reveal pertinent information from childhood and adult illnesses, previous surgery, and anesthetic complications that can be critical in the patient’s care. More often than not oral soft tissue disease represents infectious, traumatic, or a reactive systemic process rather than a neoplastic process. Therefore, additional comprehensive histories of autoimmune disease, allergic disease, cardiovascular disease, hypertension, diabetes, hyperthyroidism, infectious disease, as well as cancer are important considerations in developing an accurate diagnosis.
A drug allergy history should differentiate true allergies from side effects of medications. Latex protein allergens can rapidly incite anaphylactic shock in sensitive individuals; children with spina bifida are a high-risk group for latex allergy. Patients with soy or egg allergies may react to propofol, and patients allergic to shellfish may have contrast allergies. Patients with ester type local anesthesia allergies should avoid cocaine, procaine hydrochloride (Novocain), and tetracaine (Pontocaine). Ester class anesthetics have 1 letter i in the name; the amide class has 2 (lidocaine, mepivacaine). The medication history of current prescription and nonprescription medications, their dosages, schedules, and patient compliance should be reviewed and recorded.
The social and family history can indicate social, environmental, and genetic risk factors associated with certain diseases that can affect the diagnosis. Tobacco exposure, specifically cigarette, cigar, pipe and chewing tobacco history should be recorded. If possible, alcohol consumption should be quantified as type, frequency, and duration of use. Recreational drug use and lifestyle risk factors for communicable diseases like human immunodeficiency virus (HIV), hepatitis, and tuberculosis should be addressed. Exposures to hazardous materials, environmental toxins, and accidental radiation exposure may be important to discuss and document. Family history for genetic disorders, diabetes, heart disease, allergic and autoimmune diseases, and cancer can be important questions when looking for diseases that can have a genetic basis and have not been considered before.
Table 1 lists a recent history of the pertinent system disorders that may contribute to the chief oral complaint. It should include recent constitutional changes such as weight loss, fatigue, night sweats, rashes, heat and cold intolerance, and others that might give insight into the patient’s problem.
| System | Review |
|---|---|
| General | General health, blood pressure, weight change, appetite, weakness, fatigue, fever, night sweats, sleeping pattern, unexplained falls |
| HEENT | Head: headache or facial pain, head injury; change in vision, pain, inflammation, infections Eyes: double vision, scotomata, blurring, tearing, glaucoma Ears: hearing loss, tinnitus, deafness, ear pain, or discharge; light-headedness, dizziness Nose: nasal obstruction, bleeding, discharge, sinusitis, allergies Throat: dental problems, ulcers or sores in the mouth, bleeding, dryness, tumors; saliva gland diseases, bad breath or taste in mouth, denture fit, hoarseness, dysphagia, sore throat, swollen glands in the neck, neck masses, thyroid disease, neck pain, or decreased motion |
| Breasts | Masses, change in contour or skin color, nipple discharge, pain |
| Respiratory | Cough, sputum color, hemoptysis, dyspnea, wheezing, pleurisy, asthma, bronchitis, emphysema, pneumonia, tuberculosis, chronic obstructive pulmonary disease, night sweats, nocturnal dyspnea |
| Cardiovascular | Cardiac: heart disease, arrhythmias, hypertension, angina, rheumatic fever, murmur, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, myocardial infarction, congestive heart failure, swelling feet or ankles, bacterial endocarditis, electrocardiogram or other test results. Heart surgery and prosthetic heart valve patient is at risk for sub-acute bacterial endocarditis (SBE) Vascular: claudication, varicosities, blood clots, extremity swelling or color change in cold weather, redness, or tenderness. Vascular diseases common to head and neck include hemangioma, arterial/venous/lymphatic malformations, Kaposi sarcoma, Sturge-Weber syndrome, hereditary hemorrhagic telangiectasia or Osler-Weber-Rendu (see Fig. 3 A) |
| Gastrointestinal and hepatic diseases | Dysphagia, globus, heartburn, appetite, nausea, bowel habits, stool size and color, pain on defecation, bleeding, hemorrhoids, constipation, diarrhea, food intolerance, jaundice, liver or gall bladder problems, hepatitis, cirrhosis, peptic ulcer disease. Inflammatory bowel disease (IBD)/ulcerative colitis and Crohn disease are associated with increased risk of aphthous stomatitis in both, cobblestone mucosa, lymphadenopathy, and periodontitis in active Crohn disease. Immunosuppressants used to treat IBD including steroids, azathioprine (Imuran), cyclosporine (Neoral), and methotrexate can aggravate infection and may cause gingival hyperplasia |
