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Burket’s ORAL MEDICINE Eleventh Edition Burket’s ORAL MEDICINE Eleventh Edition Martin S. Greenberg, DDS, FDS RCS Professor and Chairman Oral Medicine Associate Dean Hospital Affairs School of Dental Medicine University of Pennsylvania Chief of Oral Medicine University of Pennsylvania Medical Center Philadelphia, Pennsylvania Michael Glick, DMD, FDS RCS Professor of Oral Medicine Arizona School of Dentistry & Oral Health Associate Dean for Oral-Medical Sciences College of Osteopathic Medicine-Mesa A.T. Still University Mesa, Arizona Jonathan A. Ship, DMD, FDS RCS Professor, Department of Oral & Maxillofacial Pathology, Radiology, and Medicine Director, Bluestone Center for Clinical Research New York University College of Dentistry Professor, Department of Medicine New York University School of Medicine 2008 BC Decker Inc Hamilton iv Contents BC Decker Inc P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com © 2008 BC Decker Inc All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. 08 09 10/BCD/9 8 7 6 5 4 3 2 1 ISBN 978-1-55009-345-2 Printed in India Production Editor: Petrice Custance; Typesetter: Charlesworth; Cover Designer: Alex Wheldon Sales and Distribution United States BC Decker Inc P.O. Box 785 Lewiston, NY 14092-0785 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com Canada BC Decker Inc 50 King St. E. P.O. 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Avenida Maurílio Biagi, 2850 City Ribeirão, Ribeirão Preto — SP — Brasil CEP: 14021-000 Tel: 0800 992236 Fax: (16) 3993-9000 E-mail: [email protected] India, Bangladesh, Pakistan, Sri Lanka Elsevier Health Sciences Division Customer Service Department 17A/1, Main Ring Road Lajpat Nagar IV New Delhi – 110024, India Tel: 91 11 2644 7160-64 Fax: 91 11 2644 7156 E-mail: [email protected] Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment. Contents ▼ Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 1. Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient Michael Glick, DMD, FDS RCS, Martin S. Greenberg, DDS, FDS RCS, Jonathan A. Ship, DMD, FDS RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Pharmacology Jonathan A. Ship, DMD, FDS RCS, Michael T. Brennan, DDS, MHS, Martin S. Greenberg, DDS, FDS RCS, Peter B. Lockhart, DDS, FDS RCS, Spencer W. Redding, DDS, MEd, Vidya Sankar, DMD, MHS, David Sirois, DMD, PhD, David Wray, BDS, MD, FDS RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3. Ulcerative, Vesicular, and Bullous Lesions Sook Bin Woo, DMD, MMSc, Martin S. Greenberg, DDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 4. Red and White Lesions of the Oral Mucosa Mats Jontell, DDS, PhD, FDS RCS, Palle Holmstrup, DDS, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 5. Pigmented lesions of the oral mucosa Faizan Alawi, DDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 6. Benign Lesions of the Oral Cavity A. Ross Kerr DDS, MSD, Joan A. Phelan, DDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 7. Oral Cancer Joel Epstein, DMD, MSD, FRCD (C), Isaäc Van Der Waal, DDS, PhD . . . . . . . . . . . . . . . . . . . . . . . . . 153 8. Salivary Gland Diseases Philip C. Fox, DDS, FDS RCS, Jonathan A. Ship, DMD, FDS, RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 9. Temporomandibular Disorders Bruce Blasberg, DMD, FRCD(C), Martin S. Greenberg, DDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 10. Orofacial Pain Bruce Blasberg, DMD, FRCD(C), Eli Eliav, DMD, PhD, Martin S. Greenberg, DDS, FDS RCS . . . . . 257 11. Headache Scott S. DeRossi, DMD, John A. Detre, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 12. Diseases of the Respiratory Tract Sandhya Desai, MD, Frank A. Scannapieco, DMD, PhD , Mark Lepore, MD, Robert Anolik, MD, Michael Glick, DMD, FDS RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 vi 13. Contents Diseases of the Cardiovascular System Peter B. Lockhart, DDS, FDS RCS, Laszlo Littmann, MD, Michael Glick, DMD, FDS RCS . . . . . . . . 323 Diseases of the Gastrointestinal Tract Michael A. Siegel, DDS, MS, FDS RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 15. Renal Disease Scott S. Derossi, DMD, Debbie L. Cohen, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 16. Hematologic Diseases Lauren L. Patton, DDS, FDS RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 17. Bleeding and Clotting Disorders Lauren L. Patton, DDS, FDS RCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 18. Immunologic Diseases Jane C. Atkinson, DDS, Matin M. Imanguli, DDS, Stephen Challacombe PhD, FDS RCS, FRCPath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435 19. Transplantation Medicine Thomas P. Sollecito, DMD, Andres Pinto, DMD, MPH, Ali Naji, MD, PhD, David Porter, MD . . . . 461 20. Infectious Diseases Lakshman Samaranayake, Hon DSc, Hon FDS RCS, DDS(Glas), BDS, FRCPath, FHKCPath, MIBiol, FCDSHK, FHKAM(Path), FHKAM(DSurg), Michaell A. Huber, DDS, Spencer W. Redding, DDS, MEd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481 14. 21. Diabetes Mellitus and Endocrine Diseases Sunday O. Akintoye, BDS, DDS, MS, Michael T. Collins, MD, Jonathan A. Ship, DMD, FDS RCS . 509 22. Neuromuscular Diseases Eric T. Stoopler, DMD, David A. Sirois, DMD, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537 23. Basic Principles of Human Genetics: A Primer for Oral Medicine Harold C. Slavkin, DDS, Mahvash Navazesh, DMD, Pragna Patel, PhD . . . . . . . . . . . . . . . . . . . . . . . . 549 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569 vii Contents ▼ Preface The first edition of this pioneering text titled Oral Medicine: Diagnosis and Treatment, was published in 1946 just after World War II. The text was written entirely by one man, Dr. Lester W. Burket, with the exception of a small section on “Oral Aspects of Aviation Medicine” written by a major in the Dental Corps, Dr. Alvin Goldhush. In this preface, Dr. Burket wrote that “Oral Medicine discusses the many important relationships between oral and systemic disease and it suggests opportunities for a more universal and intimate cooperation between medical and dental practitioners in giving the best possible health service to our common patients.” We believe that the 11th edition of this text follows the example set by Dr. Burket and provides the clinician with an up-to-date description of all major aspects of the science and practice of modern Oral Medicine, with the goal to enable the clinician to provide the best health service to their patients. During the past decade, the field of Oral Medicine has expanded in both scope and complexity and it is no longer possible for one author or even one editor to have the expertise to write or oversee a majority of a book such as Burket’s Oral Medicine. In order to accommodate the new knowledge, a third editor, Dr. Jonathan Ship, was added and four entirely new chapters and 27 new authors of international prominence