An extraoral exam can make the difference in detecting a life-threatening disease

July 1, 1997
The importance of extraoral examinations cannot be overly stressed. With all the additional time spent taking universal precautions, dental professionals are having to cut corners and eliminate some of the services they used to include in regular recall examinations.

Cynthia R. Biron, RDH

The importance of extraoral examinations cannot be overly stressed. With all the additional time spent taking universal precautions, dental professionals are having to cut corners and eliminate some of the services they used to include in regular recall examinations.

Extraoral examinations may be cut short or eliminated entirely. Patients are not complaining about the absence of this service since they are unaware of its importance.

The following case is a prime example of what just a visual assessment of the patient`s head and neck can mean for the patient. The dentist and dental hygienist have permitted their names to be used, but the patient`s name has been changed to provide confidentiality.

A patient gets defensive

Ms. Mary Beth Compton is a dental hygienist in the office of Dr. Jay White, a general dentist, whose practice is located in Alexandria, Va. In July 1995, Mary Beth seated her patient, Lana, a 41-year-old woman. Mary Beth began to update Lana`s medical history and found that there were no changes in her unremarkable medical history.

While questioning Lana, Mary Beth noticed that Lana`s right eye appeared to be protruding more than her left eye. Mary Beth thought about causes of bulging eyes and thought to herself that this could be a sign of Grave`s disease (hyperthyroidism).

"Have you noticed that your right eye is bulging? Have you had any problems with your eye or your vision?" Mary Beth asked.

Lana got very defensive and responded by saying, "There is nothing wrong with either of my eyes, I just had an examination by my ophthamologist this week, and he gave me a clean bill of health."

Mary Beth dropped the subject. But throughout the appointment, she was concerned about the appearance of that eye. She felt that she had to discuss it with Dr. White so he would assess it when he came in to check her patient. Mary Beth completed the bitewing X-rays, the complete assessment, and the prophylaxis before signaling Dr. White that she needed to discuss something with him privately. Dr. White met Mary Beth in his office where she told him about Lana`s eye and her defensiveness.

In the operatory, Dr. White exchanged pleasantries with Lana, read the X-rays, and examined her teeth and oral tissues. Then he asked her to look into a hand mirror with him so he could show her the difference between her right and left eyes. When she looked at her eyes and the specific areas that Dr. White was pointing to, she realized that her right eye was bulging out. The cause? Dr. White told her he could not really say, but that the eye had to be evaluated by a specialist as soon as possible.

Lana was not too happy about needing more health-care examinations. She thought this dental visit was the last of a series of doctors visits before she went out of the country again to work as a missionary.

A few days later Mary Beth received a phone call from Lana, who told her that the doctors had found a benign brain tumor (meningioma) between her brain and her spheroid bone. The tumor was pressing on her optic nerve.The tumor was surgically removed and underwent radiation therapy.

The following letter was sent to Mary Beth from Lana:

"Dear Mary Beth, thank you again for mentioning your observation about my right eye appearing to bulge slightly. If you had not, the benign tumor between my optic nerve and brain would not have been diagnosed until it had become more extensive and harder to treat. Our travel to Cypress has been delayed for the surgery and radiation, but when we move to Nicosia, I will be in good health. Your outspokenness helped save my sight. I will forever be grateful to you. - Lana James"

Treatment of meningiomas

"These meningiomas," say Robert G. Ojemann, MD, at Massachusetts General Hospital in Boston, "involve the region of the anterior crinoid, adjacent medial spheroid wing, superior orbital fissure, and cavernous sinus. They may grow into the orbit. As the tumor becomes larger, it may encase the internal carotid and proximal middle and anterior cerebral arteries. The optic nerve may be compressed or be surrounded by the tumor. Large tumors put pressure on the frontal and temporal lobes and provoke edema in the adjacent brain tissue resulting in necrologic deficits or seizures."

Meningiomas often are difficult to diagnose. Signs and symptoms can be so mild that they frequently go unnoticed, as in the case with Lana. Symptoms frequently are confused with other disease conditions. The symptoms include headaches, behavior changes, seizures, nausea and vomiting, swelling of one or both eyes, blurred or double vision, and loss of sense of smell.

