practical oral medicine 2
TRANSCRIPT
Practical Oral Practical Oral Medicine 2Medicine 2
Ahmed A. Abdelazim
10 Marks over the following:1-Cardiovascular diseases2-Endocrine diseases3-Infectious diseases:a)AIDSb)Hepatitis4-Oro-facial pain5-Tongue diseases
1- 1- Cardiovascular Cardiovascular
diseasesdiseases
Case 1 A 62-year-old male came to your clinic he is
smoker with medical history of type 2 diabetes mellitus ,hypertension and with a history of
exertional chest pain radiated to left shoulder, arm, side of neck and mandible. This patient complained of pain related to upper molars on examination you noticed a generalized gingival
enlargement 1-Dental Management.
2-Cause of generalized gingival enlargement
A 59-year-old man came to your clinic .He had a history of placing a pacemaker and a 90-minute severe crushing chest pain He was taking aspirin daily . He asked for Scaling and fixed prosthesis.
How to manage this patient in your clinic ??
Case no 2 :
60 years old patient presented to your clinic with history of prosthetic valve on examination you found that his upper third molar should be extracted How to mange this patient ??
Case no 3 :
A cyanotic patient with clubbing fingers and edema of his extremities what would you suspect
and How to deal with this patient ??
Case no 4 :
Case 1This 65-year-old male This 65-year-old male
patient suffers during patient suffers during the dental treatment the dental treatment from Pain in the left from Pain in the left arm and shoulder, he arm and shoulder, he also gave a history of also gave a history of previous attacks that previous attacks that resolved resolved spontaneously spontaneously
1- Diagnosis ?1- Diagnosis ?
2- Management ?2- Management ?
Case 2A patient presented to A patient presented to Your clinic giving a history Your clinic giving a history Of taking this drugOf taking this drug
1- What is the 1- What is the Scientific name ofScientific name ofThis drug ?This drug ?
2- Its Uses ?2- Its Uses ?
3- Common side 3- Common side Effect of this drugEffect of this drug
Case 370-year-old patient gave70-year-old patient gaveA history of severe chestA history of severe chestPain and a heart attack thatPain and a heart attack thatOccurred 2 years agoOccurred 2 years agoAnd he was taken to theAnd he was taken to theHospital for pain reliefHospital for pain relief
1- Diagnosis1- Diagnosis
2- Is elective dental treatment possible ?2- Is elective dental treatment possible ?
3- What is the drug that relieves pain in such attacks ?3- What is the drug that relieves pain in such attacks ?
Case 4A female patient admitted to your clinic gave a history
of anginal attacks that were relieved by nitroglycerine tablets. You noticed that after treatment when she started to stand up from the dental chair, Symptoms of dizziness and loss of consciousness started to appear.
1- Explain what happened to the patient
2- How to prevent this from occurring again ?
Case 5
Mention Uses ofThis drug
Case 6Case 6During extraction of the lower third molar of a 55-
year-old female patient, Severe bleeding occurred.Upon questioning the patient she gave a history of a
past heart attack (Myocardial infarction) and that she was admitted to the hospital for relief of pain.
1- Explain the cause of bleeding ?
2- What are the tests needed for MI patients before dental procedures ?
Case 7During the dental
treatment of this patient, he suffered from severe chest pain
The dentist gave him 3 tablets of sublingual nitroglycerine that proved not effective in relieving pain
1- Diagnosis1- Diagnosis2- Management ?2- Management ?
Case 8This patient presented toYou suffering from persistentSevere headache, and also Reported the presence ofDental pain without thePresence of caries orPeriodontal disease(Odontalgia)
1- Possible DiagnosisAnd how to confirm ?
2- Write 3 drugs taken by these patients
Case 9After 2 months from dental extraction, a patient started to
suffer from fever, tiredness and mild clubbing of his fingers. The patient has a history of a congenital heart disease. The patient was admitted to the hospital for management.
1- Possible Diagnosis ?
2- What would you do for similar patients before extraction ?
Case 10
1- Diagnosis2- Describe it and mention 2 diseases
associated with it ?
Note
Clubbing of fingers
35-Clubbing finger
Case 10Female patient who is allergic to Penicillin came to your
clinic for the extraction of her lower second molar.She gave a history of a previous cardiac surgery involving
implanting a prosthetic valve.
