Oral medicine lecture 1

Al Azhar University Gaza
Dr. lama khaled El Banna
Faculty of Oral and Dental Medicine

1. Oral Medicine Dr. Rawand Samy Mohamed Abu Nahla Oral Medicine, periodontology& oral Radiology Department. Dr. Haydar . A. Shafy Faculty Of Dentistry. El Azhar University.

2. Lecture 1

3. The field of oral medicine consists chiefly of the diagnosis and medical management of the patient with complex medical disorders involving the oral mucosa and salivary glands as well as orofacial pain and temporomandibular disorders . Specialists trained in oral medicine also provide dental and oral health care for patients with medical diseases that affect dental treatment, including patients receiving treatment for cancer, diabetes, cardiovascular diseases, and infectious diseases.

4. Oral medicine is the specialty of dentistry that is concerned with the oral health care of medically compromised patients and with the diagnosis and nonsurgical management of medically related disorders or conditions affecting the oral and maxillofacial region . Oral medicine specialists are concerned with the nonsurgical medical aspects of dentistry. These specialists are involved in the primary diagnosis and treatment of oral diseases that do not respond to conventional dental or maxillofacial surgical procedures. The practice of oral medicine will provide optimal health to all people through the diagnosis and management of oral diseases.

5. Fundamental to this vision are the following: 1. Recognition of the interaction of oral and systematic health. 2. Integration of medical and oral health care. 3. Management of pharmaco therapeutics necessary for treatment of oral and systemic diseases 4. Investigation of the etiology and treatment of oral diseases through basic science and clinical research. 5. Research, teaching, and patient care.

6. 6. Provision of care for medically complex patients and for those undergoing cancer therapy. 7. Prevention, definition and management of the following disorders : Salivary gland disease. Orofacial pain and other neurosensory disorders. Disorders of the oral mucosa membranes.

7. To get relevant medical and dental information (including the examination of the patient) and the use of this information for dental treatment. This process can be divided into the following four parts: 1. Taking and recording the medical history. 2. Examining the patient and performing laboratory studies. 3. Establishing a diagnosis 4. Formulating a plan of action (including dental treatment modifications and necessary medical referrals)

8. MEDICAL HISTORY Obtaining a medical history is an information gathering process for assessing a patient’s health status. The medical history comprises a systematic review of the patient’s chief or primary complaint, a detailed history related to this complaint, information about past and present medical conditions, pertinent social and family histories.

9. 1-Chief Complaint and History Of The Present Illness The chief complaint is established by asking the patient to describe the problem for which he or she is seeking help or treatment . The chief complaint is recorded in the patient’s own words as much as possible and should not be documented in technical ( ie , formal diagnostic) language unless reported in that fashion by the patient. Patients may or may not volunteer a detailed history of the problem for which they are seeking treatment, and additional information usually needs to be elicited by the examiner. The patient’s responses to these questions constitute the history of the present illness (HPI).

10. The HPI is the course of the patient’s chief complaint: W hen and how it began; what exacerbates and what ameliorates the complaint (when applicable); if and how the complaint has been treated, and what was the result of any such treatment ; and what diagnostic tests have been performed. Direct and specific questions are used to elicit this information and should be recorded in the patient record in narrative form, as follows:

11. 1. When did this problem start? 2. What did you notice first? 3. Did you have any problems or symptoms related to this ? 4. What makes the problem worse or better? 5. Have the symptoms gotten better or worse at any time? 6. Have any tests been performed to diagnose this complaint? 7. Have you consulted other dentists, physicians, or anyone else related to this problem? 8. What have you done to treat these symptoms?

12. 3-PAST MEDICAL HISTORY(PMH): The past medical history (PMH) includes information about any significant or serious illnesses a patient may have had as a child or as an adult. The patient’s present medical problems are also enumerated under this category. The PMH is usually organized into the following subdivisions : (1) Serious or significant illnesses . (2) H ospitalizations . (3 ) T ransfusions. (4) Allergies . (5) M edications. (6) Pregnancy .

13. 2 -PAST DENTAL HISTORY (PDH) Despite its frequent omission from the dental record, the past dental history (PDH) is one of the most important components of the patient history. This is especially evident when the patient presents with complicating dental and medical factors such as restorative and periodontal needs coupled with a systemic disorder such as diabetes .

14. Significant items that should be recorded routinely are the frequency of past dental visits: previous restorative, periodontic , endodontic, or oral surgical treatment . Reasons for loss of teeth; untoward complications of dental treatment . F luoride history, including supplements and the use of well water. A ttitudes towards previous dental treatment; experience with orthodontic appliances and dental prostheses; and radiation or other therapy for oral or facial lesions.

