Oral Medicine I
-
date post
03-Dec-2015 -
Category
Documents
-
view
221 -
download
0
description
Transcript of Oral Medicine I
Assessment & investigation of
dental patient
Oral Medicine I
Al-Azhar University – Gaza Dr. Haidar A. Al-Shafi Faculty of Dentistry
Dr. Rami Aljuidi
Patient Assessment • History - Complaint - Medical history - Drug history - Social history
• Clinical examination - Extra-oral - Intra-oral • Investigations - Blood - Biochemical - Radiographic - Histological
History - Basis of investigation
- Complaint in patient’s own words
- Clinician should not try to influence patient’s response
- Should not hurry
- Confidentiality
- History of any previous dental treatment, oral/panoral abnormality, systemic disease, skin disorder, trauma/accident, major surgery
- Drug therapy
- Use of alcohol & tobacco
- Consult patient’s general practitioner or go through patient’s file
Clinical examination • Extra-oral:
- General appearance
Wasted, mal-nutritioned, anxiety, agitation?
- Breathlessness
Cardiorespiratory problem?
- Face
Shape & symmetry
Cranio-facial syndromes
Cushingoid appearance?
Neurological deficits?
Cyanosis?
- Scalp & face
Scant hair
- Eyes
Conjuctival sacrring (pemphigoid)
Pale, yellow or blue sclera
Exophthalmia
- Neck
Lymph nodes
Goitre
- Hands
Raynaud’s phenomenon
Koilonychia
Joints
Palmar keratosis
-Wrists
Purple papules
-Skin
Petechiae or ecchymoses, cyanosis. Jaudice, pigmentation
• Intra-oral (with adequate light source)
- Remove all removable appliances
- Gently retract lips & cheeks
- Examine the whole oral mucosa
- Tongue
- Teeth
- Hard & soft palate
- Floor of mouth
In the end, a well taken clinical photograph
Normal Structures : Normal Structure within the mouth are sometimes mistaken for pathological conditions. Examples:
Special Investigations • Special investigation should only be requested to answer
specific question
• Some investigation have high specification and sensitivity for particular Disease
• Few diseases like mumps may be diagnosed on the basis of a single test, but others such as Sjogren’s syndrome may require many tests
Clinical investigation • Percussion test
• Palpation test
• Thermal changes test: - Heat test - Cold test
• Electric sensitivity testing
Imaging
• Conventional Radiography: – Intra-oral [occlusal, Periapical, bitewing] – Panorama – Cephalometric • Computerized tomography (CT scan) • Sialography & Arteriography • MRI • Ultrasound Indication: To detect: Caries – Periodontal disease – Periapical lesion. Neoplasm – cysts – TMJ disease - Results of trauma to teeth or Jaws – to locate foreign objects and to find impacted teeth.
Computerized tomography (CT):
• CT Scanning provides tomographic images (Section) of high clarity in any plane
• Advantages:
- Disease in the Maxillofacial complex
- CT scanning images of cysts
- CT is sensitive for neoplasm
• Disadvantages:
- Expensive
- Not always available
- High x-ray dose
- Less information on soft tissue lesion
- Radio-opaque dental restoration cause artifact shadow
Magnetic Resonance Imaging (MRI)
• It produces clear tomographic images particularly for soft tissue lesion, it can differentiate between two densities of soft tissues 4 times better than CT Scan and 40 times better than conventional radiograph, no x-ray dose is present in this method.
• Disadvantages:
- MRI is expensive and limited availability
- Does not image the bone.
- Long imaging time
Ultrasound
• Ultrasound examinations use high frequency sound pulses. Ultrasound requires expertise.
• Indication:
-Used to determine whether any structure is solid or cystic [solid objective absorb almost all of the sound and are less echoes than the soft tissue].
- Examination of salivary gland (Tumors, cyst, stones).
- Detect the lesion in the thyroid gland and neck.
- Evaluation of lymph node, post surgical edema and hematoma.
Sialography • Radio-opaque contrast agent like (Iodine derivative) is
infused into the ductal system of salivary gland. There is low radiation exposure.
• Disadvantages: -There is some discomfort or pressure when the contrast material is injected into the ducts. -The contrast material may taste unpleasant. • Contraindication: Sialography is contraindicated in acute infection of salivary gland. We use with acute infection the ultrasound to demonstrate the abscess. Salivary calculi is questionable
Histopathology
• Biopsy: Removing tissue from a patient for histopathological examination.
• Indications 1- Persistent oral ulcers. 2- Persistent red and white lesion 3- suspected neoplasm or any unidentical tissue masses.
A- surgical biopsy 1-Excisional 2-Incisional 1- Excisional biopsy: is the removal of whole lesion. - Can be performed when the lesion no larger than 1 cm in diameter - When it is removal doesn’t necessitate a major surgical procedure
2- Incisional biopsy: Removal only part of lesion which also include normal tissue margin.
Indications: If the lesion is too large for an excisional procedure.
Contraindications:
Incisional biopsy of parotid gland tumors (plemorphic adenoma) is contraindicated but may be examined microscopically only after excision with a margin of surrounding normal tissue.
