General Considerations

The mouth and oral cavity are used by individuals to express the entire range of emotions. As early as infancy, the mouth provides gratification and sensory pleasure.

Approximately 20% of all visits to primary care physicians are related to problems of the oral cavity and throat. Most patients with these problems present with throat pain, which may be acute and associated with fever or difficulty in swallowing. A sore throat may be the result of local disease, or it may be an early manifestation of a systemic problem.

It has been estimated that more than 90% of patients infected with human immunodeficiency virus (HIV) have at least one oral manifestation of the disease. It appears that as further immunologic impairment develops, the risk of oral lesions increases. There are several important oral manifestations that are strongly associated with early HIV infection. The presence of any of them mandates HIV testing.

Oral cancer represents about 3% of all cancers. Cancer of the oral cavity and pharynx was responsible for 7550 deaths in 2007, killing approximately 1 person per hour, 24 hours per day. The rate of death from oral cancer is higher than those from cervical cancer;Hodgkin's disease; cancer of the brain, liver, testis, kidney, or ovary;or malignant melanoma. One of the reasons for this high death rate is that the cancer is routinely discovered late in its development, with metastases to other areas or invasion deep into local structures. Oral cancer is also particularly dangerous because it has a high risk of producing second primary tumors. This means that patients who survive a first encounter with the disease have up to a 20 times higher risk for development of a second cancer. There is a 2:1 male-to-female incidence ratio and a 2:1 African-American-to-white death rate ratio. It is estimated that a man has a 1:72 lifetime risk for development of oral cancer. The American Cancer Society estimates that approximately 34,360 new cases of oral cancer were diagnosed in 2007 in the United States, with 24,180 cases occurring in men and 10,180 in women. Worldwide, the problem is much greater: More than 350,000 to 400,000 new cases are diagnosed each year. Although the exact cause of tongue cancer remains unknown, it most often occurs in people who use tobacco products (cigarettes, cigars, pipes, and smokeless tobacco), consume alcohol (especially when combined with tobacco use), or chew betel nuts. Chewing of betel nuts is not a common practice in the United States, but it is a widespread habit in many parts of the world, especially in Taiwan (see Fig. 12-51).

Many physician visits for oral problems are associated with psychiatric disturbances. Psychosomatic disease symptoms often center on the mouth. Patients with psychosomatic disease may complain of ''burning'' or ''dryness'' of the mouth or tongue. Bruxism, or grinding

Figure 12-1 The oral cavity.

Soft palate

Tongue

Posterior pillar

Uvula

Anterior pillar

Tonsils

Hard palate

Soft palate

Tongue

Posterior pillar

Uvula

Anterior pillar

Tonsils

of the teeth other than for chewing, occurs especially during sleep. This overuse of the muscles of mastication has often been interpreted as a manifestation of rage or aggression that is not overtly displayed;it may also be an infantile response to reduce psychic tension. Bruxism can produce facial pain, which causes further spasm of the muscles and continued bruxism, resulting in a vicious circle. Individuals who habitually have something in their mouths, such as a pipe, a thumb, or a pencil, may cause damage to their oral cavities.

Although it is often thought that the oral cavity is examined only by dentists, other healthcare professionals must have competency in evaluating this important region of the body. The health-care provider must be able to accomplish the following:

1. Appraise oral hygiene

2. Recognize dental caries and periodontal disease

3. Recognize the presence of oral lesions, as well as disorders of the regional lymph nodes, salivary glands, and bony structures

4. Recognize oral manifestations of systemic disease

5. Recognize systemic problems caused by oral disease and procedures

6. Assess physical findings concerning the range and smoothness of jaw motion

7. Identify dental appliances

8. Know when a dental consultation is required or should be postponed because of a

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