Oral Medicine & Diagnosis PDF - Cairo University 2021

Faculty of Dentistry, Cairo University PRINCIPLES OF ORAL DIAGNOSIS Department of Oral Medicine and Periodontology 2021 PRINCIPLES OF ORAL DIAGNOSIS Prof Dr Fat’heya Zahran Professor of Oral Medicine &...

Faculty of Dentistry, Cairo University PRINCIPLES OF ORAL DIAGNOSIS Department of Oral Medicine and Periodontology 2021 PRINCIPLES OF ORAL DIAGNOSIS Prof Dr Fat’heya Zahran Professor of Oral Medicine & Head of Oral Medicine and Periodontology Department Contributors Dr Gihan Ghareeb Hassan Ass Prof, Oral Medicine Dr Shereen Ali Hassan Ass Prof, Oral Medicine Dr Wessam Abdelmoneim Ass Prof, Oral Medicine Dr Mai Zakaria Ibrahim Lecturer, Oral Medicine Dr Eman Mohamed Amr Ass Prof, Oral Medicine Dr Mariam Fakhr Lecturer, Oral Medicine Dr Amal Ali Hassan Lecturer, Oral Medicine Dr Basma Abdelaleim Lecturer, Oral Medicine  CONTENTS Pages  Oral Diagnosis 1  Communication Skills in Dentistry 5  Patient’s History: 10 - Identification data 12 - Chief Complaint 15 - History of chief complaint 16 - Pain as Chief Complaint 21 - Ulcer as Chief Complaint 32 - Swelling as Chief Complaint 34 - Burning Sensation 36 - Paraesthesia and Numbness 36 - Bleeding as Chief Complaint 37 - Other Common Complaints 38 - Dental History 40 - Health History 43  Clinical Examination 54 - Examination Methods 54 - Extraoral Examination 59 - Intraoral Examination 86  Laboratory Investigation 104 - Hemogram 104 - Tests for Hemostasis 112 - Tests for Diabetes mellitus 118 - Liver Function Tests 124 - Kidney Function Tests 129 -Biopsy 130  Oral Cancer Detection 140  Treatment Planning 160  Referral and Consultation 166  References 176  ORAL DIAGNOSIS Oral diagnosis is the art of using scientific knowledge to identify oral disease processes and to distinguish one disease from another. Oral diseases refer to diseases either localized in the oral cavity or those which appear as oral manifestations of systemic diseases. Types of Oral Diagnosis: 1) Comprehensive oral diagnosis: It is done for the patients requiring total dental care. It entails the listing of all dental problems (performing a "problem list") comprising all oral findings that require dental treatment (caries, exposure, edentulous areas, etc...) then a comprehensive dental treatment plan can be designed to achieve optimal oral functions. Any comprehensive diagnostic procedure should include: 1- History taking. 2- Clinical examination. 3- Laboratory investigations (if needed). 2) Emergency diagnosis: The immediate diagnosis of the patient's complaint that requires immediate attention and management by the dentist (acute dental pain, accidental fractures,..). The emergency interferes with obtaining adequate history or full clinical examination (only the area of chief complaint). 3) Spot (snap) diagnosis: In simple cases where rapid diagnosis can be achieved perfectly, based on minimal data e.g. palatal ulcer + history of eating hot pizza = diagnosis of pizza burn. 4) Differential diagnosis: It is the collection and categorization of data to develop a list of two or more different diseases having common primary clinical presentation (though different in etiology). This presentation may be in the form of: - Change in colour: i. White lesions, or white and red lesions ii. Pigmented lesions (red, yellow, brown,…) - Loss of mucosal integrity in the form of ulcers or erosions. - Soft tissue swelling (fibroma, lipoma,….) - Bony lesions. The most likely lesion is put on top of list (presumptive diagnosis, according to clinical impression) then through history, clinical examination and special investigations (if needed), final diagnosis can be reached by "exclusion". 0  White lesion Red and white lesion. Brown lesion Ulcers Soft tissue swelling Bony lesion 5) Tentative (working or provisional) diagnosis: It is primary, uncertain diagnosis before all diagnostic data are assembled. Final or definitive diagnosis is then reached by confirming the tentative diagnosis or changing it according to: either: response to treatment (+ve or – ve) or : result of diagnostic aid e.g. biopsy. 6) Definitive (final) diagnosis: It is the final diagnosis based on accurate appraisal of all available data (case history, clinical examination and special investigations) that point clearly to a specific disease entity. Some Definitions Used: Technical aid (diagnostic aid) Any technique or special instrument used to help the establishment of a diagnosis such as pulp testing procedures, biopsy, radiographs, blood analysis, urine analysis, … etc. Symptoms and signs: All findings can be grouped as either symptoms (subjective) or signs (objective). Symptoms (subjective): 1  Symptoms are complaints that are described and reported by the patient and cannot be detected by the examiner. For example, pain, sensitivity to hot or cold, altered taste, paraesthesia, nausea and past occurrence of bleeding or swelling. Signs (objective findings): Objective findings are the changes or deviations from normal that can be detected by the examiner. For example, discoloration of teeth or soft tissues, swelling, tenderness to palpation and abnormal consistency of a part. Obviously some overlap between subjective and objective findings is possible. Common conditions such as discoloration, bleeding and mobility of teeth are noticed by both the patient and dentist. Also, a patient may report feeling hot and feverish (symptom) and have a measurable fever (39ºC) detected by the examiner (sign). Prognosis Prognosis is to guess the final outcome of the disease. It is the prediction of the duration, course and termination of the disease and the likelihood of its response to treatment. Prognosis is usually expressed in general terms as ―excellent, ―good or ―poor. Prognosis must be determined before the treatment is planned. It depends on the patient‘s attitude, his oral hygiene and desire to retain his natural dentition. It also depends on condition of teeth, costs as well as experience and technical skill of the operator. 2  COMMUNICATION SKILLS IN DENTISTRY Communication skills is a term used to describe verbal words and non-verbal actions used in the interaction between two persons. Verbal communication is the ability to present one‘s ideas in clear words to different persons. Non-verbal communication is the ability to express one‘s ideas through the use of body language, voice tone, facial expressions, clothing, and also the use of pictures, posters, symbols, … etc. Effective communication is important to achieve good dentist-patient, dentist-coworkers, and patient-coworkers relationships. This is crucial for a successful dental clinic. Active listening involves trying to understand what the speaker is trying to transmit. It includes not only the speaker‘s own words, but also the tone spoken with, the facial expression, and the body language. Dealing with difficult patients Types of difficult patients:  The talkative patient  The silent patient  The angry patient  The depressed, sad patient  The anxious patient  The dramatic patient  The long suffering patient  The restless patient The main rules to handle difficult patient or co-worker:  Keep cool & calm  Don‘t try to change him (her)  Set firm boundaries  Acknowledge his (her) feelings  Use fewer words  Use the word ―we‖ or ―the clinic‖ instead of ―I‖  Write the patient‘s comments down To allow proper dentist-patient communication, there are main five points that should be carefully managed during the dental visit. 1- Patient first contact & history taking: Since first impression lasts long, focusing on some points is necessary: 3  Receive the patient while standing and introduce yourself with a friendly smile.  Introduce your staff.  Explain what will happen during the visit  Sit at the patient‘s eye level & keep eye contact.  Listen to the patient‘s complaint & watch his (her) body language.  Listen to his (her) concern & try to have an idea about the expectations from treatment.  Don‘t use scientific or technical words (dental jargon).  Ask the permission for adjusting chair position & starting examination. 2- The dental examination: Careful dental examination is one of the most important steps during the visit. 3- Discussing treatment options: In order to help the patient to take the decision that meets his (her) expectations, detailed discussion of treatment plan options is of great importance.  First explain the findings after your examination  Explain in details every treatment option including steps, the overall duration, the longevity, etc…  Use simple words  Use pictures, models, or posters to simplify your words  Summarize what you said to check out that you have been understood INFORMED CONSENT - This is “permission obtained as a result of information sharing in the dialogue between the dentist and patient”. No treatment should be performed without the consent of the patient. - Consent must be obtained in advance of treatment – not in the middle and not after. Remember to document consent decisions in the patient’s chart. 4- Discussing fees: Discussing fees is rarely comfortable.  Many patients are embarrassed to ask about the fees, so you have to take the lead.  Never let the subject be told by co-workers  Hold the discussion while the patient is sitting in upright position  The patient needs to know that fees are determined on many factors, most of them can‘t be changed like materials, lab work, … etc  Don‘t conclude the conversation while the patient is walking away  Use your patient‘s name at least at the beginning and at the end of the conversation 5- Concluding the visit 4   Paraphrase and summarize the treatment plan options and the one chosen by the patient  End the visit by asking the patient ―Do you have any other questions or concerns?