| Urogenital | Urinary frequency, retention, polyuria, dysuria, nocturia, urgency, pain/burning, bleeding, infections, flank pain, stones colic, suprapubic pain, incontinence, chronic renal failure, dialysis |
| Endocrine | Thyroid disease, goiter, exophthalmus, heat or cold intolerance, excessive sweating, thrust or hunger, tremor, palpitations, polyuria, polydipsia, mood swings, depression, visual changes, thin hair, constipation, dry skin, change in hat, glove or shoe size, diabetes mellitus, adrenal disorders, steroid therapy, lactation, pregnancy. intravenous bisphosphonates (Aredia, Bonefos, Didronel, or Zometa) for hypercalcemia and bone pain associated with metastatic breast cancer, prostate cancer, and multiple myeloma are at high risk for bisphosphonate-associated osteonecrosis of the jaw especially after dental extraction (see Fig. 14 A) |
| Neurologic | Headaches, strokes, seizures, attention, speech, memory, judgment, dizziness, weakness, imbalance, blackouts, paralysis, numbness, tingling, tremors, incontinence, seizure disorders, cerebrovascular disease, orofacial neurologic disorders (glossodynia, trigeminal neuralgia, Costen syndrome, burning mouth syndrome, and others) |
| Hematologic | Anemia, purpura, bruising or bleeding, anticoagulant therapy, past transfusions and reactions, hematologic malignancies, leukemia (see Fig. 14 B and C), lymphoma (Hodgkin and non-Hodgkin lymphoma), transplantation, hemostasis during surgery, infection risk (HIV, hepatitis), hematologic disease may cause oral lesions (see article on this topic in this issue) |
| Infectious | Viral infections: HSV-1 and HSV-2, chicken pox, varicella zoster, herpangina, coxsackievirus (hand foot and mouth disease), Epstein-Barr (NPC), hepatitis (A,B,C), HIV, human papilloma virus Fungal infections: Candida albicans , histoplasmosis, mucormycosis, aspergillosis, blastomycosis, coccidiomycosis Bacterial infections: previous systemic infection, methicillin-resistant Staphylococcus aureus , vancomycin-resistant Staphylococcus aureus , tuberculosis, previous odontogenic infection, pseudomembranous colitis, oral infections by sexually transmitted disease |
| Cutaneous | Rashes, lumps, sores, ulcers, decubitus, pruritus, dryness, color change, hair/nails change, change in size/color of moles. Sun exposure history. May have oral manifestations of systemic disease. Oral mucosa pigmented lesions are: endogenous, bilirubin from cirrhosis, iron in hemochromatosis or melanin deposition in Addison disease, Peutz-Jeghers syndrome, McCune-Albright syndrome, Von Recklinghausen disease; exogenous, heavy metal in lead and bismuth toxicity, chromophilic bacteria or fungi in black hairy tongue, foreign material deposits in amalgam tattoo. Mucosal melanoma are dark brown to bluish black and must be differentiated from other oral pigmentation |
| Musculoskeletal | History and location of muscle or joint pain, redness, weakness, decreased motion, trauma, stiffness, arthritis, gout, backache, or prosthetic joint. High-risk infection in prosthetic joints occurs in new joints (<2 years), prior joint infection, hemophilia, diabetes mellitus, rheumatoid arthritis, and patients on immunosuppressive therapy. Temporomandibular joint is affected by arthritis and is a common source of ear pain. Bone diseases such as osteoporosis can cause thinning of the cortical plate, loss of trabeculation, loss of edentulous ridge, delayed healing of extraction sites, and thinning of maxillary sinuses that may refer pain to the teeth. Other systemic resorptive bone diseases that affect the oral cavity include vitamin D deficiency, osteomalacia (malabsorption syndromes, chronic renal failure), hyperparathyroidism, fibrous dysplasia, McCune-Albright syndrome, Paget disease, histiocytosis, multiple myeloma |
| Psychiatric | Nervousness, instability, tension, insomnia, mania, memory loss, mood swings, disorientation, depression, suicide ideation. Psychiatric disease and psychotropic medications can cause xerostomia |
History
A detailed patient history is the foundation for an accurate diagnosis. An incomplete history leads to a flawed diagnosis, unnecessary testing, a delay in disease management, and possibly a misdiagnosis. The surgeon has the responsibility to minimize patient risk by defining the patient’s comorbidities and instituting appropriate measures and treatments. Previous medical records, including operative reports, radiographic and laboratory information pertaining to the patient’s problem are important sources of information and should be used whenever possible to supplement an accurate history.