15. 4 -FAMILY HISTORY Serious medical problems in immediate family members (including parents, siblings, and children) should be listed. Disorders known to have a genetic or environmental basis (such as certain forms of cancer, cardiovascular disease including hypertension, allergies, asthma, renal disease, stomach ulcers , diabetes mellitus, bleeding disorders, and sickle cell anemia ) should be addressed.

16. 5 -SOCIAL HISTORY Different social parameters should be recorded. These include marital status (married, separated, divorced, single, or with a “significant other”); place of residence (with family, alone, or in an institution); educational level ; occupation; religion; travels abroad ; tobacco use (past and present use and amount ); alcohol use (past and present use and amount ). When obtaining the social history, the clinician should take into account the patient’s chief complaint and PMH in order to gather specific information pertinent to the patient’s dental management .

17. 5-EXAMINATION OF THE PATIENT The routine oral examination ( ie , thorough inspection, palpation, auscultation , and percussion of the exposed surface structures of the head, neck, and face; detailed examination of the oral cavity, dentition, oropharynx, and adnexal structures, as customarily carried out by the dentist) should be carried out at least once annually or at each recall visit

18. The examination procedure in dental office settings includes the following: 1.Registration of vital signs (respiratory rate, temperature, pulse , and blood pressure ). 2 . Examination of the head, neck, and oral cavity, including salivary glands, temporomandibular joints, and lymph nodes. 3. Examination of cranial nerve function. 4. Special examination of other organ systems. 5. Requisition of laboratory studies.

19. Normal values: Normal respiratory rate during rest is 14 to 20 breaths per minute. The normal oral ( sublingual) temperature is 37°C (98.6°F), but oral temperatures < 37.8°C (100°F) are not usually considered to be significant . The normal resting pulse rate is between 60 and 100 beats per minute (bpm). A patient with a pulse rate >100 bpm (tachycardia ), Normal blood pressure Optimal Systolic Blood Pressure < 120 (mm Hg) and Diastolic Blood Pressure < 80 ( mm Hg)

20. 1-Facial Structures: Observe the patient’s skin for color, blemishes, moles, and other pigmentation abnormalities; vascular abnormalities such as angiomas , telangiectasias , nevi, and tortuous superficial vessels; and asymmetry, ulcers, pustules, nodules, and swellings. Note the color of the conjunctivae.

21. 2-Lips Note lip color, texture, and any surface abnormalities as well as angular or vertical fissures, lip pits, cold sores, ulcers, scabs, nodules, keratotic plaques, and scars . Palpate upper lip and lower lip for any thickening (induration) or swelling . Note orifices of minor salivary glands and the presence of Fordyce’s granules. 3-Cheeks Note any changes in pigmentation and movability of the mucosa , a pronounced linea alba, leukoedema, hyperkeratotic patches , intraoral swellings, ulcers, nodules, scars, other red or white patches, and Fordyce’s granules.

22. 4-Maxillary a nd Mandibular Mucobuccal Folds Observe color, texture, any swellings, and any fistulae. Palpate for swellings and tenderness over the roots of the teeth and for tenderness of the buccinator insertion by pressing laterally with a finger inserted over the roots of the upper molar teeth. 5-Hard Palate and Soft Palate Illuminate the palate and inspect for discoloration, swellings, fistulae , papillary hyperplasia, tori, ulcers, recent burns, leukoplakia , and asymmetry of structure or function. Examine the orifices of minor salivary glands. Palpate the palate for swellings and tenderness.

23. 6-The Tongue Inspect the dorsum of the tongue (while it is at rest) for any swelling , ulcers, coating, or variation in size, color, and texture. Observe the margins of the tongue and note the distribution of filiform and fungiform papillae, depapillated areas, fissures, ulcers, and keratotic areas . Note the frenal attachment and any deviations as the patient pushes out the tongue and attempts to move it to the right and left. Wrap a piece of gauze (4 cm × 4 cm) around the tip of the protruding tongue to steady it, and lightly press a warm mirror against the uvula to observe the base of the tongue and vallate papillae ; note any ulcers or significant swellings.

24. 7-Floor o f The Mouth With the tongue still elevated , observe the openings of Wharton’s ducts , the salivary pool, the character and extent of right and left secretions , and any swellings, ulcers, or red or white patches. Gently explore and display the extent of the lateral sublingual space , again noting ulcers and red or white patches. 8-Gingivae Observe color, texture, contour, and frenal attachments . Note any ulcers, marginal inflammation, resorption , festooning, Stillman’s clefts, hyperplasia, nodules, swellings, and fistulae.

