Descriptive Terminology PDF

Descriptive Terminology HYGN 2300 | Oral Pathology | Kaleigh Warden RDH, BA(IS), MAIS © KWarden All images from Microsoft ClipArt unless other...

Descriptive Terminology HYGN 2300 | Oral Pathology | Kaleigh Warden RDH, BA(IS), MAIS © KWarden All images from Microsoft ClipArt unless otherwise indicated  Session Objectives: Following participation in this session, students will be able to: 1. Understand the purpose of using descriptive terminology in DH care 2. List the components included in communicating descriptively 3. Define the commonly descriptive terminology used when describing a lesion or condition 4. Demonstrate the use of descriptive terminology when describing a lesion or condition Pre-Reading: Chapter 16 Darby & Walsh (6th ed), 2024. Unless otherwise indicated, all content from Pieren, Jennifer, and Cynthia C. Amyot. Darby & Walsh Dental Hygiene. Available from: VitalSource Bookshelf, (6th Edition). Elsevier - Evolve, 2024. Descriptive Terminology 3 important steps when assessing an IO finding Look Visual assessment Listen Patient report Feel Palpation Visual Assessment Visual Assessment – NUMBER & LOCATION A B Number: is there a single lesion or multiple lesions? Anatomic location: how would you describe the anatomic location of Image A? Anatomic Location Good Lower lip Better Lower lip, right of midline Best Lower lip, right of midline, opposite teeth #32-#43 Visual Assessment – COLOUR white red blue grey yellow brown mucosal-colored combinations e.g. white with a red halo e.g. bluish grey shade/additional descriptors: e.g. dark red, firey red, salmon pink, coral pink Visual Assessment – COLOUR Erythema Abnormal redness of the mucosa or gingiva Pallor Paleness of skin or mucosal tissue http://depts.washington.edu/hivaids/images/oral/oral_c1_d03.png http://ipj.quintessenz.de/ipj/content/2010-02/poster484/abb4.jpg Visual Assessment – SIZE Always measure to ensure accurate information Ideally, include measuring tool in at least one image  Visual Assessment – SHAPE: 1. Irregular 2. Common geometric shapes round ovoid rhomboid  Visual Assessment – SURFACE TEXTURE Term: Brief Description: Corrugated wrinkled Fissured a cleft or groove showing prominent depth Papillary small projections or elevations often found in clusters Smooth loss of texture Rough loss of smoothness Verrucous exhibiting a rough, warty surface Folded overlapping of tissue Velvety softly brushed Localized contained in one area Diffuse spread out Visual Assessment – CONSISTENCY Detected through palpation Soft Firm Semi-firm Fluid-filled Hard  Visual Assessment – BORDERS Tend to be most difficult to distinguish Important to distinguish where the lesion begins & ends Define what is lesion & what is normal mucosa Well-defined / ill-defined Images: Dr. Catalena Birek  Visual Assessment – BORDERS Regular / Irregular Images: Dr. Catalena Birek  Visual Assessment – BORDERS Elevated (rolled) / Flat Images: Dr. Catalena Birek  Visual Assessment – BORDERS What kind of borders do these lesions have? Well defined or ill defined? Regular or irregular? Images: Dr. Catalena Birek Elevated (rolled) or flat?  Descriptive Terminology Remember the normal oral mucosa….. Stratified squamous epithelium Connective tissue  Descriptive Terminology Clinically visible lesions either develop on the surface or below the surface & push upward Lesion of epithelial Lesion of connective origin tissue origin Descriptive Terminology Example of a surface epithelial lesion  Descriptive Terminology Example of a lesion that developed below the epithelium & pushed up Usually arising from the underlying tissue with normal overlying epithelium  Exophytic Lesions Exophytic: Growing outward & protruding from the surface How many measurements/dimensions does an exophytic lesion have?  Exophytic Lesions 1. Pedunculated lesion is above the level of the surrounding normal tissue and is growing on a stalk  Exophytic Lesions 2. Sessile The base is the widest part of the lesion There is no stalk  Exophytic Lesions 3. Plaque a localized abnormal patch on a body part or surface (especially common on the skin) You already know one kind of plaque….  Exophytic Lesions Papules & nodules are also exophytic A papule is an elevated solid lesion usually < 1cm A nodule is an elevated solid lesion usually > 1 cm Both usually arise from the underlying tissue with normal overlying epithelium  Endophytic Lesions Endophytic lesion: lesion is below the level of the surrounding normal tissue How many measurements/dimensions does an endophytic lesion have?  