2. Introduction
Oral Diagnosis is the art of using scientific
knowledge to identify oral disease processes &
to distinguish one disease from another.
In other words, diagnosis would mean
recognizing the disease and naming it.
3. The medical history of patient
A medical history is important as it aid’s the diagnosis of oral
manifestations of systemic disease.
It also ensures that medical conditions and medication which
affect dental or surgical treatment are identified.
Diseases most common in our Clinic
1-heart diseases
2- Diabetes
3-epilepsy
4- pregnancy
5-asthma
6-thyroid diseases
7-cancer
4. Diabetes mellitus
is a group of metabolic diseases that lead to high levels of blood
glucose (hyperglycemia), which is caused when the body does not
make any or enough insulin, or does not use insulin well.
SIGNS OF DIABETES Oral complications
-Polydipsia -Xerostomia
-Polyurea -Burning sensation
-Polyphagia -Gingivitis and periodontitis
-Weight loss -Dental caries
-Poor wound healing -Bacterial, viral, and fungal infection
-Severe infections -Periapical abscesses
-Weakness
7. Dental management of patient with diabetes
After consult the physician…If diabetes is well-controlled, all
dental procedures can performed without special precautions
before starting the procedure ,verify that the patient have taken
medication and diet as usual.
8. Dental management of patient with
diabetes
IF Diabetes is poorly controlled I.e fasting blood glucose <80mg/dL
or >200 mg/dL and ANY complications [post MI, renal disease,
congestive heart failure, symptomatic angina, old age, cardiac and
blood pressure ≥180/110 mm Hg ,All elective dental procedures
should be postponed.
Provide Only emergency care,
Consult patient physician
Critical setting: hospital
9. Dental Management of the Patient With Diabetes and
Acute Oral Infection
Non–insulin-controlled patients may require insulin;
consultation with physician , need modification to lower
blood glucose level below 200 mg/dl
Insulin-controlled patients usually require increased
dosage of insulin; consultation with physician required
11. Dental Management: Stable Angina/Post-MI >4-
6 months
•Minimize time in waiting room
•Short, morning appointments
•Pre-op, intra-op, and post-op vital signs
•Pre-medication as needed
–anxiolytic (benzodiazepines, ssri); night before and 1 hour before
–Have nitroglycerin available : may consider as prophylactic .
•Use pulse oximeter to assure good breathing and oxygenation
•Oxygen intra-operatively (if needed)
•Excellent local anesthesia - use epinephrine free,
•Avoid epinephrine in retraction cord
-SSRI-selective serotonin re-uptake inhibitors
12. Dental Management: Unstable Angina or MI < 3
months
•Avoid elective care
•For urgent care: be as conservative as possible; do only what
must be done (e.g. infection control, pain management)
•Consultation with physician .
•Consider treating in outpatient hospital facility or refer to
hospital dentistry
•ECG, pulse oximetry, IV line
•Use vasoconstrictors cautiously if needed
13. Dental Management of the Patient With Diabetes and
Acute Oral Infection
Non–insulin-controlled patients may require insulin; consultation with
physician required
Insulin-controlled patients usually require increased dosage of insulin;
consultation with physician required
15. Asthma
Is a chronic inflammatory disorder of the airways, causes
recurrent episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in the early
morning.
Dental treatment may lead to anxiety of patient this
lead to bronchi construction , And if not treated
immediately it may lead to a condition called status
asthmaticus (a severe condition in which asthma
attacks follow one another without pause), it
consider as sever form of asthma and as live threat.
16. Dental Management of the Patient With
respiratory disease
consultation with patient’s physician before any treatment
-review the patient’s medical history to see:
*severity of the disease
*if there have taken corticosteriods
*the medications taken by the patient
-For asthmatic patients , remind them to bring their
inhalers.
-For local Anesthesia , avoid using epinephrine.
-Avoid aspirin or aspirin containing analgesics for
patients who have aspirin-induced asthma
-Do not use equipments that produce aerosols.
17. Pregnancy
Drug to avoided in pregnant woman include aspirin , ibuprofen,
tetracycline and doxycycline.
nitrous oxide not recommended during pregnancy.
