Medical problems 1 4

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Medical problems 1 4

  1. 1. Islam Kassem, BDS , MSc, MOMS RCPS Glasg,FFD RCSIConsultant Oral & Maxillofacial SurgeonMedical Topics inOrthodonticsikassem@dr.com
  2. 2. 1- Patient assessment and medical history2-Orthodontic management for diabeticpatients Orthodontic management of patientwith Cardiovascular emblications3-Orthodontic management of Asthmaticpatients Orthodontic management ofpatients with phschatic implications4-Orthodontic treatment for geriatricpatientsikassem@dr.com
  3. 3. 5-Cleft lip & palate6-Head & neck syndrome7-TMJ & pain8-Laser9-Facial plastic surgery10-Emergency in orthdontics11- Examikassem@dr.com
  4. 4. Study source?ikassem@dr.com
  5. 5.  1- Lectures onhttp://www.slideshare.net/islamkassem/newsfeed 2-Readers 3-Medical problems in Dentistry Bu scullyikassem@dr.com
  6. 6. 1- Patient assessment andmedical history Importance of medical assessment Step wise medical assessment Common oral lesion Cancer detection Halitosis Salivary disordersikassem@dr.com
  7. 7. Patient safety come firstikassem@dr.com
  8. 8. ikassem@dr.com
  9. 9. What does this area consistof? Mouth? Pharynx? Larynx? Trachea? Oesophagus? Neck?Best to view as muchas possible
  10. 10. Oral cavity Open wide! Two tongue depressors Examine every mucosal surface Protrude tongue Look at salivary orifices Bimanual palpation Percuss teethikassem@dr.com
  11. 11. Neck Inspect Palpate Auscultateikassem@dr.com
  12. 12. Inspection Scars Lumps Sinuses Asymmetry Stoma Ask patient to swallow and protrude tongue Ask patient to breathe deeply Ask patient to count to tenikassem@dr.com
  13. 13. Palpation Adequate exposure Systematic Develop system From in front then mainly from behindSubmandibular area, both trianglesSupraclavicular areaikassem@dr.com
  14. 14. ikassem@dr.com
  15. 15. Auscultation Listen for bruitThyroid and carotidikassem@dr.com
  16. 16. Summary See patient as a whole – don’t focus in onone part of the body too soon Be systematic Adequate exposure Be familiar with toys Suggest further assessmentsikassem@dr.com
  17. 17. Regular screening for oralcancerikassem@dr.com
  18. 18. Oral Cancer Risk Factors 75% of all oral cancer cases arerelated to tobacco use and/ormoderate/heavy alcohol use. Human Papilloma Virus may be acausative factor of oral cancerikassem@dr.com
  19. 19. Oral Cancer Risk Factors Poor Oral hygiene and chronicirritation (poor fitting dentures,broken fillings). HIV infection or compromisedimmune system. 25% of oral cancers occur in peoplethat do not smoke or have other riskfactors.ikassem@dr.com
  20. 20. Human Papilloma Virus and OralCancer The human papilloma virus (HPV) is a common virusgroup that causes skin and mucosal infections. There are over 80 types of HPV in humans. Some types of HPV infect the mouth, throat, tongue andtonsils. The skin covering sexual organs can also be infectedwith HPV. The infection is manifested with skin ulceration and pain. Infected skin can transfer the virus to other parts of thebody or other humans.ikassem@dr.com
  21. 21. Human Papilloma Virus and OralCancer Warts are a form of HPV infection Warts are small, cauliflower-type growthson the skin. Warts are usually painless, but can causesome irritation, itching, or burning.ikassem@dr.com
  22. 22. Human Papilloma Virus and OralCancer Some HPV types can cause cervical or oral cancer The types associated with these cancers are: HPV-16,HPV-18, HPV-31, and HPV-45. HPV causes abnormal alteration and growth of theinfected mucosa covering the inner of the mouth(dysplasia). Dysplasia is not cancer, but it is a tissue change seenprior to the formation of cancer. The most dangerous types of HPV-- 16 and 18-- aretransmitted through sexual contact and are known tocause up to 95% of cervical cancers.– These two types have also been linked to oral cancer.ikassem@dr.com