The chief complaint should be evaluated by determining onset, location, duration, intensity, frequency, progression, character, severity, triggers, factors that improve or worsen the condition, effect on function, and results of previous treatments. The symptoms of pain, burning, dry mouth, paresthesia, hypesthesia, swelling, texture, and visual abnormality evaluated with the patient’s pertinent medical history gives the surgeon an initial level of concern regarding the urgency of the complaint.
The past medical and surgical history can often reveal pertinent information from childhood and adult illnesses, previous surgery, and anesthetic complications that can be critical in the patient’s care. More often than not oral soft tissue disease represents infectious, traumatic, or a reactive systemic process rather than a neoplastic process. Therefore, additional comprehensive histories of autoimmune disease, allergic disease, cardiovascular disease, hypertension, diabetes, hyperthyroidism, infectious disease, as well as cancer are important considerations in developing an accurate diagnosis.
A drug allergy history should differentiate true allergies from side effects of medications. Latex protein allergens can rapidly incite anaphylactic shock in sensitive individuals; children with spina bifida are a high-risk group for latex allergy. Patients with soy or egg allergies may react to propofol, and patients allergic to shellfish may have contrast allergies. Patients with ester type local anesthesia allergies should avoid cocaine, procaine hydrochloride (Novocain), and tetracaine (Pontocaine). Ester class anesthetics have 1 letter i in the name; the amide class has 2 (lidocaine, mepivacaine). The medication history of current prescription and nonprescription medications, their dosages, schedules, and patient compliance should be reviewed and recorded.
The social and family history can indicate social, environmental, and genetic risk factors associated with certain diseases that can affect the diagnosis. Tobacco exposure, specifically cigarette, cigar, pipe and chewing tobacco history should be recorded. If possible, alcohol consumption should be quantified as type, frequency, and duration of use. Recreational drug use and lifestyle risk factors for communicable diseases like human immunodeficiency virus (HIV), hepatitis, and tuberculosis should be addressed. Exposures to hazardous materials, environmental toxins, and accidental radiation exposure may be important to discuss and document. Family history for genetic disorders, diabetes, heart disease, allergic and autoimmune diseases, and cancer can be important questions when looking for diseases that can have a genetic basis and have not been considered before.
Table 1 lists a recent history of the pertinent system disorders that may contribute to the chief oral complaint. It should include recent constitutional changes such as weight loss, fatigue, night sweats, rashes, heat and cold intolerance, and others that might give insight into the patient’s problem.