18. Pregnancy
Drug to avoided in pregnant woman include aspirin , ibuprofen,
tetracycline and doxycycline.
nitrous oxide not recommended during pregnancy.
Insulin-controlled patients usually require increased dosage of insulin;
consultation with physician required
19. Dental management of patient under
chemotherapy(bisphosphonates)
General side effects of chemotherapy
bone marrow suppression, resulting in leukopenia (observable in
peripheral blood towards day 10 after the start of chemotherapy),
thrombocytopenia (after 10-14 days) and anemia (less frequent and
slower in developing).
Other common effects are nausea and vomiting , hair loss (alopecia),
and hand-foot syndrome (clinically characterized by painful,
symmetrical erythema of the palms and soles, often preceded by
Paresthesia in the affected zones).
Most of the side effects gradually disappear after the end of treatment,
though in some cases permanent damage may be observed at
Cardiac (myocardiopathy) , pulmonary (fibrosis), renal (chronic
renal failure) or reproductive level (sterility).
20. Dental management
The dentist should consult the oncologist.
meticulous examination of the oral cavity: dignose periapical lesions
and/or bone alterations, and the evaluation of periodontal health.
General prophylactic measures: tartar removal, dental fluidization and
rinses with 0.12% chlorhexidine.
Analgesics: paracetamol/metamizole , NO NSAID , Antibiotics: dose
adjustment is required according to the observed creatinine clearance
values in patients with kidney problems.
Minor surgery: al least two weeks before chemotherapy.
Major surgery: 4-6 weeks before chemotherapy.
it is recommended the use of amoxicillin/clavulanate , doxycycline or
azithromycin as antibiotic of choice
21. Drugs interfere with dental management
Local anesthesia-drug interactions
Local anesthesia and vasoconstrictor may interact with other
prescribed drugs.
Potential adverse outcome(s)Drugs Interacts with L.ACommon drug used
in dentistry
Drug class
Lidocaine concentrations
Respiratory depression
Respiratory depression
H2 blocker(ranitidine)
CNS depressants
CNS depressants
Lidocaine
Prilocaine
Articaine
Anesthetic
Increase blood pressuremonoamine oxidase.Epinephrinevasoconstrictor
22. Drugs cause abnormal bleeding
Reduced blood clotting is a side effect of aspirins ,plavix and
anticoagulants, such as heparin or warfarin. These
medications can be helpful in preventing stroke or heart
disease, but can cause bleeding problems during oral
surgery or treatment for periodontal diseases.
Management of bleeding tendency
-if patient take Aspirine
-he should leave Aspirine for 5 days
-we must have Haemostatic measures in our clinc
23. Drugs cause enlargement of gum Tissue
Overgrown or enlarged gum tissue is known as
“gingival overgrowth.” It is sometimes associated
with Anti-epileptic drugs such as phenytoin,
immunosuppressant drugs such as those taken after
organ transplantations and calcium channel blockers
(including nifedipine, verapamil, diltiazem and
amlodipine) that are taken by some heart disease
patients.
24. previous surgery
-Kidney disease :dialysis
Two types
A-hemodialysis B-Peritoneal dialysis
Dental management:
1-avoid the use of drugs that depend on renal metabolism
Or excretion.
2-avoid the use of nephrotoxic drugs , such as non steroidal anti
inflammatory drugs.
3-defer dental care until the day after dialysis has been given.
4-consult physician concerning use of prophylactic antibiotics
25. 5-monitor blood pressure and heart rate.
6-consider Hepatitis B screening before dental
treatment . Take hepatitis precautions if unable to
screen for hepatitis
26. Cardiac surgery: risk of infective endocarditis
patient with past cardiac surgery have high potential for
develop infective endocarditis due to dental treatment ..
DENTAL CONSIDERATIONS-
To prevent complication of infective endocarditis ,all dental
procedures should be carried under antibiotic cover.
Amoxicillin prophylaxis-1 hour before and 6 hours after the initial
dose.
Good oral hygiene measures ,fluoride treatment, chlorhexidine
rinses and routine cleaning to reduce harmful bacteremia.