‖ According to the American Dental Association, the top 10 skills for success in dental communication can be summarised as follows: 1. Build rapport with patients Verbal skills: conversation starters (about work, school,study…), compliment plus question, free information Non- verbal skills: greeting patient with their name Introduce yourself to the patient Smiling Firm confident hand shake Eye to eye contact When appropriate, compliment patient 2. Listen carefully Why? For diagnostic accuracy, patient satisfaction, and patient persuasion You need:  Attention  Patience  Time  Emotional control Examples: Turn away from the computer Put the chart down or the history taking sheet Eye to eye contact Move closer to the patient Nod and smile Interrupt with more focused questions to save time Use less open end questions and more leading questions 3. Speak with confidence and assertiveness 4. Explain dental condtions Communication Support for the Oral Examination 5   Tell the patient what is about to happen  Explain the head and neck examination  Explain the oral examination  Involve the patient 5. Convince patient to accept the treatment  Begin with outline  Appeal to patient values and priorities  Don‘t refer to teeth by numbers  Avoid medical jargon  Don‘t tell them what you like to do  Use more patiepractical examples  Use appropriate humor  List advantages and disadvantages of treatment 6. Overcome patient objection to treatment 7. Respond to difficult patients 8. Manage financial discussion at a later stage 9. Get patient to take actions 10. Effective team communication PATIENT’S HISTORY A History Serves the Following: 1- To discover complaints about oral structures. 2- Recognition of underlying medical problems which is important in : a. Prophylactic measures may be necessary for the safety of patient and clinician. b. Unusual reaction to drugs can be discovered c. Referral to a physician may be necessary. 3- To detect any complications associated with previous dental treatment. 4- To detect any diseases running in the family that may be of dental significance or may be a potential threat to the patient during dental treatment. 5- To provide information about oral hygiene methods of the patient, patient‘s diet, and any habits such as smoking. Methods for Obtaining a Patient's History 1. Printed questionnaires. 2. Patient interview. 6 3. Combination of both. It is obvious that a combination of the direct interview and the printed questionnaire would make use of the advantages of each and tend to minimize their disadvantages. Methods of Presenting Questions During the Diagnostic Interview: 1. Open-ended questions Open-ended questions urge the patient to be a narrative. The patient should be allowed to respond fully to the question with few interruptions from the dentist. For example ―Can you tell me about your surgery that was performed last year?‖. The question will direct the patient to describe the entire topic. 2. Closed-ended questions Simple and specific answers are expected for closed-ended questions. After the answer is given the clinician quickly proceed to the next question. The patient answer is limited to a small single sentence or even Yes or No For example: - Do you smoke? 3. Leading questions Leading is a technique, which suggests the answer within the question. For example; the dentist may suspect that recurring morning headache described by the patient is caused by bruxism. The dentist asks: ―Do you grind your teeth during sleep?‖. 4. Indirect questions Indirect question is a way of revealing information beyond what is requested by the question. An example of indirect questions is to give information about the manifestation of a systemic disease e.g. ―have you had chest pain especially following exertion‖. If the answer is ―Yes‖ it may reveal heart problem. 5. Loaded questions: A loaded question is considered a variant of the indirect approach in which an emotional element is inserted into the phrasing to get the patient‘s attention. For example ―With the problems you have, do you think it might be best to extract all of your teeth? Non-verbal responses such as nervous shifting of position or negative facial expressions may reveal the response of the patient to this type of indirect questions. 6. Contradiction questions: The contradiction question states inconsistent information and allows the patient to resolve the contradiction. For example; ―Since you said that you do not have epilepsy, is there another reason for you to be taking a medicine that is usually prescribed to control seizures? 7 Items of History: a. Identification data b. Chief complaint c. History of chief complaint d. Health history e. Past dental history A- Identification Data ( the administrative chart) Recording of routine data of the patient such as code number, name, age, sex, marital status , occupation , address , etc ….. Significance of components of the administrative chart 1 – Code number Code number is essential for record keeping and retrieval of the patient‘s file. 2 – Name Patient‘s full name and how he or she prefers to be addressed should be recorded. Patient‘s name is important for: Record keeping and retrieval of the file. Better communication between the dentist and the patient. 3 – Date of birth (patient’s age) Age is important as certain diseases occur generally in certain age groups and rarely in others. For example : Primary acute herpetic gingivostomatitis, moniliasis, measles and mumps occur commonly in childhood. Squamous cell carcinoma, atrophic and degenerative changes are common in old age. 4 – Sex (gender) Recording the sex of the patient is important particularly in those who carry names that could be taken for both sexes e.g. Esmat. Also, some diseases are common in males e.g. leukoplakia and carcinoma of the lip, while females more frequently suffer from the manifestations of iron deficiency anemia and carcinoma of the breast. 5 – Birth place Birthplace is important to detect diseases acquired in childhood (endemic diseases) such as 8  Dental fluorosis occurs in areas drinking water from wells. Bilharziasis is of common occurrence in Egyptian villages. 6 – Race A race is a genetically determined population group having the same criteria regarding skin colour, hair characters and shape and form of the body and head as well as facial features. Race is important, as certain diseases are dominant in certain races. For example: Blond race is more liable for skin carcinoma, which is rare in Africans and dark skinned individuals. Negroes are more susceptible to Burkitt‘s lymphoma. Jews are more liable to develop pemphigus vulgaris. 7 – Address Address may help in throwing light about the patient‘s social and home background. Patients living near factories are liable for pulmonary diseases. Also, in absence of a phone number, the address may be useful for recalling the patient. Address may also throw light on the socio-economic level of the patient. 8 – Phone number The telephone number of home, office and mobile is important for recalling the patient. Also, rapid recalling of the patient is of special importance during taking oral biopsy when malignancy is suspected. 9- Occupation In some instances, the diagnosis of some diseases will be based on the knowledge of the patient‘s occupation or the nature of his work. Occupational diseases are generally defined as those characteristic of a certain field of human activity and resulting from the effect of the harmful factors of the working environment. For example: Industrial use and manufacture of acids may produce tooth erosion, discoloration and decalcification of the enamel as well as inflammation of the mucosa. Lead intoxication may occur in workers in battery factories, while mercury intoxication may occur in workers in fluorescent lamp manufactures. These heavy metals may form dark metallic line on the patient‘s gingiva. Cancer of the mouth and tongue may occur in industrial workers with tar and arsenicals. Cancer lip may appear following contact with tar and after prolonged exposure to solar rays. Cervicofacial actinomycosis is likely to occur in individuals concerned with cattle. 9 10- Marital status Psychological stress of some married people should be taken into consideration. It may exacerbate or predispose to certain oral diseases such as lichen planus and aphthous ulceration. Also, the marital status may be a source of infection in certain diseases such as T. B., AIDS, and other viral infections. 11- Parent or guardian name and address A parent or guardian, such as a grandparent or a relative, must provide the patient history for a child or legally disabled adult. It is critical to ascertain who can give consent for treatment, and who will be responsible for payment of fees. 12- Physician name and address In some instances, the only dependable source of information may be the patient‘s physician. Medical consultation may be unavoidable to obtain an adequate patient history. B- Chief Complaint The underlying cause for the patient‘s visit to the dentist is known as the chief complaint. It is recorded in the patient‘s own words and in chronological order if the patient has more than one complaint. Common oral chief complaints include: 1- Pain. 2- Sores (ulcers). 3- Swelling. 4- Burning sensation. 5- Paraesthesia and numbness 6- Bleeding. 7- Hypersensitivity with thermal changes. 8- Loose teeth. 9- Occlusal problem. 10- Delayed tooth eruption. 11- Xerostomia (dry mouth). 12- Ptyalism (too much saliva). 13- Bad taste. 14- Halitosis (bad odor). 15- TMJ problems. 16- Esthetic problems. N.B. Patients may come to the dental clinic having no chief complaint:. Regular check-up (notation – no chief complaint) Some patients are accustomed for regular recall appointments usually for routine dental care and treatment of all dental needs. Referred patient The most common type of referred patients is the referral from a general practitioner to a specialist for a specialty level care such as the referrals to an oral surgeon, periodontist, endodontist, orthodontist...etc. In these cases, the complaint of the patient was previously diagnosed by the former dentist and the specialist should concentrate his effort to treat only the complaint for which the patient is referred. 10 C- History of Chief Complaint Learning more about the chief complaint is the "History of the Present Illness." Once it is known why a patient seeks care, it is important to learn as much as possible about the condition that brought her/him to the dentist. How long has the condition been present? Is there pain? What events initiated the condition? These are but a few questions that may be asked to obtain a history of the condition (history of present illness). Onset a) Character of onset: - Sudden (abrupt) - Gradual - Insidious (1) Acute inflammatory conditions Sudden onset = e.g. Acute dento-alveolar abscess, erythema multiforme or (2) Allergic conditions Gradual onset = (1) Chronic inflammatory conditions (2) Neoplastic lesions Insidious onset: The patient discovers the lesion by chance, and can‘t give a precise answer regarding its onset, such lesions include: (1) Congenital malformations (2) Developmental anomalies (3) Physiologic conditions e.g. racial pigmentation. (b) Date of onset: Should be recorded in day, month and year. When compared to date of presentation, the duration can be deduced. Duration: Recorded is hours, days, weeks, months, years, including periods of remissions and exacerbations. Short duration (hours – days): characteristic for acute conditions. Weeks–months: characteristic for chronic conditions and neoplastic lesions ( if with large size malignancy is suspected) Years: characteristic for chronic conditions and benign neoplasms Character and severity : Severity: (Mainly of pain) : This will be affected by pain threshold of patient and may be described as : mild, moderate or severe. 