Transcript Lesion Description

Haley Williams, RDH, BS
November 22, 2013
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

 Red or white

Multiple Colors
Morphology
Shape
 Arrangement

 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!

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
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 2.5 cm X 1
cm X 5 mm. Present for
approximately 7 months, pt
asymptomatic.
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.
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
 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!!

Pt reports a painful lesion present
for about 3 days after biting his
tongue.
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.
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!

2 x 4 mm-present for 2 years
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

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??