principles of oral diseases diagnosis

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2/16/2011 1 Principles of oral disease diagnosis Prepared by Dr.Faiq M. Amen lecturer B.D.S MSc Oral medicine University of sulaimani College of dentistry sulaimani iraq Email –dfaiq@yahoo.com

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2/16/2011 2 Also Provide dental and oral health care for patients with medical diseases that affect dental treatment , including patients receiving treatment for: Cancer, Diabetes, Cardiovascular diseases, and Infectious diseases. The field of oral medicine consists chiefly of the diagnosis and medical management of the patient with complex medical disorders involving the: Oral mucosa Salivary glands Oro facial pain and Temporomandibular disorders.

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2/16/2011 3 Early detection of oral disease very important, because: Some of them fatal like squamous cell carcinoma, Cyanosed patient (give us a hint of heart or lung problem). palatal petechia give us a hint of bleeding tendency, other oral diseases may be a sign and symptom of systemic disease like diabetes mellitus, diagnosis of these disease, depend on some important points, we hope that every dentist can diagnose these lesions.

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2/16/2011 4 This process can be divided into the following four parts: 1-Taking and recording the medical history. (Subjective) 2- Examining the patient and performing laboratory studies. (Objective) 3- Establishing a diagnosis. (Assessment) 4- Formulating a plan of action (including dental treatment modifications and necessary medical referrals). (Plan)

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2/16/2011 5 Medical history: A-Name-Age-Sex- Address –Occupation: B-Chief complaint: C-History of present illness: D-Past medical history: E-family history: F-Social history: G-Past dental history: H-Review of systems: Weight changes, Changes in appetite Sinus problems. Epistaxis, Chest pain, Rashes, jaundice. Polyuria, polydipsia, polyphagia, Temperature intolerance, Easy bruising, Spontaneous gingival bleeding, increased bleeding after trauma, Swollen or enlarged lymph nodes.

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2/16/2011 7 Clinical examination: Starts as soon as the patient enter the clinic whether he looks ill or in good health, pale or cyanosed. A-Inspection (visual examination) B-Palpation (digital examination) C-Percussion D-Auscultation E- Vital signs: Normal blood pressure, 120/80 , Tempreture, 37 c. Breathing. 16 times/minute Pulse rate (is between 60 and 100 beats per minute)

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2/16/2011 8 We can devide clinical examination in to: 1-Extra oral examination including: Asymmetry of the face any swelling. Pigmentation. Colour changes. Conditions that affect facial appearance. Anaemia, thyroid disease, jaundice, parotid swelling, cervical nodes, tempro mandibular joint (deviation ).

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2/16/2011 9 Can only be performed with: Good light Mirror Compressed air or other means of drying. Examine: Lips, Bucal mucosa of vestibule , Hard or soft palate , Pharynx, Tongue, Floor of mouth , Jaw relation. Salivary glands, Lymph nodes. 2-Intra oral examination: Be familiar with some anatomical variants: Fordyce granules, Lingual tonsils , Circumvallate papilla, Leukoedema , Tori . Consistency upon palpation Colour upon palpation Dermatologic lesions

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2/16/2011 10 To perform this examination procedure successfully, the examiner needs the following: 1. Adequate knowledge of the anatomy of the region to be able to recognize normal structures and their common variations. 2. A well-practiced technique for displaying all of the skin and mucosal surfaces of the head, neck, and oral cavity with minimal discomfort to the patient and a routine that ensures the systematic examination of all the tissues that can be approached in this way. 3. Knowledge of the variety of disease processes that can affect the superficial structures of the head, neck, and oral cavity. 4. The ability to succinctly record (in writing) both normal and abnormal findings noted during the examination.

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2/16/2011 11 1. Macules. Well-circumscribed, flat lesions that are noticeable because of their change from normal skin color. They may be red due to the presence of vascular lesions or inflammation, or pigmented due to the presence of melanin, hemosiderin, and drugs. 2. Papules. Solid lesions raised above the skin surface that are smaller than 1 cm in diameter. Papules may be seen in a wide variety of diseases including erythema multiforme simplex, rubella, lupus erythematosus, and sarcoidosis. 3. Plaques. Solid raised lesions that are over 1 cm in diameter;they are large papules. 4. Nodules . These lesions are present deep in the dermis,and the epidermis can be easily moved over them. 5. Vesicles. Elevated blisters containing clear fluid that are under 1 cm in diameter.

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2/16/2011 12 6. Bullae. Elevated blisterlike lesions containing clear fluid that are over 1 cm in diameter. 7. Erosions. Moist red lesions often caused by the rupture of vesicles or bullae as well as trauma. 8. Pustules. Raised lesions containing purulent material. 9. Ulcers. A defect in the epithelium; it is a well-circumscribed depressed lesion over which the epidermal layer has been lost. 10. Purpura . Reddish to purple flat lesions caused by blood from vessels leaking into the subcutaneous tissue.Classified by size as petechiae or ecchymoses, these lesions do not blanch when pressed. 11. Petechiae. Purpuric lesions 1 to 2 mm in diameter.Larger purpuric lesions are called ecchymoses.