| System | Review |
|---|---|
| General | General health, blood pressure, weight change, appetite, weakness, fatigue, fever, night sweats, sleeping pattern, unexplained falls |
| HEENT | Head: headache or facial pain, head injury; change in vision, pain, inflammation, infections Eyes: double vision, scotomata, blurring, tearing, glaucoma Ears: hearing loss, tinnitus, deafness, ear pain, or discharge; light-headedness, dizziness Nose: nasal obstruction, bleeding, discharge, sinusitis, allergies Throat: dental problems, ulcers or sores in the mouth, bleeding, dryness, tumors; saliva gland diseases, bad breath or taste in mouth, denture fit, hoarseness, dysphagia, sore throat, swollen glands in the neck, neck masses, thyroid disease, neck pain, or decreased motion |
| Breasts | Masses, change in contour or skin color, nipple discharge, pain |
| Respiratory | Cough, sputum color, hemoptysis, dyspnea, wheezing, pleurisy, asthma, bronchitis, emphysema, pneumonia, tuberculosis, chronic obstructive pulmonary disease, night sweats, nocturnal dyspnea |
| Cardiovascular | Cardiac: heart disease, arrhythmias, hypertension, angina, rheumatic fever, murmur, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, myocardial infarction, congestive heart failure, swelling feet or ankles, bacterial endocarditis, electrocardiogram or other test results. Heart surgery and prosthetic heart valve patient is at risk for sub-acute bacterial endocarditis (SBE) Vascular: claudication, varicosities, blood clots, extremity swelling or color change in cold weather, redness, or tenderness. Vascular diseases common to head and neck include hemangioma, arterial/venous/lymphatic malformations, Kaposi sarcoma, Sturge-Weber syndrome, hereditary hemorrhagic telangiectasia or Osler-Weber-Rendu (see Fig. 3 A) |
| Gastrointestinal and hepatic diseases | Dysphagia, globus, heartburn, appetite, nausea, bowel habits, stool size and color, pain on defecation, bleeding, hemorrhoids, constipation, diarrhea, food intolerance, jaundice, liver or gall bladder problems, hepatitis, cirrhosis, peptic ulcer disease. Inflammatory bowel disease (IBD)/ulcerative colitis and Crohn disease are associated with increased risk of aphthous stomatitis in both, cobblestone mucosa, lymphadenopathy, and periodontitis in active Crohn disease. Immunosuppressants used to treat IBD including steroids, azathioprine (Imuran), cyclosporine (Neoral), and methotrexate can aggravate infection and may cause gingival hyperplasia |
| Urogenital | Urinary frequency, retention, polyuria, dysuria, nocturia, urgency, pain/burning, bleeding, infections, flank pain, stones colic, suprapubic pain, incontinence, chronic renal failure, dialysis |
| Endocrine | Thyroid disease, goiter, exophthalmus, heat or cold intolerance, excessive sweating, thrust or hunger, tremor, palpitations, polyuria, polydipsia, mood swings, depression, visual changes, thin hair, constipation, dry skin, change in hat, glove or shoe size, diabetes mellitus, adrenal disorders, steroid therapy, lactation, pregnancy. intravenous bisphosphonates (Aredia, Bonefos, Didronel, or Zometa) for hypercalcemia and bone pain associated with metastatic breast cancer, prostate cancer, and multiple myeloma are at high risk for bisphosphonate-associated osteonecrosis of the jaw especially after dental extraction (see Fig. 14 A) |
| Neurologic | Headaches, strokes, seizures, attention, speech, memory, judgment, dizziness, weakness, imbalance, blackouts, paralysis, numbness, tingling, tremors, incontinence, seizure disorders, cerebrovascular disease, orofacial neurologic disorders (glossodynia, trigeminal neuralgia, Costen syndrome, burning mouth syndrome, and others) |
| Hematologic | Anemia, purpura, bruising or bleeding, anticoagulant therapy, past transfusions and reactions, hematologic malignancies, leukemia (see Fig. 14 B and C), lymphoma (Hodgkin and non-Hodgkin lymphoma), transplantation, hemostasis during surgery, infection risk (HIV, hepatitis), hematologic disease may cause oral lesions (see article on this topic in this issue) |
