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

2. 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.

3. 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.

4. 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

5. Describe this lesion…

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

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

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

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

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

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

12. 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?

13. 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…

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

15. 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

16. 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

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

18. 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.

19. 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.

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

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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. Any questions??