11  Character (of pain ) : may be (1) Throbbing pain means fluid accumulation e.g.: pus accumulation in acute dento- alveolar abscess (2) Lancinating, stabbing, shooting or electric shock like pain: pain of nerve origin e.g. herpes zoster, post herpetic neuralgia and paroxysmal trigeminal neuralgia.. (3) Interference with sleep and work: Acute dental pain e.g. acute pulpitis. Location and site: Location: is the anatomical area : tongue, cheek, gingiva, etc.. Site: is the specific area in an anatomical location e.g. lateral aspect of the tongue N.B. Sometimes pain may be referred from its origin to a remote area. Precipitating factors and relation to other activities: Pain may increase by eating, swallowing, sleeping, cold or hot drinks: which are then called "precipitating factors" (ppt). According to precipitating factors diagnosis could be guessed: e.g. Any exposed dentin will lead to sensitivity with thermal changes specially cold, e.g. carious lesions, exposed root dentin Differentiation should then be done between pain which stops as the stimulus disappears and pain that persists. On the other hand, pain with mastication is related to disease in the supporting structures e.g. periodontal disease, periapical abscess. Relation to other activities: Sometimes pain may accompany activities not related to the oral cavity: Pain on exertion referred particularly to left mandibular region indicates cardiac condition. Pain in upper teeth increasing with leaning downwards indicates maxillary sinusitis. Pain with sleeping may indicate accumulation of edema fluid leading to pressure on nerve endings. Relieving factors: Factors which relieve chief complaint e.g. rest, medications as simple analgesics, vasodilators or morphine should be noted. Also, dental pain relieved by cold water or conversely by hot fomentation. Course: Could be recorded as: Progressive: (increasing in severity) e.g. tumours, acute inflammatory lesions. 12 Regressive (decreasing in severity) e.g. self-drained abscess. Recurrent, intermittent, remission and exacerbation. Recurrent Intermittent Remission/Exacerbation * One lesion heals * It is the same lesion, * Lesion is present all the and a similar one with signs and time, signs are present and appears in the symptoms the change is in the severity same site or disappearing then of symptoms. another site reappearing *Patient is * Patient is completely * During remission no or less completely free free from signs and severe symptoms, from signs and symptoms between reappearing with symptoms between attacks exacerbation attacks * Frequency well * Frequency of attacks * Frequency well separated separated (weeks, is within very short e.g. seasonal. months, years) period of time e.g. within the same day e.g.RAU, - e.g salivary gland e.g. lichen planus erythema stone, accompanied multiforme by intermittent gland swelling, at meal times Paroxysmal trigeminal neuralgia attacks History of recurrence: The history of previous occurrence of the lesion may be of importance in diagnosis, e.g. RAU, erythema multiforme. Distribution: (A) The lesion may be (1) Solitary e.g. traumatic ulcer or (2) Multiple: Multiple lesions are either: i) Unilateral e.g. Herpes Zoster or ii) Bilateral lesions which are either symmetrically distributed e.g. lichen planus or in asymmetrical (random) fashion e.g. erythema multiforme. (B) Lesions may be restricted to one region of the oral cavity e.g. anterior part as 1 ry herpetic gingivostomatitis or posterior part as herpangina. (C) The lesions may be restricted to the oral cavity or distributed both extra and intra orally. Intra oral only e.g. traumatic ulcer, RAU Extra + intra-oral e.g. dermatologic diseases with oral manifestations as lichen planus, lupus erythematosus. 13 Unilateral ulcers of Herpes zoster Single aphthous ulcer Intra-oral lesion of lichen planus Extra-oral lesion of lichen planus (bilaterally symmetrical on cheeks) (violaceous flat topped & polygonal ) Associated phenomena: These are manifestations associated with the complaint: eg Fever (hyperpyrexia with acute abscess). Prodrome of fever, malaise, lymphadenopathy 1 ry herpetic gingiva-stomatitis Foetid odour + pain + bleeding gingiva + mild fever + lymphadenopathy ANUG Previous medication: Mouth washes, analgesics, antibiotics, previously used by the patient, and their effect on c/c., as well as duration of treatment should be noted. e.g. Mouth wash: patient may use anti-inflammatory mouth wash as benzydamine hydrochloride, if pain is relieved, therefore pain is of gingival origin, if not, therefore it is of dental origin. Antibiotics: if c/c. is relieved or better, therefore it is due to bacterial infection. Mild analgesic: if pain is relieved, therefore the condition is not severe Also: sometimes previous medication is the cause of c/c: e.g. Long term antibiotics or cortisone oral candidiasis. I- Pain as Chief Complaint: Pain is the most common symptom for which patients seek help. Causes of oral or maxillofacial pain : 1- Diseases of teeth and supporting tissues. 14  2- Oral mucosal diseases. 3- Diseases of the jaw. 4- Pain in the edentulous patient. 5- Postoperative pain. 6- Pain induced by mastication. 7- Referred pain. 8- Neurological diseases. 9- Psychogenic (atypical) facial pain. Pain from teeth or supporting tissues: May be due to: 1- Pulpal disease. 2- Pulpo-periapical disease. 3- Gingival and periodontal disease. a) Pulpitis: Pulpitis is usually the cause when hot or cold food or drinks trigger the pain. It is also the main cause of spasmodic, poorly localized attacks of pain which may be mistaken for a variety of other possible causes. The pain of acute pulpitis is of a sharp lancinating character peculiar to itself, impossible to describe but unforgettable once experienced. Recurrent attacks of less severe, subacute or chronic pain, often apparently spontaneous, suggest a diseased and dying pulp. b) Acute Periapical Periodontitis: Pain form acute periapical periodontitis should be readily identifiable as there is precisely localized tenderness of the tooth in its socket. Radiographs are of little value in the early stages but useful after sufficient destruction shows itself as loss of definition of the periapical lamina dura. In other cases, acute inflammation may supervene on chronic, and a rounded area of radiolucency is seen. c) Lateral, Periodontal Abscess The tooth is tender in its socket, but is usually vital and there is deep localized pocketing. Occasionally both a periodontal and periapical abscess may form together on a non-vital tooth with severe periodontal disease, or a periodontal abscess may be precipitated by endodontic treatment when a reamer perforates the side of the root. Pain from mucosal lesions: Ulcers generally cause soreness not pain, however, deep ulceration may cause severe aching pain. Examples are: Carcinoma causes severe pain when nerve fibers become involved. Herpes zoster causes severe aching that may be mistaken for toothache. Jaw Diseases: Fractures Osteomyelitis Infected cysts Malignant neoplasms Sickle cell infarcts 15  With the exception of fractures and osteomyelitis which depend in their diagnosis on clinical presentation and radiographic picture, diagnosis depends on biopsy and histological examination. Pain in Edentulous Patients: Denture trauma Excessive vertical dimension Diseases (enumerated earlier) of the denture-bearing mucosa Diseases of the jaws Teeth or roots erupting under a denture Traumatic ulcers, usually the consequence of over-extension, often cause trouble with a new denture. After the denture has been relieved, these ulcers heal within 24-48 hours. Lack of freeway space due to excessive vertical dimension of the dentures prevents the mandible and masticatory muscles from reaching their natural rest position. This causes the teeth to be held permanently in contact. Aching pain is usually felt in the fatigued masticatory muscles, but the excessive stress imposed on the denture-bearing area sometimes causes pain in this region. Very occasionally patients seem unable to tolerate dentures, however carefully they are constructed and complain of such symptoms as gripping, burning, or drawing pain particularly under the upper denture. These symptoms are not associated with any physical changes and are psychogenic. A painful swelling of the jaw in the edentulous patient is probably most often due to an infected residual cyst. Malignant tumours are very much less common but must be considered. As they cannot be reliably distinguished from cysts and other benign conditions by radiography alone , histological examination is therefore essential. Osteomyelitis of the jaws in edentulous patients must be considered virtually only in those who have had radiotherapy to this region. In such patients denture ulceration can allow infection to penetrate and set up persistent painful chronic osteomyelitis of the ischemic bone. Retained roots or rarely, late eruption of buried teeth beneath a denture become painful as they reach the surface, causing the mucosa to be pinched between them and the denture. This trouble will be obvious on clinical or radiographic examination, as are the late effects of a healed malaligned fracture. Postoperative Pain: Alveolar osteitis (dry socket) Fracture of the jaw Damage to the temporomandibular joint Osteomyelitis Damage to nerve trunks or involvement of nerves in scar tissue. Pain induced by Mastication: Diseases of teeth and supporting tissues Diseases of the temporomandibular joint Pain dysfunction syndrome Temporal arteritis 16  Trigeminal neuralgia (rarely) Salivary calculi The common dental cause for pain on mastication is apical periodontitis, but any conditions which causes the tooth to be tender in its socket, whether it be a lateral periodontal abscess or occasionally, maxillary sinusitis can cause this symptom. Open contact between teeth as the case with proximal caries leading to forceful impaction of food interdentally is one of the most common causes of pain during mastication. The least common cause of pain during eating is organic disease of the temporomandibular