introduction to oral diagnosis. In dentistry pptx

Intruduction to oral diagnosis, different types of symptoms and diagnosis

1. Introduction to oral diagnosis BY Mahmoud Ahmed Mizar Lecturer, Department of Oral Medicine, Periodontology, Oral Diagnosis and Dental Radiology

2. Oral diagnosis is the art of scientific knowledge that used to identify oral lesions and to differentiate each one from another.

3.   A correct diagnosis is the most important step in the treatment of oral lesions 

4. Terminology Subjective symptoms: The subjective symptoms means complains recorded by the patients i.e (chief complain) e.g. Pain, Headache, Hemorrhage and Swelling.

5. Objective findings (signs) The objective findings is a sign which detected by the examiner e.g. change in gingival contour, consistency, edg of an ulcer etc...

6. Spot Diagnosis: Spot diagnosis means immediate and rapid diagnosis of the case, which depends on minimal data from the patient. Tentative (provisional) Diagnosis: Tentative diagnosis is an initial diagnosis of the case that performed before assembling of all diagnostic steps

7. Differential Diagnosis: Is a scientific knowledge used to differentiate each lesion from another when two or more lesions are similar as in case of white lesions, pigmented lesions and ulcerative lesions.

8.   Definitive Diagnosis: It is a final diagnosis of the patient following assembling of diagnostic data.

9. Commonly used terms to describe oral mucosal lesions :

10. Vesicle : a small blister (less than half a centimeter in greatest dimension) on oral mucosa. Examples include recurrent intraoral herpes and herpangina.

11. Bulla : a large blister (more than half a centimeter in greatest dimension) on mucosa. Examples include the oral mucosal lesions of cicatricial pemphigoid and pemphigus vulgaris

12. Ulcer : a localized area of complete loss of oral epithelium and submucosal connective tissue is exposed at the base of the ulcer. Examples include traumatic ulcers and recurrent aphthous ulcers.

13. Desquamate : sloughing of the oral epithelium caused by separation from the submucosa. Desquamative lesions are often preceded by bullae. Examples include the oral mucosal lesions of cicatricial pemphigoid and pemphigus vulgaris.

14. Petechia an area of oral submucosal hemorrhages less than 3mm in greatest dimension. Oral ecchymoses are usually caused by trauma. Ecchymosis an area of oral submucosal hemorrhages greater than 2 centimeters in greatest dimension. Oral ecchymoses are usually caused by trauma.

15. Erythematous an oral mucosal lesion that is red in color. The red color can result from erosion of the epithelial surface of the lesions.( eg , erosive lichen planus), or from an increase in the number of blood vessels in the lesion ( eg , pyogenic granuloma). Erosion thinning of the epithelial surface of oral mucosa. Erosions are characteristically red (erythematous) in color. Erosive lichen planus is an example.

16. Keratosis : (Callous) An adherent (cannot be wiped off) white patch caused by excess keratin on the epithelial surface of oral mucosa. Keratosis is characteristically white in color. Frictional keratosis and smoking-related leukoplakia are examples

17. Exophytic an oral mucosal lesion that extends outward from the surface of the adjacent mucosa. Squamous papilloma are characteristically exophytic.

18. . Nodule: an elevated circumscribed lesion on oral mucosa. Irritation fibroma is an example of a nodule. Papule: a slightly elevated circumscribed lesion on oral mucosa. Macule : a flat, circumscribed, pigmented lesion on oral mucosa. The lesion is not elevated. Examples include amalgam tattoo and oral melanotic macule

19. Papillary : an oral mucosal lesion with a surface composed of numerous blunted projections. Inflammatory papillary hyperplasia is an example. Verrucous : an oral mucosal lesion with a surface composed of numerous elongated projections. The projections are commonly white in color because of hyperkeratosis. Verrucous carcinoma is example .

20. Sessile : an oral mucosal lesion that is attached to the adjacent mucosa by a broad base . A broad base characteristically attaches irritation fibroma Pedunculated : an oral mucosal lesion that is attached to the adjacent mucosa by a narrow stalk. (Example includes squamous papilloma).

