Al-Azhar University Gaza

Dr. Haidar A. Al-Shafi Faculty of Dentistry

Oral Medicine I
Assessment & investigation of
dental patient
Dr. Rami Aljuidi

Patient Assessment
History
- Complaint
- Medical history

- Drug history
- Social history
Clinical examination
- Extra-oral
- Intra-oral
Investigations
- Blood

- Biochemical
- Radiographic
- Histological

 History
-

Basis of investigation
Complaint in patients own words
Clinician should not try to influence patients response
Should not hurry
Confidentiality
History of any previous dental treatment, oral/panoral abnormality,
systemic disease, skin disorder, trauma/accident, major surgery
- Drug therapy
- Use of alcohol & tobacco
- Consult patients general practitioner or go through patients file

 Clinical examination
Extra-oral:
- General appearance
Wasted, mal-nutritioned, anxiety, agitation?
- Breathlessness
Cardiorespiratory problem?
- Face
Shape & symmetry
Cranio-facial syndromes
Cushingoid appearance?
Neurological deficits?
Cyanosis?
- Scalp & face
Scant hair

- Eyes
Conjuctival sacrring (pemphigoid)
Pale, yellow or blue sclera
Exophthalmia
- Neck
Lymph nodes
Goitre
- Hands
Raynauds phenomenon
Koilonychia
Joints
Palmar keratosis
-Wrists
Purple papules
-Skin
Petechiae or ecchymoses, cyanosis. Jaudice, pigmentation

 Intra-oral (with adequate light source)

- Remove all removable appliances
- Gently retract lips & cheeks
- Examine the whole oral mucosa
- Tongue
- Teeth
- Hard & soft palate
- Floor of mouth
In the end, a well taken clinical photograph

Normal Structures :
Normal Structure within the mouth are sometimes mistaken for pathological
conditions. Examples:

 Special Investigations
Special investigation should only be requested to answer
specific question
Some investigation have high specification and sensitivity for
particular Disease
Few diseases like mumps may be diagnosed on the basis of a
single test, but others such as Sjogrens syndrome may require
many tests

Clinical investigation

Percussion test
Palpation test
Thermal changes test: - Heat test - Cold test
Electric sensitivity testing

Imaging
Conventional Radiography:
Intra-oral [occlusal, Periapical, bitewing]
Panorama
Cephalometric
Computerized tomography (CT scan)
Sialography & Arteriography
MRI
Ultrasound
Indication: To detect: Caries Periodontal disease Periapical lesion.
Neoplasm cysts TMJ disease - Results of trauma to teeth or Jaws
to locate foreign objects and to find impacted teeth.

Computerized tomography (CT):

CT Scanning provides tomographic images (Section) of high clarity in any
plane
Advantages:
- Disease in the Maxillofacial complex
- CT scanning images of cysts
- CT is sensitive for neoplasm
Disadvantages:
- Expensive
- Not always available
- High x-ray dose
- Less information on soft tissue lesion
- Radio-opaque dental restoration cause artifact shadow

Magnetic Resonance Imaging (MRI)

It produces clear tomographic images particularly for soft tissue lesion, it
can differentiate between two densities of soft tissues 4 times better than
CT Scan and 40 times better than conventional radiograph, no x-ray dose is
present in this method.
Disadvantages:
- MRI is expensive and limited availability
- Does not image the bone.
- Long imaging time

Ultrasound
Ultrasound examinations use high frequency sound
pulses. Ultrasound requires expertise.
Indication:
-Used to determine whether any structure is solid or
cystic [solid objective absorb almost all of the sound
and are less echoes than the soft tissue].
- Examination of salivary gland (Tumors, cyst, stones).
- Detect the lesion in the thyroid gland and neck.
- Evaluation of lymph node, post surgical edema and
hematoma.

Sialography
Radio-opaque contrast agent like (Iodine derivative) is
infused into the ductal system of salivary gland. There
is low radiation exposure.
Disadvantages:
-There is some discomfort or pressure when the contrast
material is injected into the ducts.
-The contrast material may taste unpleasant.
Contraindication:
Sialography is contraindicated in acute infection of
salivary gland. We use with acute infection the ultrasound
to demonstrate the abscess. Salivary calculi is
questionable

 Histopathology
Biopsy: Removing tissue from a patient for histopathological
examination.
Indications
1- Persistent oral ulcers.
2- Persistent red and white lesion
3- suspected neoplasm or any unidentical tissue masses.

A- surgical biopsy
1-Excisional 2-Incisional
1- Excisional biopsy: is the removal of whole lesion.
- Can be performed when the lesion no larger than 1 cm in diameter
- When it is removal doesnt necessitate a major surgical procedure

2- Incisional biopsy: Removal only part of lesion which also

include normal tissue margin.
Indications: If the lesion is too large for an excisional procedure.
Contraindications:
Incisional biopsy of parotid gland tumors (plemorphic adenoma)
is contraindicated but may be examined microscopically only
after excision with a margin of surrounding normal tissue.