and expertise were invited to coauthor chapters. The first chapter of this text presents a basic but also an innovative approach to the evaluation and assessment of patients. It provides the necessary tools to properly evaluate and treat patients with acute and chronic health conditions, which is imperative when considering our aging and more medically complex population Several chapters have been entirely rewritten by new authors including the chapters on Red and White Lesions, Pigmented Lesions, Neuromuscular Diseases, Renal Disease, Hematologic Disease, and Immunology. For the first time in Burket’s Oral Medicine, a comprehensive guide to the use of pharmacotherapeutics is available. This chapter provides the entire scope of medical management of major disorders in Oral Medicine for practicing clinicians with detailed information on prescribing drugs in accompanying tables. The chapters on Ulcerative, Vesicular and Bullous lesions as well as the chapters on Benign Tumors and Oral Cancer have been extensively rewritten with the addition of a new group of color photos and a more clinician-friendly format for the evaluation, diagnosis, and treatment of these common oral diseases. An increasingly important discipline in Oral Medicine is the diagnosis and management pain syndromes, and this portion of the text has been enhanced with the addition of a chapter devoted to Headache. There is also a major revision of advances in Orofacial Pain syndromes and Temporomandibular disorders. The chapter on Salivary Diseases has also been revised and provides a state-ofthe-art overview of this growing field. Details are provided on clinical presentation, diagnosis including imaging using new multimodal techniques, and treatment. A new section has been added on siallorhea and its pharmacological and surgical treatment options. viii viii Preface Contents The medical chapters of this new text have been updated to reflect recent advances and how these changes alter guidelines and recommendations for safe effective dental care. One major rationale for rewriting these chapters was to add more focus on the provision of dental care for patients with complex medical conditions. We have combined all of the information on endocrine diseases including diabetes mellitus into one comprehensive chapter that provides the reader with an updated, review of the major endocrinological diseases, their treatment, and head/ neck/intraoral manifestations. A new chapter is dedicated to Genetic Diseases. Increasingly our understanding of disease is enhanced by genetic sciences, and this chapter details the craniofacial genetic diseases of interest to the Oral Medicine and dental practitioner. The illustrations have been redone and are all in color. The vast majority of references are also updated. The accompanying CD contains supplementary material including the complete bibliography and an expanded section on Principles of Diagnosis. This text reflects the expertise, experience and hard work of clinical scholars from many institutions, countries and specialties. We believe the eleventh edition of this classic text provides the student, resident as well as the experienced practitioner the information required to master the complex field of diagnosis and medical management of maxillofacial diseases as well as provide dental treatment for patients with complex medical disorders. Martin S. Greenberg, DDS, FDS RCS Michael Glick, DMD, FDS RCS Jonathan A. Ship DMD, FDS RCS July 2007 ix Contents ▼ Contributors Sunday O. Akintoye, BDS, DDS, MS Department of Oral Medicine University of Pennsylvania Philadelphia, Pennsylvania Michael T. Collins, MD Department of Craniofacial and Skeletal Diseases National Institutes of Health Bethesda, Maryland Faizan Alawi, DDS Department of Pathology University of Pennsylvania Philadelphia, Pennsylvania Scott S. DeRossi, DMD Department of Oral Diagnosis Medical College of Georgia Augusta, Georgia Robert Anolik, MD Allergy and Asthma Specialists Blue Bell, Pennsylvania Sandhya Desai, MD Allergy and Asthma Specialists Blue Bell, Pennsylvania Jane C. Atkinson, DDS Center for Clinical Research National Institute of Dental and Craniofacial Research Bethesda, Maryland John A. Detre, MD Center for Functional Imaging University of Pennsylvania Philadelphia, Pennsylvania Bruce Blasberg, DMD, FRCD(C) Department of Oral Medicine and Biological Sciences University of British Columbia Vancouver, Canada Eli Eliav, DMD, PhD Department of Diagnostic Sciences New Jersey Dental School Newark, New Jersey Michael T. Brennan, DDS, MHS Department of Oral Medicine Carolinas Medical Center Charlotte, North Carolina Joel Epstein, DMD, MSD Interdisciplinary Program in Oral Cancer Chicago Cancer Center Chicago, Illinois Stephen Challacombe, PhD, FDS RCS, FRCPath Department of Oral Medicine Kings College Dental Institute London, England Philip C. Fox, DDS, FDS RCS Department of Oral Medicine Carolinas Medical Center Charlotte, North Carolina Debbie L. Cohen, MD Department of Medicine University of Pennsylvania Philadelphia, Pennsylvania Michael Glick, DMD, FDS RCS Department of Oral Medicine Arizona School of Dentistry A.T. Still University Mesa, Arizona Martin S. Greenberg, DDS, FDS RCS Department of Oral Medicine University of Pennsylvania Philadelphia, Pennsylvania Palle Holmstrup, DDS, PhD Department of Periodontology Copenhagen University Copenhagen, Denmark Michaell A. Huber, DDS Department of Dental Diagnostic Science University of Texas San Antonio, Texas Matin M. Imanguli, DDS Center for Clinical Research National Institute of Dental and Craniofacial Research Bethesda, Maryland Mats Jontell, DDS, PhD, FDS RCS Clinic of Oral Medicine Göteborg University Göteborg, Sweden A. Ross Kerr, DDS, MSD Department of Oral & Maxillofacial Pathology, Radiology and Medicine New York University New York, New York Contributors Contents Peter B. Lockhart, DDS, FDS RCS Department of Oral Medicine Carolinas Medical Center Charlotte, North Carolina Ali Naji, MD, PhD Department of Surgery University of Pennsylvania Philadelphia, Pennsylvania Mahvash Navazesh, DMD Department of Diagnostic Sciences University of Southern California Los Angeles, California Pragna Patel, PhD Department of Biochemistry and Molecular Biology University of Southern California Los Angeles, California Lauren L. Patton, DDS, FDS RCS Department of Dental Ecology University of North Carolina Chapel Hill, North Carolina Joan A. Phelan, DDS Department of Oral & Maxillofacial Pathology, Radiology and Medicine New York University New York, New York Andres Pinto, DMD, MPH Department of Oral Medicine University of Pennsylvania Philadelphia, Pennsylvania Mark LePore, MD Allergy and Asthma Specialists Blue Bell, Pennsylvania David L. Porter, MD Department of Medicine University of Pennsylvania Philadelphia, Pennsylvania Laszlo Littmann, MD Department of Internal Medicine Carolinas Medical