Endophytic Lesions 1. Erosion Denudation (wearing away) of epithelium above basal cell layer Shallow, not crater-like  Endophytic Lesions 2. Ulcer Complete loss of epithelium (beyond the basal cell layer) causing a crater-like depression you are actually seeing the underlying connective tissue Applies to any epithelial surface either inside or on the surface of the body  Endophytic Lesions Ulcers are very common in the oral cavity Ulcerative craters fill with yellow debris containing desquamated epithelial & inflammatory cells Since there is no epithelial covering for protection, ulcers tend to be very painful  Other Special Terminology Reticular A pattern of intersecting lines (“net-like”)  Other Special Terminology Macule Circumscribed area with different color but same texture as the surrounding tissue No elevation or depression but level with surrounding tissue  Other Special Terminology Scar Permanent mark or cicatrix (scar from the formation & contraction of fibrous tissue in a flesh wound) remaining after wound healing Typically lighter in color than surrounding soft tissue  Other Special Terminology Fissure A linear crack or cleft in tissue Traps bacteria & debris  Other Special Terminology Vesicle An elevated, fluid-filled, circumscribed lesion Fluid has escaped into the surrounding tissue so there is no epithelial lining < 1cm If pus filled, referred to as a pustule  Other Special Terminology Bulla A large vesicle (>5mm) Fluid can be any liquid ▪ mucin, blood or edematous fluid  Other Special Terminology Unilocular – radiolucent lesion having a single compartment Multilocular – radiolucent lesion having several compartments Image: https://www.researchgate.net/figure/OPG-of-the-female-patient-showing-multilocular-radiolucent-lesion-root-resorption-of-46_fig9_236655047 Now let’s give it a try… Your Task is to: 8 minutes In groups of 4, review your lesion Based on today’s session & your pre-existing knowledge of documentation, work together to determine how you would document this lesion in your patient’s EHR NOTE: Since no rulers/probes present in the photos, your measurements will be estimations based on your knowledge of the surrounding anatomical structures Please assign a note-taker & group presenter Be ready to present your response to the class Group Number: Case: Group #1 Case A Group #2 Case B Group #3 Case C Group #4 Case D Group #5 Case E Group #6 Case F Case A  Case B Image/Case Contributor: ESTOP; Dr. Angela Chi, Med. Univ. S. Carolina Case C  Case D Image/Case Contributor: ESTOP; Dr. Kristin McNamara Case E Case F You’ve identified an IO lesion, now what? Informing the Patient: Now that we have accurately documented the physical appearance of the lesion, we must inform the patient & continue our information gathering process. It’s time to ask questions to learn more about the lesion Key Information Symptoms Onset/duration of lesion Potential etiologic factors Previous treatment for lesion, if any IO Assessment: I am noticing something on the (insert location). Show patient in the mirror. Have you noticed it before? If yes, when did you first notice it? Look back in EHR to see if it has been documented previously. If it has been documented, compare your findings with those of the previous provider(s) Is it bothering you or causing you any discomfort? Pain/symptomatic Have you taken anything to manage the pain? Does anything make it feel better? Does anything make it feel worse? Do you have any idea what might be causing the lesion? IO Assessment Depending on lesion presentation, consider the following additional probing questions: Have you started any new medications recently? Have you started using a new toothpaste/mouthrinse lately? Can you recall injuring this area lately? Do you wear a nightguard or any other oral appliance? Do you have any oral habits (e.g. nail biting, cheek chewing, clenching, etc.) that might be contributing to this lesion? Do you have any other symptoms, such as fever, fatigue, or swollen lymph nodes? Do you frequently consume acidic, spicy, or hot foods that might irritate the area? Do you have habits like smoking, vaping, or chewing tobacco? We do not watch lesions that we do not have a diagnosis or a known etiology for If we are concerned about a lesion, or if it does not resolve within 2 weeks, we must refer.  Recap – Descriptive Terminology Discussed the purpose of using descriptive terminology in DH care Reviewed the components included in communicating descriptively Practiced using descriptive terminology when describing a lesion and/or condition  Next Class: Wednesday, January 15th at 11:00 – 11:50am Topic: Developing a Differential Diagnosis Pre-Reading: Chapter 16 in Darby & Walsh (6th edition), 2024. This Photo by Unknown Author is licensed under CC BY-NC-ND