Oral Exam Clinical Case #2

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Question 1 of 3

1. Question
Mr. Green, a 52-year old male, presents to your office for his annual evaluation. As part of that visit, you plan to perform a comprehensive physical examination.

Which one of the following statements describes the appropriate decision making process as to whether or not to include an intraoral examination as part of today’s visit?
- If he has seen his dentist within the last 6 months, there is no need to examine his oral cavity. The oral cavity is the domain of both dental and medical professionals. Although a thorough, comprehensive screening exam of the entire oral cavity should be included in a dental visit, this is not always the case, so the physician should perform this examination too.
- If he has not seen his dentist within the last 6 months, an open-mouth observational examination is adequate. The open-mouth observational examination is useful to view the posterior pharynx, soft palate, dorsum of the tongue and tonsillar pillars, but misses the most cancer-prone areas of the mouth such as the lateral tongue margins, floor of the mouth and ventral surface of the tongue. Primary care clinicians need to evaluate the entire mouth and also palpate the floor of the mouth and neck.
- If he does not smoke cigarettes, his risk of oral cancer can be assumed to be very low, so an oral examination is not necessary. Although cigarette smoking is a major risk factor for oral cancer, other factors should also be considered including family history, use of alcohol, HPV exposure to the oral cavity, and use of smokeless tobacco. Therefore, an oral examination should be performed.
- If he smokes cigarettes, he is at increased risk for both lip and intraoral cancer, so a careful examination is necessary.
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Question 2 of 3

2. Question
Mr. Green responds “no” when asked about whether he smokes cigarettes. However, on further inquiry, he acknowledges that he uses smokeless tobacco on a daily basis.

As you prepare to perform an oral examination, which of the following choices best describes the supplies and equipment you will require to perform an adequate examination?
- Gloves and a small piece of gauze Although gloves and piece of gauze will enable you to manipulate and palpate the lips and tongue, a tongue blade allows you to retract the cheek to look at the gums and the sulci where the gums and cheeks meet.
- Gloves, a small piece of gauze and a tongue blade
- Gloves, a small piece of gauze, a tongue blade and a mouth mirror A mouth mirror can be used either for indirect viewing or as a retractor, but is not necessary. A thorough intraoral exam can be performed without special equipment.
- Gloves, a small piece of gauze, a tongue blade, a mouth mirror, and a dedicated examination chair with a headrest.
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Question 3 of 3

3. Question
On examination, you identify this white lesion on the floor of Mr. Green’s mouth:

National Institute of Health

Which of the following statements is NOT correct about this white lesion?
- The differential diagnosis includes cancer, pre-cancer as well as benign conditions such as oral candidiasis. If a white lesion in the mouth cannot be wiped off with gauze, the likelihood of pre-cancer or cancer should be strongly considered.
- This lesion should be biopsied promptly to rule out pre-cancer and cancer. Prompt biopsy of any white lesion in the mouth that cannot be wiped off is always appropriate.
- This lesion is likely to coincide with the area that the patient “parks” his smokeless tobacco. In a patient who uses smokeless tobacco, dysplastic or premalignant lesions are commonly found in the area where the patient “parks” the tobacco.
- Treatment with an antifungal agent is an appropriate first step in the evaluation and management of this condition.
- If a white lesion in the mouth cannot be wiped off with gauze, the likelihood of pre-cancer or cancer should be strongly considered. The white lesions of oral candidiasis can usually be wiped off with a piece of gauze. Microscopic examination of the white material will reveal mycelia. If the lesion cannot be wiped off pre-cancerous or cancerous lesions should be considered, and prompt biopsy performed.
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The Oral Examination

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