1- Dental Management
2- What complications can happen to her if the proper drug wasn’t administered ?
Case 11This patient presented withBluish discoloration of his handsAnd bilateral lower limb edemaTogether with distention of The neck veins. He wanted toExtract his lower incisors
1- Diagnosis
2- Discuss emergencySituations possible withThis patient and theirmanagement
Note
Digoxin (Digitalis) is usedBy heart failure patients
Side effects Gag reflex
Note
Nifidepine (Calcium antagonist) cause generalized gingival enlargement
2- Endocrine diseases
Case 1This patient presents withChronic fatigue, tiredness andHypotension and melanin Hyperpigmented macules onThe skin and vermilion border
1- Diagnosis
2- Explain the reason of hyperpigmentations ?
NoteMoon’s face in Cushing
Buffalo hump
Case 2A 55-year-old female patient was taking 60 mg cortisone daily
for the treatment of her auto-immune disease.She stopped taking cortisone abruptly, after which she suffered
from severe hypotension, hypoglycemia then she fainted and was taken to the hospital.
1- Diagnosis
2- Explain what happened to the patient ?
3- How to avoid that ?
Case 3A patient came to your clinic suffering from badly broken down
upper right first molar that requires extractionIn history taking: the patient admitted taking prednisone for 6
years in treating rheumatoid arthritis
1- Dental Management of this patient
2- Explain why ?
Case 4This female patient who is taking Daily steroid for several years lostHer consciousness with a rapidDrop in blood pressure. She alsoBecame mentally confused andNot responsive to the dentist
1- Diagnosis ?
2- Dental Management ?
Case 550 years old patient came to your clinic for operative
restoration of his mandibular second molar toothHistory revealed taking daily steroid (6 mg prednisone) for 3
months
How to avoid the occurrence of adrenal Crisis in this patient ?
Case 6During the history taking of a patient admitted for
extraction of his wisdom tooth, He gave a history of stopping prednisone tablets 3 weeks ago. He reported taking the drug for 10 years.
Dental Management for this patient ?
Case 7This patient presents with severeAphthous ulcers on his lips andOral mucosa. You decided to startA steroid therapy taken orallyFor the management of theOral ulcers.
1- What will you do to minimize the risk of occurrence of adrenal insufficiency ?
2- Which is better to start with: Topical or systemic steroids ? And why ?
Case 855-year diabetic female
complaining of burning sensation of his tongue.
On examination, Diagnosis of Pseudo membranous candidiasis was done.
Her last random blood glucose level was 350 mg/dl
1- What is the normal value of random blood glucose level ?
2- What is the proper treatment ?
Case 9During the dental treatment of a 33 years old Type
1 diabetic female patient, she appeared to be sweating heavily with the increase in heart rate. Minutes later, she began to be mentally confused and started to faint gradually.
1- Name this condition ?
2- Mention 3 causes for this problem ?
3- How will you manage this ?
Case 104 days after the onset of a severe odontogenic infection, this
diabetic patient started to feel tired and confused with heavy urination and acetone breath. His skin started to be dry and he showed signs of increased rate of respiration. After that the patient was comatosed.
The most probable diagnosis is:The most probable diagnosis is:
1- The patient developed hypoglycemic coma
2- The patient developed hyperglycemic coma
3- Signs and symptoms of odontogenic infection
4- Respiratory diseases associated with Diabetes
Case 11Female patient with exophthalmia of her eyes came to your
clinic requiring the extraction of her teeth. During the baseline recording of vital signs you noticed that her blood pressure is 220/130 mmHg. She also complained of irregularity in her heart beats. She was nervous and anxious and felt restless during dental treatment.
The patient began to be very worried, her skin was very hot and her BP began to be very high when she felt pain during the extraction of her badly decayed lower molar
1- Diagnosis of the patient’s disease
2- Why did she suffer from these symptoms during the dental treatment ?
3- What is your dental management ?
Case 121- Name ThisEye phenomenon
2- It occurs with …………………..
