complete chairside investigations in oral medicine

1. CHAIRSIDE INVESTIGATIONS
PRESENTED BY
DR RUMELA GHOSH
POST GRADUATE STUDENT
ORAL MEDICINE AND RADIOLOGY
GUIDED BY
DR G SUBHAS BABU
DR VIDYA AJILA
DR SHRUTHI HEGDE
DR RENITA
CASTELINO
DR KUMUDA RAO
DR SUPRIYA BHAT

2.  Investigations
Investigations are an extension of the physical
examination in which tissue, blood, other specimens are
obtained from the patient and subjected to microscopic,
biochemical, microbiological or immunologic
examination.
 Chairside investigations
Simple tests & examination procedures
performed at the chairside.

3. Investiga
tions
Dental
Caries
Pulp
Disease
Periodon
tal
Disease
Mucosal
Disease
Neuro
sensoryImmune
TMJ &
Muscles
Malocclu
sion
Salivary
Gland
Disease

4. Dental Caries

5. Caries Detection
 Caries dyes
 Transillumination
- FOTI
- D-FOTI
 Electrical Conductance Measurement
 QLF - Laser fluorescence
- Diagnodent
 NIR
 ENDOSCOPE
 MINI D CARIES
 PNC

6. CARIES DYE

7.  Various dyes like PROCION have been used to detect
enamel caries but have not been successful for clinical
use
 However, dyes are useful to detect carious dentin
 Originally 0.5% basic fuchsin in propylene glycol was
used
 This stains the infected, demineralised dentin selectively
while the affected dentine remains unstained
 Clinically, this has been useful in identifying the infected
dentin

8.  Currently, basic fuchsin is considered to be carcinogenic
 Hence, it has been replaced by 1% acid red dye in
propylene glycol

9. TRANSILLUMINATION
 Fiberoptic transillumination
 Digital fiberoptic transillumination

10. FOTI EQUIPMENT

11. NORMAL CLINICAL VISION WITH FOTI

12. ADVANTAGES:
 Non invasive method
 No hazards of radiation
 Comfortable to patients
 Useful in patients with posterior crowding
DISADVANTAGES:
 Subject to observer bias
 Does not provide a permanent record of findings
 Difficulty in placing the probes in some areas

13. DIGITAL FIBEROPTIC
TRANSILLUMINATION
 This is a relatively new technique which combines
FOTI and a digital CCD camera
 Images captured by the camera are sent to a
computer for analysis, which produces digital
images that can be viewed
 This method overcomes the shortcomings of FOTI

14. DIFOTI HANDPIECE

15. FIBEROPTIC
TRANSILLUMINATION
 Carious lesions have a lowered index of light transmission
 When teeth are examined with a fiberoptic light source,
caries appears as a darkened shadow
 After drying the tooth, a fiberoptic probe can be placed in
the buccal or lingual embrasure directly beneath the
contact area between two adjacent teeth
 If caries is present, it is evident as a dark shadow beneath
the marginal ridge

17. ADVANTAGES:
 Instantaneous image projection
 Image quality is easy to control
 Can detect incipient and recurrent caries very early
 Non invasive
DISADVANTAGES:
 Does not measure the depth of the lesion
 Difficult to distinguish between deep fissure, stain and
dental caries

18. ELECTRICAL CONDUCTANCE
MEASUREMENT
 The theory behind the use of electrical conductance
measurements is that sound enamel is an insulator due
to its high inorganic content
 On the other hand, carious enamel has a measurable
conductivity which increases with the degree of
demineralisation
 Based on the differences in the electrical conductance of
sound and carious enamel, two devices were developed
in the 1980’s
 Vanguard electronic caries detector
 Caries meter

19.  Both instruments measure the electrical conductance
between the tip of a probe placed in a fissure and a
connector attached to an area of high
conductance(gingiva or skin)
 The measured electrical conductivity indicates the
degree of demineralisation

20. ADVANTAGES:
 More accurate in diagnosing early occlusal caries than
visual method, radiographs of FOTI
 Can monitor the progress of caries
DISADVANTAGES:
 Hypomineralised areas, enamel cracks can cause
misleading readings
 Time consuming procedure
 Requires the use of sharp metal explorers which can
cause traumatic defects in pits and fissures

