Some say the mouth is the body’s mirror. And while associations between oral and systemic health can be made and research is on the rise, specific cause-and-effect relationships remain elusive. Life—and certainly health—are not so easily defined, packaged, and distributed.
Links have been made between oral health and cardiovascular disease, diabetes, respiratory disease, and osteoarthritis. But establishing cause and effect can be a complex and confusing process, confounded by a myriad of variables. Wherever the quest eventually leads, the basic oral health assessment is a good starting point. Remember that all clinical contacts should include protection for both your patient and yourself. This means using examination gloves, face mask, and a mirror or tongue depressor. These simple devices along with a good light source will facilitate a thorough examination.
The examination should begin with an evaluation of the face and neck. Symmetry of the face is expected; asymmetry could be a sign of an intraoral infection or tumor manifested extraorally. Engage the patient in conversation to assess speech production and muscular function in the perioral structures. Palpate the neck for any masses or irregularities. To assess the temporomandibular joints, ask the patient to open and close his or her mandible. Pain, deviation to one side, and popping or clicking noises may all be signs and symptoms of degenerative joint disease.
A close look at the skin is particularly important during extraoral assessment. The skin should be free of ulcerated, cratered, crusted, or pigmented lesions (painful or not). Light-skinned individuals living in geographic areas of intense sun exposure and high altitude are particularly susceptible to basal cell carcinoma (BCC). The most common sites are the lower lip, top of the ear, and tip or side of the nose. Traditionally, these neoplasms have been considered slow-growing and noninvasive, but recent reports indicate that approximately 11% of BCCs are aggressive and feature deep-tissue invasion and metastasis.1 Evaluate the degree of skin hydration for clues to underlying dehydration, and investigate any bruises or discolorations by inquiring into the patient’s medical and/or personal history. Last, the lips should be examined for lesions, palpated for lumps or bumps, and checked for signs of dehydration or infection.
Inspect all aspects (dorsal, ventral, lateral) of the tongue. The tongue is normally pink to red with variable fissures on the dorsal surface. The lingual tonsils (often mistaken for neoplastic growths) are located on the posterior lateral border. The tongue, floor of the mouth, and mucosa of the cheek should appear intact, pinkish-red, and well hydrated. Ulcerated and/or discolored tissue (red or red-white) are a red flag for referral to an oral medicine or oral surgery service. Use two fingers to feel the floor of the mouth from within and outside the oral cavity, attempting to locate any mass or lump.
Gingival tissues and the hard and soft palates should also be pink to reddish in color and firm in consistency.
The condition of the teeth may vary from absence of dental caries or filling material to serious disease and multiple missing teeth. Various restorations (e.g., crowns, veneers, bridges, partial or complete dentures, and dental implants) may be found. Most patients have a realistic grasp of their dental history and are able to provide accurate answers when questioned.
Benign soft- and hard-tissue lesions to look out for include Fordyce granules in the cheek, papillomas, fibromas, geographic tongue, trauma (e.g., burns, lacerations), and palatal and mandibular tori (i.e., outgrowths of normal bone).
Intraoral disease processes
The two most prevalent disease processes in the oral cavity are dental caries and periodontal disease. Both conditions may have profound links to severe systemic disease. Teeth may suffer dental caries so severe that the nerve has been compromised and bacteria have invaded the alveolar bone at the apex of the root(s). As these periapical abscesses expand, fluid pressure may bore through the bone and into soft tissues. From there, the infection spreads by separating fascial planes and creating, then occupying, anatomical “spaces” between fascial planes.
These so-called “space infections” constitute life-threatening episodes. An infection of the submandibular or sublingual space resulting from an abscessed lower tooth can distort the floor of the mouth and push the tongue posteriorly, causing an airway obstruction. A canine-space infection resulting from an abscessed upper canine or first bicuspid tooth has the potential for causing massive periorbital edema and obliterating the nasolabial fold. These infections may penetrate the valveless angular veins in the forehead and enter the cavernous sinus, causing thrombosis and death. Immediate surgical and antibiotic interventions (amoxicillin 500 mg daily for 10 days) are required.
Periodontal disease, or periodontitis (Figure 1), often begins as gingivitis but constitutes a far more serious condition. Rather than healthy, firm, pink gingival tissue, the clinician will usually notice red, edematous gingivae; exposed roots; deposits of dental plaque (oral biofilm); and calculus (tartar). These findings are accompanied by bleeding gums, purulent exudate, and halitosis. Periodontal disease is a chronic, progressive, inflammatory process. Its etiology has been traced to predominantly anaerobic gram-negative rods and spirochetes. The end point of this disease process is loss of alveolar bone, which anchors the teeth to the jaw. The result can be loose, diseased teeth that must be extracted. This inflammatory disease is a suspected source of antigens and virulence factors that circulate throughout the body.
Other soft-tissue conditions commonly encountered in the oral cavity include angular cheilitis at the commissures of the lips, usually in the elderly patient. This condition presents as cracked, weeping epithelium. Treatment consists of nystatin/triamcinolone (Mycolog II) cream or ketoconazole 2% cream to fight perioral yeast organisms.
Herpes simplex virus and recurrent intraoral herpes may cause painful ulcerated vesicles, but both conditions are self-limiting (7-14 days). OTC interventions include antiviral creams (docosanol [Abreva]) and lysine 1,000 mg t.i.d. for three to five days. Acyclovir 800 mg daily for three to five days is also helpful to accelerate healing.
Aphthous ulcers are painful, erythematous lesions with gray-yellow-white central pseudomembranes. Although these lesions are self-limiting, symptoms may be alleviated by OTC oral rinses, such as Rincinol, or prescribed medications, such as dexamethasone (Decadron) elixir one tablespoon four times daily (swish and spit), or lidocaine cream 4% (LMX 4%) applied t.i.d. to the affected area for five to seven days.
Xerostomia (dry mouth) can contribute to dental caries and uncomfortable or painful dentures. The most effective therapies are OTC enzyme products (e.g., mouthwash, toothpaste, chewing gum, oral moisturizer) from Biotene.
Oral candidiasis may present as areas of white, red, or white/red soft tissue. Causative yeast organisms are always present in the mouth but are usually kept in check. This condition may be prevalent in immunocompromised patients or on the palate beneath an ill-fitting denture. Treatment consists of such topical preparations as nystatin oral suspension or clotrimazole troches. Severe cases are usually treated with such systemic antifungals as fluconazole.