Treatment decisions are difficult when the tumors do not produce progressive symptoms. An initial magnetic resonance imaging (MRI) will outline the extent of the tumor and show its relationship to the arterial structures, but it is difficult to determine if the tumor is encasing the internal carotid artery and its branches.

Angiography is necessary for such a diagnosis and usually is used before surgical removal of the tumor. The treatments for meningiomas include periodic clinical evaluation. MRI helps patients whose tumors involve non-progressive symptoms, as well as patients who would be at significant risk of debilitation or death from surgery. Surgery and radiation therapy in combination are the most common treatments for meningiomas.

Removing the entire tumor is very difficult as it is intertwined in vessels and nerves, which could easily be adhered to by the tumor itself. When the tumor is lifted away during the surgical procedure, the vessels can rupture and hemorrhaging can cause post-operative debilitation. Neurological function could be impaired if the nerves encased by the tumor are damaged.

Surgical removal of a brain tumor always poses significant risks due to the area of the surgery. The post-operative radiation therapy can provide additional removal of residual tumor tissue. In the future, chemotherapy will be used to treat this benign tumor.

There is so much you can tell about your patients by assessing their eyes. Bulging eyes commonly are a sign of Graves Disease, which is a condition of hyperthyroidism. The condition is termed exopthalmos and may involve one or both eyes. Usually there is an associated enlargement of the thyroid gland, which can be determined by palpating the thyroid gland. The thyroid gland may or may not be nodular as well.

A patient`s eyes also can reveal signs of drug abuse. The pupils of the eyes should react to light with a normal spasm of accommodation. That is to say, they should dilate and constrict according to the amount of light to which they are exposed. Pinpoint pupils (miosis) is a sign of narcotic intake. Widely dilated pupils can be a sign of CNS stimulant intake, as associated with the use of amphetamines or cocaine.

Patients who are very fearful may demonstrate a sympathetic nervous system response that also causes moderately dilated pupils.

Very widely dilated pupils are seen in an unconscious patient who is experiencing loss of cerebral blood flow. When that patient has been positioned to provide increased cerebral blood flow (trendelenburg) and provided with high concentrations of oxygen, pupils will return to their normal spasm of accommodation. If their consciousness is not restored with these measures, a more profound situation prevails, such as shock, stroke or cardiac arrest.

As we go along day-to-day in our routine of private practice and uneventful patient treatment, we do not expect to find anything life threatening. But when we make a habit of thoroughly assessing our patients, we occasionally find signs of disease processes that could be life threatening.

Every hygienist who provides extraoral and intraoral examinations on every patient has a great chance of saving a patient from experiencing the devastation of disease and/or death. There is no greater sense of purpose and accomplishment.

References available upon request.

Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She is also a certified emergency medical technician.

In the blink of an eye, an assessment is made

When looking at the whites (sclera) of a patient`s eyes, it is important to evaluate the color and the clarity.

- Redness in the whites of the eyes can indicate allergy, hayfever or alcohol intake.

- A very yellow appearance of the sclera suggests bilousness associated with jaundice of the liver.

- A bluish appearing sclera can be indicative of chronic oxygen deprivation as associated with pulmonary disorders such as chronic obstructive pulmonary disease. Patients whose sclera has a bluish hue from chronic oxygen deprivation usually will have bluish nail beds and sometimes their lips and mucosa tissue has a bluish tint.

- Sclera that has a stark whiteness with no normal trace of vessels can indicate excessive vasoconstriction as associated with some types of hypertension. Simply taking the patient`s blood pressure can differentiate this assessment.

The eyes should be symmetrical in size, shape and function. It is important to do more investigating about a finding. Ask questions and gather more information for a very thorough physical assessment in extraoral and intraoral examinations. Take the patient`s vital signs.

Deviations in any of these factors of the eyes suggests a need for evaluation by an ophthamologist and physician. In patient records, always document in accurate and complete description, any findings, and suggestions for referral to physicians. A phone call to patient a week after the referral demonstrates your concern about the seriousness of the findings and serves as legal documentation should a legal situation arise concerning the patient`s condition.