Extraoral and Intraoral Quick Reference Sheet

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A complete description of each finding MUST include:

the history, location, and symptoms; size, extent, color, surface texture, consistency, type & shape, and morphology should also be noted relative to the condition.

Existence of the lesion:

If so, when first noticed

Duration of the lesion:

How long has it been present?

Symptoms of the lesion:

Discomfort; oozing; exudate; etc

Changes in the lesion:

Changes in size and appearance; changes in surface texture; etc...

LOCATION

Note location in relation to adjacent non-movable anatomical structures.

HISTORY

(Duration & Symptoms)

Examples of Location:

Anterior, posterior, superior, inferior, lateral, etc

EXTENT

(DISTRIBUTION)

Localized:

Lesion is limited to a small focal area

Generalized:

Involves most of an area or segment

Single Lesion:

One lesion of a particular type with a distinct margin

Multiple Lesions:

More than one lesion of a particular type

Separated:

Discreet, not running together; may be arranged in clusters

Coalescing:

Close to each other with margins that merge

Circumscribed:

Well-defined

SIZE

Measure in mm. with probe

Size descriptions:

Length, Width, and Height (if large, may be described in cm)

COLOR

May be more than one color

Color of Common lesions:

Red (erythematous), pink, white (pallor), and red & white

Color of Rare lesions:

Blue, purple, gray, yellow, black, or brown

Smooth:

Even outer layer of stretch soft tissue

Cratered:

Central depression

Corrugated:

Wrinkled

Crusted:

Hard outer layer formed by drying of exudates or secretion(s)

Papillary:

Raised, crowded, short, finger-like projections

Fissured:

Cracks, clefts or grooves

Verrucoid:

Cauliflower or wart-like growth

Pseudomembranous:

Loose membranous layer produced during an inflammatory reaction on the surface of the tissue

Granular:

Grainy or pebbly

Hyperkeratotic:

Increase in thickness of keratin on a naturally keratinized surface, or the appearance of keratin on a surface that does not normally become keratinized.

Fluctuant:

Easily compressible, soft, spongy

Indurated:

Resilient, fibrous, hardened soft tissue

Nodular:

Solid mass < 1cm in diameter in soft tissue

Elevated:

Above the plane of the skin or mucosa

Sessile:

Attached with a wide base

Depressed:

Below the plane of the skin or mucosa

Pedunculated:

Attached by a narrow stalk

Superficial:

Less than 3 mm deep

Deep:

Greater than 3 mm

Outline:

Regular or irregular?

Border:

Flat or raised?

Flat:

Same level as the skin or mucosa; usually described as Macule(s) Single or Multiple; Regular or Irregular

Blisterform:

Vesicles, pustules, or bullae that contain fluid

Nonblisterform:

Papules, nodules, tumors, or plaques that are solid and do not contain fluid

Macule:

Flat, circumscribed area of color change less than 1 cm in diameter

Patch:

Circumscribed flat lesion larger than a macule; differentiated from surrounding epidermis by color or texture

Plaque:

Patch that may be appear as macular or popular, > 1 cm in diameter

Papule:

Solid elevation < 1 cm in diameter

Nodule:

Solid mass < 1 cm in diameter, extending deeper into the dermis

Tumor:

Deep, solid mass > 1 cm

Lobule:

Definite lobes or segments that are part of a whole.

Swelling:

Mass, tumor or enlargement of a structure

Wheal:

Welt or hive, serum filled

Vessicle:

Blister or fluid-filled elevation less than 1 cm in diameter

Pustule:

Raised lesion filled with purulent exudate

Bulla:

Large blister or fluid-filled elevation greater than 1 cm in diameter

Petechia:

Small, localized area of hemorrhage into the tissue; may be red, purple, or yellowish

Granule:

Grain-like or pebbly

Ulcer:

Most common; loss of continuity of the epithelium; destruction that exposes underlying connective tissue. Extends to basal layer

Erosion:

Denuded tissue of epithelium, not extending into the basal layer

Aptha:

Small white or reddish ulcer

Cyst:

Closed, epithelial lined sac, normal or pathologic, that contains fluid or other material

Lesion:

Generic term if other "types" do not apply

Leukoplakia (Pre-cancerous Tissue Change):

White patch or plaque not characterized as any other disease; may be associated with use of tobacco or other physical or chemical agent(s)

Erythroplakia ((Pre-cancerous Tissue Change):

Red patch or plaque not characterized as any other disease