joint. Fractures and dislocations of the temporomandibular joint are usually obvious from the history, their effects on the occlusion and the radiographic changes. Pain dysfunction syndrome usually causes dull, aching pain, often associated with clicking sounds from the joint, episodes of locking and some limitation of opening in varying combinations. However , no pathology can be revealed in the TMJ. Young women are predominantly affected and there is typically a strong neurotic element. The typical manifestation of temporal (giant-cell) arteritis is headache. However, it is also a cause of masticatory pain and should be considered particularly in patients over middle age with this symptom. The pain is due to ischaemia of the masticatory muscles, caused by the arteritis. The characteristic pain of trigeminal neuralgia is occasionally triggered by mastication. Trigeminal neuralgia may then be misdiagnosed as dental or due to pain dysfunction syndrome. Calculi, particularly when obstructing the parotid duct, can cause pain when salivation is triggered by eating. Hence the history of the relationship of the pain to stimulation of salivation is distinctive. Pain from Extra-oral Disease (Referred Pain): Diseases of the maxillary antrum Acute sinusitis Carcinoma, particularly when it involves the antral floor Diseases of salivary glands Acute parotitis Salivary calculi Sjogren‘s syndrome Malignant neoplasms Diseases of the ears Otitis media Neoplasms Myocardial infarction Antral disease can cause pain felt in the upper teeth but a sinus radiograph should provide the diagnosis. Acute sinusitis is the most common paranasal disease that causes facial pain but antral carcinoma is rare. Mumps is a common cause of pain from and swelling of the parotid glands. In children the diagnosis is usually quickly made on clinical grounds. In adults the diagnosis 17 may not be immediately suspected and occasionally, these patients think they have dental disease. Suppurative parotitis is uncommon but may be a complication of dry mouth. Acute parotitis may therefore be seen as a complication of Sjogren‘s syndrome or irradiation damage to the glands. Sjogren‘s syndrome itself can occasionally cause parotid pain and swelling of the glands. Swelling rather than pain is usually the first symptom of malignant tumors of salivary glands. Parotid gland tumors can also cause facial palsy and finally ulceration and fungation. Myocardial infarction usually causes constricting or crushing pain substernally but pain may radiate down the inside of the left arm or up into the neck or jaw. Rarely cardiac pain is felt in the jaw alone. This pain can come on at any time at rest or during exercise. The clinical picture is variable but in typical cases the patient is obviously anxious, pale and sweating with a rapid pulse and low blood pressure. Neurological Diseases: a) Trigeminal Neuralgia: Typical Features of Trigeminal Neuralgia: Pain confined to the distribution of one or more divisions of the trigeminal nerve. Pain is paroxysmal and very severe Trigger zones in the area Absence of objective sensory loss Absence of detectable organic cause. The pain is paroxysmal, severe, sharp and stabbing in character but lasts only seconds or minutes and may be described as like lightning. However, attacks may sometimes be quickly recurrent at short intervals. Stimuli to an area (trigger zone) within the distribution of the trigeminal nerve can provoke an attack. Common stimuli are touching, draughts of cold air or tooth-brushing. Occasionally mastication induces the pain. There are no objective signs. Either the second or third division of the trigeminal nerve is usually first affected, but pain soon involves both. The first division is rarely affected and pain does not spread to the opposite side. Less typical features of trigeminal neuralgia which make diagnosis difficult are more continuous, long-lasting, burning or aching pain with absence of trigger zones, and extension of the pain beyond the margins of the trigeminal area, though not to the opposite side. A careful search should be made for diseased teeth, though pain of this severity is unlikely to be due to dental disease. An inflamed pulp can cause stabs of severe pain in its early stages, but the pain changes in character and soon becomes more prolonged. Pulpitis can usually also be identified as tooth- ache by most patients and is felt to be different in character from pain in the face due to neuralgia. b) Glossopharyngeal Neuralgia: This rare condition is characterized by pain similar to that of trigeminal neuralgia but felt in the base of the tongue and fauces on one side. It may also radiate deeply into the 18 ear. The pain, which is sharp, lancinating and transient, is typically triggered by swallowing, chewing, or coughing. It may be so severe that patients may be terrified to swallow their saliva and try to keep the mouth and tongue as completely immobile as possible. c) Post herpetic Neuralgia: Up to 10% of patients who have trigeminal herpes zoster, particularly if elderly, may develop persistent neuralgia. The pain is more variable in character and severity than trigeminal neuralgia. It is typically persistent rather than paroxysmal. The diagnosis is straightforward if there is a history of facial zoster or if scars from the rash are present. d) Intracranial Tumors: Pain resembling trigeminal neuralgia can rarely be caused by intracranial tumors. Features suggesting an intracranial lesion are associated sensory loss especially if associated with cranial nerve palsies. e) Bell’s Palsy: Bell‘s palsy is a common cause of facial paralysis. It probably results from compression of the facial nerve in its canal as a result of inflammation and swelling. A viral infection, particularly herpes simplex, is suspected as the cause. Either sex may be affected usually between the ages of 20 and 50.Pain in the jaw sometimes precedes the paralysis or there may be numbness in the side of the tongue. Though this disease is uncommon in dental practice, its recognition is important as early treatment may prevent permanent disability and disfigurement. Function of the facial nerve is tested by asking the patient to perform facial movements. When asked to close the eyes, the lids on the affected side cannot be brought together but the eyeball rolls up normally, since the oculomotor nerves are unaffected. When the patient is asked to smile, the corner of the mouth on the affected side is not pulled upwards and the normal lines of expression are absent. The wrinkling around the eyes which accompanies smiling is also not seen on the affected side and the eye remains staring. The patient cannot blow his mouth. The affected part of the face sometimes also contracts involuntarily in association with movement of another part. There may, for example, be twitching of the mouth when the patient blinks. More uncommon is unilateral lacrimation (crocodile tears) when eating. The majority of patients with persistent denervation develop contracture of the affected side of the face. Watering of the eye (epiphora) due to impaired drainage of tears, or occasionally to excessive and erratic lacrimal secretion, may remain particularly troublesome. Psychogenic (atypical) Facial Pain: Features Suggestive of Psychogenic (atypical) Facial Pain: Women of middle age or older mainly affected Absence of organic signs Pain often poorly localized Description of pain may be bizarre Delusional symptoms occasionally associated 19  Lack of response to analgesics Unchanging pain persisting for many years Lack of any triggering factors Sometimes good response to anti-depressive treatment It must be emphasized that the diagnosis of psychogenic facial pain is a diagnosis by exclusion but it is important to try to recognize the condition, however limited diagnostic methods may be. The symptoms cause real enough suffering to the patient and should, if possible, be relieved. It is also important to avoid unnecessary surgery. Pain is usually not provoked by any recognizable stimulus such as hot or cold foods or by mastication. Despite the fact that the pain may be said to be continuous and unbearable, the patient‘s sleeping or even eating may be unaffected. Analgesics are often said to be completely ineffective, but some patients have not even tried them, despite the stated severity of the pain. Objective signs of disease are absent. Although teeth have often been extracted and diseased teeth may be present, none of these can be related to the pain. As a consequence, treatment of diseased teeth does not relieve the symptoms. Other signs of emotional disturbance are highly variable. Some patients are more or less obviously depressed; some of them mention, in passing, difficulties they have had, for instance, at work with their colleagues. Others may complain how miserable the pain makes them. Others may complain of bizarre (delusional) symptoms such as ―slime‖ in the mouth or ―power coming out of the jaw. Burning Mouth Syndrome: Features Suggestive of “Burning Mouth Syndrome”: Middle-aged or older women are mainly affected No visible abnormality or evidence of organic disease No haematological abnormality Pain typically described as ―burning‖ Persistent and unremitting soreness without aggravating or relieving factors, often of months or years duration; no response to analgesics. Bizarre patterns of pain radiation inconsistent with neurological or vascular anatomy. Sometimes, bitter or metallic taste associated. Associated depression, anxiety or stressful life situation. Obsession with symptoms which may rule the patients life. Constant search for reassurance and treatment by different practitioners. Occasionally, dramatic improvement with anti-depressant treatment. In this distressing and troublesome condition, symptoms may affect the whole mouth or only the tongue may be sore. This complaint has many features in common with 20 atypical facial pain and may be a variant of it. Clinical features may suggest psychogenic factors. Psychogenic Dental Pain (Atypical Odontalgia): This is a less common variant of atypical facial pain. Pain is often precisely localized in one tooth or in a row of teeth. Which are said either to ache or to be exquisitely sensitive to heat, cold, or pressure. If dental disease is found, treatment has no effect, or if, as a last resort, the tooth is removed, the pain moves to an adjacent tooth. Again, if no organic cause can be found and treatment is ineffective, psychiatric assessment is needed. Early diagnosis is essential to avoid over treatment and serious dental morbidity. 