General principles:
sterilization protocols to be followed
Patient consent & councelling
LA to be given in the adjacent area & not within the lesion
Better taken with a knife than with a cutting diathermy
Specimen should be big enough to allow the pathologist to
make a diagnosis
Specimen should preferably at least 1x 0.6 cm x 3mm deep.
Specimen edges should be vertical not beveled
After excision, put into a fixative (10 formol saline being the
standard solution)
Apply stitches to the specimen for orientation
If the specimen is thin, lay it on a piece of card
Label the container with patients name & age & site of biopsy
Fill the biopsy form, draw the specimen diagram if necessary

B- Fine needle aspiration

The fine needle is inserted into the lesion and cell aspirated and
smeared on a slide. The cells can be fixed, stained and examined within
minutes.
Advantages
1- Avoid damage in vital structures in the neck and head
2- To prevent the spread of tumor cells
3- Less risk of delayed wound healing and infection
4- Rapid diagnosis and treatment
5- It is economy.
Indication:
- Diagnosis of swelling in lymph node
- Metastatic carcinoma, Hodgkins and
non Hodgkins Lymphoma
- Tumors of parotid gland.

C- Thick needle/ Core biopsy.

This method useful for inaccessible tumors, e.g. in the
pharynx.
But:
- it has risks of seeding some types of neoplasm into the tissues
and
- damaging adjacent anatomical structures.
- It is less used in the head and neck now that FNA is more
widely available.

D- Exfoliative cytology
It is examination of cells scraped from the surface of the
lesion
Indication:
- Most useful for detecting virally- damaged cells, acantholytic
cells of pemphigus or candidal hyphae.
- Used for patient who should be biopsied but for whom
surgical risk or some other factors prevent it.
- For patients refuse biopsy.
Contraindication:
- In obvious malignancy.
- In leukoplakia

 Immunofluorescence & Immunohistochemistry

Use of highly specific binding between antibody and
antigen to stain specific molecules within the tissue
Indication:
- Pemphigus and pemphigoid
- Suspected Lymphoma
- Undifferentiated Malignant neoplasm
- Autoimmune disease

 Microbiology
1- Culture and antibiotic sensitivity testes
a) Detect un usual pathogens e.g: Actinomycosis in soft tissue
infection.
b) Antibiotic sensitivity for all infections, especially:
-Osteomyelitis and acute facial soft tissue infection.
-Throat infection.
-Exudates from sinus infections.
-Root canal infections.
-Skin, mucus membrane infection.
2- Smear for candida: for candidiasis.
3- Viral culture or antigen screen.
4- Plain swab
5- Concentrated oral rinse

 Hematology & Blood chemistry

Indications:
- Diagnosis of Disease such as leukaemia, Myloma and
leukopenia which have oral manifastation.
- Diagnosis of other conditions such as some infections, sore
tongue and recurrent aphthae which are sometimes associted
with anaemia.

Types of blood tests useful in oral diagnosis

CBC: RBC (numbersize) Hb And white cell count:
Anaemia, lenkaemias, infections
ESR (erythrosedimentation rate): Raise in systemic
inflammatory and autoimmune disease
Iron test: Angular cheilitis, painful atrophic glossitis,
microcytic anemia
Folate level and vit. B12 level: Recurrent aphthous,
ulceration, recurrent candidosis and atrophy of papillae
of the tongue
Viral antibody titers e.g herpes simplex, varicella zoster,
mumps virus
Syphilis serology: Syphilis

 Serum calcium and parathormone level:

A- increase the level of Ca++
Hyperparathyroidism, Malignent Metastasis to bone, Multiple
Myeloma, Hypovitaminosis, pagets disease of bone.
B- decrease the level of Ca++
Hypoparathyroidism, Vitamin D diffeciency (rickets, osteomalacia
decrease intestinal calcium absorption and renal insufficiency and in
cases of tetani
Serum phosphate po4
A- increase the level of po4
Chronic renal disease, healing bone fracture, hypopara- thyrodism,
Hypervitaminosis D, increase of level of Growth Hormon
B- decrease the level of po4
Rickets disease and osteomalacia

 Blood Glucose level

A- Increase blood glucose level.
Diabetic Mellitus, cushinges diseases, in patient taking corticosteriod and
thiazid diuretic drug.
B- decrease blood glucose level.
Insulin secreting tumor, extensive liver disease, pituitary hypofunction,
addisons disease Mal absorption of monosaccharides.
Serum Bilirubine
Haemolytic anaemia, biliary obstruction, hepatitis, hepatic malignancy.
Serum uric acid
Gout, renal failure, leukaemia lymphoma, thiazid diuretic.
Serum Alkaline phosphate
High level in condition with increased bone turnover e.g pagets disease,
hyperparathyroidism, hypophosphatasia.
Serum creatinin Increased in kidny disease, acromegaly and patient with
large muscle mass.

 OTHER TESTS
URINE TEST
Diagnosis of diabetes, autoimmune conditions which damage the
kidney
TEMPERATURE TEST
- if the bone or soft tissue infection are suspected
- It helps distinguish facial inflammatory odema from cellulitis
- Systemic effect of infection and the need for more aggressive
treatment
BLEEDING TIME TEST
CLOTTING TEST
BLOOD PRESSURE
- Hypertension
- Hypotension

Thank You