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