| Infectious | Viral infections: HSV-1 and HSV-2, chicken pox, varicella zoster, herpangina, coxsackievirus (hand foot and mouth disease), Epstein-Barr (NPC), hepatitis (A,B,C), HIV, human papilloma virus Fungal infections: Candida albicans , histoplasmosis, mucormycosis, aspergillosis, blastomycosis, coccidiomycosis Bacterial infections: previous systemic infection, methicillin-resistant Staphylococcus aureus , vancomycin-resistant Staphylococcus aureus , tuberculosis, previous odontogenic infection, pseudomembranous colitis, oral infections by sexually transmitted disease |
| Cutaneous | Rashes, lumps, sores, ulcers, decubitus, pruritus, dryness, color change, hair/nails change, change in size/color of moles. Sun exposure history. May have oral manifestations of systemic disease. Oral mucosa pigmented lesions are: endogenous, bilirubin from cirrhosis, iron in hemochromatosis or melanin deposition in Addison disease, Peutz-Jeghers syndrome, McCune-Albright syndrome, Von Recklinghausen disease; exogenous, heavy metal in lead and bismuth toxicity, chromophilic bacteria or fungi in black hairy tongue, foreign material deposits in amalgam tattoo. Mucosal melanoma are dark brown to bluish black and must be differentiated from other oral pigmentation |
| Musculoskeletal | History and location of muscle or joint pain, redness, weakness, decreased motion, trauma, stiffness, arthritis, gout, backache, or prosthetic joint. High-risk infection in prosthetic joints occurs in new joints (<2 years), prior joint infection, hemophilia, diabetes mellitus, rheumatoid arthritis, and patients on immunosuppressive therapy. Temporomandibular joint is affected by arthritis and is a common source of ear pain. Bone diseases such as osteoporosis can cause thinning of the cortical plate, loss of trabeculation, loss of edentulous ridge, delayed healing of extraction sites, and thinning of maxillary sinuses that may refer pain to the teeth. Other systemic resorptive bone diseases that affect the oral cavity include vitamin D deficiency, osteomalacia (malabsorption syndromes, chronic renal failure), hyperparathyroidism, fibrous dysplasia, McCune-Albright syndrome, Paget disease, histiocytosis, multiple myeloma |
| Psychiatric | Nervousness, instability, tension, insomnia, mania, memory loss, mood swings, disorientation, depression, suicide ideation. Psychiatric disease and psychotropic medications can cause xerostomia |
Physical examination
This physical examination section is limited to a comprehensive head and neck examination. References for examination of systems other than the head and neck can be found in Bates’ Guide to Physical Examination and History Taking or other guides to the physical examination. During the comprehensive head and neck examination it is important to look, listen, and feel the site being examined. Manual and bimanual palpation of high-risk areas, especially the tongue base, tonsils and floor of mouth (FOM), salivary glands, and thyroid may detect primary cancers early before they become metastatic. Listening to the patient’s voice and speech are important in consideration of tumor location. A hot potato voice may represent an oropharyngeal tumor and a raspy hoarse voice might suggest a laryngeal neoplasm. The examination proceeds in 3 phases: (1) obtaining vital signs; (2) examination of the head, neck, and the oral cavity; (3) obtaining radiographic and laboratory studies. Additional special examinations of other organ systems may be necessary for patients whose signs and symptoms are suggestive of a systemic cause. A detailed physical examination of a patient of the opposite sex should be done in the presence of a medical assistant of the same gender as the patient. History taking helps the clinician to develop a rapport with the patient to allow the patient to feel comfortable and confident during the examination. Explaining what you are about to do helps put the patient at ease; it is also a time to educate the patient about the early signs and symptoms of head and neck cancer. The examination must be done using universal precautions, protective gloves, eyewear, and a mask if indicated. The clinician should have adequate equipment and supplies on hand for an efficient and professional examination, such as a good light source, mirrors, tongue blades, 2×2 gauze pads, topical decongestants, anesthesia, suction, flexible nasopharyngoscope, pneumatic otoscope, and a nasal speculum.
Head and neck examination
General Appearance
Changes in appearance such as weight loss, anorexia, and fatigue could indicate malignancy.
