After performing the intraoral examination on the patient, you record a lesion description—a standardized method for the process of documenting and describing extra and intraoral soft tissue lesions and deviations from the normal—in the chart. To manage a lesion correctly, it is important to accurately and properly document the lesion and arrive at a probable diagnosis.
On your patient, you note a single localized 6 mm x 7 mm white nodule located on the left lateral tongue. The lesion is smooth-surfaced and does not rub off during palpation. Duration reveals that it has grown slightly over the past three weeks since the patient first became aware of it.
'Your 'Diagnosis'
After the description and history you can come up with a differential diagnosis that includes three to five probable options. Here’s a step-by-step in developing your conclusions.
Investigate. Look around. Ask more questions. Do you see any fractured or chipped teeth that may rub against the tongue when eating or chewing, causing a callus? Ask the patient if she ever experienced anything like this before—does it come and go? Perhaps she had hot food or a change in toothpaste—anything new? Has there been a burning sensation? Has the patient inadvertently bitten her tongue?
| | Pathways
As hygienists, we recognize the importance of oral health screenings and are committed to raising patient awareness as it relates to good dental health. In addition, we must be capable of recognizing the clinical signs and symptoms of common oral diseases and lesions. This column will help you be able to differentiate normal from abnormal changes in your patients and to establish a differential diagnosis, enhancing your ability to communicate effectively with dentists, physicians, and other healthcare providers.
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Document. Be sure to document the color, size, consistency, location, and duration/history. Other terms to aid in description include: Localized—confined to one area, found only in a single area; and Generalized— found throughout or in multiple areas. It also is very important to document the patient’s chief complaint or anything the patient may have said about the lesion; this is important from a legality point as well.
Hygiene differential diagnosis. In school, we learned that we can not diagnose, but we can come up a list of possibilities—a “hygiene differential diagnosis.” When the doctor comes in to perform the exam, you should be able to describe the lesion accurately and have a list of possibilities you came up with. You would call the lesion a leukoplakia because it is white and does not rub off. Remember this is only a descriptive term with an unknown etiology until a histiopathic examination of the biopsy is obtained.
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