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2/16/2011 13 Investigations: 1- Imaging: 2- Biopsy: 3- Haematological, Chemical, Bacteriological, and Serological examination.

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2/16/2011 14 1- Imaging: a- Radiography (extra oral and intra oral). b- Computerized tomography (CT-scan) provides tomography (sectional) clear images with out superimposition. c- Using contrast media with plain radiography or CT-SCAN Ex : in salivary gland ducts sialography , hollow lesions such as cystic or blood vessels arteriography. d- Magnetic resonance imaging (MRI) .good for soft tissue lesions. e- Ultrasound useful for soft tissue masses such as salivary gland, cysts and stones also dental lesions in the thyroid gland and neck.

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2/16/2011 15 Plain occlusal film This is a sialogram of the submandibular gland demonstrating an uncalcified sialolithiasis in Wharton’s duct

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2/16/2011 17 2-Biopsy: A biopsy is the removal of a small piece of tissue for microscopic examination and/or culture, often to help the physician make a diagnosis.

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2/16/2011 18 SCC

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2/16/2011 20 3-Haematological ,Chemical, Bacteriological, and Serological examination:

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2/16/2011 21 A complete blood count (CBC) test: measures the following: The number of red blood (RBCs) The number of white blood (WBCs) The total amount of hemoglobin in the blood The platelet count is also usually included

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2/16/2011 22 a-Hb concentration: Normal concentration for: Adult male 14-18 gm/dl Female 12-16 gm/dl (At birth 18gm/dl ). b-Erythrocytes count: Normal value for: Adult male is 4.5-6.5 million/mm3 Female 4.5-5.0 million/mm3

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2/16/2011 23 High numbers of RBCs may indicate: Low oxygen tension in the blood Congenital heart disease Cor pulmonale (congestive heart failure) Pulmonary fibrosis Polycythemia Dehydration (such as from severe diarrhea) Renal (kidney) disease with high erythropoietin production.

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2/16/2011 24 Low numbers of RBCs may indicate: Blood loss Anemia(various types) Hemorrhage Bone marrow failure (for example, from radiation, toxin, fibrosis, tumor) Erythropoietin deficiency (secondary to renal disease ) Hemolysis (RBC destruction) Leukemia Multiple myeloma Malnutrition (nutritional deficiencies of iron, folate, vitamin B12 or vitamin B6 ).

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2/16/2011 25 c-Packed cell volume (PCV): Volume occupied by erythrocytes in 100 ml of centrifuged blood. Normal: Male 40-50% Female 35-45% If PCV increase Polycythemia If PCV decrease Anemia.

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2/16/2011 26 d-W.B.C. counts: Normal value 4-11 thousand/ mm3 of blood. The differential W.B.C.: Nutrophiles: 40-75% Lymphocytes: 20-45% Monocytes : 2-10% Eosinophilis: 1-6% Basophilis: 0-1%

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2/16/2011 27 Increase or decrease in each one of these types is an indication of some disease problem: Nutrophiles : Bacterial infections. Lymphocytes : Viral infections. Monocytes : TB, Malaria, Hepatitis, Syphilis, Lukemia. Eosinophilis : Allergic disease. Basophilis: Leukemia.

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2/16/2011 28 Low numbers of WBCs (leukopenia) may indicate: Bone marrow failure (for example, due to infection, tumor or fibrosis). Presence of cytotoxic substance. Autoimmune/collagen-vascular diseases (such as lupus erythematosus ). Disease of the liver or spleen. Radiation exposure. High numbers of WBCs (leukocytosis) (Above 11000/m m3) may indicate: Infectious diseases. Inflammatory disease (such as rheumatoid arthritis or allergy). Leukemia. Severe emotional or physical stress. Tissue damage, such as burns.

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2/16/2011 29 e-Blood film examination: Is a survey of a stained of a blood looking for abnormal cells. Abnormal W.B.C. is indication of leukemia. R.B.C. may also show variation in: Size, shape maturity ,depth of staining in the blood film. Size : Normocyte, Microcyte, Macrocyte. Depth of stain : Normochromic,Hypochromic,Hyperchromic. Microcytic and hypochromic cells (small size with faintly stained because of less continent of Hb) on examination of iron deficiency anaemia. Macrocytic and hyperchromic cells (large size and deeply stained because of contain large amount of Hb) found in pernicious anaemia.

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2/16/2011 30 f-Serum vit.B12: Normal value 140-725 mg/L Vit.B12 defeciency associated with recurrent aphthous ulceration and recurrent candidosis. G-Serum folate level: Normal value 1.9-9.0 mg/L. Folic acid deficiency associated with: recurrent aphthous ulceration and recurrent candidosis. It decreases in certain situation such as pregnancy, Mal absorption , Diet deficiency. H.ESR: Normal Male 0-15 ml/hr Female 0-20 ml/hr. It is a non specific indication of pathological changes. (Arthritis, Malignancy).

