Introduction to Soft Tissue Diseases

Introduction to Soft Tissue Diseases

• The module is about Oral & Dental Sciences
• The lecturer is Mariya Mahmood
• The location is Eastman Dental Hospital LSBU Education Centre

GDC Learning Outcomes

• Describe oral diseases and their relevance to prevention, diagnosis and treatment
• Explain the aetiology and pathogenesis of oral disease
• Recognise the importance of and carry out an appropriate systematic intra- and extra-oral clinical examination
• Recognise the importance of and record a comprehensive and contemporaneous patient history
• Recognise abnormalities of the oral cavity and the rest of the patient and raise concerns where appropriate
• Recognise the need for and make arrangements for appropriate follow-up care

SPF Learning Outcomes

• Clinical knowledge and skills: C1.1, C1.2, C1.17, C1.25, C1.31, C1.38, C2.1.1, C2.1.11
• Interpersonal skills: I(B)1, I 1.6
• Self-management: S(B)2

Intended Learning Outcomes

• Outline the significance of a soft tissue examination and linked history taking in identifying signs of disease
• Describe influencing factors that may exacerbate soft tissue conditions
• Demonstrate accurate history taking and recording of soft tissues conditions
• Identify the first considerations of supporting/managing and treating patients with soft tissue conditions
• Reflect on experience of learning

Scope of a DH/DT

• What is your remit?
• What manifests in the mouth?
• What is your level of responsibility?

Examining Soft Tissues and Their Diseases

• What is the purpose of intra oral and extra oral examination?
• Preparation for Year 2 Oral Medicine – conditions explained in more depth

What are the Soft Tissues?

• When does the examination begin?
• Who holds responsibility?

Benefits of Early Detection

• Preventable
• Easily treated
• Slow down progression
• Fatality prevented
• Early identification improves prognosis

Factors Hindering Screening

• Awkward conversations
• Self-doubt
• Assumption of providing diagnosis
• Competency
• Assumption another will identify

Most common conditions

• Cancer
• Lichen Planus
• Pemphigoid
• Candida
• Pemphigus
• Leukoplakia
• Ulcers
• Herpes

Common Conditions Continued

• Oral Cancer: Cancerous lesions of 3 distinct sites: oral cavity (mouth), oropharynx (throat), and lip (outer)
• Lichen planus: Chronic, cell-mediated inflammatory disease affecting the oral mucosa, <3% turns cancerous
• Ulcers: Loss or erosion of the delicate mucous membrane, repeat ulcers are manifestation of other disease

Individual Disease Susceptibility

• Predisposed to developing a certain disease
• Individual's disease susceptibility is influenced by a combination of genetic and environmental factors
• Host Factors
• Acquired Immune Response
• Environmental Influences

Influencing Factors With Soft Tissue Diseases

• The host response is crucial in onset and influenced by:
  • Immunocompromised (e.g., Lupus, HIV, Diabetes)
  • Stress
  • Tiredness
  • Nutritional deficiency (e.g., vitamin D risk factor for oral cancer)
• These issues impact how the patient responds to pathology, affecting the onset, duration, and outcome of the disease.

Exacerbating factors related to soft tissue disease

• Alcohol
• Smoking
• Betal nut
• Vaping
• Human papillomavirus (HPV 16)
• Nutritional deficiency
• Spicy food
• Poor oral hygiene

How would you describe the oral environment?

• Plaque exacerbates most oral conditions

Dental Diversity

• Physiological/racial pigmentation of gingivae
• Soft tissue size
• Differing anatomy
• Gingival biotypes

Is self-screening important?

• Yes, self-screening is valuable.

Screening for oral cancer

• Follow the steps as pictured.
• Examine yourself monthly using a mirror, a good light source, and clean fingers to find anything unusual (especially any lumps, red or white patches, changes in colour/texture or lingering ulcers.)
• If concerned, contact a dentist or doctor immediately.

Clinician considerations for soft tissue diseases

• Clear and accurate record keeping
• Clinical photos
• History taking
• Referral to Oral Medicine Specialist to confirm diagnosis
• Maintaining optimum health for the whole mouth
• Dietary/lifestyle advice
• Specific and tailored oral hygiene advice
• Specific adjunct requirements if needed

Descriptive Language

• Size measured in millimeters (e.g., 7mm x 5mm)
• Location (e.g., Dorsal tongue, adjacent)
• Raised/Elevated lesion
• Blister/Vesicle/Bulla
• Crusty edges
• Borders (poorly/well defined)
• Shallow/Deep crater
• Red/white halo
• Colour (e.g., white/red/speckled)
• Painful/Not painful

Communicating with the patient

• Avoid "C" word
• Remain calm and composed
• Avoid subjectivity in response
• Inform patients about urgent referral to ensure appropriate care pathway
• Remind patients that you haven't diagnosed them
• Emphasize your lack of training to counsel or deliver cancer diagnoses

Suspected Pathway

• Urgent suspected cancer (USC) referral forms (previously known as "Two Week Wait")
• NHS fast-track two week referral policy
• Can a DH/DT refer?

Activity - How would you describe this?

• Describe the clinical presentation of the lesion
• What questions would you ask the patient for a history?
• Are you concerned? Why or why not?

Holistic Approach

• Identify abnormality
• Consider relevant histories
• Communication and documentation
• Predisposing/Host factors
• Referral/Support/Maintenance

Case Study Examples

• Condition
• Definition
• Photograph
• Descriptors
• Patient Management

Cancer

• A malignancy
• Most common type: Squamous Cell Carcinoma
• Classic descriptors:
  • Most common location: Floor of mouth/lateral side of tongue
  • Ragged ulcer slow to heal
  • Raised poorly defined borders
  • Classically not painful
  • Malodor/Halitosis
  • Stiffness of the tongue
  • Lymphadenopathy
  • Change in colour

Management (Cancer)

• Urgent Suspected Cancer (USC) referral forms
• Depending on diagnosis, impact on patient care differs
• DH/DT involvement: Pre/post surgery to ensure optimal dental health prior
• Oral health advice
• Debridement
• Dietary advice
• Adjunct suggestions as needed

Lichen Planus

• Classic descriptors:
  • Painless white lines (striae)
  • Red painful erosions/ulcers on attached gingivae
  • Mucosa loss, desquamative gingivitis
  • Purple, raised skin lesions, sometimes itchy

Management (Lichen Planus)

• Regular supportive periodontal therapy
• Dietary support
• Guidance on mouthwash/toothpaste adjuncts as needed
• Possible medications prescribed by oral medicine specialists (e.g., Betamethasone)
• Malignant transformation possible, approximately 1%

Importance of Thorough Examination

• Describe soft tissues in image B
• Compare to soft tissues in image C
• How could this be missed?

Activity - Soft Tissue Lesions

• Select a condition
• Describe its appearance
• Management
• Presentation

Reflect

• 3 things learnt
• 3 things known
• 3 things would like to know