Head and Neck
Inspect the head and neck for facial tone or palsy, skin changes, discoloration, pigmentation, ulceration, asymmetry, neck range of motion in flexion, extension, and lateral bending. Palpate the facial bones for asymmetry, masses, scalp abnormalities, swelling, and temporal wasting. Palpate the cervical chain lymph nodes. These are divided into large and smaller anatomic triangles or into lymph node regions (levels). The latter are endorsed by the American Head and Neck Society and the American Academy of Otolaryngology – Head and Neck Surgery. Level IA are the submental nodes, level IB are the submandibular nodes. Level II is part of the upper jugulodigastric chain above the hyoid bone ( Fig. 1 A). Level II is divided into IIB above and IIA below the spinal accessory nerve. Level III extends from the hyoid to the cricoid and level IV from the cricoid to the clavicle (see Fig. 1 B). Level V is the posterior triangle and is separated into VA (spinal accessory nodes) above and VB (transverse cervical and supraclavicular nodes) below (see Fig. 1 C). The parotid (or preauricular), retroauricular, and suboccipital node regions are denoted P, R, and S but are not part of this classification system. Infection produces mobile and tender nodes, whereas malignancy produces asymptomatic and fixed nodes. Auscultation of the neck with the bell of the stethoscope of a thyroid goiter can indicate Graves disease, carotid bruits, or the sounds of airway obstruction over the larynx and trachea.
Thyroid
Inspect the thyroid gland first then proceed to palpation. The normal thyroid gland is often difficult to feel. Palpation can be from the front or for the heavy neck by standing behind the patient. Palpate the entire gland. Have the patient turn toward the examining side to relax the sternocleidomastoid muscle. During palpation of the lobe ask the patient to swallow, this elevates the gland upward and may help identify a nodule. Note the characteristics of any nodules or abnormality as cystic or hard and record tender areas. If the inferior pole of the gland is difficult to palpate it may suggest substernal extension of the thyroid gland.
Salivary Glands
The second most common extra oral mass after lymphadenopathy is a salivary gland neoplasm. Parotid neoplasms are palpated in the preauricular and infra-auricular regions. Sublingual and submandibular gland masses are often tender and are more effectively evaluated by bimanual palpation.
Eyes
The cranial nerves II, III, IV, and VI can be tested here by examining extraocular movements and visual acuity by using a Snelen chart. Eye swelling, epiphora, or neural deficits could represent invasive cancer arising from the nose, sinuses or facial skin.
Ears
The external ears should be closely inspected noting color changes, ulcers, or deformities especially in the sun-exposed areas. Evaluate the external auditory canal for masses, drainage, or obstructing cerumen that may need to be removed to be able to see the tympanic membrane. Assess the integrity of the tympanic membranes by pneumatic otoscopy and hearing acuity with a finger rub or using tuning forks. Exclude ear pathology in the differential diagnosis for referred otalgia.
Nose
The nasal septum and anterior turbinates can be evaluated by anterior rhinoscopy using a headlight and nasal speculum. Nasal endoscopy allows examination of the posterior portions of the nasal cavity and the nasal pharynx. The scope is passed after applying local anesthetic spray to the nose. It is helpful to view the nose in its native state before and after decongestant use to determine soft tissue obstruction.
Throat
Note the position of the trachea in the anterior neck; deviation may suggest a neck mass or lung abnormality. The oral and pharyngeal examinations are discussed less later.
Temporomandibular Joint
Temporomandibular joint (TMJ) disease can be best identified by TMJ palpation during opening and closing. Examine both joints simultaneously by gently placing the middle finger anterior to the tragus. Tenderness on opening and closing can localize the problem to the TMJ. Maximum opening distance, opening symmetry, popping, clicking, or grinding should be noted. Ear pain after normal ear and TMJ examinations may be referred from cranial nerves IX and X and represent an upper airway carcinoma. Patients at risk for throat cancer should undergo nasopharyngoscopy before treatment of a suspected temporal mandibular disorder.
