What to document as you describe your lesions: Differential Diagnosis • Location and distribution • Size and shape • Color • Texture • Attachment and depth • Consistency • Mobility • Symptomatology Atrophy • Atrophy is the thinning of tissue layers, with a shiny and tr anslucent appearance. Bulla • A bulla is a circumscribed blister containing clear, watery fluid or blood. It is larger than 0 .5 cm in size (>0.5 cm) Macule • A macule is a flat, nonnpalpable area. Nodule • A nodule is an elevated solid mass, deeper and firmer than a papule. • It ranges in size from 0.5 cm to 2 cm. Papule • A papule is a circumscribed, solid elevation. • It is palpable and usually less than 0.5 cm in size (<0.5 cm). Plaque • A plaque is a discrete, slightly elevated area of altered t exture or coloration. • It is usually greater than 0.5 cm (>0.5 cm). Pustule • A pustule varies in size and is similar to a vesicle but is filled with pus. • An example is acne. Ulcer • Size varies. • There is deep loss of epithelial layer and may extend to connective tissue layers. Vesicle • The size is <0.5 cm. • It is a smaller circumscribed blister filled with clear, watery fluid. Wheal • Size varies. • It is an irregularly shaped, elevated area of superficial localized edema. Terminology Used to Descr ibe Lesion Surface Texture • Terminology used to describe surface texture of a lesion includes crater, crust, induration, papillary, pseudomembrane, smooth, and verrucous. Terminology Used to Indicate Consistency of a Lesion Basic Anatomic Termino logy Lymphatic Drainage System of the Head and Neck Parietal and Occipital Regions Temp oral and Auricular Regions Salivary Glands and Associated Structures Submandibular and Submental Triangles Intraoral Assessment Anatomi c Landmarks in the Oral Cavity Buccal and Labial Mucosa Palate Conductin g Intraoral Assessments • Look at the lips overall. • Have the client smile and then open the mouth slightly. Visually inspect and bidigitally palpate the lower lip. • Us e the same technique for the upper lip. Gently pull the lower lip away from the teeth to observe the labial mucosa. Bidigital P alpation of Inner Cheek • Gently pull the buccal mucosa slightly away from the teeth to bidigitally palpate the inner cheek on e ach side using circular compression. • The parotid papilla and duct should be the same color and firmness as surrounding tissue. They should be able to produce saliva. • Dry the area with gauze and observe the salivary flow from each parotid duct. Abnormal fin dings may include excessive flow or xerostomia. • Retract the mucosal tissue enough to visually inspect the vestibular area and gingival tissue, including the maxillary tuberosity, posterior to the last maxillary molar, and the retromolar pad, posterior to t he last mandibular molar. • Bidigitally palpate these areas using circular compression. • Oral mucosa should be a continuous pinkish - red color or pigmented in relation to the normal coloration of the client’s skin. It should be firm in texture, free of lesions , and moist. • Labial and buccal mucosa should have a pebbly consistency and rough surface texture owing to minor salivary glands. • Attached gingiva should have stippling with a firm consistency and it should be anchored to the teeth and underlying alveolar b one. • Abnormal findings include: P igmented, red or white or a combination of red and white, ulcerated lesions , which may indicate erosive dermatologic disease or oral cancer; whitened areas caused by candidiasis or lichen planus. • Look for signs of odontogen ic infections; trauma associated with domestic abuse; ulceration and scarring associated with parafunctional habits; alcohol and smoker’s breath; halitosis associated with caries and periodontal disease, necrotizing periodonti t is , or sweet and fruity ketos is associated with diabetic acidosis. Other considerations to note include Fordyce spots, the white raised line of linea alba at the occlusal plane ; bony projections or exostosis on alveolar ridges, mandibular torus, amalgam tattoo ; and scarring from third molar removal. Palate and Pharynx • The intraoral examination of the palate and the pharynx include the hard and soft palate, faucial pillars, palatine tonsils, uvula, oropharynx, and nasopharynx. • Have the client tilt the head back slightly. Use the mou th mirror and light source. • Have client extend the tongue, and view the soft palate. Gently place the mouth mirror on the middle of the tongue and ask the client to say “ah.” Visually observe the uvula and visible part of the pharynx. • Palatal and pharynge al tissue