  23. 23. Human Papilloma Virus and OralCancer Human papilloma virus associated tumoron the lip.ikassem@dr.com
  24. 24. Who Can Get Oral Cancer?Oral cancer is most common in: Men African Americans Adults over 40 years old Smokers and heavy drinkersikassem@dr.com
  25. 25. Early Detection is Key5 Year Cancer Survival RatesLocalized 80%Regional 50%Distant 32%
  26. 26. Where to Start? Early Detection starts with:–Listen–Look–Feelikassem@dr.com
  27. 27. What Do You Need? Oral cancer screenings will require thefollowing tools:– Listen Oral Screening form– Look and Feel Gloves Gauze Disposable mirrorikassem@dr.com
  28. 28. Oral Screening Form Make sure these items are included:– Current or past tobacco use– Age 40 or older– Sore on lips, mouth, or cheeks that doesn’t heal intwo weeks– Sore in throat or a feeling that something iscaught in the throat– Numbness of the tongue or other area of themouth– Swelling of the jaw that causes denture to fitpoorly or become uncomfortableikassem@dr.com
  29. 29. Oral Screening Form– Persistent ear pain– Hoarseness or voice changes– A lump or mass in the neck, behind the ear orunder the jawbone– Had or scheduled to have chemotherapy orradiation treatment– Sexually transmitted disease such as HIV orSyphilisikassem@dr.com
  30. 30. Oral Cancer ScreeningLocation of lymph nodes in head and neck
  31. 31. Oral Cancer Screening Ask the individual or patients whetherthey have felt new lumps in the mouth,head, neck, or behind their ears. Arethese lumps present on both sides ofthe face or head? (Symmetricalpresence may be sign that the lump isa normal structure.)
  32. 32. Oral Cancer Screening Begin with the hairlineand look for any changesin skin color, includingmoles, lumps, bumps andsores. Both sides of the faceand neck should be thesame size, shape andform. Feel the entire facefor lumps and numbness.
  33. 33. Oral Cancer ScreeningNext, the neck exam: Feel the front andback of the largemuscles running fromthe ears to the collarbone. Feel under the jawfrom the ears to thechin.
  34. 34.  Find the “Adam’sApple” and ask thepatient to swallow. Feel for lumps andsoreness on bothsides to thecollarbone.Oral Cancer Screening
  35. 35.  Lymph nodes:– Normally lymph nodes feellike peas under our fingersas we press the tissueagainst the neck musclesor jaw bone.– A cancerous lymph nodewill feel rubbery or hard totouch, it can present as alump in the neck that doesnot move when pressure isappliedOral Cancer Screening
  36. 36. Oral Cancer ScreeningNext the patients’ lipsshould be examined: Squeeze the lip andcheck for swelling,tenderness and colorchange Pull the upper andlower lips back andlook for sores or colorchanges.
  37. 37. Oral Cancer ScreeningNow the cheeks will beexamined: Place the index fingeron the outside of thecheek and the thumbon the inside and gentlysqueeze the cheek tocheck for any swelling,lumps or soreness. Pull the patients’ cheekback and look for colorchanges such as red,white or dark areas.
  38. 38. Oral Cancer ScreeningNext the gums will beexamined: Look on the insideand outside of thegums for lumps,bleeding, or red andwhite areas Ask, “Are there anysores that have nothealed for longer than2 weeks?”
  39. 39. Oral Cancer ScreeningNext the tongue will beexamined: Ask the patient to place the tipof their tongue on the roof oftheir mouth to look for soresunder the tongue. Using gauze pull the tongue tothe side and examine the topand sides for color changes,lumps or sores.
  40. 40. Oral Cancer ScreeningNext the floor and roofof the mouth will beexamined: Feel the floor of themouth for lumps andgrowths. Use an index finger togently press againstthe roof of the mouthto feel for lumps,swelling or soreness.
