I. Problem/Condition.

Hospitalists are frequently asked to evaluate diseases of the oral soft tissues and pharynx. Understanding oral manifestations of local or systemic disease is fundamental in the care of patients with a variety of conditions that affect oral health in the hospital setting.

II. Diagnostic Approach

A. What is the differential diagnosis for this problem?

Differential diagnosis of dental disease is categorized into diseases of the teeth and periodontal structures, diseases of the oral mucosa, diseases of the tongue, and systemic disease with dental manifestations.

Diseases of the teeth and periodontal structures include dental caries, pulpal infection, periapical abscess, periapical cyst, acute or chronic gingival infection, periodontitis, localized juvenile periodontitis, acquired immune deficiency syndrome (AIDS) related periodontitis, Ludwig’s angina, and osteonecrosis.

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Diseases of the oral mucosa include herpes simplex virus (HSV) type 1 or type 2 (less common), varicella zoster virus (VZV), Epstein-Barr virus (EBV), herpangina, hand, foot, and mouth disease, primary human immunodeficiency virus (HIV) infection, acute necrotizing ulcerative gingivitis (trench mouth), syphilis, gonorrhea, tuberculosis, cervicofacial actinomycosis, histoplasmosis, candidiasis, other dermatologic or rheumatic conditions, and malignancy.

Diseases of the tongue include macroglossia, fissured “scrotal” tongue, median rhomboid glossitis, benign migratory glossitis, hairy tongue, “strawberry” and “raspberry” tongue, and “bald” tongue.

B. Describe a diagnostic approach/method to the patient with this problem

Initial evaluation of dental complaints involves obtaining a complete health history, including dental history, making a complete oral and generalized physical examination, and obtaining appropriate laboratory studies when systemic disease is involved. Radiographic evaluation should be obtained for involvement of the tooth or periodontal structure. Differentiation between pain involving the tooth and periodontal structure versus pain involving the oral mucosa is imperative.

1. Historical information important in the diagnosis of this problem.

Special attention should be paid to the features of systemic disease, a history of premature or rapid tooth loss, hematologic complaints, frequent systemic or local infections, systemic signs of malnutrition, and history of alcohol and tobacco use.

In the setting of tooth enamel abnormalities or malocclusion, developmental history is relevant with particular focus on history of intrauterine infection or exposure.

For diagnosis of periodontal disease, important additional historical information to obtain includes history of periodic dental professional examinations, dental hygiene history, and current medication use.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

Physical examination should focus on close evaluation of the tooth, gum-tooth margin, tongue, oral mucosa, evaluation for systemic bruising or bleeding, examination of the temporomandibular joint and muscles of mastication, and thyroid gland.

When examining the oral mucosa, lesions may be categorized into vesicular, bullous, or ulcerative in order to aid in diagnosis.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Microbiologic testing may be of utility in the setting of closed-space odontogenic infections. For close-spaced infections, needle aspiration is recommended with rapid transportation for microbiologic analysis under anaerobic conditions. Given the prominence of normal oral flora, other intraoral lesions are best evaluated with microscopic evaluation of stained smears. Specifically, gram stain, acid fast staining, and potassium hydroxide staining for fungi should be performed on all other superficial lesions. Evaluation of the specimen with polymerase chain reaction or immunofluorescence is particularly helpful when mycobacterial, fungal, or viral etiology is suspected. If osteomyelitis is suspected, a bone biopsy with histopathology and culture is required for definitive diagnosis.

Imaging modalities should be considered given the clinical setting. Radiographs (bitewing or orthopantomograms) may be useful in determining the presence or extent of dental caries, periodontitis, or periapical abscess. Computed tomography (CT) remains the most useful imaging modality for diagnosis of odontogenic infections. CT is also helpful to determine if the infection is in the retropharyngeal space or prevertebral space. Magnetic resonance is preferred if concern for deep fascial space infections exists.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

Dental disease may be approached by identifying the location in the mouth and classifying salient features of the lesion. Oral spaces may be broken down into the following categories: buccal, segmental, masticator, canine, and infratemporal spaces.

  • Buccal: suggests mandibular/maxillary bicuspid or molar root infection. These infections often present with marked cheek edema, pain, and trismus.

  • Segmental: chin swelling, pain, and erythema suggests mandibular incisor root infection.