Exophthalamus in Hyperthyroidism
Case 13This patient presented withPuffiness of his face andLips also macroglossia wasSeen intra-orally.The patient is very tired andObese and shows signs of edemaallover his body.His skin is cold and very dry
1- Diagnosis ?2- How to confirm it ?3- Possible complication during dental treatment
3-Infectious 3-Infectious diseasesdiseases
AIDSAcquired immune
deficiency syndrome
Important to Know
Atrophic Candidiasis
Chronic Herpes Simplex infection with lesions on tongue and lips.
Herpetic whitlow
Linear gingival erythema
Linear Gingival erythema
- Mild pain- Responds poorlyTo conventionalTreatmentHIV periodontal Triad:1- HIV associated gingivitis1- HIV associated gingivitis2- HIV associated periodontitis2- HIV associated periodontitis3- HIV associated Necrotizing gingivitis & 3- HIV associated Necrotizing gingivitis &
periodontitis periodontitis
Linear gingival erythema
Linear gingival erythema
Linear Gingival Erythema
Necrotizing Ulcerative Periodontitis
Squamous cell papilloma
Squamous cell papilloma
(3)
Haemoglobin 11.5 g/dl WBS 6.1 X 103/ml Neutrophils 5.2 X 103/ml Lymphocytes 0.2 X 103/ml Monocytes 0.6 X 103/ml CD 4 210 cells /ml HIV antibody positive HIV viral load undetectable
(4) CD 4 20 cells / ml HIV viral load 120.000 copies/ ml
(5)
Hb 14.5 g/dl Reticulocyte 0.68% (N: 0.5-2.4%) Platelets 266.000 Bilirubin 45 mg/dl (N: 0.3-1.0 mg/dl) AST 136 IU/L (N: 10-40 U/L) ALT 240 IU/L (N: 9-60U/L)
(6)Hb 14.5 g/dl Reticulocyte 0.68% (N: 0.5-2.4%) Platelets 266.000 Bilirubin 55 mg/dl (N: 0.3-1.0 mg/dl) AST 136 IU/L (N: 10-40 U/L) ALT 640 IU/L (N: 9-60U/L) HBsAg positive HBeAg positive Anti-HCV negative
(7) Platelets 100.000 Prothrombin time 20 sec (control 11.5-15.5) Serum bilirubin 75 mg/dl (N: 0.3-1.0 mg/dl) AST 101 IU/L (N: 10-40 U/L) ALT 38 IU/L (N: 9-60U/L) HBsAg positive
(8)
Platelets 130.000 Prothrombin time 20 sec (control 11.5-15.5) Serum bilirubin 45 mg/dl (N: 0.3-1.0 mg/dl) AST 101 IU/L (N: 10-40 U/L) ALT 38 IU/L (N: 9-60U/L) HBsAg positive Anti HBs negative HBe Ag positive Anti-HBe negative
Case 1This HIV + patient presented to theOral Medicine department sufferingFrom asymptomatic corrugated White lesion on the lateral borderOf the tongue.The patients says he feels gagging Because of the lesion and complainedOf its bad appearance.
1- Diagnosis ?
2- What is the causative organism ?
3- Mention other diseases showing the same lesion?
Case 2This 66-year-old AIDS patients presented to yourClinic suffering from extremely painful ulcers,Erosions and crusts on his face, cheeks and ears
The patient reported the presence of the lesionsFor 3 months now
1- Diagnosis ?
2- Causative organism ?
3- Management ?
Case 3A 28-year-old black male presented with numerous nodules on the face, and with multifocal, purple-red, maculo-papular lesions on the gingivae, and on the hard palate . The patient said that the facial and intra-oral lesions had appeared three months prior to our examination.
1- Diagnosis ?
2- What is the causativeOrganism ?
Case 4This 40-year-old patient Who gave a history ofIV drug abuse for severalYears, presented with manyDeep painful ulcers on Her upper and lowerLip that aren’t healingAnd are chronic
1- Diagnosis ?
2- What underlying disease you suspect ?3- Management ?
Case 1This patient suffers from drop
of the angle of the mouth & inability to close his eyes. He reported that these manifestations had a rapid onset. The facial muscles tend to be deviated to one side of the face.
1-What is your diagnosis ?
2-What is the treatment ?
3-What are the causes ?