  41. 41. Oral Cancer Screening The dentist should also examine othertissues such as the lingual tonsil and mayperform other tests (such as brush biopsy)ikassem@dr.com
  42. 42. LeukoplakiaWhite patchPotentially pre-cancerousikassem@dr.com
  43. 43. Leukoplakia Is a clinical term for awhite plaque thatcannot be removedby scraping, andcannot be classifiedclinically orhistologically asanother diseaseentity. Some leukoplakias arecancerous.
  44. 44. Homogenous or thick leukoplakiaikassem@dr.com
  45. 45. Proliferative verrucous leukoplakia- precancerousikassem@dr.com
  46. 46. Proliferative verrucousleukoplakia on the buccalmucosaikassem@dr.com
  47. 47. Other White Patchesikassem@dr.com
  48. 48. Lichen planus: a benign inflammatorylesion. Typically this type of lacy whiteplaque is seen bilaterally on the buccalmucosa in a patient with lichen planus.ikassem@dr.com
  49. 49. Tongue Bitingikassem@dr.com
  50. 50. Candidiasis: yeast infection on the tongueCandidiasis can present as a white plaque thatwipes off, leaving small bleeding pointsunderneath. The are may be painful orsensitive.ikassem@dr.com
  51. 51. Differential Diagnosis Most red or white lesions, such as lichenplanus, should be assessed by biopsy. There is no way to be absolutely certainthat these lesions are not cancer, sobiopsy is necessary.ikassem@dr.com
  52. 52. Erythroplakia = Red Batch Red lesions can be caused by processes such asinfection, trauma and inflammatory diseases. An erythroplakia with no known cause/diagnosis ismore likely to undergo malignant transformationthan a white lesion Speckled erythroplakia is a combination ofleukoplakia and erythroplakia– 5I% of cases will show invasive carcinoma on biopsy.ikassem@dr.com
  53. 53. Erythroplakia: a red lesion that maybe caused by cancerikassem@dr.com
  54. 54. Erythroplakia: a red lesion withswelling that is most likely cancerousikassem@dr.com
  55. 55. Erythroleukoplakia:Red and white lesionikassem@dr.com
  56. 56. Erythroleukoplakia (Red-WhitePatch)ikassem@dr.com
  57. 57. Ulcerative erythroplakia on the buccal mucosaikassem@dr.com
  58. 58. Kaposi Sarcoma: HIVikassem@dr.com
  59. 59. Kaposi Sarcoma: AIDSikassem@dr.com
  60. 60. Kaposi Sarcoma: AIDSikassem@dr.com
  61. 61. Kaposi Sarcoma: AIDSikassem@dr.com
  62. 62. Prevention of Oral Cancerikassem@dr.com
  63. 63. ikassem@dr.comVITAL SIGNS Blood pressure______ Pulse__________ Height_____ Weight____ Tobacco use: Never Former Current Glasses of alcohol drinks per day:1-2 3+
  64. 64. Prevention of Oral Cancer Stop smoking or chewing tobacco. Decrease use of alcohol (0-1 drinks/day). Eat more fruits and vegetables. See a dentist regularly. Get screened- Early detection saveslives.ikassem@dr.com
  65. 65. Self-Determination Theory Self-Determination Theory proposes thatbehavior changes motivated by intrinsicfactors (e.g., inherently novel, enjoyable,stimulating, self-driven, and satisfying) aremore sustainable than those produced byextrinsic factors (e.g., coercion, externalreward, or fear) as well as those that areamotivational. People have to decide when and how tochange. Your role is to assist people in the changeprocess, only if they choose to change afterreceiving information that they choose tohear from you.ikassem@dr.com
  66. 66. Tobacco Use The "5 As" of a tobacco prevention program asrecommended by the Surgeon General Expanded to include alcohol use in this lesson.ikassem@dr.com
  67. 67. Tobacco Use Ask– Identify and document tobacco use statusfor every patient at every visit. Identifywhether the individual is a heavy alcoholdrinker. Assess– Is the tobacco user willing to attempt toquit? Is the individual willing to reducetheir consumption of alcohol?ikassem@dr.com
  68. 68. Tobacco Use Advise– It is important to engage the user in an opendialogue on what he thinks about tobacco use andthe impact on his/her health. Work towards aposition where the patient provides you with whathe or she should do. Assist– For the patient willing to attempt to quit, usecounseling and pharmacotherapy to help him orher quit.– For the patient willing to reduce alcoholconsumption, use counseling or refer to alcoholaddiction counseling programs in his/her area.ikassem@dr.com
