Special Investigation


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Oral Diagnosis II
Forth Year

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Special Investigation

  1. 1. Special Investigations
  2. 2. Principles of Investigations Personal Data. Present complain. Family history. Social history. Medical history. Vital signs. Clinical examination. Differential Diagnosis Special Investigations Final Diagnosis Plan of treatment
  3. 3. 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 Sjogren’s syndrome may require many tests Haematology Blood chemistry and electorlyte test Microbiology Culture Smear Viral Culture ImmunofluorescentHistopathology (1) Biopsy Surgical biopsy Fine needle aspiration (2) Exfoliative cytology IncisionalExcisional Imaging. Conventional Radiography Computerized Tomography(CT) Magnetic Resonance Imaging (MRI) Ultra sound Sialography Thick needle/ core biopsy Sialochemistry All special Investigation needed in Oral Medicine Immunohistochemistry & Molecular biological test.
  4. 4. * Percussion test * Palpation test * Thermal changes test: - Heat test - Cold test * Electric sensitivity testing Clinical Investigations
  5. 5. 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.
  6. 6. 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 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. Magnetic Resonance Imaging (MRI)
  7. 7. 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. Ultrasound
  8. 8. 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. Sialography sialodochitis * 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
  9. 9. Biopsy: Removing tissue from a patient for histopathological examination. Histopathology 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 doesn’t necessitate a major surgical procedure
  10. 10. 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. 2- Incisional biopsy: Removal only part of lesion which also include normal tissue margin. Punch biopsy
  11. 11. The biopsy must be: - choose from the most suspected area - Avoid ulcers slough or necrotic area - Give regional or local anesthesia far from the biopsy - Include normal tissue margin. - Specimen should preferably at least 1x 0.6 cm x 3mm deep. - Specimen edges should be vertical not beveled
  12. 12. Indication:  Diagnosis of swelling in lymph node  Metastatic carcinoma, Hodgkin’s and non Hodgkin’s Lymphoma  Tumors of parotid gland. 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. B- Fine needle aspiration 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.
  13. 13. 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.
  14. 14. 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
  15. 15. Indication: • Pemphigus and pemphigoid • Suspected Lymphoma • Undifferentiated Malignant neoplasm • Autoimmune disease Immunofluorescence & Immunohistochemistry Use of highly specific binding between antibody and antigen to stain specific molecules within the tissue
  16. 16. Immunohistochemistry
  17. 17. Immunohistochemistry Cytokeratins
  18. 18. 4- 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.
  19. 19. 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. Hematology & Blood chemistry
  20. 20. Types of blood tests useful in oral diagnosis CBC: RBC (number–size) Hb And white cell count: Anaemia, lenkaemias, infections ESR (erythrosedimentation rate) Rais 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
  21. 21. Types of blood tests useful in oral diagnosis Serum calcium and parathormone level – A- increase the level of Ca++ Hyperparathyroidism, Malignent Metastasis to bone, Multiple Myeloma, Hypovitaminosis, paget’s 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
  22. 22. Types of blood tests useful in oral diagnosis • 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, addison’s 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 paget’s disease, hyperparathyroidism, hypophosphatasia. • Serum creatinin Increased in kidny disease, acromegaly and patient with large muscle mass.
  23. 23. OTHER TEST 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