21  According to origin: pain may be: (1) Somatic (2) Neurogenous or neurogenic (3) Psychogenic (1) Somatic pain: Due to noxious stimulation of normal neural structures that innervate body tissues. (2) Neurogenic pain: due to pathology or abnormality in the neural structures themselves (within the nervous system), i.e. neuropathy.. (3) Psychogenic pain : due to psychic stress. Somatic pain Neurogenic Pain Psychogenic Pain - Usually acute - Usually chronic ? - Cause is apparent - No cause is usually - No apparent causes (usually inflammation) apparent (except with neuorotropic viruses infection e.g. Herpes zoster) - Throbbing,..aching, sharp, mild,- Lancinating, electric - No specific Character moderate shock like , stabbing - May be progressive in severity - Constant in severity - Bizarre pattern (variable in severity) - Localized at affected region and- Localized to affected - No localization; vague, may cross mid line nerve distribution and not crossing anatomical crossing mid line boundaries e.g. bilateral -May be referred to - Not referred - Referred to abnormal neighbouring or opposing locations structures ( same side). - No trigger zones - There may be trigger zones - No trigger zones. (½ inch sign of trigeminal neuralgia) _ _ - History of psychic stress or antidepressant drug II- Ulcer as Chief Complaint Onset a- Primary ulcer (not preceded by vesicles) Traumatic ulcer Aphthous ulcer b- 2 ry ulcer to vesiculobullous lesion Viral ulcers Pemphigus vulgaris 22  BMM pemphigoid Bullous pemphigoid Bullous erosive lichen planus Also onset may be: a- Sudden : Erythema multiform ANUG Traumatic ulcer b- After prodrome Viral ulcers. Aphthous ulcer Duration: Short (disappears within 2-3 weeks spontaneously or with non- surgical treatment): Traumatic ulcer Viral ulcers Minor aphthae. Prolonged (persistent): Major aphthous Pemphigus vulgaris Malignant Course: Exacerbation and remission: Bullous erosive lichen planus BMM pemphigoid History of Recurrence: Aphthous Recurrent intra oral herpes Erythema multiforme Behcet‘s syndrome Previous medication: Drugs to which patient is allergic allergic stomatitis. Erythema multiforme Cytotoxic drugs. Associated phenomena: Pain : + ve in aphthous, traumatic, viral and erythema multiforme ulcers - ve in malignant ulcers (early), but later there may be severe pain due to invasion of nerves. -ve in gummatous ulcer Pain + bleeding + foetid adour ANUG Location / Site: Tongue: Tip: T.B, 23  Postrolateral: more prevalence of malignant ulcers. Dorsal : gummatous ulcer Keratinized Mucosa: Recurrent intra oral herpes BMM pemphigoid Non Keratinized Mucosa: Minor aphthous (usually) pemphigus On both keratinized and non-Keratinized: 1 ry herpetic gingiva-stomatitis Major aphthous ulcer Malignant ulcer. Distribution: Intra-Orally: Solitary: traumatic ulcer, aphthous ulcer (usually) Multiple : (1) Unilateral : Herpes zoster (2) Bilateral a) Symmetrical lesions: bullous erosive lichen planus b) Randomly distributed: may be : More in anterior part of mouth: 1 ry herpetic gingivostomatitis More in posterior part herpangina , acute L.N. pharyngitis. Anywhere (ant. /post): multiple aphthous ulcers, erythema multiform Some oral ulcers are accompanied by extra oral lesions: Herpes zoster Lichen planus Muco cutaneous ocular syndromes (Steven Johnson, Behcet‘s, Reiter‘s). Autoimmune ulcers: pemphigus, bullous pemphigoid, BMM pemphigoid. Each characteristic extra oral lesion will help to differentiate the condition. III-Swelling as Chief Complaint : The following entities should be considered: 1- Inflammation and infection. 2- Cysts. 3- Retention phenomena. 4- Inflammatory hyperplasia. 5- Benign and malignant tumors. Diagnosis will depend on the history obtained: Onset - Sudden: o Acute inflammation o Allergic condition - Gradual: Chronic inflammatory condition. Neoplasm 24  Salivary gland disease o Bony lesion Duration Short: Hours, days: Acute inflammation Long: Months, years: Chronic inflammation Benign neoplasms Course Progressive: Acute inflammation Neoplasms Regressive: Self-drained abscess Intermittent: Salivary gland stone (repeated swelling with meals and relief in between meal times). Exacerbation and remission: Chronic periapical abscess History of recurrence may imply chronicity e.g. acute exacerbations of chronic periapical abscess. Distribution: Unilateral : Acute dentoalveolar abscess Bilateral : Mumps, allergy. Associated Phenomena: Fever: Acute inflammation Pain + ve with acute inflammation - ve with neoplastic lesions Salty taste: Cyst Previous Medication: Drugs to which the patient is allergic Antibiotics: if giving good response, thus swelling is caused by bacterial infection. Location and Site: According to the tissue constituents, various neoplastic growths will be recognized. Also; periapical, periodontal and gingival abscesses can be usually differentiated by their site in relation to the vestibule and gingiva. IV- Burning Sensation Usually felt in the tongue, but may involve anywhere in the oral cavity. It may be due to: 1- Superficial mucosal lesions such as viral and fungal infections, thinning or erosion of surface epithelium, etc.. 2- Xerostomia. 3- Anemia. 4- Vitamin deficiency. 5- Diabetes mellitus. 25  6- Fissured tongue. 7- Psychosis/neurosis. 8- Burning mouth syndrome. V– Paraesthesia and Numbness Usually felt in the lip, but may involve anywhere in the oral cavity. It may be due to: 1-Vitamin deficiency. 2- Pressure on the mandibular nerve such as neurofibromatosis. 3- Injury to the trigeminal nerve. 4- Trauma from anesthetic needles and following surgical procedures. 5- Diabetes mellitus. 6- Pernicious anemia. 7- Syphilis. 8- Prolonged use of some medications such as streptomycin, sedatives, tranquilizers and hypnotics. VI- Bleeding as Chief Complaint It‘s either spontaneous or due to trauma, etc.. Local causes Systemic causes 1- Periodontitis 1- Blood vessel wall abnormality 2- Trauma a- Scurvy (Vit C deficiency) 3- Post-operative infection b- Hereditary Hemorrhagic Telangiectasia (H.H.T) 2- Platelet disorders: a- Thrombocytopenia b- Aspirin (long duration) 3- Clotting disorders: (coagulation deficiency) a- Haemophilia b- Anticoagulant therapy c- Liver disease 26  4 -Fibrinolytic pathway activation Anticoagulant therapy Evaluation of the case before management: Based on the history of bleeding disorder, examination and lab. investigations, patients may be classified into three categories: 1) Patients at Low Risk: A. Patients with no history of bleeding disorder, normal examination and normal bleeding parameters. B. Patients with nonspecific history of excessive bleeding but with normal bleeding parameters (normal platelets count, PT, PTT and bleeding time rule out clinically significant bleeding disorder).These patients can be managed by normal protocol. 2) Patients at moderate risk: Examples are patients on anticoagulant therapy or on chronic aspirin therapy. A. Patients on anticoagulant therapy and a PT in the therapeutic range (1.5-2 times the control value). B. Patients on chronic aspirin therapy. In these patients we have to modify the therapeutic regimen before elective dental therapy. 3) Patients at High Risk: A. Patients with known bleeding disorders: thrombocytopenia, thrombocytopathy and clotting factors defects. B. Patients without known bleeding disorders who were found to have abnormal platelets count, PT, PTT or bleeding time. Dental management of these patients requires close coordination of care with the patient's physician or haematologist and hospitalization is often advised. Other Common Complaints: Loose Teeth: loss of supporting bone or the resorption of roots may result in loose teeth and may indicate the presence of any of the following 1. Periodontal disease 2. Trauma 3. Normal resorption of deciduous teeth 4. Pulpoperiapical lesions 5. Malignant tumors 6. Benign tumors that may induce root resorption (chondromas, myxomas, hemangiomas) 7. Histiocytosis X 8. Hypophosphatasia 9. Familial hypophosphatemia 27  10. Papillon-lefevre syndrome 11. Acquired immunodeficiency syndrome (AIDS) Bad Taste a complaint of bad taste may result from any of the following: 1. Aging changes 2. Heavy smoking 3. Poor oral hygiene 4. Dental caries 5. Periodontal disease 6. Acute necrotizing ulcerative gingivitis (ANUG) 7. Diabetes 8. Hypertension 9. Medication 10. Psychoses 11. Neurologic disorders 12. Decreased salivary flow 13. Uremia 14. Intraoral malignancies Halitosis although this is more frequently classified as an objective symptom, patients may come with it as a complaint. It may be due to: 1. Poor oral hygiene 2. Periodontal disease 3. Third molar opercula 4. Decayed teeth 5. ANUG 6. Oral cancer 7. Spicy food 8. Tobacco use 9. Nasal infection 10. Sinus infection 11. Tonsillitis 12. Pharyngeal infections or tumors 13. Gastric problems 14. Diabetes 15. Uremia D. Dental History The dental history provides the dentist with reliable information about the patient‘s dental hygiene practices, attitude towards dental care and the nature of past dental treatment as well as any complications related to previous dental procedures. Components of Routine Dental History: (1) Attitude of the patient towards his previous dentist and/or treatment: 28  The patient‘s perception of a former dentist is likely to become the attitude toward the current dentist unless the patient is carefully managed. Negative comments about a previous dentist or previous dental treatment often reveal potential attitude problem such as unsatisfactory doctor patient relationship or unsatisfactory cost. 2) Past Dental Care: The frequency of past oral health care can be an important predictor for the patient‘s compliance with the new treatment recommendations. Attitude of most patients towards dental care can be summarized as one of the three forms: A – Routine dental care Implies regular recall appointments and regular treatment of most dental needs. B – Episodic dental care Implies less than comprehensive dental care and an irregular pattern of recall examinations. C – Symptomatic dental care Implies that the patient has generally consulted a dentist for relief of pain without regular attention to dental health. 3) Periodontal Therapy Regular periodontal care as well as past periodontal therapy and type of treatment the patient had received (scaling, occlusal adjustment, gingivectomy… etc) are of value in the evaluation of periodontal condition and prognostic sequence. 