25. 8-Teeth a nd Periodontium Note missing or supernumerary teeth, mobile or painful teeth, caries , defective restorations, dental arch irregularities, orthodontic anomalies , abnormal jaw relationships, occlusal interferences, the extent of plaque and calculus deposits, dental hypoplasia , and discolored teeth. 9-Tonsils a nd Oropharynx Note the color, size, and any surface abnormalities of tonsils and ulcers, tonsilloliths , and inspissated secretion in tonsillar crypts . Palpate the tonsils for discharge or tenderness, and note restriction of the oropharyngeal airway . Examine the faucial pillars for bilateral symmetry, nodules, red and white patches , lymphoid aggregates, and deformities . Examine the postpharyngeal wall for swellings, nodular lymphoid hyperplasia, hyperplastic adenoids, postnasal discharge, and heavy mucous secretions .

26. 9-Salivary Glands Note any external swelling that may represent enlargement of a major salivary gland. A significantly enlarged parotid gland will alter the facial contour and may lift the ear lobe; an enlarged submandibular salivary gland (or lymph node) may distend the skin over the submandibular triangle . With minimal manipulation of the patient’s lips, tongue, and cheeks, note the presence of any salivary pool, and note whether the mucosa is moist, covered with scanty frothy saliva, or dry.

27. 10-Neck a nd Lymph Nodes Examination of the neck is a natural extension of a routine dental examination and includes examination of the submandibular and cervical lymph nodes (draining the oropharynx and other tissues of the head and neck and anastomosing with lymphatics from the abdomen, thorax, breast , and arm), the midline structures (hyoid bone, cricoid and thyroid cartilages, trachea, and thyroid gland), and carotid arteries and neck veins. With the patient’s neck extended, note the clavicle and the sternomastoid and trapezius muscles, which define the anterior and posterior triangles of the neck . Palpate the hyoid bone, the thyroid and cricoid cartilages, and the trachea, noting any displacement or tenderness.

28. 11-Cranial Nerve Function In examining patients with oral sensory or motor complaints, it is important to know if there is any objective evidence of abnormality of cranial nerve function that might relate to the patient’s oral symptoms. A definitive answer to this question usually comes from specific testing of cranial nerve function as part of a general physical examination carried out by either the patient’s physician, an internist, or a neurologist . When the results of a neurologist’s examination are not readily available, a cranial nerve examination carried out by the dentist.

29. Establishing The Diagnosis In some circumstances, the diagnosis ( ie , an explanation for the patient’s symptoms and identification of other significant disease process) may be self-evident. When clinical data are more complex, the diagnosis may be established by: 1. Reviewing the patient’s history and physical, radiographic, and laboratory examination data; 2. Listing those items that either clearly indicate an abnormality or that suggest the possibility of a significant health problem requiring further evaluation. 3 . Grouping these items into primary versus secondary symptoms , acute versus chronic problems, and high versus low priority for treatment . 4. Categorizing and labeling these grouped items according to a standardized system for the classification of disease.

30. Formulating A Plan Of Treatment And Assessing Medical Risk Plan of Treatme nt The diagnostic procedures (history, physical examination, and imaging and laboratory studies) outlined previously are designed to assist the dentist in establishing a plan of treatment directed at those disease processes that have been identified as responsible for the patient’s symptoms. A plan of treatment of this type, which is directed at the causes of the patient’s symptoms rather than at the symptoms themselves, is often referred to as rational, scientific, or definitive (in contrast to symptomatic , which denotes a treatment plan directed at the relief of symptoms, irrespective of their causes). Like the diagnostic summary, the plan of treatment should be entered in the patient’s record and explained to the patient in detail (procedure, chances for cure [prognosis], complications and side effects, and required time and expense).

31. 45-year-old Caucasian female presents for evaluation of a swelling in her lower lip. The swelling has been present for 1 month. Her past medical history is remarkable for several angina attacks during the past 4 years. The angina is being treated with nitroglycerins only when necessary. Patient is not taking any daily medications. No history of any other cardiovascular disease . No chest pains for the past 6 months .. Examination reveals a 2 mm × 2 mm hard nonmovable pea-shaped lesion 10 mm medial to the right lip commissure and 5 mm inferior to the vermilion border. The lesion is consistent with a traumatic injury of a minor salivary gland . Patient has been advised that the lesion may resolve by itself or the she can have it surgically removed with local anesthesia. Any dental treatment of this patient needs to address her cardiovascular condition.

32. Thank you