21. Indurates : an oral mucosal lesion that is firm to palpation. An ulcer with indurated margins is a characteristic clinical presentation of oral squamous cell carcinoma.

22. Pseudo membrane : a nonadherent (can be wiped off) accumulation of necrotic debris on the surface of an oral ucler . Pseudomembranous is usually white to yellow in color. Pseudomembranous candidiasis and mucous patches of secondary syphilis are examples of oral lesion, which have a pseudomembrane on their surface .

23. How to diagnose any oral lesion? To diagnose any oral disease we must follow the following outlines:- 1] Case History. 2] Clinical Examination. 3] Special investigations. 4] Differential diagnosis. 5]Diagnosis.

24. Case history is a planned, professional conversation between the patient and the clinician in which the patient communicates the symptoms, feelings and apprehensions and the sequences of the disease and possible effects of its treatment. The purpose of case history is to guide the physician to conduct relevant clinical examination and arrive at a provisional diagnosis for the chief complaint and determine if any systemic factors/ condition exists that might affect the oral health care.

25. Importance of case history: It introduces the patient to the examiner to detect his personality. Helps, to determine the nature of the present illness i.e. the lesion is acute or chronic. Helps, to relate the present and past illness to the present condition and thus assist our diagnosis . Case history can be taken by 3 basic ways: 1) By use of printed questionnaire. 2) By direct interview with the patient. 3) Combination of the above

26. The health questionnaire should provide information that will enable you to assess the patient’s.... 1- Overall health status (general health). 2- Disease history of serious illnesses, hospitalization and surgical procedures. 3- Current medications. 4- Allergies (drugs, food, other). 5- Personal history (tobacco, alcohol). 6- Family history (health status of family members).

27. Advantages of printed questionnaire: 1)Broad in scope 2)Time saving 3)Consistent Disadvantages of printed questionnaire: 1)Non personal 2)Lacking in depth 3)Inflexible.

28. Direct patient-dentist interview Advantages. 1) Flexibility. 2) Personal contact. 3) Deep in discussion . Dis advantages Time consuming

29. Plan of case history taking 1) Personal data. 2) Chief complaint. 3) History of chief complaint. 4) Past dental history. 5) Past & present medical history. 6) Personal and Family history. 7) Socioeconomic history.

30. 1- Personal data A- Name B- Age C- Sex D- Marital status E- Birthplace F- Telephone Number G- Occupation H- Race

31. Name: Name taking is a part of the initial communication between the dentist and patient and personalizes the process of history taking . Recording the complete name establishes the identity of the individual and may also be of medicolegal importance .

32. Age: Knowledge of the patient's age is beneficial as many diseases have certain age predilection. Primary herpetic gingivostomatitis , mumps, haemangioma and Ewing's sarcoma are seen in childhood. The recurring lesions of lichen planus , pemphigus and other subepithelial bullous dermatoses are seen in middle-age group. The problems of xerostomia , osteoarthritis, trigeminal neuralgia, Parkinson's disease and Paget's disease are encountered in older age group .

33. Sex: There are some diseases that occur in ONLY one sex e.g. hemophilia affecting male only and pregnancy gingivitis affecting female only. Many diseases have greater predilection for a particular sex. For example, osteoporosis and burning mouth syndrome are often seen in females while cluster headache, tobacco-related oral mucosal changes and oral cancer are more often found in men. Genetic predisposition explain the preference of gender for the disease, whereas in few conditions the cause remains unknown.

34. Marital status : It gives an idea about sexually transmitted diseases of dental interested e.g. AIDS. It give also idea about psychological disorders that may implicated in etiology of some oral lesions e.g. lichen planus . Birthplace: Certain diseases are common in some towns or district as epidemic or endemic e.g. chronic dental flourosis . Occupation: Carpenters & shoemakers using the nails in their mouth, this habit could affect the hard and soft oral structures. Hepatitis-B more likely related to dentists / surgeons. also to Assessing socioeconomic status. Race: Some diseases occur in certain races e.g. cooly’s , anemia (Mediterranean area) Sickle cell anemia ( Nigroes ).

