Examination in Oral Diseases 3 & Principles of Treatment in Oral Diseases PDF

Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. SPECIAL EXAMINATION PROCEDURES Special examination procedures: A. Blood tests (complete blood count, hemoglobin amount) are used to reveal anemia. B. Serum iron, total iron binding capacity (requested in iron deficienci...

Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. SPECIAL EXAMINATION PROCEDURES Special examination procedures: A. Blood tests (complete blood count, hemoglobin amount) are used to reveal anemia. B. Serum iron, total iron binding capacity (requested in iron deficiencies) C. Erythrocyte sedimentation rate measurement. Important in chronic inflammatory conditions and neoplasms. In recurrent oral ulceration and stomatitis, there is a decrease in red blood cell levels and serum B12 levels. Conditions where the sedimentation rate is increased: Infectious diseases Inflammatory diseases Rheumatic fever Rheumatoid arthritis Tumors Connective tissue diseases (collagen vascular diseases) Glomerulonephritis (kidney diseases) Tuberculosis Myocardial infarction Biopsy Biopsy involves taking a sample from the suspicious tissue and conducting a histopathological examination. No matter which biopsy method is applied, if the correct sample is taken from the correct place, the pathology diagnosis will also be accurate. Incorrect or insufficient sampling or improper fixation makes pathology diagnosis impossible. A biopsy can be defined as the process of taking a part or all of the suspicious tissue to send it to pathology for a definite diagnosis. If the suspicious tissue is small, all of it is sent to pathology, completing the surgery. This is called excisional biopsy. If the lesion is large and anatomical relationships are important, a sample is taken from the suspicious tissue and sent to pathology. The operation is completed based on the result from pathology. This is called incisional biopsy. Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. Types of Biopsies: Oral cytology Aspiration biopsy and fine needle aspiration technique Incisional biopsy Excisional biopsy Frozen section technique ORAL CYTOLOGY It is a method that can assist in the diagnosis and monitoring of dysplastic lesions specific to mucous membranes; it is similar to the PAP-smear method used in gynecology (exfoliative cytology). It is not widely used due to evaluation difficulties and a high number of false-positive results. In this simple technique, the surface is scraped with a spatula that does not have sharp edges, and the material is spread on a slide. The sample taken is transferred to bottles containing special liquid prepared for such studies and sent to pathology. In the liquid-based cytology technique, special sticks called "swabs" are used. The pathology laboratory examines the sent material by staining it using appropriate methods. However, recent advances have shown that "computer-assisted brush biopsy" reduces the disadvantages in cytology. In this method, samples are taken with special brushes. During the microscopic examination, images transferred to a computer are evaluated by a special program. ASPIRATION BIOPSY It is a useful method for evaluating the physical and chemical properties and cellular content of fluid-filled cystic formations. It is generally applied to central (intra-bone) lesions. It is based on the principle of drawing fluid by creating negative pressure in a syringe using special needles. FINE NEEDLE ASPIRATION BIOPSY "Fine needle aspiration biopsy" is a method applied to solid tumors as well; it is an alternative to large operations in central lesions. In this method, tissue samples are taken by entering the lesion with a needle of appropriate thickness (tru-cut method). Having a pathology specialist present during the procedure helps determine whether the material is sufficient for diagnosis. Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. INCISIONAL BIOPSY It generally involves taking samples from large lesions, those that cannot be excised due to their location, and lesions suspected of malignancy. The biopsy sample should include some healthy tissue in three dimensions and avoid areas of necrosis and degeneration. During the surgical procedure, care should be taken to ensure that the biopsy sample has reached sufficient depth and that the tissues grasped with forceps or similar instruments are not crushed. When performing an incisional biopsy of a lesion like leukoplakia, which is a mucosal lesion, sufficient tissue depth should be obtained (about 6 mm). PUNCH BIOPSY TECHNIQUE The punch biopsy technique, especially for taking samples from skin and mucous membranes, is another option. The instrument used in