Center Charlotte, North Carolina Spencer W. Redding, DDS, MEd Department of Dental Diagnostic Science University of Texas San Antonio, Texas xi Contributors Contents Vidya Sankar, DMD, MHS Department of Dental Diagnostic Science University of Texas San Antonio, Texas Harold C. Slavkin, DDS Department of Health Promotion and Epidemiology University of southern California Los Angeles, California Lakshman Samaranayake, DSc, FDS RCS, DDS Department of Oral Biosciences University of Hong Kong Hong Kong, China Thomas P. Sollecito, DMD Department of Oral Medicine University of Pennsylvania Philadelphia, Pennsylvania Frank A. Scannapieco, DMD, PhD Department of Oral Biology University at Buffalo Buffalo, New York Eric T. Stoopler, DMD Department of Oral Medicine University of Pennsylvania Philadelphia, Pennsylvania Jonathan A. Ship, DMD, FDS RCS Department of Oral & Maxillofacial Pathology, Radiology, and Medicine Department of Medicine Bluestone Center for Clinical Research New York University New York, New York Isaac Van der Waal, DDS, PhD Department of Oral & Maxillofacial Surgery VU Medical Center Amsterdam, the Netherlands Michael A. Siegel, DDS, MS, FDS RCS Department of Diagnostic Sciences Nova Southeastern University Fort Lauderdale, Florida David A. Sirois, DMD, PhD Department of Oral & Maxillofacial Pathology, Radiology, and Medicine Department of Neurology New York University New York, New York Sook Bin Woo, DMD, MMSc Department of Dental Services Brigham and Women’s Hospital Boston, Massachusetts David Wray, BDS, MD, FDS RCS Department of Oral Medicine Glasgow University Glasgow, Scotland xiii Contents This book is dedicated With love to my wife Patti, granddaughters Rachel, Hannah, Jade and Peytan and in memory of my mother Pearl. Martin S. Greenberg With love and affection to my wife Patricia and children, Noa, Jonathan and Gideon. Michael Glick With love and gratitude to my wife Shari and children Nina, Zachary and Maxwell. Jonathan A. Ship 1 ▼ Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient Michael Glick, DMD, FDS RCS Martin S. Greenberg, DDS, FDS RCS Jonathan A. Ship, DMD, FDS RCS Over the past several decades, the need for oral health care professionals to understand basic principles of medicine and diagnosis has grown exponentially.1 This is due, in part, to changing characteristics of patients seeking oral health services. The population is aging, and an increasing number of patients seeking oral health services are living with chronic illnesses, are taking multiple medications, and have undergone surgical procedures (eg, cardiac surgery, organ transplantation) that prolong life but have a profound effect on craniofacial health and function, as well as on the provision of dental care. Oral health is an integral part of total health, and oral health care professionals must adapt to demographic changes and medical advances and shoulder the responsibility of being part of the patient’s overall health care team. Oral medicine is a specialty within dentistry that focuses on the diagnosis and management of complex diagnostic and medical disorders affecting the mouth and jaws. Clinicians with advanced training in this discipline manage oral mucosal disease, salivary gland disorders, and facial pain syndromes and also provide dental care for patients with complicating medical disease. However, all general dentists and dental specialists must be more aware of oral medicine and the ▼ Medical History Review of Systems Supplementary Examination Procedures Laboratory Studies Specialized Examination of Other Organ Systems ▼ Examination of the Patient ▼ Establishing the Diagnosis ▼ Medical Referral (Consultation) Procedure ▼ Formulating a Plan of Treatment and Assessing Medical Risk Medical Risk Assessment Modification of Dental Care for Medically Complex Patients Monitoring and Evaluating Underlying Medical Conditions Oral Medicine Consultations The Dental/Medical Record: Organization, Confidentiality, and Informed Consent Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient medical status of their patients in order to provide a high level of oral heath care. Patients consult all oral health care professionals for management of problems related to orofacial structures, and the opportunity and the need to evaluate and assess patients’ overall medical status become part of the responsibility of the dentist. This chapter addresses the rationale and method for gathering relevant medical and dental information, including the examination of the patient, and the use of this information to provide safe and appropriate oral health care. This process is divided into five parts: 1. Obtaining and recording the patient’s medical history 2. Examining the patient 3. Establishing a differential diagnosis 4. Acquiring the additional information required to make a final diagnosis, such as relevant laboratory and imaging studies and consultations from other clinicians 5. Formulating a plan of action, including oral health care modifications and necessary medical referrals ▼ Medical History Obtaining a medical history is an information-gathering method for assessing a patient’s health status that will facilitate the diagnostic process for the patient’s orofacial complaint and substantiate the institution of necessary modi fications for the provision of oral health care. The medical history comprises a systematic review of the patient’s chief or primary complaint, a detailed history related to this complaint, information about past and present medical conditions, pertinent social and family histories, and a review of symptoms by organ system. A medical history also includes biographic and demographic data used to identify the patient. An appropriate interpretation of the information collected through a medical history achieves several important objectives; it affords an opportunity for (1) gathering the information necessary for establishing the diagnosis of the patient’s chief complaint (2) monitoring known medical conditions (3) detecting underlying systemic conditions that the patient may or may not be aware of (4) providing a basis for determining whether dental treatment might affect the systemic health of the patient (5) assessing the influence of the patient’s systemic health on patient’s oral health (6) providing a basis for determining necessary modifications to routine dental care There is no one universally accepted method for gathering the pertinent information that constitutes the medical history; rather, individual approaches are tailored to specific needs. The nature of the patient’s dental visit (ie, initial dental visit, complex diagnostic problem, emergency, elective continuous care, or recall) often dictates how the history is obtained. The different formats include self-administered preprinted forms filled out by the patient, direct interview of the patient by the clinician, or a combination of