35. 2- Chief complaint Chief complaint is the problem for which the patient seeks help or treatment. The chief complaint is recorded in the patient's own words avoiding technical terms unless used by the patient. If there are more than one complaints, they are recorded in the order of their severity or chronologically . Some of the common chief complaints are pain, swelling, ulcers, decayed teeth, mobility of teeth, bad breath, bleeding from gums, dryness of mouth and burning mouth. Some patients may come for a routine check-up; some seeking treatment for improved aesthetics and some who have cancer phobia. The description or the details of the Chief Complaint may be affected by 1- Mental attitude and ability to expression. 2- Age of patient .

36. 3- History of Chief complain The history commences from the beginning of the first symptom and extends to the time of examination, recorded in a chronological order including onset, location, duration, character, loss/altered function, effect of previous treatment and relation to other health conditions. For example if the chief complaint is pain, following points should be noted. 1. Location: Location is important to ascertain the source of pain and to point out the area of pain. For example, pulpal pain is diffuse whereas pain due to acute periapical inflammation can be localized. 2. Onset and duration: The onset of pain may be sudden or gradual and its duration can be in terms of time, days, weeks, months or years.

37. 3. Character: The character or nature of pain can be described as throbbing, pricking, dull and so on. 4. Frequency: The pain may be continuous or intermittent in frequency. 5. Intensity: The intensity of pain varies from mild, moderate to severe. In case of chronic pain, the use of a numeric or visual analogue scale may be useful. 6. Effect on function: Effect on functions of the affected part such as the extent of mouth opening, mastication, speaking and swallowing should be noted. 7. Aggravating and relieving factors: These can be temperature variations, postural variations and effect of any medication, rest

38. 4- Past dental history The past dental history constitutes the frequency of past dental visits, the types of dental treatment received and expected complications of treatment received. This gives an idea of importance the patient gives to his/her oral health and his/her expectations from the dentist. Any history of complications like excessive bleeding, delayed wound healing or lack of effectiveness of previous treatment warrants special investigations and alterations in the treatment plan

39. Importance of Past & Present Medical History: The past medical history gives the clinician idea about systemic condition. Some diseases may contraindicate any oral surgery at the dental clinic such as leukemia and hemophilia. The leukemic and hemophilic patients must be hospitalized for any dental treatment to avoid excessive hemorrhage and severe infection.

40. A- Cardiovascular system I. Hypertensive patients have more chances of developing an adverse event during dental treatment. No elective dental treatment is advisable when the BP is more than 180/110 mm Hg . 2. Medications prescribed for hypertension may cause oral dryness, ulcerations and gingival enlargement. 3. Use of epinephrine in concentrations greater than 1:100,000 is not recommended in hypertensive patients due to its vaso -constrictive activity leading to further increase in BP. 4. Stressful and invasive procedures in patients with coronary artery disease carry the risk of precipitation of myocardial infarction. 5. Anticoagulation therapy results in impaired haemostasis . The patient's physician should be consulted if temporary stoppage of anticoagulant becomes necessary for some dental surgical procedures. 6. Patients with congenital heart disease having prosthetic heart valves are at a risk of infectious endocarditis. Antibiotic prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

41. B- Diseases of Gastrointestinal system 1. Gastrointestinal involvement with perioral pigmentation is an indication of Peutz-Jeghers syndrome. 2. In patients suffering from peptic and/or duodenal ulcers. (a) Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) and steroids should be avoided as they may exacerbate the condition. (b) Antacids may interfere with absorption of antibiotics such as erythromycin and tetracycline. 3. Jaundice, should be recognised by the dentist in the sublingual mucosa and timely referral to the physician is essential. 4. Diseases of the hepatobiliary system such as alcoholic hepatitis, cirrhosis and drug-induced hepatotoxicity deserve special attention with regard to haemostatic defects, as they can cause inability to synthesise clotting factors. 5 . Hepatitis virus (HV) infection is an occupational hazard for dental health care workers.