Case 250-year old female patient came to the dental clinic
suffering from a very tender area on her upper lip. She said that when she touches this specific area, an
attach of electric shock like pain occurs. This pain attack last for 5 minutes.
1-What is your diagnosis ?
2-How can you confirm your diagnosis ?
3-What is the possible treatment ?
Case 3This patient suffers from loss of
taste sensation, inability to whistle and inability to close the eyes.
Ears showed multiple vesicles, ulcers and crusts on the external ear.
1-What is the diagnosis ?
2-What are the lesions A & B ?
Case 4This male patient suffered
from severe pain in front of the ear that is worst upon awakening and radiates to the neck.
On clinical examination, Wear facets were noticed on the mandibular posterior teeth
1-What is the diagnosis ?
2-What is the treatment
Management of MFPDS1. Elimination of cause e.g.:
high filling occlusal adjustments.
2. Occlusal splints (Bite raiser – night guard) if no local factor can be detected.
3. Patient reassurance .
Case 5A 45-year-old female patient suffering from depression
and anxiety from several years. She was suffering from chronic dull aching pain allover her head that doesn’t respond to analgesics
1-What is the diagnosis ?
2-What is the management ?
Tongue diseases Tongue diseases and disordersand disorders
ExaminationExaminationInspectionInspection
B- Palpation B- Palpation BidigitalBidigital Consistency Consistency
C- Function evaluationC- Function evaluation
Tongue Tie
Tongue deviation
Disorders of Tongue
• Glossodynia (burning mouth syndrome)- spontaneous burning, discomfort, pain, irritation, or rawness of the tongue, has no identifiable etiology most of the time
Etiology of Glossodynia
• Neurologic– Peripheral nerve
damage– Diabetic neuropathy – Trigeminal neuralgia
• psychiatric– Depression– Anxiety– Cancerophobia
• Systemic disorders– Anemia (iron deficiency,
pernicious)– Nutritional deficiency – Gastroesophageal reflux
disease– Sjogren syndrome– Hypothyroidism– Acquired
immunodeficiency syndrome
Treatment
• Tricyclic antidepressant
Disorders of Tongue…• Glossitis- presents as pain, irritation or burning,
hypogeusia, or dysgeusia
• Atrophic glossitis– Due to filiform de-papillation– Mild patchy erythema to a completely smooth,
atrophic, beefy-red surface
– Etiology - pernicious anemia, protein and other nutritional deficiencies, chemical irritants, drug reactions,, vesiculobullous diseases, oral candidiasis and systemic infections
Disorders of taste dysgeusia
• Viral infections• Candidiasis• Malnutrition• Neoplasms• Xerostomia• Metabolic disturbance• Drugs• Radiation• Zinc deficiency
COMMON LESIONS
Normal variations
Varicosities
Foliate papillae
They are occasionally mistaken fortumors or inflammatory disease
Developmental lesions
Fissured tongue
• normal variant seen in 5-11% individuals
• Numerous small irregular fissures oriented laterally on the dorsal tongue
• Also seen in - Melkersson-Rosenthal syndrome, psoriasis, Down syndrome, acromegaly, Sjogren syndrome
Macroglossia• Congenital or acquired process, tongue is
disproportionately large relative to the patient’s jaw size• Difficulty with mastication and speech and accidental
tongue biting are common• Differential- Down syndrome, hypothyroidism,
haemangioma, neurofibromatosis, infection by mycobacteria, or deep fungus, amyloidosis………
MicroglossiaMacroglossia\Fissured tongue
Hairy tongue• Hypertrophy of filiform papillae
resembling hair-like projections• Associated with - heavy tobacco
use, mouth breathing, antibiotic therapy, poor oral hygiene, general debilitation, radiation therapy, chronic use of antacids.
• White, yellow green, brown, or black color is due to chromogenic bacteria or staining from exogenous sources
Black hairy tongue
Brown hairy tongue
TREATMENT: Treatment consists of brushing the tongue with a soft bristle toothbrush . Surgical scraping.