both. All of these methods have benefits and drawbacks. The use of self-administered screening questionnaires is the most commonly used method in dental settings (Figure 1). This technique can be useful in gathering background medical information, but the accurate diagnosis of a specific oral complaint requires a history of the present illness, which is obtained verbally. The challenge in any health care setting is to use a questionnaire that has enough items to cover the essential information but is not too long to deter a patient’s willingness and ability to fill it out. Preprinted self-administered health questionnaires are readily available, standardized, and easy to administer and do not require significant “chair time.” They give the clinician a starting point for a dialogue to conduct more in-depth medical queries but are restricted to the questions chosen on the form and are therefore limited in scope. The questions on the form can be misunderstood by the patient, resulting in inaccurate information, and they require a specific level of reading comprehension. Preprinted forms cover broad areas without necessarily focusing on particular problems pertinent to an individual patient’s specific medical condition. Therefore, the use of these forms requires that the provider has sufficient background knowledge to understand why the questions on the forms are being asked. Furthermore, the provider needs to realize that a given standard history form necessitates timely and appropriate follow-up questions, especially when positive responses have been elicited. An established routine for performing and recording the history and examination should be followed conscientiously. The oral health care professional has a responsibility to obtain all relevant medical and dental health information, yet the patient cannot be held accountable to know this information and cannot always be relied upon to provide an accurate and comprehensive assessment of his or her medical or dental status. All medical information obtained and recorded in an oral health care setting is considered confidential and constitutes a legal document. Although it is appropriate for the patient to fill out a history form in the waiting room, any discussion of the patient’s responses must take place in a safeguarded setting. Furthermore, access to the written or electronic (if applicable) record must be limited to office personnel who are directly responsible for the patient’s care. Any other release of private information should be approved, in writing, by the patient and retained by the dentist as part of the patient’s medical record. Changes in a patient’s health status or medication regimen should be reviewed at each office visit prior to initiating dental care. This is important as many medical conditions are associated with slow and gradual changes, medication regimens frequently change, and the monitoring of patients’ compliance with medical treatment guidelines and Burket’s Oral Medicine FIGURE 1 Health history questionnaire. medications and possible drug interactions is part of the oral health care professional’s responsibilities.2 Consultations with other health care professionals are initiated when additional information is necessary to assess a patient’s medical status. Evaluations from other specialists may also be required to make an accurate diagnosis of an orofacial complaint. For example, a patient with facial pain may require a consultation from an otolaryngologist to rule out sinus or ear pathology, whereas a patient with oral mucosal disease and skin lesions would benefit from an evaluation by a dermatologist. Any verbal and written consultation should be documented in the patient’s record. A consultation letter should identify the patient and contain a brief overview of the patient’s pertinent medical history and a request for specific medical information (Figure 2). A physician cannot “clear” a patient for treatment. A physician’s advice and recommendation may be helpful in managing a dental patient, but the responsibility to provide safe and appropriate care lies ultimately with the oral health care provider. For an overview of the medical history components, see the attached disc. Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient FIGURE 1 Continued. Review of Systems The review of systems (ROS) is a comprehensive and system atic review of subjective symptoms affecting different bodily systems (Figure 1). The value of performing a ROS together with the physical examination has been well established.3–5 The clinician records both negative and positive responses. Direct questioning of the patient should be aimed at collecting additional data to assess the severity of a patient’s medical conditions, monitor changes in medical conditions, and assist in confirming or ruling out those disease processes that may be associated with patient’s symptoms. The design of the ROS is aimed at categorizing each major system of the body so as to provide the clinician with a framework that incorporates many different anatomic and physiologic expressions reflective of the patient’s medical status. The ROS includes general categories to allow for completeness of the review. Numerous examples can be provided to underscore the importance of the ROS. The ROS may help establish the primary diagnosis by uncovering important symptoms involving other parts of the body. For example, a patient with Burket’s Oral Medicine FIGURE 2 Consultation. facial pain may also have complaints such as paresthesia, anesthesia, or weakness, indicating that the facial pain may be a symptom of a neurologic disorder. In addition, seemingly unrelated systemic disorders that significantly affect a patient’s dental care may be disclosed. The ROS may also allow the dentist to detect an undia gnosed medical disease, which may require modification of dental treatment. For example, the dentist may suspect undiagnosed or poorly controlled congestive heart failure in a patient with orthopnea, a bleeding disorder in a patient with recent severe nose bleeds and easy bruising, or diabetes in a patient with polyuria and polydipsia. Supplementary Examination Procedures With the information obtained from the history and the routine physical examination, a diagnosis can usually be made, or the information can at least provide the clinician with direction for subsequent diagnostic procedures. Additional questioning of the patient or more specialized examination procedures may still be required to confirm a diagnosis or distinguish between several possible diagnoses. Examples of more specialized physical examination procedures are dental pulp vitality testing; detailed evaluation of salivary gland function (see Chapter 8, “Salivary Gland Diseases”); and assessment of occlusion, masticatory muscles, and temporomandibular joint function (see Chapter 9, “Temporomandi bular Disorders”). Radiography