should be pink or pigmented in relation to the normal coloration of the client’s skin. It should be moist and devoid of lesions. • Compress the hard and soft palates, but avoid circular compression to prevent initiating the gag reflex. Red dots or petechiae may be caused by nicotinic stomatitis or denture stomatitis, an indication of cancer, or inflammation from postnasal drip; trauma may be caused by child or sexual abuse; sagging tissue may be caused by facial paralysis. Check tonsils for tonsill itis or tonsillar masses. Assessing the Tongue • To access the tongue, have the client extend it. Wrap a gauze square around the anterior third of the tongue to obtain a firm grip. Digitally palpate the dorsal surface. Turn the tongue slightly on its side to inspect its base and lateral borders. Bidigitally palpate the lateral surfaces. Be aware of triggering the gag response. • To access the ventral surface, have the client lift the tongue to permit inspection and digital palpation. • It should be bilater ally symmetric, extremely vascular, reddish - pink in color or pigmented in relation to client’s skin, all moist, and with full range of motion. • Atypical findings may include clefts on ventral surface resulting from fissured tongue; geographic tongue; papill ary atrophy; lingual varicosities; coated or stained tongue; large tongue, called macroglossia ; tongue - thrusting habit; scalloped or scarred lateral surfaces. Abnormal findings may include hairy leukoplakia; tenderness; color changes; shortened lingual fre num with limited movement; enlargement or induration, or sign of cancer; extreme loss of papillae related to nutritional disorders; trauma caused by child abuse; infection from piercings; difficulty swallowing. Floor of the Mouth TALKING POINTS: • The li ngual frenum is a midline fold of tissue between the tongue’s ventral surface and the mouth floor. • The sublingual folds are tissue ridges on each side of the mouth that form a V - shaped configuration from the lingual frenum to the base of the tongue. The s ublingual folds contain duct openings from the sublingual salivary gland. • The sublingual caruncle, located at the anterior end of each sublingual fold, contains the submandibular and sublingual duct openings. The mandibular torus (singular) or tori (plural ) is an atypical finding that may be found on the mandibular lingual surface in the premolar area. Floor of the Mouth • Have the client lift the tongue to the roof of the mouth. Check the lingual frenum. Note range of motion. A tight lingual frenum attachm ent , or ankyloglossia, may present problems with speech. • Use the mouth mirror to observe the mucosa of the floor of the mouth for lesions, swelling, or color changes. • Look for a blocked duct resulting from sialolithiasis or ranula; excessive salivary flow or xerostomia; tenderness; enlargement; induration; pigmented red or white or combination - colored lesion; ulcerative lesion; or trauma from child abuse. • Wipe the sublingual caruncle with gauze and observe the saliva flow from the duct. • Bimanually palpate the sublingual area by placing the right index finger intraorally and the fingertips of the left hand extraorally under the chin to feel the tissue between the two hands. Use bidigital palpation for the sublingual gland on the floor of the mouth behind eac h mandibular canine by placing the index finger of one hand intraorally and the index finger of the other hand extraorally, with the gland compressed between Frontal Region • Visually inspect the frontal region, forehead, and frontal sinuses. • Bilaterally palpate the forehead, including the frontal sinuses. • Areas should be firm and smooth. • Note any tenderness or signs of increased temperature. Note any pigmented, red, or ulcerous lesions. Parietal and Occipital Regions • Stand near the client to visually inspect the entire scalp by moving the hair, especially around the hairline. Move from one ear to the other ear. • Scalp should be firm and continuous and without any changes noted. • Hair should be free of debris. • Nodes should not be clinically palpable or v isible. • Skin cancer may appear as pigmented, red, or ulcerous lesions hidden by the hair on the scalp. • Tender, soft, enlarged, and freely movable nodes may indicate an acute infection. • Hard, nontender, and fixed nodes may indicate a chronic infection or c ancer. Tempora l and Auricular Regions • Temporal and auricular regions include the scalp, ears, and auricular nodes. • Stand near the client to visually inspect the areas, moving the hair as needed. • Bilaterally palpate