42. ORAL HEALTH CONSIDERATIONS Common cold, T.B and COVID 19 The use of decongestants and antihistamines may be associated with oral dryness. Bronchial asthma Sinus pain must be differentiated from an odontogenic pain. Mouth breathing in patients with chronic sinusitis increases the occurrence of gingivitis. C- Diseases of the respiratory system

43. D- Endocrinal diseases To detect diabetic patients: Ask the following : Are you urinate much daily? Are you feel your mouth dry? Are you eat more than normal? Are you loose much weight than before? Thyroid gland disease: Ask the following : Do you have hyperthyroidism ? if the answer is No ask about the following: - Sweating - Hand tremor - Palpitation - Intolerance to hot seasons

44. Oral health considerations for diabetes mellitus In a patient with diabetes mellitus, response to dental treatment depends on glycaemic status, concomitant medical problems and habits like alcohol, tobacco chewing and oral hygiene habits. These patients are highly susceptible to dentoalveolar infections. Glycaemic control is mandatory prior to initiating any treatment except for acute inflammatory conditions. The most common emergency related to diabetes mellitus in dental office is hypoglycaemia , a potentially life-threatening situation. Signs and symptoms include confusion, sweating, tremors, anxiety, dizziness, tingling or numbness, and tachycardia.

45. Oral health considerations for Adrenal gland disorders 1. Patients with Cushing's syndrome and those on long-term moderate to high dose glucocorticoid therapy are immunocompromised and are more susceptible to infections. 2. Patients with established severe adrenal insufficiency usually require premedication with oral and intramuscular glucocorticoids before an invasive procedure. Dosage and treatment plan must be determined by the patient's physician.

46. E- Allergic conditions The dentist should ask the patients about the following: 1- Are you allergic to certain drugs? 2- Do you take antihistaminic or cortisone? 3- Are you allergic to local anesthesia? 4- Are you have allergic diseases such as bronchial asthma, hey fever, urticaria , angioeodema and stomatitis medicamentosa or venenata ?

47. F-Blood disease The dentist should ask the patient the following question: 1- Are you bleed from mouth or nose? 2-Are you have skin manifestations as petechiae , eccymosis or heamatoma ? 3- Are you feel weakness, fatigue or headache? 4- Are you hospitalized for blood transfusion? 5- Are you complaining from recurrent oral infections ?

48. G- Gynacology and obstetrics 1- Are you pregnant ? which trimester? 2- Are you taking contraceptive? 3- What about menstrual period?

49. H- Systemic conditions dangerous for the dentist A- Liver disease: such as Hepatitis B and C . Hepatic patient should be asked about the following: 1- Are you have jaundice or hepatitis? 2- Are you feel weakness or fatigue? 3- Are you have any investigations e.g. liver function tests , prothrombin time or complete blood picture ? Are you feel your abdomen swollen than normal? B- Others : AIDS , Tuberculosis and Syphilis .

50. I- Drug administration The patient should ask about - Anticoagulant - Cortisone - Aspirin - Sedative or tranquilizer Non-steroidal anti inflamatory drug - Gold salts - Nitroglycerine - Anti diabetic - Antihypertensive - Iodine preparation Others e.g., chemotherapy, cytotoxic or ionizing radiation etc

51. 6- Personal and Family History The personal history includes obtaining the information about the oral hygiene methods employed by the patient, patient's diet details, habits of smoking and alcohol consumption should be recorded. The family history may require asking open-ended questions like are there any illnesses that run in your family? This gives information about the genetically related disorders like haemophilia and diabetes mellitus.

52. The following diseases are hereditary conditions so the family history may be a positive finding in one or more member in the family as: - Hemophilia -Diabetes mellitus - Sickle cell anemia - Cooly’s anemia Hereditary ectodermal dysplasia Amelogenesis & dentinogenesis imperfecta Papillon Lefever's syndrome Ehler Danlo´s syndrome - Down’s syndrome.

53. 7- Socioeconomic history Knowledge of the patient's socioeconomic status indicates/suggests certain disease possibilities such as tuberculosis being more prevalent among people living in poor condition . It is also useful to consider the extent of treatment if under insurance coverage or under special schemes of the government for the underprivileged .