Proper history should be taken to identify history of rheumatic
fever during childhood.
27. Suspicious cases should be referred to cardiologist for
cardiac evaluation prior to dental procedures.
Clindamycin or erythromycin prophylaxis during dental
treatment.
Elective dental treatment after physician consultation.
28. ( Epilepsy)
Epilepsy is a disease that involves seizures which are
characterized by an alteration of perception, behavior
and mental activities, as well as by involuntary muscle
contractions, temporary loss of consciousness and
chronic changes in neurological functions that result
from abnormal electrical activity in the brain.
Dental management
1) knowledge of the patient’s previous seizure episodes
and medication,
2) knowledge of the conditions that provoke epileptic
seizures, in order to avoid such conditions, and
29. 3) dentist should be able to recognize the early signs of a
seizure, take precautions before it occurs, and provide
the patient with supportive care if it does occur.
most of the medicines prescribed by dentists react with
AEDs and reduce the effects of it. non-steroidal anti
inflammatory drugs and some of anti-fungals such as
fluconazole and miconazole affects the metabolism of
carbamazepine sodium valproate and phenytoin
negatively. Therefore, it has been stressed that these drug
combinations need to be avoided.
30. Dental history
We ask about PAST DENTAL HISTORY which
given us information about
-patient cooperation
-socio-economic state of the patient
-attitude towards previous dental treatment
-failure rate
-patient oral hygiene experience
-post operative pain
32. 3-Extra-oral examination
FACIAL ASYMMETRY: General appearance of the patients
face may be suggestive of certain diseases as: Acromegaly
and Cretinism
Eyes: ex: examine color of sclera if yellow indicate jaundice
,if dry and red eye in sjogren's syndrome patient and
exophthalmos in thyyroid diseased patient.
Skin: Dermatologic Signs of Systemic Disease ex autoimmune
Erythema Multi-forme and infectious herpes simplex virus
Tone of muscle: Masseter and temporal muscle are
palpated which give us hint about parafunctional habits
,deep bite and myofunctional pain.
TMJ:examine mouth opening, tmj pain , tenderness ,
limitation or deviation of mandibular movement , joint
sounds .
33. 4-Systemic manifestation
the most common medical conditions accompanied
with systemic symptoms like fatigue, fever , malaise
and pale skin. Which is a sign for many infectious ,
autoimmune disease and other disease.
35. A-CHIEF COMPLAINT
It is patient’s own words.
COMMON CHIEF COMPLAINTS(Pain , Swelling , Ulcer).
Characteristics of pain it is subjective sign
-onset
- Duration
-Nature of pain
-Severity
-Precipitate factors
Relieving factors
-Associated symptoms
-Treatment taken
36. Pain of Facial tissue
due to
-tooth
-supporting tissue
-mucosal pain(ulcer or lump)
-bone pain(cyst , osteomyelitis , fracture , malignancy ).
-TMJ pain (clicking , limitation of mouth opening)
-neurological pain (trigeminal neuralgia, glossopharyngeal
neuralgia)
multiple sclerosis herpes zoster (shingles) infections
idiopathic causes
37. Referred pain
-heart attack( angina): chin pain +tightness of chest)
-ear infection (otitis media)
-sinusitis (multiple maxillary tooth pain)
-chronic musculoskeletal pain (for example,
temporomandibular disorder (TMD)
38. Myofacial pain sydrome
-psychological pain ( atypical facial pain)
pain without organic origin patient describe pain
with delusion , not relive by analgesics worsen at
wake up and night relived by antidepressant
drugs.
39. Post operative pain
1- Post extraction pain
-Traumatic extraction
-dry socket
-osteomyelitis
-fracture
2-post operative pain
-high spot
-overhang filling
-lack of insulation
-lack of condensation
- hyperemic pulp and remnant caries.
40. 3- post endodontic pain (flare up )
-remnant inflamed pulp tissue
-missed canal
-infected canal.
-over instrumentation.
-over irrigation.