of the teeth and jaws, computer-assisted scanning (computed tomography), and magnetic resonance imaging of the temporomandibular joint, salivary glands, and other soft tissue structures of the head and neck can provide visible evidence of suspected physical abnormalities. Furthermore, a variety of laboratory Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient tests (serology, biopsy, blood chemistry, hematologic and microbiologic procedures) can be used to confirm a suspected diagnosis or to identify a systemic abnormality contributing to the patient’s signs and symptoms. Laboratory Studies There are times when an oral health care professional will want to order laboratory tests to help make a diagnosis of an oral disease, rule out an underlying medical problem, or determine if a patient with a specific disease is healthy enough for the proposed dental treatment plan. It is important to realize the limitations of any laboratory test. There are no tests that can detect “health”; rather, labora tory tests are used to discriminate between the presence or absence of disease or are used as a predictor or marker of disease. The frequency with which a test indicates the pre sence of a disease is called sensitivity; specificity is the frequency with which a test indicates the absence of the disease.6,7 A test that identifies a disease every time has a sensitivity of 100%, whereas a test that identifies the absence of disease every time has a specificity of 100%. Consequently, a test with a sensitivity of 98% has a 2% false-negative rate, and a test with a specificity of 98% has a 2% false-positive rate. The significance of choosing a test with a particular sensitivity or specificity usually corresponds with the outcome of the test result. For instance, it is highly desirable to use a human immunodeficiency virus (HIV) test with a high sensitivity to minimize false-negative results because individuals who believe they are HIV negative may continue to transmit the disease and may not seek medical care. However, sensitivity improves at the expense of specificity, and vice versa. Another important aspect of a test is its efficacy, or predictive value. Predictive value is defined as the value of positive results indicating the presence of a disease (positive predictive value) or the value of negative results indicating the absence of a disease (negative predictive value). These predictive values are dependent on the prevalence of the particular condition in the population, as well as on the sensitivity and specificity of the test. Even normal values in tests used to screen asymptomatic populations for disease fall within two standard deviations of the mean. Consequently, a single test will produce an abnormal result 5% of the time. For a “panel” of tests, the percentage of abnormal results increases significantly. Thus, for any decision (or even diagnosis) based on any laboratory test, many different criteria need to be considered. Laboratory studies are an extension of the physical examination; tissue, blood, urine, or other specimens are obtained from the patient and are subjected to microscopic, biochemical, microbiologic, or immunologic examination. A laboratory test alone rarely establishes the nature of an oral lesion, but when interpreted in conjunction with information obtained from the history and the physical examination, the results of laboratory tests will frequently establish or confirm a diagnostic impression. Specimens obtained directly from the oral cavity (eg, scrapings of oral mucosal cells, tissue biopsy specimens, and swabs of exudates), as well as the specimens more commonly submitted to the clinical diagnostic laboratory (eg, blood), may provide information that is of value in the diagnosis of oral lesions, such as herpes virus infection. Lesions of the oral cavity may also be complicated by coexistent systemic disease or may be the direct result of such disease. Many of the laboratory studies needed in dental practice are those that are widely used in medicine. The systemic disease suspected by an oral health care professional may often be of greater significance to the patient’s health than the presenting oral lesion. By investigating a problem of this type, the oral health care professional is, in effect, investigating a medical problem. It has been argued that the patient in whom systemic disease is suspected should be referred to a physician without further tests being ordered by the dentist. This procedure is clearly the correct one under some circumstances, and professional judgment is required. However, in many situations, laboratory studies made by the oral health care professional prior to medical referral are appropriate and may be necessary to identify the nature of the patient’s problem or to assess the severity of an underlying medical condition. Diseases affecting the oral cavity often exhibit features peculiar to this region, and an oral health care professional trained in the management of diseases of the oral cavity may be better equipped to select appropriate laboratory tests and evaluate their results than is a physician with no specific knowledge of the region. A diagnostic problem can be solved by referral only when the patient accepts the referral. If a lesion is minor or if the patient is unwilling to admit that the lesion may be of systemic origin, then she or he may reject the dentist’s advice, delay in following up the referral, or even seek treatment elsewhere. Failure to follow up a referral may sometimes stem from the patient’s belief that the dentist is straying beyond his or her area of competence but is more often the result of anxiety created by the dentist’s suggesting that the patient may have an undiagnosed medical problem. Referral to a physician is possible only when confidence is firmly established between dentist and patient. Patients who seem unwilling to accept referral to a physician often agree to a screening laboratory test carried out through the oral health care professional’s office. When the results of such tests are positive, they strengthen the oral health care professional’s recommendation and often achieve the desired referral. Clinical and laboratory procedures, such as blood pressure measurement, complete blood cell count, blood chemistry screening, throat culture for infections with beta-hemolytic streptococci, and detection of antibodies to hepatitis viruses and HIV, have also been used for epidemio logic purposes in dentistry.8–12 Except in limited situations, however, the cost of standard screening tests such as a complete blood count or plasma glucose determination has discouraged their routine use in oral health care professional offices and clinics, even though the detection of elevated blood pressure has become customary. Burket’s Oral Medicine The results of screening tests of this type—and, in fact, the majority of