Medical history sheets which include lifestyle questions and soft tissue assessment
charts can save a lot of time for dentists. Mouth maps will help with soft tissue
monitoring. It will also help to flag up patients who are ‘at risk’ as shown on
- History and physical examination. Includes risk factor analysis and exposure to
- Head and neck examination: Direct visualization, mirror examination,
manual palpation and toluidine blue staining.
- Laboratory tests: CBC liver function.
Radiology: CT or MRI of head and neck, chest X-ray, dental films, bone scan when
- Pathology: Incisional biopsy, excisional biopsy, fine needle aspiration
biopsy, molecular markers, flow cytometry.
- Panendoscopy: T- stage schematic
tumour map, evaluate for second malignancies.
- Pre-therapy consultation with:
Radiation oncology, medical oncology, head and neck surgery, reconstructive surgery,
dental oncology, speech pathology and psychosocial service.
Tumour Board: Finalize staging and formulate treatment plan.
Screening is the process by which practitioner evaluates an asymptomatic patient
to determine if he or she is likely or unlikely to have a potentially malignant
or malignant lesion. This can be done by a conventional oral examination.
Conventional/Routine Oral Examination
To ensure completeness, a soft tissue examination needs to follow a pattern. Work
out a logical sequence and then stick to it. Since your first step will be a general
appraisal of the patient’s well-being, it could make sense to start with soft tissues,
before moving on to examination of the teeth and gums. But this is a personal choice
- carry out the examination in an order that you are comfortable with and that you
find easy to explain to the patient. Use gloved fingers or preferably, two mouth
mirrors to retract the tissues. The visual inspection should be supplemented by
palpation of any suspicious area and the submandibular and cervical lymph nodes.
Any intraoral prostheses (dentures or partial dentures) are removed before starting
the inspection. The extraoral and perioral tissues are examined first, followed
by the intraoral tissues.
I. The Extra Oral Examination
- Face:The extra-oral assessment includes an examination
of the face, head and neck. The face, ears and neck are observed, noting any asymmetry
or changes on the skin such as crusts,fissuring, growths and/or colour change. The
regional lymph node areas are bilaterally palpated to detect any enlarged nodes
and if detected, their mobility and consistency are checked. A recommended order
of examination includes the preauricular, submandibular, anterior cervical or auricular
and posterior cervical regions.
II. Perioral and Intraoral Soft Tissue Examination:The
perioral and intra-oral examination procedure follows a seven-step systematic assessment
of the lips; labial mucosa and sulcus; commissures, buccal mucosa and sulcus,gingiva
and alveolar ridge, tongue, floor of the mouth and hard and soft palate.
Early stage lesions often are asymptometric and may mimic other conditions, whereas
others may not be readily evident in routine examination. Malignent and benign lesions
may not be clinically distinguishable, the dentist cannot predict the biological
relevance of lesions on the basis of physical features alone. The following screening
aids assist dentist with the detection of early cancerous changes or for the assessment
of the biological relevance of mucosal lesion.
1. Toluidine blue stain
Toluidine blue (also known as tolonium chloride) is a vital dye that may stain nucleic
acids and abnormal tissues. It has been used for decades as an aid to the identification
of mucosal abnormalities of the cervix as well as in the oral cavity. It has been
valued by surgeons as a useful way of demarcating the extent of a lesion prior to
excision. Toluidine blue has been used for several decades as a means of identifying
clinically occult lesions in patients whose oral mucosa may otherwise be normal
– that is, as a screening test or adjunct.
- Lips: Observe the lips with the patient's mouth
both closed and open. Note the colour, texture and any surface abnormalities of
the upper and lower vermilion borders.
- Labial Mucosa: With the patient's mouth partially
open, visually examine the labial mucosa and sulcus of the maxillary vestibule and
frenum and the mandibular vestibule. Observe the colour, texture, and any swelling
or other abnormalities of the vestibular mucosa and gingiva.
- Buccal Mucosa: Retract the buccal mucosa. Examine
first the right then the left buccal mucosa extending from the labial commissure
and back to the anterior tonsillar pillar. Note any change in pigmentation, colour,
texture, mobility and other abnormalities of the mucosa, making sure that the commissures
are examined carefully and are not covered by the retractors during the retraction
of the cheek.
- Gingiva: First, examine the buccal and labial
aspects of the gingiva and alveolar ridges (processes) by starting with the right
maxillary posterior gingiva and alveolar ridge and then move around the arch to
the left posterior area. Drop to the left mandibular posterior gingiva and alveolar
ridge and move around the arch to the right posterior area. Second, examine the
palatal and lingual aspects as had been done on the facial side, from right to left
on the palatal (maxilla) and left to right on the lingual (mandible).
