Examining soft tissues

Unlike many other areas of healthcare, dentists generally get to examine fit ambulant patients at varying intervals, and at times when they may have no symptoms or any particular reason for attending, other than for a periodic review of their oral health.

This provides dentists, dental hygienists, dental therapists and clinical dental technicians with an almost unique opportunity that is not shared by many of their colleagues working elsewhere in healthcare.

Meaningful comparisons

Monitoring the health of the oral soft tissues presents clinicians with a particular challenge because of the relative lack of objective measures to facilitate meaningful comparisons from one examination to another. This makes the soft tissue examination very different from orthodontic monitoring (where study models can be used), or the monitoring of caries or periodontal disease. The visual record provided by radiographs is not appropriate for these tissues. Furthermore, caries and periodontal disease are more prevalent than the pathology affecting the oral soft tissues, and it is perhaps not surprising that historically, these diseases have been the focus of the greatest attention.

As a result most clinical records tend to contain much more information about the status of the teeth and restorations than of the periodontal tissues, and in turn, more information about the periodontal tissues than about the health of the soft tissues in and around the mouth.

Risk groups

The profile of patients who are most likely to be at risk of oral cancer and other forms of oral pathology, because of their age, sex, ethic background and other genetic factors, are well known. So also is the range of other risk factors which are readily identifiable from a well taken history. There is a self-evident logic for clinicians to consider how best to monitor and record the health of the oral soft tissues - especially for patients in these high risk groups, of course, but ideally for all patients.

What is normal?

It goes without saying that before any abnormalities can be identified, it is necessary to have a working familiarity not only with the normal appearance of all these tissues in health, but also with the variations of a normal presentation that are not indicative of a significant problem. With this in mind, clinical members of the dental team should periodically refresh their memory of the soft tissue lesions which might be encountered in and around the oral tissues, their aetiology and presentation, and their management. Because the incidence of these lesions is low, it is easy for our knowledge of the subject to become less precise with the passage of time.

Develop a routine

A consistent, reproducible approach should be taken, examining each of the tissues in turn, and recording the findings individually (from the tongue, lips, palate, floor of mouth, retromolar area, etc). Any unusual presentation should be noted, which may take the form of changes in:

1. Colour (inflammatory changes, dark or pale appearance, white patches or other discolouration).
2. Surface profile/texture (for example, swelling, ulceration, induration, loss of normal roughness/smoothness).
3. Shape and anatomical features (for example, loss of papillae, asymmetry, etc).

Images

While it is possible to record the location, size and shape of lesions or areas of unusual appearance by means of diagrams, and this is certainly better than nothing, intra oral photography has the added advantage that it can capture changes in colour and surface profile that could otherwise become very difficult to record with any degree of accuracy.

The key to monitoring the health of the oral soft tissues is the ability to compare the appearance and presentation from one visit to another.

Capturing and retaining such images digitally is convenient, cost-effective and can be integrated very easily into a patient's electronic record, which is precisely where this information needs to be stored. This approach also makes it very much easier to transmit the information to third parties to whom the patient might be referred for a second opinion. A picture can also assist the specialist team to prioritise patients.

Audits

1. Review a sample of clinical records in your practice, and note how often there is a specific mention of the soft tissues having been examined, in a clearly-dated entry in the records.
2. In how many cases are there successive entries, confirming that this screening process is being repeated at appropriate intervals?
3. Are each of the soft tissues of the mouth referred to in turn, confirming that they were each specifically examined?
4. If an unusual appearance has been recorded, what form do these records take (written description, diagrams or digital images)?
5. Is it clear from the records at what intervals such lesions would be reviewed?
6. Is it clear what arrangements were put into place to achieve this?
7. Where applicable, have second opinions been sought, and if so, have copies of the referral correspondence being retained within the clinical records?

Targeted audit

Review a more targeted sample of records for patients who fall within one of the high risk groups.

It is relevant to record (and update) whether or not a patient uses tobacco in one of its various forms, and to note the form of tobacco and the frequency of its use. Obtaining details of a patient’s use of alcohol is more difficult, but may sometimes be apparent from their social history.

The task of identifying at-risk patients in order to carry out a baseline audit of the available records is considerably less daunting for computerised practices, than for those using conventional (paper) records. Nevertheless, it is a good idea to make the effort to obtain some kind of baseline measurement, in order to achieve an objective measure of any improvement in the practice’s future record keeping.

Agree practice protocols to identify which patients fall into the high risk category, and put systems in place to:

1. Ensure that soft tissue examinations are carried out for these patients at appropriate intervals.
2. Maximise the quality of the records that are kept for such examinations.
3. Make patients aware of the desirability of carrying out this screening exercise at appropriate intervals.