studies carried out by oral health care professionals for the detection of systemic diseases—do not themselves constitute a diagnosis. For example, an oral health care professional who finds elevated plasma glucose levels (ie, from a glucometer) should not tell the patient that he or she has diabetes but should inform the patient that the results of the test indicate an abnormality and advise the patient to seek medical consultation. Reports of abnormal results with systemic implications should be sent directly to the patient’s physician, and the diagnosis of diabetes, hypertension, or other disease should be made by the physician on the basis of the physical examination, history, and (possibly) further laboratory tests. The management of medical disorders of the mouth and jaws is within the scope of dentists and dental specialists, whereas systemic medical diseases are within the domain of physicians. The dentist should not consider prescribing medication or other treatment for a systemic disease, even though he or she might be required to provide local care for the oral manifestations. The success of all screenings for systemic disease, whether carried out by public health authorities or by oral health care professionals, depends on the availability of physicians who are willing to accept such referrals. When ordering or carrying out a laboratory test for the detection of a systemic disease, always consider what can practically be done with the results of the test. Laboratory testing without follow-up is not only futile but can lead to serious anxiety in the patient. reader is advised to consult texts that describe the physical examination of these organs13 and to obtain training in the use of the headlamp, the otoscope, and the ophthalmoscope, as well as in techniques such as indirect laryngoscopy and the inspection of the nasal cavity. Knowledge of disease processes that affect these organ systems is desirable. The oral health care professional’s initial evaluations of extraoral tissues neither infringe on the rights of other medical specialists nor reduce their professional activities. These evaluations can contribute significantly to the collaboration of dentist and physician in the management of many craniofacial and oral problems. More important, information gathered during these examinations will provide invaluable diagnostic information that is necessary to ensure a proper referral to a medical specialist. Provided that the patient’s permission is obtained before these nonsurgical procedures are carried out, there appears to be no legal restriction to the examination of these extraoral organ systems by the dentist. However, this may vary according to local laws and regulations, which should be consulted before initiating procedures that are perceived as outside the realm of dentistry. For example, the dentist may be prohibited by law from specifically diagnosing and treating problems outside the maxillo facial region. In all cases in which there is any concern about the presence of disease in any of these organ systems, referral and treatment for the patient must be sought from the appropriate medical service. Specialized Examination of Other Organ Systems ▼ Examination of the Patient The compact anatomy of the head and neck and the close relationship between oral function and the contiguous nasal, otic, laryngopharyngeal, gastrointestinal, and ocular structures often require that evaluation of an oral problem be combined with evaluation of one or more of these related organ systems. For detailed evaluation of these extraoral systems, the oral health care professional should request that the patient consult the appropriate medical specialist, who must be informed of the reason for the consultation. The usefulness of this consultation will usually depend on the dentist’s knowledge of the interaction of the oral cavity with adjacent organ systems, as well as the dentist’s ability to recognize symptoms and signs of disease in the extraoral regions of the head and neck. Superficial inspection of these extraoral tissues is therefore a logical part of the dentist’s examination for the causes of certain oral problems. Disorders of the temporomandibular joint, referred pain, oropharyngeal and skin cancer screening, dysgeusia, salivary gland disease, postsurgical oropharyngeal and oronasal defects, and various congenital syndromes affecting the head and neck are all conditions that are frequently brought to the attention of oral health care professionals and that require them to look beyond the oral cavity when examining the head and neck. The details of special examinations of the ears, nose, eyes, pharynx, larynx, and facial musculature and integument are beyond the scope of this chapter, and the The examination of the patient represents the second stage of the evaluation and assessment process. An established routine for the examination is mandatory. A thorough and systematic inspection of the oral cavity and adnexal tissues minimizes the possibility of overlooking previously undiscovered pathologies. The examination is most conveniently carried out with the patient seated in a dental chair, with the head supported. When dental charting is involved, having an assistant record the findings saves time and limits crosscontamination of the chart and pen. Before seating the patient, the clinician should pay attention to the patient’s general appearance and gait and should note any physical deformities or handicaps. The routine oral examination should be carried out at least once annually or at each recall visit. This includes a thorough inspection and, when appropriate, palpation, auscultation, and percussion of the exposed surface structures of the head, neck, and face and a detailed examination of the oral cavity, dentition, oropharynx, and adnexal structures. Laboratory studies and additional special examination of other organ systems may be required for the evaluation of patients with orofacial pain, oral mucosal disease, or signs and symptoms suggestive of otorhinologic or salivary gland disorders or pathologies suggestive of a systemic etiology. A less comprehensive but equally thorough inspection of the face and oral and oropharyngeal mucosae should be carried Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient out at each dental visit. The tendency for the dentist to focus on only the tooth or jaw quadrant in question should be strongly resisted. Each visit should be initiated by a deliberate inspection of the entire face and oral cavity prior to the scheduled or emergency procedure. The importance of this approach in the early detection of head and neck cancer and in promoting the image of the dentist as the responsible clinician of the oral cavity cannot be overemphasized (see Chapter 7, Oral Cancer). Examination carried out in the dental office is traditionally restricted to that of the