the external ear, scalp, face, a nd auricular nodes around each ear. • Skin should be firm and continuous and without any changes noted. • Nodes should not be clinically palpable or visible. • Note any discharge from or redness of the inner ear canal. • Note ear piercings. • Tender, soft, enlarge d, and freely movable nodes may indicate an acute infection. • Hard, nontender, and fixed nodes may indicate a chronic infection, trauma from domestic abuse, or infections from piercings. Pigmented, red, or ulcerous lesions may indicate skin cancer. Infraor bita l and Zygomatic Regions • Visually inspect the areas inferior to the eye orbits, noting the use of the muscles of facial expression. • Client should be able to use all muscles on both sides of the face. Facial paralysis can result from Bell palsy or st roke. • Palpate the TMJ. Ask the client to open and close his or her mouth. Ask client to move jaw right and left and forward. • Gently place a finger into the outer part of the external acoustic meatus. Joint movement should be smooth, continuous, and silen t. Both sides of the TMJ should function similarly. TMJ and associated musculature should be free of pain. • If TMJ function is limited or the client experiences discomfort, ask questions. Palpate the facial nodes, moving from the infraorbital region to the labial commissures, and then to the surface of the mandible Buccal Region • Visually inspect and bilaterally palpate the masseter muscle and parotid gland. • Begin in front of each ear and move to the cheek area and down to the angle of the mandible. • Place the fingers over the masseter muscle surface and ask the client to clench the teeth together several times. • Areas should be firm and smooth without tenderness or increased size or firmness. • An overdeveloped masseter muscle could indicate parafunct ional habits. • Tender, soft, enlarged, and freely movable nodes may indicate an acute infection. • Hard, nontender, and fixed nodes may indicate a chronic infection or cancer. • Constant pain in the gland may indicate cancer. Alterations in skin integrity coul d indicate skin cancer. Mental Region • Visually inspect and palpate the chin. • Area should be firm and smooth, without tenderness. • May have dimple or slight cleft associated with mandibular symphysis. • Swelling or bruising could be related to trauma or dom estic abuse. • Scars may be result from accidents. • Odontogenic infection may cause tissue enlargement or drainage. Submandibular and Submental Triangles • Stand slightly behind the client on one side and then the other. Have client lower chin. • Manually p alpate submandibular and sublingual glands and associated nodes underneath the chin and on the inferior border of the mandible. • Then push the tissue in the area over the bony inferior border of the mandible on each side, where it is grasped and rolled. An terior and Poste rior Cervical Triangles • With the client looking straight ahead, manually palpate with two hands on each side of the neck the superficial cervical node location. • Start inferior to the ear and continue the whole length of the sternocleido mastoid muscle (SCM) surface to the clavicles. • Have the client tilt the head to one side and then to the other to palpate the superior deep cervical nodes on the underside of the anterior and posterior aspects of the SCM. • Have the client raise the shoulder s up and forward to palpate over the trapezius muscle surface and the deep cervical, accessory, and supraclavicular nodes. • Changes in nodes could be indicative of acute or chronic infection or cancer, particularly breast cancer, as the axillary nodes filte r breast tissue. Anterior Midline Cervical Region • Standing near the client, place one hand on each side of the trachea. Gently displace the thyroid gland tissue to the other side of the neck while the other hand manually palpates the displaced tissue . Compare the location of the two lobes of the thyroid using visual inspection and bimanual or manual palpation. • Ask the client to swallow to check for gland mobility by visually inspecting it while it moves superiorly and then back inferiorly. • Palpate la rynx and deliberately move it. • A prominent Adam’s apple, thyroid cartilage, is common in males. • Enlargement of the thyroid gland may be goiter. • A tender gland with unusual texture, such as rubbery or hard tissue masses, may be a nodule, cyst, or cancer. • T he client may have evidence of thyroid surgery with lack of thyroid gland. • Thyroid gland and larynx may have lack of movement. Client may have changes in voice and speech.