this technique is a plastic-handled rod with a hollow metal cylinder with very sharp edges. The sharp edge is applied to the biopsy area with circular motions and slight pressure while holding the plastic handle. EXCISIONAL BIOPSY It involves removing the entire clinical lesion. The excisional biopsy method is typically applied to lesions 1 cm or smaller, those that appear benign, and those that are conveniently located. Attention must be paid to the surgical margin; there should be at least 2-3 mm of normal tissue around and beneath the biopsy. For malignant, vascular, and pigmented lesions, a wider surgical margin is necessary (at least 5 mm). During the surgical procedure, care should be taken not to crush or traumatize the tissues grasped with forceps or similar instruments. Enucleation involves the removal of cystic or solid formations in deeper tissues along with their capsule. If regional block anesthesia is not performed for excisional biopsy, local infiltrative anesthesia should be administered slightly away from the lesion to prevent tissue distortion in the operation field. Examples of Biopsy Procedures: Superficial lesions are usually pedunculated. Fibroepithelial polyps and squamous papillomas are such lesions. Since most papillomas are viral, many surgeons prefer electrosurgery for their removal. For large, broad-based lesions, an elliptical incision is preferred. The incision is made with a no. 15 scalpel blades, and 1-2 mm of normal tissue is also taken. The wound is closed flat. Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. FROZEN SECTION TECHNIQUE It is a method applied at the stage of deciding on radical operations. It is applied to tumors detected in the breast, brain, and other regions that cannot be diagnosed as benign or malignant using clinical and radiological diagnostic methods. The biopsy area is opened under general anesthesia, and a sample is taken. The pathology specialist examines and determines the nature of the lesion by freezing and staining the sections, and the result is communicated to the surgical team. This process is completed in about 10-15 minutes. If the pathology specialist reports a diagnosis of a malignant tumor, radical surgery is performed. If the lesion is benign, total excision is performed to complete the operation. When special staining methods are required without formalin fixation, the frozen section technique is used. For example, the frozen section technique is applied in autoimmune diseases with vesiculobullous characteristics that require the application of immunofluorescence techniques. PRINCIPLES OF TREATMENT IN ORAL DISEASES For certain lesions of the oral mucosa, specific treatment can be applied based on the diagnosis. For example, if the organism is known, an appropriate antibiotic can be used for infections. However, in many oral lesions, such rational treatment may not be suitable. This may be due to a lack of information about the factors causing some lesions. Therefore, treatment methods aimed at alleviating symptoms may be necessary to relieve the patient. These treatments can include topical antibiotics, topical antiseptics, local and systemic corticosteroids, and drugs affecting the immune system. 1. Topical Treatment: Topical treatment has numerous advantages over systemic drug applications. The side effects of some drugs are significantly reduced when applied locally. Additionally, locally applied agents become more effective when used for longer durations. Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. a. Occlusive Agents (Ointments): Several gels and ointments have been developed to protect ulceration areas in the mouth. There are many commercial preparations of this kind, and some can be prepared by pharmacists. Unfortunately, patients often find the application of these ointments difficult, especially at the back of the mouth. b. Topical Antiseptics: Chlorhexidine has antibacterial and anticandidal activity and is currently the most effective antiplaque agent. Chlorhexidine can be used as a mouthwash, spray, or gel and is a short-term alternative to control secondary infection in mucosal ulcerations. However, it often stains teeth brown and can affect the color of the tongue. The staining of teeth is reversible, but long-term use can create problems. Some patients report that chlorhexidine does not taste good. Occasionally, this substance causes idiosyncratic mucosal irritation. Swelling of the parotid gland has been reported in a few patients after using chlorhexidine. Apart from chlorhexidine, patients can also be given Betadine or Biokadin mouthwash after oral surgeries. c. Topical Analgesics (Anti-inflammatory Agents): Topical analgesic preparations such as benzydamine