- Tongue: With the patient's tongue at rest and
mouth partially open, inspect the dorsum of the tongue for any swelling, ulceration,
coating or variation in size, colour or texture. Also note any change in the pattern
of the papillae covering the surface of the tongue and examine the tip of the tongue.
The patient should then protrude the tongue and the examiner should note any abnormality
of mobility or positioning.
With the aid of mouth mirrors, inspect the right and left lateral margins of the
tongue. Grasping the tip of the tongue with a piece of gauze will assist full protrusion
and will aid examination of the more posterior aspects of the tongue's lateral borders.
Then examine the ventral surface. Palpate the tongue to detect growths.
- Floor: With the tongue still elevated, inspect
the floor of the mouth for changes in colour, texture, swellings or other surface
- Palate: With the mouth wide open and the patient's
head tilted back, gently depress the base of the tongue with a mouth mirror. First
inspect the hard and then the soft palate. Examine all soft palate and oropharyngeal
tissues. Bimanually palpate the floor of the mouth for any abnormalities. All mucosal
or facial tissues that seem to be abnormal should be palpated.
2. Brush biopsy
The Brush Biopsy (CDx Laboratories, Suffren, NY) was introduced as a potential oral
cancer case-finding device in 1999. It was designed for clinical lesions that would
otherwise not be subjected to biopsy because the level of suspicion for carcinoma,
based upon clinical features, was low. When an abnormal result is reported (atypical
or positive), the clinician must follow-up with a scalpel biopsy of the lesion,
as the use of brush cytology does not provide a definitive diagnosis.
3. Exfoliative cytology
A procedure to collect cells from the lip or oral cavity. A piece of cotton, a brush
or a small wooden stick is used to gently scrape cells from the lips, tongue, mouth
or throat. The cells are viewed under a microscope to find out if they are abnormal.
4. Chemiluminescence (reflective tissue fluorescence)
Chemiluminescence has been used for many years as an adjunct in the examination
of the cervical mucosa for “acetowhite” premalignant and malignant lesions. Recently,
this technology has been adapted for use in the oral cavity and is currently marketed
under the names ViziLite Plus and MicroLux DL. These products are intended to enhance
the identification of oral mucosal abnormalities. With both systems, the patient
must first rinse with a 1 percent acetic acid solution followed by direct visual
examination of the oral cavity using a blue-white light source. ViziLite Plus uses
a disposable chemiluminescent light packet, while the MicroLux unit offers a reusable,
battery- powered light source. The 1 percent acetic acid wash is used to help remove
surface debris and may increase the visibility of epithelial cell nuclei, possibly
as a result of mild cellular dehydration. Under blue-white illumination, normal
epithelium appears lightly bluish while abnormal epithelium appears distinctly white
(acetowhite). ViziLite Plus also provides a tolonium chloride solution (TBlue),
which is intended to aid in the marking of an acetowhite lesion for subsequent biopsy
once the light source is removed.
The Velcope is a portable device that allows for direct visualization of the oral
cavity and is being marketed for use in oral cancer screening. Under intense blue
excitation light (400 to 460 nm) provided by the unit, normal oral mucosa emits
a pale green autofluorescence when viewed through the selective (narrow- band) filter
incorporated within the instrument handpiece. Proper filtration is critical, as
the intensity of the reflected blue-white light makes it otherwise impossible to
visualize the narrow autofluorescent signal. In contrast, abnormal or suspicious
tissue exhibits decreased levels of normal autofluorescence and appears dark by
comparison to the surrounding healthy tissue.
Early-stage oral cancer can be cured, but most oral cancers generally spread to
lymph nodes or other areas by the time they are found.
- The topical application of toluidine blue to a suspicious area helps identify the
presence of dysplastic or carcinomatous lesions. But to verify the premalignant
status of an oral lesion a biopsy is required.
- It may be that toluidine blue selectively stains for acidic tissue components and
thus binds more readily to DNA, which is increased in neoplastic cells.
- Toluidine blue has been recommended for use as a mouthwash or for direct application
on suspicious lesions; its value comes from its simplicity, low cost, noninvasiveness
- Clinicians can use toluidine blue to help select an appropriate biopsy site within
a large lesion or monitor high-risk patients who have been previously diagnosed
with a premalignant or malignant lesion.
- Toluidine blue is an adjunct to biopsy, not a replacement for it.