superficial tissues of the oral cavity, head, and neck and the exposed parts of the extremities. On occasion, evaluation of an oral lesion logically leads to an inquiry about similar lesions on other skin or mucosal surfaces or about the enlargement of other regional groups of lymph nodes. Although these inquiries can usually be satisfied directly by questioning the patient, the dentist may also quite appropriately request permission from the patient to examine axillary nodes or other skin surfaces provided that the examination is carried out competently and there is adequate privacy for the patient. A male dentist should have a female assistant present in the case of a female patient. Female dentists should have a male assistant present in the case of a male patient. Similar precautions should be followed when it is necessary for a patient to remove tight clothing for accurate measurement of blood pressure. A complete physical examination should not be attempted when facilities are lacking or when custom excludes it. The degree of responsibility accorded to the dentist in carrying out a complete physical examination varies from hospital to hospital, from state to state, and from country to country. The oral health care professional’s involvement may range from permission to examine extraoral structures for educational purposes only, to permission to carry out certain parts of the complete physical examination under the supervision of a physician who reviews and certifies the findings, to full privileges and responsibility for conducting necessary physical examinations before and after general anesthesia or surgical procedures. The examination procedure in dental office settings includes five areas: (1) registration of vital signs (respiratory rate, temperature, pain level, pulse, and blood pressure); (2) examination of the head, neck, and oral cavity, including salivary glands, temporomandibular joints, and head and neck lymph nodes; (3) examination of cranial nerve function; (4) special examination of other organ systems; and (5) requisition of laboratory studies. For an overview of the examination process, see the attached disc. ▼ Establishing the Diagnosis When establishing a diagnosis in the orofacial region, the oral health care professional should establish a differential diagnosis based on the medical history and physical examination and order the necessary laboratory tests, such as biopsies or imaging studies, required to reach the final diagnosis only after a differential diagnosis has been determined. In other circumstances, when the patient’s symptoms suggest the presence of a general medical disease and the clinical data are more complex, the diagnosis may be established using four steps: (1) reviewing the patient’s medical history, physical, radiographic, and laboratory findings; (2) listing those items that either clearly indicate an abnormality or that suggest the possibility of a significant health problem requiring further evaluation; (3) grouping these items into primary versus secondary signs and symptoms, acute versus chronic problems, and high versus low priority for treatment; and (4) categorizing and labeling these grouped items according to a standardized system for the classification of disease. The rapidity and accuracy with which a diagnosis or set of diagnoses can be achieved depends on the history and examination data that have been collected and on the clinician’s knowledge and ability to match these clinical data with a conceptual representation of one or more disease processes. Experienced clinicians who have an extensive knowledge of human physiology, disease etiology, and a broad knowledge of the relevant literature can usually rapidly establish a correct diagnosis. Such “mental models” of disease syndromes also increase the efficiency with which experienced clinicians gather and evaluate clinical data and focus supplemental questioning and testing at all stages of the diagnostic process. For effective treatment, as well as for health insurance and medicolegal reasons, it is important that a diagnosis (or diagnostic summary) is entered into the patient’s record after the detailed history and physical, radiographic, and laboratory examination data. When more than one health problem is identified, the diagnosis for the primary complaint (ie, the stated problem for which the patient sought medical or dental advice) is usually listed first, followed by subsidiary diagnoses of concurrent problems. Previously diagnosed conditions that remain as actual or potential problems are also included, with the qualification “by history,” “previously diagnosed,” or “treated” to indicate their status. Problems that were iden tified but not clearly diagnosed during the current evaluation can also be listed with the comment “to be ruled out.” Because oral medicine is concerned with regional problems that may or may not be modified by concurrent systemic disease, it is common for the list of diagnoses to include both oral lesions and systemic problems of actual or potential significance in the etiology or management of the oral lesion. Items in the medical history that do not relate to the current problem and that are not of major health significance usually are not included in the diagnostic summary. For example, a diagnosis might read as follows: 1. Alveolar abscess, mandibular left first molar 2. Rampant generalized dental caries secondary to radiation-induced salivary hypofunction 3. Carcinoma of the tonsillar fossa, by history, excised and treated with 65 Gy 2 years ago Burket’s Oral Medicine 4. Cirrhosis and prolonged prothrombin time, by history 5. Hyperglycemia; R/O (rule out) diabetes A definite diagnosis cannot always be made, despite a careful review of all history, clinical, and laboratory data. In such cases, a descriptive term (rather than a formal diagnosis) may be used for the patient’s symptoms or lesion, with the added word “idiopathic,” “unexplained,” or (in the case of symptoms without apparent physical abnormality) “functional” or “symptomatic.” The clinician must decide what terminology to use in conversing with the patient and whether to clearly identify this diagnosis as “undetermined.” Irrespective of that decision, it is important to recognize the equivocal nature of the patient’s problem and to schedule additional evaluation, by referral to another consultant, additional testing, or placement of the patient on recall for follow-up studies. Unfortunately, there is no generally accepted system for identifying and classifying diseases, and diagnoses are often written with concerns related to third-party reimbursement and to medicolegal and local peer review, as well as for the purpose of accurately describing and communicating the patient’s disease status.14 Within different specialties, attempts have been made to achieve conformity of professional expressions and