provide temporary symptomatic relief when eating and drinking become difficult due to erosive and ulcerative lesions. In Turkey, preparations like Benzidan spray, Benzidan gel, and Benzidan mouthwash are used for this purpose. Topical anesthetic agents containing lidocaine can also be used as a mouthwash solution. This preparation provides short-term relief. Care should be taken when using lidocaine mouthwash for an extended period, as systemic effects can occur. Lidocaine gel should be used cautiously at the back of the mouth, as it may affect laryngeal reflexes. In Turkey, there are no spray and rinse (mouthwash) forms available. The lidocaine gel preparation is sold under the name 'Lidestol Gel.' After thoroughly drying the oral mucosa, lidocaine gel is applied and continued at appropriate intervals (should not be used more than three times a day). If burning occurs, the area should be washed to remove the drug. Equivalents include Lokalen ointment, Lidestol gel, Anestol ointment, and Dentinox gel. Some throat conditions and oral ulcers can be treated with lozenges that contain local anesthetics. These contain sugar and have cariogenic potential, so patients should be warned about this. d. Topical Antibiotics: Topical antibiotics have disadvantages due to the potential for hypersensitivity reactions. A 2% tetracycline solution provides Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. relief by reducing secondary infection in aphthous stomatitis, primary herpetic stomatitis, erosive lichen planus, and other ulcerative lesions. However, tetracycline may stain teeth. Using topical antibiotics to prevent symptoms related to secondary infection is an effective measure. They can be used in severe ulceration cases in the mouth, but usage must be careful. Broad-spectrum antibiotics have disadvantages as well. Hypersensitivity reactions may occur, microorganisms can develop resistance, and opportunistic organisms like Candida may proliferate. Rarely, antibiotics may cause tongue sensitivity (Antibiotic Sore Tongue). Mouth rinsing with chlorhexidine is particularly effective in reducing discomfort in herpetiform aphthous stomatitis. Topical antibiotics should be used in acute situations and not for long periods. Long-term use may lead to Candida infections. e. Topical Corticosteroids: Topical steroids can be effective in treating recurrent aphthous stomatitis. When used appropriately, steroids are effectively applied in treating minor aphthous ulcers. Their effects are twofold: they provide some degree of anti-inflammatory relief and block T lymphocytes. The most commonly used preparations for this purpose are hydrocortisone hemisuccinate and triamcinolone acetonide. Triamcinolone acetonide (Kenacort A Orabase) is applied to dry ulcers four times a day with a moist finger. Hydrocortisone hemisuccinate preparation is not available in Turkey. Steroid Mouthwashes: Betamethasone or prednisolone tablets dissolved in 10-15 ml of water are used to prepare these solutions. Steroid-containing mouthwashes should not be swallowed due to potential systemic effects. Chlorhexidine-based triamcinolone mouthwash solutions can be applied in different doses depending on the severity of the disease. High doses can result in systemic absorption, so patients should be informed about corticosteroid side effects. The concentration of steroid-containing mouthwashes should be carefully prepared based on the clinical response. Steroid Sprays: They are suitable for use on one or two isolated ulcers or erosions, especially in the anterior region. Steroid sprays are not available in Turkey. Steroid Ointments: Triamcinolone acetonide is used for application 2-4 times a day on aphthous ulcers. In Turkey, Kenacort A Orabase 0.1% is available in 20 g and 5 g ointment forms. This preparation is most effective when applied at night because saliva flow is reduced at night and the patient is not eating. 2. Systemic Treatment Yrd. Doç. Dr. Erim Tandoğdu Ağız, Diş ve Çene Cerrahisi A. D. Drugs used in this group are applicable only if topical treatment has failed. Systemic corticosteroids have significant side effects. These treatments should be applied mainly in serious diseases such as Behçet's disease and pemphigus. Patients receiving systemic corticosteroid treatment are at risk of hypotensive adrenal crisis if dental and maxillofacial procedures are performed under general anesthesia. Systemic corticosteroids include thalidomide, azathioprine, cyclosporine, colchicine, and dapsone. SIDE EFFECTS OF SYSTEMIC CORTICOSTEROID TREATMENT Hypertension Sodium and water retention Potassium loss Diabetes Osteoporosis Mental disorders Peptic ulcers Opportunistic infections Lymphomas Suppression of growth in children