  69. 69. Tobacco Use Arrange– Schedule follow-up contact, in person or bytelephone, preferably within the first weekafter the quit date or scheduled counseling forreduction of alcohol use.ikassem@dr.com
  70. 70. Advice about quitting If your patient is worried about needing tobaccoto help wake up, get moving, and stay focusedon tasks, provide examples of other ways to feelmore energetic. Encourage the patient to get enough rest,exercise regularly (which will also reducecravings), take a brisk walk when feelingsluggish, drink lots of cold water, and avoidsituations that lead to boredom.ikassem@dr.com
  71. 71. Light or Low-Tar Cigarettes “Light” cigarettes may actually be moredangerous than regular cigarettes becausesmokers may inhale more heavily or morefrequently or cover ventilation holes to getthe chemicals their bodies crave.ikassem@dr.com
  72. 72. Barriers Discuss barriers to quitting, set goals, anddevise a plan. In addition, you may wish to assess whether thepatient sees him/herself as addicted to nicotine,and recommend nicotine replacement or otherpharmacotherapy as appropriate.ikassem@dr.com
  73. 73. Alcohol DrinkingAssist individual to seek carefrom a professional groupikassem@dr.com
  74. 74. Alcohol Counseling Feedback to a patient by a primary care providerabout the results of the oral cancer screeningexamination, clarification of the association betweenexcessive alcohol consumption and negativeconsequences, and advice to reduce alcoholconsumption, are modestly effective in helpingpatients with an alcohol problem. Use the same principles followed in draftingmessages based on the stage of change. Tailor your messages based on the stage of changeand the reasons for drinking.ikassem@dr.com
  75. 75. Veloscopeikassem@dr.com
  76. 76. ikassem@dr.com
  77. 77. Salivary Flow Rate (Xerostomia) Saliva not only begins the digestiveprocess; it protects teeth by preventingdecay, regulating your mouths aciditylevel and keeping bacteria in your mouthfrom running rampant. But when salivas lacking, plaque builds,enamel erodes, cavities quickly form andfungal growth runs rampantikassem@dr.com
  78. 78. Salivary Flow Rate (Xerostomia) Diabetes and Dry Mouth– Prevalence of dry-mouth symptoms(xerostomia),– Prevalence of hyposalivation– Possible interrelationships between salivarydysfunction and diabetic complications.ikassem@dr.com
  79. 79. Self Report – Xerostomia Does your mouth usually feel dry? Do you regularly do things to keep yourmouth moist? FOX QUESTIONNAIRE– Do you have to sip liquids to aid in swallowingfoods?– Does your mouth feel dry when eating a meal?– Do you have difficulties swallowing dry foods?– Does the amount of saliva in your mouth seemtoo little?.ikassem@dr.com
  80. 80. Salivary Flow Rate MeasuresDiabetes Subjects Control SubjectsResting Salivary Flow Rate (ml/min)0.22 + 0.014 0.28 + 0.016 p = 0.045Resting Salivary Flow Rate < 0.01ml/min11.8% 2.7% p = 0.0005Stimulated Salivary Flow Rate (ml/min)0.89 + 0.047 1.02 + 0.054 p = 0.071Stimulated Salivary Flow Rate < 0.10 ml/min12.4% 5.5% p =.ikassem@dr.com
  81. 81. Treatment for dry mouthikassem@dr.com
  82. 82. Medication Recent studies have shown that drugs calledPilocarpine (Salagen™) and Cevimeline (Evoxac™) can decrease your sensation of oraldryness. These drugs are generally taken 3 - 4 times a day,after meals, and their effects usually last from 2 - 4hours.– The side-effects of these medications are generallymodest. These drugs, combined with other methods tostimulate the flow of saliva have had positive resultsikassem@dr.com
  83. 83. My Contact ikassem@dr.com You can get thelectures form http://www.slideshare.net/islamkassem/newsfeedikassem@dr.com

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