language.16 Some standardization of diagnoses has been achieved in the United States as a result of the introduction in 1983 of the diagnosis-related group (DRG) system as an obligatory cost-containment measure for the reimbursement of hospi tals for inpatient care.14 Most recently, in August 2006, the Centers for Medicare and Medicaid Services (CMS) issued a final ruling that will initiate a transition plan for replacing the current CMS DRGs with a classification methodology that more accurately reflects a patient’s severity of disease. Beyond cost containment, patient grouping classifications also are used for epidemiologic monitoring, clinical management, and comparison of hospital activity and as a prospective payment system. Yet groupings are mostly based on medical diagnoses, such as the International Classification of Diseases, Tenth Revision (ICD-10).15 Although scientifically derived, the DRG system is designed for fiscal use rather than as a system for the accurate classification of disease. It also emphasizes procedures rather than diseases and has a number of serious flaws in its classification and coding system. The ICD system, by contrast, was developed from attempts at establishing an internationally accepted list of causes of death and has undergone numerous revisions in the past 160 years, related to the various emphases placed on clinical, anatomic, biochemical, and perceived etiologic classification of disease at different times and different locations. There is still no official set of operational criteria for assigning the various diagnoses included in the ICD. In addition, the categories for symptoms, lesions, and procedures applicable to oral cavity conditions are limited and often outdated. Medicare and other third-party reimbursers are usually concerned only with diagnoses of those conditions that were actively diagnosed or treated at a given visit; concurrent problems not specifically addressed at that visit are omitted from the reimbursement diagnosis, even if they are of major health significance. The clinician, therefore, must address a number of concerns in formulating a diagnosis, selecting appropriate language for recording diagnoses on the chart, and documenting requests for third-party reimbursement. The patient (or, when appropriate, a responsible family member or guardian) should also be informed of the diagnosis, as well as the results of the examinations and tests carried out. Because patients’ anxieties frequently emphasize the possibility of a potentially serious diagnosis, it is important to point out (when the facts allow) that the biopsy specimen revealed no evidence of a malignant growth, the blood test revealed no abnormality, and no evidence of diseases, such as diabetes, anemia, leukemia, or other cancer, was found. Equally important is the necessity to explain to the patient the nature, significance, and treatment of any lesion or disease that has been diagnosed. ▼ Medical Referral (Consultation) Procedure Patients for whom a dentist may need to obtain medical consultation include (1) the patient with known medical problems who is scheduled for either inpatient or outpatient dental treatment and cannot adequately describe all of his or her medical problems; (2) the patient in whom abnormalities are detected during history taking or on physical examination or laboratory study of which the patient is not aware; (3) the patient who has a high risk for the development of particular medical problems; and (4) the patient for whom additional medical information is required that may impact the provision of dental care or assist in the diagnosis of an orofacial problem. When there is a need for a specific consultation, the consul tant should be selected for appropriateness to the particular problem, and the problem and the specific questions to be answered should be clearly transmitted to the consultant in writing. Adequate details of the planned dental procedure, with an assessment of time, stress to the patient, and expected period of post-treatment disability, should be given, as well as details of the particular symptom, sign, or laboratory abnormality that gave rise to the consultation. The written request should be brief and should specify the particular items of information needed from the consultant. Importantly, requests for “medical clearance” should be avoided. Medical risk assessment of patients before dental treat ment offers the opportunity for greatly improving dental services for patients with compromised health. It does require considerably more clinical training and understanding of the natural history and clinical features of systemic disease processes than have been customarily taught in pre-doctoral dental education programs1; however, a partial solution to this problem has been achieved through undergraduate 10 Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient assignments in hospital dentistry and (most important) through hospital-based dental general practice dentistry, oral medicine, and oral and maxillofacial surgery residency programs. It is hoped that revisions in dental pre-doctoral curricula will recognize this need and provide greater emphasis on both the pathophysiology of systemic disease and the practical clinical evaluation and management of medically complex patients in the dental student’s program. ▼ Formulating a Plan of Treatment and Assessing Medical Risk The diagnostic procedures (obtaining and recording the patient’s medical history, examining the patient, establishing a differential diagnosis, acquiring the additional information required to make a final diagnosis, such as relevant laboratory and imaging studies and consultations from other clinicians) outlined in the preceding pages are designed to assist the oral health care professional in establishing a plan of treatment directed at those disease processes that have been identified as responsible for the patient’s symptoms. A plan of treatment of this type, which is directed at the causes of the patient’s symptoms rather than at the symptoms themselves, is often referred to as rational, scientific, or definitive (in contrast to symptomatic, which denotes a treatment plan directed at the relief of symptoms, irrespective of their causes). The plan of treatment (similar to the diagnostic summary) should be entered in the patient’s record and explained to the patient in detail. This encompasses the procedure, chances for cure (prognosis), complications and side effects, and required time and expense. As initially formulated, the plan of treatment usually lists recommended procedures for the control of current disease as well as preventive measures designed to limit the recurrence or progression of the disease process over time. For medicolegal reasons, the treatment that is most likely to eradicate the disease and pres

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