Haley Williams, RDH, BS November 22, 2013 Lesion Description

Adapted From McCann, A. (n.d.). Describing soft tissue lesions of the oral cavity. Dental Hygienist News, 61(5). Darby, M., & Walsh, M. (2003). Dental hygiene theory and practice. (2 ed., p. 217). St. Louis: Saunders Elsevier.

Objectives Following this lecture, the student will be able to: Value the importance of properly documented lesions of the oral cavity. Accurately list the characteristics needed in every lesion description as discussed in lecture and in accordance to the dental hygiene clinic manual. Properly dictate lesion descriptions using the flow sheet provided to a clinically acceptable level.

Why do we describe lesions? The clinical note is a legal document and all lesions (atypical and abnormal) should be recorded Enables the dental hygienist to communicate with the dentist and other health care professionals Aids in accurate dental diagnosis

Describe this lesion…

JUST KIDDING!!! But at the end of this lecture you will be able to!

Let’s get started! A complete lesion description should contain the following: Size Color Morphology Location History

Size Measured with a periodontal probe Measure length and width (and sometimes height if it is a raised lesion) For example: 3 x 4mm

Color As it appears clinically Single color Multiple Colors Red or white Multiple Colors

Morphology Shape Arrangement Consistency Surface Texture Single or coalescing Consistency Surface Texture

Location Be as specific as possible Can use anatomic structures nearby to help describe the location of the lesion

History Some follow up questions to ask a patient include: How long has this been here? Are you experiencing any pain or discomfort? Any oral habits (ie: biting on lips or cheeks) Are you a tobacco user? If yes, what type and how long?

Now that we have the basics of what should be included in a lesion description let’s move on to more specific types of lesions…

Elevated Lesions Above the plane of the mucosa Blisterform Lesions Nonblisterform Lesions

Blisterform Lesions Filled with fluid Typically translucent Consistency is soft Vesicle: Less than 5mm, contains clear serum, and is translucent in color Pustule: can be any size, contains pus, and is yellow in color Bulla: More than 5mm and contains serum and possibly blood

Nonblisterform Lesions No fluid-all types consist of tissue Solid color Consistency is firm Papule: Less than 5 mm Nodule: Greater than 5 mm but less than 2 cm Tumor: Greater than 2 cm Plaque: Slightly raised, broad and flat in appearance

Nonblisterform Lesions Papules, nodules and tumors can be Pedunculated: on a stalk Sessile: Base is the diameter of the lesion

Let’s describe these lesions together! Localized, single vesicle, translucent in color, 3 x 4 x 3 mm in size. Located on the lower lip close to the midline. Patient reports it has been present for about 2 weeks and occurred after she bit her lip. Lesion measures 3 X 4 X 3 mm and pt reports biting her lip approximately 2 weeks ago. No pain just a nuisance.

Localized, single tumor, pink in color, 2. 5 cm x 1 cm x 5 mm in size Localized, single tumor, pink in color, 2.5 cm x 1 cm x 5 mm in size. Located on the hard palate to the right of the median palatine raphae. Patient reports it has been present for about 7 months and is asymptomatic. Lesion measures 2.5 cm X 1 cm X 5 mm. Present for approximately 7 months, pt asymptomatic.

More terminology… Terms used to describe surface texture: Verrucous Wart-like Papillomatous Cauliflower-like Fissured Cracked Corrugated Wrinkled Crusted Scab-Like

Depressed Lesions Below the mucosal plane Loss of continuity of the epithelium Usually an ulcer

Depressed Lesions Single Multiple Regular or irregular outline Coalescing or separate Regular or irregular outline Regular: like an oval or circle Smooth or raised margin Smooth: same plane as mucosa Raised: margin about the mucosal plane Superficial or deep Superficial: less than 3 mm Deep: greater than 3 mm

Your turn!! Single ulcer with a regular border and a smooth margin, superficial in depth and yellow and red in color, 6 x 4 mm in size. Located on the right lateral border of the tongue, present for 3 days and painful. Pt reports a painful lesion present for about 3 days after biting his tongue.

Flat Lesions On the same plane as the mucosa Known as “mucules” Flat lesion of abnormal color Can be single or multiple Can have a regular or irregular outline

Practice Makes Perfect! Single macule, regular in outline, bluish-gray in color, 2 x 4 mm in size. Located on the lower lip at the midline and present for approximately 2 years. Pt asymptomatic 2 x 4 mm-present for 2 years

Today we learned: The importance of recording oral lesions in the clinical notes Necessary characteristics of all lesion descriptions How to utilize the redi-reference on properly describing soft tissue lesions of the oral cavity

Any questions??