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2/16/2011 31 Investigation for clotting disorders: 1-Clotting time 4-10 minutes at 37 c Prolonged in factor 8 deficiency (hemophilia) Factor 9 deficincy (Christmas disease) 2-Bleeding time 2-3 minutes Prolonged as a result of: 1-Abnormality in structure of capillary (Von wilbrand disease). 2-Abnormality in function. 3-No. of platelets. Normal Platelet counts 150 000-500 000/mm3 Decrease in the number of platelet--thrombocytopenia (leukaemia, aplastic anemia).

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2/16/2011 32 Blood sugar concentration: Used in the diagnosis of diabetes mellitus which is clinically reflected as dryness of the mouth and burning sensation. 1-Fasting blood sugar (F.B.S). Test in the morning before breakfast, fasting 12 hours. Normal range 65-110 mg/dl=3.6-6.1 mmol. 2-Random blood sugar (R.B.S.) Normal 200mg/dl or 11 mmol. 3-Oral glucose tolerance test (O.G.T.T.) It is advantage of detecting diabetes at it is earliest stage. The patient is instructed to take 75gm glucose before the test then blood is tested after ½ hour then after 1,1.5,2.0 hour. If two of these is above 200 so the patient is diabetic. After 2 hours blood sugar should not be more than 126mg/dl.

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2/16/2011 33 4-Glycosylated hemoglobin (HbA1c): Providing a measure of the average of blood glucose level over the preceding 3 monthes (120 days) the life span of erythrocyte. It consider as an indicator for the degree of a control of a patient diabetes. Normal value is 6%. glycosylated haemoglobin Hb Sugar HbAIC it can tell you how high your blood glucose has been on average over the last 8-12 weeks. A normal non-diabetic HbA1C is 3.5-5.5%. In diabetes about 6.5% is good. Controlled diabetes, not much glucose, not much glycosylated haemoglobin Uncontrolled diabetes, more glucose, much more glycosylated haemoglobin Life span of RBC 8-12 weeks 9=240 1o=275 11=310 12=345 6=135 7=170 8=205

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2/16/2011 34 Urinalysis: It can provide valuable information regarding: Renal function. Liver function. Metabolic disease (e.g. diabetes mellitus). The presence of protein or blood could indicate renal or bladder disease. The finding of bilirubin in the urine could indicate liver disease. Bacteriological investigation: Swab may be taken from area of microorganism, the microorganism is identified and tested for antibiotic sensitivity.

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2/16/2011 35 Tuberculosis: Clinical signs and symptom, chest x ray. Tuberculin test. Demonstrating acid fast bacilli by using Zeihl nelson stain. Growth of mycobacterium tuburculosis on sputum culture. Histopathological study of biopsy from the lesion. Blood culture: When there is a sever bacterial infection culture of blood is important especially for those patients with heart problem like rheumatic heart disease and congenital heart disease or heart prosthetic, because dental procedure cause bacterimia which lead to endocarditis and may be fatal for those patient.

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2/16/2011 36 HIV infection confirmed by demonstrating the presence of antibody to HIV in serum. The current enzyme-linked immunosorbent assay ( ELISA ) test used for detection of such antibody. Immunoblot (western blot) test also detect HIV antibody. Polymerase chain reaction ( PCR ) detect the presence of virus genome in peripheral lymphocytes. AIDS:

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2/16/2011 37 Plan of Treatment: The diagnostic procedures, History, Physical examination, Imaging and laboratory studies, are designed to assist the dentist in establishing a plan of treatment directed at those disease processes that have been identified as responsible for the patient’s symptoms. A plan of treatment of this type, which is directed at the causes of the patient’s symptoms rather than at the symptoms themselves, is often referred to as rational, scientific, or definitive, (in contrast to symptomatic , which denotes a treatment plan directed at the relief of symptoms, irrespective of their causes).

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2/16/2011 38 Patients with the same clinical condition may require different treatment according to the underlying medical condition which may cause complication if the treatment is not modified. A patient with hemophilia may require factor concentrates to elevate factor VIII levels prior to oral surgery . Patient with the mobile teeth, periodontitis , xerostomia and poly urea, may give us a hint that he is a diabetic , so treatment should be modified . Also patient with congenital heart diseases or artificial values need antibiotic prophylaxis, before dental extraction. Illness for example palatal petechia give us a hint of bleeding tendency (blood dyscrasia ,thrombo cytopenia). White lesions candidal thrush may be due to immune supression (HIV infecting – drugs ) .

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2/16/2011 39 The dentist may choose to hospitalize patients for dental treatment of the following disorders: 1. Bleeding disorders due to hereditary disease, bone marrow suppression or extensive liver disease. 2. Susceptibility to shock due to adrenocortical insuffi-ciency or uncontrolled diabetes. 3. Severe cardiovascular disease. 4. Susceptibility to infection due to primary or secondary immunodeficiency. 5. Need of heavy sedation or general anesthesia. 6. Neuromuscular or other physical disability requiring special dental equipment for proper management.

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2/16/2011 40 Thanks Prepared by Dr.Faiq M. Amen B.D.S MSc Oral medicine University of sulaimani College of dentistry sulaimani iraq Email –dfaiq@yahoo.com