1. What is the clinical diagnosis
2. What are the predisposing factors?
3. What is the treatment?
Geographic tongue• Geographic tongue- benign
inflammatory condition, due to loss of filiform papillae
• Erythematous plaques with well demarcated white border
• Etiology- idiopathic, psoriasis, Reiter syndrome, atopic dermatitis, idiopathic
Hemangioma of the lateral aspect of the tongue
Lingual thyroid
Other lesions
OraI hairy leukoplakia• Caused by Epstein-Barr
virus.• Presents as
asymptomatic, corrugated, white plaques with accentuation of vertical folds along the lateral borders of tongue
• Predominantly seen in HIV infection, organ transplant recipients and patients on chemotherapy
OraI hairy leukoplakia, Diagnosis
•DNA in situ hybridization•Biopsy
CandidiasisPseudomembranous
• Etiology• Predisposing factors• Classification• Treatment
Median rhomboid glossitis• Median rhomboid
glossitis - atrophic disorder of the tongue secondary to chronic candidiasis
Atrophic (erythematous) candidiasis
Squamous cell carcinoma• Early carcinoma may
clinically appear as leukoplakia or erythroplasia.
• The tongue and floor of the mouth are the most common areas
• PROGNOSIS: The overall five year survival rate is about 50%. Early diagnosis increases the chance of survival.
Leukoplakia
unilateral indurated white patch related to the lateral surface of the tongue.
EARLY SQUAMOUS-CELL CARCINOMA OF THE LATERAL
BORDER OF THE TONGUEEARLY SQUAMOUS-CELL
CARCINOMA OF THE FLOOR OF THE MOUTH
SQUAMOUS-CELL CARCINOMA PRESENTING AS EXOPHYTIC ULCERATED TUMOR OF THE
LATERAL BORDER OF THE TONGUE..
LATE SQUAMOUS-CELL CARCINOMA ON THE DORSUM
OF THE TONGUE.
• DIFFERENTIAL DIAGNOSIS: All ulcerations present for more than 2-3 weeks in which there is no apparent cause should be biopsied to rule out carcinoma, especially in adults whose lesions are in high risk areas.
Traumatic ulcerSource of trauma should be identified
Case 11-What is the clinical diagnosis ?2-What are the predisposing factors ?
Case 2
A 22-year-old male that has been diagnosed as AIDS, has noticed this whitish lesion on both sides of his tongue.1-What is the most likely diagnosis ?2-Causative organism ?3- How to confirm your diagnosis ?
Case 3
A 55 diabetic male complaining of burning sensation in his tongue.He was on systemic antibiotic therapy (Penicillin) for the last 2 weeks
due to a severe dento-alveolar abscess1-What is the most likely diagnosis ?2-How can you confirm your diagnosis clinically ?3-What is the appropriate treatment ?
Case 4A 67-year old smoker male
complains about this 4-week duration ulcer. No history of trauma or systemic illness has been reported.
1-What is the differential diagnosis ?
2-Is there lymphadenitis ? What are its characteristics ?
3-How can you confirm you diagnosis ?
Case 5
A 67 years old smoker presented to the dental clinic with a complain of unilateral indurated white patch related to the lateral surface of the tongue.
1-What is the differential diagnosis ?2-What is the proper management ?
Case 6These tongue changes were discovered accidentally during routine examination of the oral cavity. The patient reported that both his sons have the same lesions1-What is the most likely diagnosis ?
Case 7
This lesion was observed clinically, but with no pain
1-What is the diagnosis ?
Case 81) What is the differential diagnosis ?2) How can you confirm your diagnosis ?
Case 9A 58 years hypertensive female came to the dental clinic with a complain of burning sensation related to the dorsal surface of the tongue, she also reported a sense of dryness in her mouth over the last few months.1-What is the most likely diagnosis ?2-How can we confirm the diagnosis ?3-What is the proper treatment ?
Case 10
32 parenteral drug addict male came to the dental office with a complain of mild roughness and irritation related to both lateral surfaces of the tongue. He also reported a history of frequent attacks of respiratory tract and skin infections during the last 3 months
1-What condition is important to exclude?2-What is the causative organism ?
Case 11A 33 male presented with a painful unilateral ulcer of 2 weeks duration. He reported that one of his filled lower teeth fractured recently.
What is the most likely diagnosis ?
Case 12
This patient reported the presence of this lesion since early childhood
What is the Probable diagnosis ?
Good Luck