41. B- Accused tooth
-probing
-tenderness
-mobility
-tactile sensation
-vitality test
-x-ray as (adjunctive) to conform disease that
can’t see by naked eye
42. C- Adjacent and opposing teeth should be
examined carefully.
D-periodontal tissue examination:
-inspection
-periodontal pocket depth(by periodontal probe)
-tapping apically and laterally
Test vitality of tooth give us differential diagnosis of pulpal
pain from pain due to other diseases.
We use -pulp tester -hot or cold agent for pulp test.
43. Diseases of pulp
-pulpitis
-Non localized pain
-stimulated by hot , cold and sweet
-tooth not tender to percussion .
#pulpitis include
1-reversible pulpitis
2-irreversible pulpitis
44. 1-reversible pulpitis
-pain removed as stimuli remove ,
-pain not lasting more than 1 min.
2- irreversible pulpitis
-pain still after remove of stimuli
-severe pain
-pain may relieved by cold
45. localized pain
tooth tender to percussion.
-acute apical periodontitis(is inflammatory lesion
around the apex of a tooth root which is caused by
bacterial invasion of the pulp of the tooth).
-chronic apical periodontitis
-apical abscess
B- Apical periodontitis
48. Disease of oral mucosa
1-ulcer( Aphthous) Oral ulcers are characterised
by a loss of the mucosal layer within the mouth.
causes of oral ulceration
The two most common causes of oral
ulceration are local trauma (e.g. rubbing
from a sharp edge on a broken filling)
and aphthous stomatitis ("canker sores"),
a condition characterized by recurrent
formation of oral ulcers
49. 2-oral mucosal masses
a. Masses increase in size just before eating sialolithiasis .
b. Slow-growing masses -duration of months to years-(Reactive hyperplasia
,Chronic infection , Cysts ,Benign tumors).
c. Moderately rapid-growing masses (weeks to about 2 months)
(Chronic infection , Cysts , Malignant tumors).
d. Rapidly growing masses -hrs to days- (Abscess (painful), Infected cyst
(painful), Aneurysm, Salivary retention phenomena , Hematoma).
e. Masses with accompanying fever ( Infections, lymphoma, leukemia) .
50. Oral mucosal pigmentation
Oral melanotic macula is a flat, brown, solitary or multiple
mucosal discoloration of oral mucosa, which is produced by a
focal increase in melanin deposition along with an increase in
melanocyte count. The most commonly involved sites are lip,
buccal mucosa, gingiva and palate.
51. Diseases of facial bones
-Infection(Osteomyelitis)
-mass tumor (malignant or benign)
-cyst
- fracture
52. TMJ disorder
common TMD symptoms include:
Pain in the face, jaw or ear area
Headaches (often mimicking migraines), earache,
and pain and pressure behind the eyes
A clicking or popping sound when opening or
closing the mouth
Jaw that "gets stuck," locked or goes out of place
Tenderness of the jaw muscles
Swelling of the face
55. *note: about proximity of disease to pulp tissue
And up x-ray in endo does not reveal pulp
disease but give us hint about:
-bone alteration diseases does not appear in x-ray till
three weeks
-bone healing does not appear in x-ray till six months .
-in acute pain or acute swelling cases the x-ray is
useless
56. Treatment
plan
scientific area
-Evidence based dentistry
-clinical evidence
-prognosis
-follow-up
Clinical area
-general health
-oral health
-parafunctional habits
-age of patient
-sex
Clinician area
-specialization
-clinical experience
-equipment
-skills
Patient area
-costs
-planning
-Esthetic problems
-Compliance
-psychosis
57. Communication with patient
-body language (55%)
- body posture
- eye contact
- facial expression
- Touch: touch is a very powerful means of communication.
-verbal communication (15%):-content of your massage.
-tone of your voice (30%)
58. NOTE: patient don’t knows how much your know
or information your have, but he knows how much
you care.
59. Dental Ethics
“The moral duties and obligations of a dentist towards
his/her patients.
Principles of Dental Ethics
To do good (Beneficence)
To do no harm (Non-maleficence)
Autonomy (Self Governance)
Justice (Fairness)
Truthfulness
Confidentiality (There should be understanding
between dentist and patient).