Cranial Nerves
The cranial nerve (CN) examination ( Table 2 ) begins when the patient walks in the room. Eye movement and vision assessment clears CN II–VI and VI. Olfactory nerves can be checked by a simple alcohol sniff test using a 70% isopropyl alcohol disposable pad. Motor assessment of CN V, VII, XI, and XII is by simple jaw, face, shoulder, and tongue movement. Afferent and efferent gag reflex tests CN IX and X. CN VIII can be tested by finger rub or more sophisticated tuning fork testing.
| Cranial Nerve | Examination |
|---|---|
| Olfactory (I) | Test with coffee, vanilla, peppermint, alcohol sniff test, or University of Pennsylvania Smell Identification Test |
| Optic (II) | Visual fields (Snelen chart), pupillary light reflex, swinging flashlight |
| Oculomotor (III) | Ptosis, nystagmus, pupillary size (PERRLA), eye movement, accommodation reflex |
| Trochlear (IV) | Eye movement, superior oblique |
| Trigeminal (V) | Light touch, pain, temperature, corneal reflex, jaw movement toward side of lesion |
| Abducens (VI) | Eye movement, lateral rectus |
| Facial (VII) | Motor: facial muscles, close eyes, wrinkle forehead, smile and show teeth Sensory: taste testing |
| Auditory (VIII) | Hearing acuity, Rinne test, Weber test, balance function testing |
| Glossopharyngeal (IX) | Mostly sensory to tonsils, pharynx, posterior tongue, loss of gag reflex (afferent limb) |
| Vagus (X) | Uvula away from side of lesion, hoarseness, dysphagia, loss of gag reflex (efferent limb) |
| Spinal accessory (XI) | Shrug shoulders, turn head right and left |
| Hypoglossal (XII) | Movement deviates toward side of lesion, tongue atrophy or fasciculations |
Oral soft tissue anatomy
The oral examination evaluates the lips, oral cavity, and oropharynx. The oral cavity is the anterior two-thirds of the tongue, the gingiva, buccal mucosa, FOM, hard palate, and retromolar trigone. The oropharynx is the posterior one-third of the tongue, soft palate, tonsils, and the lateral and posterior walls of the visible pharynx.
The oral soft tissues are covered by 3 types of mucosa: nonkeratinized, keratinized, and specialized. Nonkeratinized mucosa is nonmasticatory mucosa, the unattached lining mucosa on lips, cheeks, FOM, ventral tongue, soft palate, and the alveolar mucosa that is not firmly attached to underlying bone. This mucosa can be stretched or compressed and has a basal layer, an intermediate layer, and a superficial layer that does not produce keratin. This is the common site of the aphthous ulcer formation ( Fig. 2 A).
Keratinizing mucosa is masticatory mucosa that is the attached to gingiva around the teeth and hard palate, and is the common site for herpetic ulcer formation. It occurs in parakeratin and orthokeratin forms. Both forms of keratinized epithelium have basal layers, a prickle cell layer (bulk of the epithelium), a granular layer (keratohyaline granules), and a superficial keratin of varying thickness. Parakeratin contains nucleated keratinocytes, whereas the less common orthokeratin contains none. Hyperkeratosis is a microscopic diagnosis of the thickening of the stratum corneum, often associated with a qualitative abnormality of the keratin and can be the result of an irritant or vitamin A deficiency.
Specialized mucosa is papillae on the dorsum and lateral tongue. The filiform papillae are most numerous and guide food in swallowing, and contain no taste buds. In addition to normal filiform papillae in Fig. 3 A, the patient has small angiomas consistent with her diagnosis of Osler-Weber-Randu. The child in Fig. 3 B exhibits filiform papillae atrophy from benign migratory glossitis. Note the anterior tongue appears similar to strawberry tongue, with fungiform hypertrophy and filiform atrophy giving the tongue an enanthema or bright red background. Strawberry tongue is seen in scarlet fever and can occur in Kawasaki disease. The fungiform papillae (see Fig. 3 A and B) are red mushroom like structures over the dorsum of the tongue and contain taste buds. The folate papillae (see Fig. 3 C) appear on the lateral boarders of the tongue and have taste buds. The large circumvale papillae (see Fig. 3 C) also have taste buds and are 10 to 14 large, raised, round papillae in a V-shaped pattern at the boarder of the anterior two-thirds and posterior one-third of the tongue. In addition, lingual varices can be seen in this region and on occasion the surgeon may be asked to take a biopsy from one of these normal posterior tongue structures because of abnormal presentation.