4) Local Anaesthesia History of common problems that have emerged when the patient received local anaesthesia including general anxiety, syncope (fainting), allergy and unwanted reaction to anaesthetic agent may alert the dentist about the possible serious complications that he may face during injection of local anaesthesia or indicates the use of general anaesthesia. 5) Extraction History of fractured tooth during extraction or excessive hemorrhage, infection and delayed wound healing following extraction should be recorded and evaluated before proceeding with additional surgery. 6) Missing Teeth The dentist should establish the reason for any unerupted or missing teeth, including the exact time at which they were removed. 7) Tooth Restorations Knowing the age of restorations may yield important perspectives on the quality and success of previous work, the patient‘s oral hygiene as well as the prognosis for new work. 29 8) Root Canal Fillings Endodontically treated teeth are fragile and liable for easy fracture or fracture during extraction. It should be covered with crown. Moreover, failure of endodontic therapy may lead to periapical pathosis which needs further interference from the dentist. 9) Removable Prosthetic Appliance: History of partial or complete dentures including length of time of wearing , type and design of the appliance as well as any modifications such as fracture, relining, rebasing or addition of teeth should be recorded. Also, personal care of the appliance as well as soreness, burning sensation or sensitivity to denture base material should be reported. 10) Fixed Prostheses Satisfactory design, type of prosthesis, length of service, comfort and personal care should be established. 11) Orthodontic Therapy Past orthodontic treatment including nature of the appliance, removable or fixed and its duration should be reported. It is important to establish whether the patient has had any surgical procedures necessary for success of treatment such as extraction or orthognathic surgery. Also, the effect of therapy on periodontal condition, personal care and received treatment during the period of orthodontic therapy should be evaluated. 12) Surgical Procedures: Past surgical procedures in and about the mouth other than extraction, nature of tissue removed, the manner in which it was removed, complications and possible recurrence should be established. 13) TMJ Therapy Night guard, TMJ splint or other types of treatment should be reported. 14) Radiographs Pre-existing recent panoramic and/or intra-oral radiographs may exclude the need for further exposure for radiation. E- Health History The health history has four components: Past and present medical history Review of systems 30  Social history Family history 1- Medical history During this step the dentist collects information required for assessing a patient‘s health status that can facilitate the diagnostic process for the patient‘s orofacial complaint or require certain modifications for the provided oral health care. Although the main goal of medical history is to identify medically complex patients, it has the added benefit of establishing understanding relationship and communication between dentist and patient. Standard health questionnaires are available. Although a dentist can construct her/his own health questionnaire, it makes little sense to do so. Excellent expert- constructed forms are readily available from the American Dental Association (ADA) and other professional organizations. Dentists who use these forms are, therefore, in the mainstream of dental practice. Certainly, practitioners should be encouraged to add questions on the ADA-type forms to fit special needs. It must be understood that obtaining a health history does not end with administration of a health questionnaire. To the contrary, it serves only to elicit basic information that must be checked and expanded during the patient interview. Objectives: An appropriate interpretation of the collected information achieves these objectives: Gathering information necessary for establishing the diagnosis of the chief complaint. Monitoring known medical conditions. Detecting underlying systemic conditions that the patient may or may not be aware of it. Determining whether dental treatment might affect the systemic health of the patient. Assessing the influence of the patient‘s systemic health on patient‘s oral health. Determining necessary modifications to routine dental care. The dentist should review changes in a patient‘s health status or medication regimen at each visit before starting dental care. This is important as many medical conditions are associated with slow gradual changes and medication regimens frequently change. Consultations with other health care professionals are required when additional information is necessary to assess a patient‘s medical status. These consultations (verbal or written) should be documented in the patient‘s file. A consultation letter should identify the patient first, then include a brief overview of the medical history and a request for specific medical information. A physician‘s advice and recommendation is helpful in managing a dental patient, but the responsibility to provide safe and appropriate care lies with the dentist. Significance of medical history Identify Medically Complex Patients: 31 They are: Patients with a known medical condition Patients with an undetected medical condition Patients recovering from a medical condition Patients taking medication Patients following a special diet Patients in need of special dental care Patients that may transmit infection Patients with a Known Medical Condition: Some patients know that they have a serious medical condition. These patients have been diagnosed and treated by a physician and are likely to continue under a physician's care. Some of these diseases may cause serious complications during dental treatment. Several diseases may require special precautions and/or pre-medication before any kind of dental treatment. Also, some systemic conditions have oral manifestations. Diseases that may cause serious complications during dental treatment Disease Complications what shall we do Leukemia excessive bleeding and -patient requires antibiotic infection therapy and blood transfusion before dental treatment Hemophilia excessive bleeding -avoid NSAIDs to avoid GIT bleeding -give Factor VIII concentrate before surgery Addison‘s adrenal crisis (fatal) additional exogenous steroids disease before stress condition are necessary (double the dose of cortisone before treatment) Uncontrolled thyroid crisis (fatal) -give L.A. without adrenaline hyperthyroidism (adrenaline may result in thyroid crisis). -give the patient beta blocker before dental treatment to avoid hypertension and crisis Patients at risk for infective endocarditis include: High risk patients Prosthetic cardiac valve. Previous history of IE. 32  Congenital heart disease (CHD): unrepaired, repaired with residual defects, or completely repaired during last 6 months. Cardiac transplantation recipients who develop cardiac valvulopathy. Variable risk patients Rheumatic heart disease or history of rheumatic fever without valvular lesions. Pacemakers. IVDA. SLE. Diseases that may require precautions or premedication before dental treatment Disease Diseases/conditions that give oral/ manifestations Precautions Premedication Patients at risk for Premedication: prophylacticOral Disease/Conditions manifestation antibiotic Vitamin infectivedeficiency angular cheilitis, glossitis endocarditis Anemia pallor, atrophy of tongue coating Diabetes mellitus Premedication: prophylactic Leukemia ulceration, antibiotics gingival enlargement, their anti-diabetic drugs bleeding Agranulocytosis Precaution: risk ofulceration, wound infection infection Skin diseases such as: delayed wound healing check the clinical photographs below Coronaryplanus Lichen heart Premedication: - Lupusfor stress management diseases (AP – Precaution: patients taking anticoagulants need to check erythematosus MI) Erythema multiformeINR and reverse coagulation if necessary. - Pemphigus Hypertension vulgaris Premedication: for stress management Precautions: Antihypertensive drugs may cause orthostatic hypotension Renal failure Precaution: avoid drugs mainly excreted by kidney Liver diseases Precautions: risk of bleeding avoid drugs mainly metabolized by the liver Epilepsy Premedication: for stress management Patients with an Undetected Medical Condition: Some patients are unaware that they have a serious medical condition. They do not have a physician or have not visited a physician for some years may not know that their medical condition could be aggravated by dental treatment. By being alert to the signs and symptoms of important medical conditions, by assessing vital signs, and by appropriate referral to a physician, a dentist may uncover an important medical condition that could endanger general health and safety during and following dental treatment. An orderly review of systems will be of great help. Patients Who Have Recovered From a Medical Condition: Patients who have recovered from a medical condition may be at risk. In some circumstances, a patient who has recovered from a disease or surgery may be predisposed to a medical complication from dental treatment. For example, patients who have recovered from cardiac valve replacement surgery are predisposed to acquiring infective endocarditis. 33  It is important that dentists know of such possibilities and determine whether their patients have the underlying medical conditions that can cause them. Patients taking medications: Use of medications may complicate dental treatment Some medications cause physiologic changes that may cause complications during or following dental treatment. Example, patients who regularly take aspirin to prevent blood clots are susceptible to prolonged bleeding after oral surgery. Use of medications may provide clues about patient's medical status Medication Indicate Medication Indicate Dilantin Epilepsy Nitroglycerine Angina pectoris Anticoagulants Myocardial infarction Nifedipine Hypertension Diuretics Hypertension Digitalis Heart failure Heart failure Carbamazepine Neuralgia Carbimazole Hyperthyroidism (tegretol) Use of medications may produce oral manifestations Medications Oral manifestations -Dilantin used in treatment of epilepsy *Gingival hyperplasia -Nifedipine used in treatment of hypertension Drugs that contain salts of heavy metals such as *Metallic intoxication -Bismuth and Gold used in treatment of skin diseases *Stomatitis -Mercurial diuretics used in treatment of hypertension -Cytotoxic drugs and antimetabolites used in cancer *Oral ulceration chemotherapy *Bleeding *Increased tendency for infection Drugs may need certain adjustment and special management before and during dental procedures, such as : -Steroids. -Anticoagulants. Drug interaction may occur between medications taken by the patient & those prescribed or given by the dentist Medications taken Medications prescribed Drug interaction by patient by dentist Anti-hypertensive Barbiturates & Barbiturates and tranquilizers potentiate drugs Tranquilizers hypotension. So, the dose of barbiturates and tranquilizers should be reduced. 