• General principles: - sterilization protocols to be followed - Patient consent & councelling - LA to be given in the adjacent area & not within the lesion - Better taken with a knife than with a cutting diathermy - Specimen should be big enough to allow the pathologist to
make a diagnosis - Specimen should preferably at least 1x 0.6 cm x 3mm deep. - Specimen edges should be vertical not beveled - After excision, put into a fixative (10 formol saline being the
standard solution) - Apply stitches to the specimen for orientation - If the specimen is thin, lay it on a piece of card - Label the container with patient’s name & age & site of biopsy - Fill the biopsy form, draw the specimen diagram if necessary
B- Fine needle aspiration • The fine needle is inserted into the lesion and cell aspirated and
smeared on a slide. The cells can be fixed, stained and examined within minutes.
• Advantages 1- Avoid damage in vital structures in the neck and head 2- To prevent the spread of tumor cells 3- Less risk of delayed wound healing and infection 4- Rapid diagnosis and treatment 5- It is economy.
• Indication: - Diagnosis of swelling in lymph node - Metastatic carcinoma, Hodgkin’s and non Hodgkin’s Lymphoma - Tumors of parotid gland.
C- Thick needle/ Core biopsy.
• This method useful for inaccessible tumors, e.g. in the pharynx.
• But:
- it has risks of seeding some types of neoplasm into the tissues and
- damaging adjacent anatomical structures.
- It is less used in the head and neck now that FNA is more widely available.
D- Exfoliative cytology • It is examination of cells scraped from the surface of the
lesion • Indication: - Most useful for detecting virally- damaged cells, acantholytic cells of pemphigus or candidal hyphae. - Used for patient who should be biopsied but for whom
surgical risk or some other factors prevent it. - For patients refuse biopsy.
• Contraindication: - In obvious malignancy. - In leukoplakia
Immunofluorescence & Immunohistochemistry
• Use of highly specific binding between antibody and antigen to stain specific molecules within the tissue
• Indication:
- Pemphigus and pemphigoid
- Suspected Lymphoma
- Undifferentiated Malignant neoplasm
- Autoimmune disease
Microbiology 1- Culture and antibiotic sensitivity testes a) Detect un usual pathogens e.g: Actinomycosis in soft tissue
infection. b) Antibiotic sensitivity for all infections, especially: -Osteomyelitis and acute facial soft tissue infection. -Throat infection. -Exudates from sinus infections. -Root canal infections. -Skin, mucus membrane infection. 2- Smear for candida: for candidiasis. 3- Viral culture or antigen screen. 4- Plain swab 5- Concentrated oral rinse
Hematology & Blood chemistry
• Indications: - Diagnosis of Disease such as leukaemia, Myloma and
leukopenia which have oral manifastation.
- Diagnosis of other conditions such as some infections, sore tongue and recurrent aphthae which are sometimes associted with anaemia.
Types of blood tests useful in oral diagnosis
• CBC: RBC (number–size) Hb And white cell count: Anaemia, lenkaemias, infections
• ESR (erythrosedimentation rate): Raise in systemic inflammatory and autoimmune disease
• Iron test: Angular cheilitis, painful atrophic glossitis, microcytic anemia
• Folate level and vit. B12 level: Recurrent aphthous, ulceration, recurrent candidosis and atrophy of papillae of the tongue
• Viral antibody titers e.g herpes simplex, varicella zoster, mumps virus
• Syphilis serology: Syphilis
• Serum calcium and parathormone level: A- increase the level of Ca++ Hyperparathyroidism, Malignent Metastasis to bone, Multiple Myeloma, Hypovitaminosis, paget’s disease of bone. B- decrease the level of Ca++ Hypoparathyroidism, Vitamin D diffeciency (rickets, osteomalacia decrease intestinal calcium absorption and renal insufficiency and in cases of tetani
• Serum phosphate po4 A- increase the level of po4 Chronic renal disease, healing bone fracture, hypopara- thyrodism, Hypervitaminosis D, increase of level of Growth Hormon B- decrease the level of po4 Rickets disease and osteomalacia
• Blood Glucose level
A- Increase blood glucose level.
Diabetic Mellitus, cushinges diseases, in patient taking corticosteriod and thiazid diuretic drug.
B- decrease blood glucose level.
Insulin –secreting tumor, extensive liver disease, pituitary hypofunction, addison’s disease Mal absorption of monosaccharides.
• Serum Bilirubine
Haemolytic anaemia, biliary obstruction, hepatitis, hepatic malignancy.
• Serum uric acid
Gout, renal failure, leukaemia lymphoma, thiazid diuretic.
• Serum Alkaline phosphate
High level in condition with increased bone turnover e.g paget’s disease, hyperparathyroidism, hypophosphatasia.
• Serum creatinin Increased in kidny disease, acromegaly and patient with large muscle mass.
OTHER TESTS
• URINE TEST Diagnosis of diabetes, autoimmune conditions which damage the kidney • TEMPERATURE TEST - if the bone or soft tissue infection are suspected - It helps distinguish facial inflammatory odema from cellulitis - Systemic effect of infection and the need for more aggressive treatment • BLEEDING TIME TEST • CLOTTING TEST • BLOOD PRESSURE - Hypertension - Hypotension
Thank You