  • Masticator: trismus, pain, or pain with palpation of the body or ramus of the mandible suggests third molar (wisdom tooth) infection. Edema is often not present secondary to the large muscle masses inferior to the compartment, which may obscure swelling.

  • Canine: purulent maxillary sinus drainage, moderate pain, edema of the upper lip, canine fossa, and periorbital tissues are often present in the setting of maxillary incisor or canine infection.

  • Infratemporal space infection results from infection of the posterior maxillary third molar and is marked by trismus and pain with little edema in the early clincal course. As infection progresses, extension into the orbit or lateral pharyngeal wall may occur, often with dysphagia.

Lesions of the tongue may often be difficult to diagnose based on visual inspection alone. Given the prevalence of squamous cell carcinoma of the oral cavity, persistent papules, plaques, or erosions on the tongue or intraoral mucosa should be evaluated with biopsy. Additionally, lesions may also be categorized as ulcers, tumors, infections, or affecting the tongue.

  • Aphthae: painful, localized, shallow, round, often with grayish base. Generally present from 10 to 14 days then resolve without scarring.

  • Coxsackievirus: also known as hand, foot, and mouth disease with combination of intraoral and palmar/plantar lesions. Intraoral lesions appear similar to aphthae but generally spare lips and gingiva and are preceded by fever and sore throat.

  • Primary HIV infection: marked by exquisitely painful, shallow, sharply demarcated ulcers. May be present on intraoral mucosa, anus, genitals, or esophagus.

  • Behcet’s disease: ulcers histopatholgically and grossly similar to aphthae, but tend to be more extensive and multiple. Accompanied by genital ulcers in 75 percent of patients.

  • Squamous cell carcinoma: painful ulcers, may be associated with a mass, often present on lips or tongue. High association with tobacco and alcohol use and up to two thirds of patients with tongue lesions have nodal disease.

  • Herpes simplex virus type 1 (HSV1): can affect multiple areas of the body, including intraoral cavity. Lesions present as sudden onset of multiple vesicular lesions and erosions with erythematous, painful lesions, most often on lips or buccal mucosa. May also present as small ulcers.

  • Varicella zoster virus (VSV): lesions appear as painful vesicular erosions on the unilateral hard palate, buccal mucosa, tongue, or gingiva.

  • Candidiasis: white plaques on the buccal mucosa, palate, tongue, or oropharynx.

  • Leukoplakia: white plaques or patches, often seen on areas of mouth subject to trauma such as cheek or dorsum of the tongue.

Pigmented lesions
  • Melanosis: common in individuals with darkly pigmented skin. Darkly pigmented macules present on lips and tongue, symmetric with sharp borders.

  • Melanoma: pigmented lesions with asymmetry, irregular borders, variable or changing colors, or increasing size.

  • Amalgam tattoos: blue-black lesions most commonly seen on gingiva or buccal mucosa adjacent to amalgam fillings.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.


III. Management while the Diagnostic Process is Proceeding

A. Management of dental disease

Basic oral hygiene is the mainstay for prevention of dental caries and odontogenic infections. International consensus recommends that all adults brush using toothpaste containing fluoride and floss daily. Older patients are particularly susceptible to dental caries and gingival recession and should be encouraged to maintain daily brushing and flossing as well as a minimum of yearly dental exams.

Initial visual exam, or caries diagnosis, may be done in any clinical setting though providers must realize that this method is imperfect. International consensus recommends screening with bitewing radiographs to increase the sensitivity of detection of dental caries.

Dental professionals should be consulted in the setting of visible dental caries, tooth pain in the setting of thermal change, tooth pain with palpation or percussion, or discoloration or bleeding of the gingiva. Additionally, deep fascial space infection should be suspected if trismus is present.

In the setting of dental caries, treatment generally falls into two categories, preventative and restorative. Preventative treatment focuses on meticulous removal of the biofilm, application of fluoride or sealants, and is targeted towards preserving tooth structure. Restorative treatment that involves altering the tooth’s surface or removal of the tooth and should be done by a dental professional.

In the setting of dysphagia and candida due to dentures, patients should be reminded to clean their dentures thouroughly and frequently in addition to standard antifungal treatment.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem


IV. What's the evidence?

Selwitz, RH, Ismail, AI, Pitts, NB. “Dental caries”. Lancet. vol. 369. 2007. -51.