34 MAO inhibitors Barbiturates MAO inhibitors may intensify the action of [hypertensive barbiturates. patients] So, barbiturates should not be given for patients receiving MAO inhibitors. MAO inhibitors Adrenaline MAO inhibitors potentiate the action of adrenaline. So, adrenaline should not be given for patients receiving MAO inhibitors. Antacid and Drugs Tetracycline Tetracycline chelates with antacids and with iron salts drugs with iron salts. So, when tetracycline is prescribed it should be taken two hours after the antacid or the iron therapy * MAO inhibitors= monoamine oxidase (MAO) inhibitors are anti-depressants Use of medications may produce allergic and adverse reactions Any complications caused by any drug should be recorded with details including: - The name of the drug. - Route of administration. - The nature of the reaction. - Chemical structure of the drug to avoid cross-reaction between similar drugs such as sulpha and ester type of anaesthesia. Patients Following a Special Diet: Special diet may give an idea about a patient‘s medical status. For example, low fat diet: may be prescribed to patients with diabetes mellitus and\or atherosclerosis, low sodium diet: is often prescribed to patients with arterial hypertension. Patients In Need Of Special Dental Care: Patients may need special dental care prior to receiving medical care. Patients scheduled for cancer chemotherapy or radiotherapy may need to have careful evaluation of their dental status. Patients may need special dental care to prevent serious medical condition. For example the elimination of periodontal and periapical disease may prevent infective endocarditis after heart catheterization. Patients Who May Transmit Disease: Patients with infectious diseases (viral hepatitis B & C, herpes, HIV, syphilis and active tuberculosis) may complicate dental treatment. Patients with such diseases need to be managed in a way that: 35 1- Prevents transmission of infection to dentist, dental personnel and other patients. 2- Prevents further damage to them. Identify History of Infections and Immunizations: The history of characteristic infections such measles, herpes simplex as well as immunizations may be significant for the dentist. Past infection or previous immunization can exclude the specific infectious diseases from diagnostic consideration of a new infection. Identify History of Hospitalization/Surgery: Any past hospitalization or surgical procedures, together with any accompanying complications or blood transfusion should be reported. This will reveal: The patient‘s ability to tolerate surgical stress. The cause of hospitalization or surgery, e.g. facial injury, malignancy. Patient‘s exposure to infection. Identify History of Radiotherapy: Radiotherapy for treatment of malignancy may have complications on oral and paraoral structures including: Radiation mucositis and Candidosis. Fibrosis of salivary glands, ascending parotitis and xerostomia. Loss of taste sensation. Increased incidence of periodontal disease. Radiation caries and hypersensitivity of teeth. Fibrosis of the masticatory muscles. Osteoradionecrosis Identify Pregnant Females: Only emergency treatment is performed in the first and late third trimesters. The middle trimester is the safest. Radiographs should be avoided unless it is necessary with certain precautions. Administration of drugs should be limited and those having teratogenic effect should be avoided. Review of Systems The review of systems (ROS) is a comprehensive and systematic review of subjective symptoms affecting different bodily systems. 36  Usually each system has its unique disease symptomatology that is not duplicated elsewhere. In order not to miss anything of significance, an orderly review of systems is essential. Significance: The ROS may help establish the primary diagnosis by uncovering important symptoms involving other parts of the body. For example, a patient with facial pain may also have complaints such as paresthesia, anesthesia, or weakness, indicating that the facial pain may be a symptom of a neurologic disorder. The ROS may also allow the dentist to detect an undiagnosed medical disease, which may require modification of dental treatment. For example, the dentist may suspect undiagnosed or poorly controlled congestive heart failure in a patient with orthopnoea or diabetes in a patient with polyuria and polydipsia. Examples of questions used in ROS are as follows: Do you have or you ever had? Disease revealed Short breath, dyspnea on exertion, heart murmur , swollen ankles , Heart trouble pain over the hear, pain in chest on exertion , fast or irregular beating of the heart , palpitation Nervousness, loss of weight, tremors of hands and tongue, intolerance Hyperthyroidism of hot weather, excessive sweating, insomnia and tachycardia Excessive urination (polyuria), excessive thirst (polydipsia) and characteristic excessive appetite (polyphagia) associated with weight loss undiagnosed diabetes mellitus Constant fatigue Anemia (may be the only sign) Unusual progression of infections affecting the mouth, GIT, gut, skin White blood cells … etc, with common involvement of the regional lymph nodes and diseases recurring characteristic oral ulceration Social History During this step the dentist collect learns about a patient's personal habits, marital status and number of children, current employment and level of education. Examples: A history of stress (due to position of responsibility, family situations) may suggest presence of psychosomatic diseases (e.g. LP & burning tongue) or exaggerating the oral manifestations of several conditions. A history of cigarette smoking or heavy alcohol use may suggest a predisposition to oral malignancies. 37 A history of check/lip biting may suggest a predisposition to frictional keratosis. Family History During this step the dentist collect information concerning history of family illness. As this may indicate diseases to which the patient may be predisposed. It is common for physicians to ask their patients about parent health or death to determine the risk for familial diseases which involve: Familial diseases: Are diseases running in certain families and does not follow rules of gene transmission, such as diabetes mellitus, hypertension and allergy Hereditary diseases: Are diseases running in certain families and follow the rules of gene transmission (recessive, dominant & sex-linked), such as hemophilia, sickle cell anemia, thalassemia, ectodermal dysplasia and amelogenesis imperfecta. Infectious diseases: Transmission of certain infections through contact with a member of the family. such as in TB, syphilis and HCV. CLINICAL EXAMINATION Examination Methods The common techniques of examination are: 1- Observation 2- Inspection 3- Palpation 4- Percussion 5- Probing 6- Auscultation 7- Olfaction. Observation: "...an act or instance of noticing or perceiving." Observation refers to examining the patient from afar. As a patient enters the operatory the dental practitioner should observe her/his general appearance and her/his general physical status. Inspection: "...the act of inspecting or viewing, especially carefully or critically." During the examination, particularly the soft tissue part, the operator must look at the features of, for example, a lesion up close. This close, careful, examination is called inspection. Through inspection we examine: 1- Colour: Usually the oral mucosa is pale pink, it is affected by : a) White colour of the covering stratified squamous epithelium , keratin (if present) and collagen bundles in the underlying connective tissue. Any increase in the thickness of these structures (e.g. hyperkeratosis , acanthosis 38  ,…..etc ) increases the pallor of the mucosa in varying degrees to the extent of reaching a frank white colour (white lesions).In contrast , their decrease (e.g. epithelial atrophy) causes redness of the mucosa. b) Red colour of the vasculature of the connective tissue ; as the oral epithelium is translucent it reflects the colour of this vasculature, giving the pale pink colour. If the vascularity decreases (e.g. anemia) a whitish colour is obtained. If vascularity increases (e.g. inflammation) there is redness. c) Degree of fixation to underlying structures: Loosely attached tissues are more translucent to underlying structures.Attached gingiva is firmly attached and thus appears more pale. Hard palate: firmly attached to underlying structures together with the presence of areas of adipose tissue and heavy keratinization so it appears very pale in colour. On the other hand , the vestibule, soft palate and free gingiva , being loosely attached appear more red in colour. d) The presence of melanin brown pigmentation e) Yellowish discoloration due to lipopigments or jaundice 2- Surface Texture Usually the oral mucosa looks smooth except for the attached gingiva which when dry shows stippling (orange peal appearance) and the rugae area of the palate which appears pebbled. The surface of pathologic lesions may appear a) Smooth (masses that arise in tissues beneath the lining mucosa). b) Papillomatous (lesions that arise in epithelium as papilloma, warts, verrucous carcinoma ). c) Ulcerated (break in surface epithelium continuity). d) Necrotic. e) Flat or raised surface: o Macule (discolored: brown, red, ….). It is flat lesion due to lack of cell proliferation (hyperplasia) or increase in cell size (hypertrophy). o Nodule or papule: Surface is raised due to hyperplasia hypertrophy. o Pustule: Pus-filled nodule or papule. 3- Contours: The diagnostician should be familiar with normal contours in and around the oral cavity e.g. o Facial symmetry o Nasolabial fold (appears normally as depression). 4- Aspiration: If any lesion contains fluid: This fluid can be aspirated and inspected: o Straw – coloured fluid with cholesterol crystals = cyst. o Pus = infected lesion or abscess. 5- Transillumination may be used, it is a visual diagnostic method that relies on the passage of light through relatively thin, translucent tissues. Transillumination can demonstrate the accumulation of fluid and pus within the maxillary sinus. The patient is placed in a darkened room and an intense light source is placed intraorally with the patient‘s lips closed around the probe.The tissues overlying the normal maxillary sinus exhibit a dull glow, while congestion or abnormal soft tissues within the sinus block the 39  diffusion of light. The frontal sinus can be similarly examined by placing the light source inferior to the supra orbital ridge at the nasal aspect of the orbit. It can be also used to visualize proximal caries in anterior teeth Palpation: "...the act of examination by touch, especially for the purpose of diagnosing disease or illness." Touching a part of a patient -- a structure or a lesion, for example -- is known as palpation. This procedure is of particular importance in the soft tissue portion of the physical examination. Palpation Techniques: A. Bidigital palpation: It is the manipulation of the tissues using the two fingers of one hand. It is used for thin tissues such as lips. B. Bimanual palpation It is the manipulation of the tissues using the two hands or two fingers of both hands. It is used for examination of cheeks, floor of the mouth and soft tissue swellings to detect presence of fluids ( fluctuation test ) C. Bilateral palpation It is the simultaneous manipulation of the symmetrical structures to detect a difference from one side to another. It is used for examination of T.M.J, lymph nodes and parotid glands. From palpation: 1- The shape, size, consistency and anatomic location of the suspected lesion can be estimated. 2- The presence of tenderness usually indicates inflammation and is revealed by the patient‘s response when pressure is applied. 3- Lesions are considered well delineated if palpation reveals separation from adjacent tissues or diffuse if this distinction is difficult to discern. 4- Independent lesions are mobile relative to adjacent tissues during manipulation, while resistance to movement suggests fixation. 5- Palpation of lesions that contain blood (e.g. haemangioma) causes the red lesion to become pale or blanch. The use of a glass slide to compress the lesion while observing the area is called diascopy and may demonstrate this feature. Release of pressure allows refilling of the vessels and a rapid return of the red color. Red lesions produced by extravasation of blood into the connective tissue do not blanch during palpation. 6- Bimanual palpation helps to detect the presence of fluids inside soft tissue lesions (fluctuation test). 7- Surface temperature. Percussion: "...the striking or tapping of the surface of a part of the body for diagnostic or therapeutic purposes." Occasionally, it is necessary to tap on a tooth to determine if periapical disease is present. This tapping act is known as percussion. 40 Two types of percussion can be applied: 1- Teeth percussion Percussion of the teeth is performed by striking the cusp or incisal edge of each tooth with a gentle but firm blow with the blunt end of no.17 explorer or similar light instrument, the blow should be directed in the long axis of the tooth. - During percussion on teeth the examiner should be aware of: 1. The feel of the blow. 2. The sound produced. 3. The reaction of the patient. A sound tooth with healthy periodontium will ―feel‖ firm and resistant and will produce solid sound on percussion, while teeth with periodontal disease and sufficient bone destruction will ―feel‖ soft or will not be resistant to percussion and produce a dull sound. The presence of inflammation within the periodontal tissues will lead to tenderness (patient feels pain) during percussion. 2- Soft tissue Percussion: This method of percussion is of value in observing muscle reflex mechanism, muscle tenderness, hypertonicity of the muscles of mastication and demonstration of Chvostek‘s sign (in latent tetany tapping over the facial nerve in front of the ear causes twitching of the facial muscles). Probing : "...the use of a slender device to examine a narrow tract or cavity" The dental probe may be : 1-Sharp (explorer) used to: o Detect carious cavities. o Test local anaesthesia o Explore sinus tract o Explore deposits on tooth surface 2-Blunt (periodontal graduated probe) used to : o Detect periodontal pockets o Measure periodontal pockets Auscultation: "...the act of listening, either directly or through a stethoscope or other instrument, to sounds within the body as a method of diagnosis." Other than listening to the functioning temporomandibular joint with a stethoscope, auscultation is of limited use in dental physical examinations. Olfaction:" the sense of smell occasionally contributes to diagnostic information." As: o Foetid odour of bacterial infection in necrotic teeth, abscesses and ANUG o Garlic or bad odour of chronic periodontitis. o Acetone odour in uncontrolled diabetic patient with ketoacidosis. 41 I- EXTRAORAL EXAMINATION Extra-oral examination recommended for the average general practice in dentistry consists of: 1) Observation of general appearance 2) Inspection and palpation of the head and neck 3) Observation of other parts of the body 4) Measurement of vital signs. Patient's general appearance: A great deal can be learned by observing patients in the waiting room, as they enter the operatory, as they sit in the dental chair, as they talk during the interview, and as they leave. These observations should include the following: Body height or Stature-- The body ratio is the upper skeletal segment length divided by that of the lower segment. Abnormal ratios may reveal disproportional growth related to endocrinal disorders. The patient may be giant, dwarf or normal. Body weight -- Abnormal thinness or heaviness may indicate serious underlying disease. Weight loss is seen mainly in starvation, malnutrition, eating disorders, cancer (termed cachexia), HIV disease (termed ‗slim disease‘), malabsorption and tuberculosis. Obesity is usually due to excessive food intake and insufficient exercise. However, an increase in body weight may indicate a hormonal disorder as in hypothyroidism. Dress and Grooming -- Observe the level of care in dress and grooming. Sick or disturbed patients often let these external appearances deteriorate. Agility and Energy -- Observe the presence or absence of energy and enthusiasm. The degree to which patients are alert and aware of their surroundings may indicate the absence or presence of disease. Similarly, the facility with which patients are able to sit, stand, and walk may also indicate their general state of health. Also, observe the patient‘s weight; overly obese individuals may be afflicted with one of several systemic diseases. Demeanour -- Observe the patient's behavior towards dental treatment, towards family members, and towards office staff. Presence of nervousness or abnormal response to ordinary events may indicate psychological disorders or, at the very least, future management difficulties. Breathing -- Observe whether or not patients have difficulty in catching their breath after walking from the waiting room and sitting in the dental chair. If they cannot talk for several minutes after being seated, it may indicate the presence of serious underlying cardiac and/or pulmonary disease. Odours -- Observe any unusual body odors. Tobacco and alcohol odors are common and may indicate potential systemic disease (lung/oral cancer or liver cirrhosis). Acetone breath may indicate that a patient suffers from uncontrolled diabetes mellitus. Putrefied breath odor may indicate oral or pulmonary infections. Generally unpleasant body odor may speak about a patient's grooming habits. 42 Walking pattern (Gait) -- Gait is the manner of walking and most gait abnormalities relate to neuromuscular disability from injury , stroke or degenerative neuromuscular diseases. The different gaits may be named as follows: Waddling gait in Paget‘s disease. To walk with short steps that tilt the body from side to side Circumduction gait: in hemiplegia (semi-circular lateral swing of the affected leg). Tabetic gait: Tabes dorsalis refers to neurologic degeneration of tertiary syphilis and results in an ataxic gait with a tendency for the patient to watch the feet to compensate for lost proprioception. Ataxic gait: irregular, wide-distanced walk common in alcohol intoxication. Parkinsonian gait: consists of limited stride, hanging arms and rapid steps. Inspection and Palpation of the Head and Neck General appraisal of head (skull) size and shape may reveal important diseases. Size - Small head (microcephalus): may be due to a developmental anomaly causing brain hypoplasia or early brain damage by anoxia, trauma, infection or radiation. - Large head (macrocephalus): as in Paget‘s disease, hydrocephalus or acromegaly. Shape Rickets: The frontal eminences and posterior parietal areas are prominent causing boxy head. Inspection and palpation of the face may reveal important diseases. Dental practitioners operate very close to a patient's face. Given the proximity, there is enough opportunity to observe the eyes, skin, and other facial parts. Eyes -- Some diseases manifest with eye changes. 1 - Sclera color: - Jaundice may appear first as yellow sclera. - Osteogenesis imperfecta and dentinogenesis imperfecta are accompanied by blue sclera. N.B. faint bluish white sclera is normal in new born - Redness may be due to inflammation, trauma or Sjogren syndrome 2 - Exophthalmous or proptosis: Hyperthyroidism is often accompanied by bulging eyes bilaterally (exophthalmos); while unilateral eye protrusion indicates swelling within the orbit distorting eye position. 3- The eye lids: 43  Multiple sclerosis, neurosyphilis or neoplasm cause ptosis which is dropping of upper eye lid and inability to open the eye completely. It is due to paralysis of levator muscle supplied by third occulomotor nerve - Facial nerve paralysis (Bell‘s palsy) causes inability to close eye lids and leads to constant excessive irritation, lacrimation and dryness. 4- Eye pupil: - In neurosyphilis the eye pupil only reacts to location and fails to react to light (Argyll Robertson pupil). 5- Cornea: - Congenital syphilis (together with saddle nose and Hutchinson‘s teeth) , hereditary benign intra epithelial dyskeratosis and vitamin A deficiency are all accompanied by localized or diffused dull cloudy or opaque areas over the cornea referred to as ―Interstitial keratitis”. 6- Scarring Seen in trauma, infection or pemphigoid..Skin -- Observe and inspect the skin of the face for obvious lesions. Bas