21. QUANTITATIVE LASER
FLUORESCENCE
 This method is related to the endoscopic filtered
fluorescence method
 Recently it has been found that bacterial
metabolites within caries produce fluorescence
that can be enhanced by laser light
 QLF is a means by which the laser induced
fluorescence can be measured to quantify tooth
demineralisation

22.  Here the tooth is illuminated with a broad beam of blue
light(488 nm) from an argon ion laser
 The fluorescence in enamel is observed in the 540 nm
range
 This fluorescence is observed through a yellow high
pass filter (520 nm) to exclude the tooth scattered blue
laser light
 Demineralised enamel appears dark and this can be
recorded on a photographic film or measured by means
of a computer

23.  Recently, a commercial laser fluorescence system has been
introduced, called the Kavo-DIAGNOdent
 The DIAGNOdent is a portable diode laser with a fiberoptic
probe designed for commercial use
 This uses red laser light (665 nm wavelength) via a fiberoptic
probe to examine a tooth surface
 Normal healthy tooth structure shows no fluorescence
resulting in a low reading on the display
 Carious tooth structure produces considerable fluorescence
which is revealed as a digital numerical readout(0-99) on the
display

24. White light image of early
caries affecting maxillary
teeth
QLF image. Note the
improved detection of
lesions as a result of the
increased contrast between
sound and demineralised
enamel
6 months after the institution
of an oral hygiene
programme, the lesions have
resolved

25. DIAGNOdent device

26. ADVANTAGES:
 Reliable method for diagnosis of early occlusal caries
 Convenient and fast method
DISADVANTAGES:
 Expensive
 Cannot differentiate between caries, hypoplasia, stains
and calculus
 Cannot differentiate between active or inactive lesions

27. Near-infrared hyperspectral imaging
of teeth for dental caries detection
 Near-infrared (NIR) is preferred for caries
detection compared to visible light imaging
because it exhibits low absorption by stain
and deeper penetration into teeth
 Previous measurements have demonstrated
that dental enamel is highly transparent in the
near-IR at 1300 nm.

28. ENDOSCOPE
 A blue light (400-500 nm)
is used to excite
Fluorescence with in the
tooth.
 Difference seen in
fluoresced tooth is viewed
through a specific broad
band gelatin filter; white
spot lesions appear
darker than enamel.

29.  Advantage :
 5-10 fold magnification
 Disadvantage :
 Requires meticulous drying and isolation.
 Takes 5-10 minutes compared to 3-5minutes for
conventional technique.

30.  Additionally a camera can be used to store the image. The
integration of camera endoscope is called video scope.
 A miniature colour video camera is mounted in a custom
made metal holder. Thus image is directly viewed on a
television screen.

31. MINI D CARIES

32. PHOTON UNDULATORY NON
LINEAR CONVERSION (PNC)
 Based on He-Ne system
Fibre optic
device
Spectrophotomet
er

33.  Caries Activity Tests:
o Streptococcus mutans test
o Lactobacillus colony count test
o Snyder tests
o Salivary Buffer capacity test
o Salivary reductase test
o Fosdick calcium dissolution test

34. Streptococcus mutans test
saliva/plaque samples are obtained by using tongue blades and toothpicks
and are transferred to S.mutans strip which is incubated in Mitis Salivarius
Bacitracin agar. The number of S.mutans colonies are used to estimate the
caries activity and more than 105 colonies per ml of saliva is indicative of
high caries activity

35. Lactobacillus colony count test
 Introduced by Hadley in 1933
 It estimates the number of bacteria in the patients
saliva by counting the number of colonies appearing on
tomato peptone agar or Rogosa agar
 Stimulated saliva is collected before breakfast by
chewing paraffin
 This is shaken and a 1:10 and 1:100 dilution is made
 It is then mixed thoroughly and 0.4ml of each dilution is
spread on the surface of an agar plate
 Incubated at 37o C for a period of 3-4 days

36.  The number of LB is then counted with a Quebec
counter
CFU/ml Caries activity
0-<103 immune
103 - 5000 slight
5000- 104 medium
>104 high

37. Snyder test
 Measures the ability of the microorganisms in saliva to
form acids from carbohydrate media
 0.2 cc of saliva is pipetted into the media which is
incubated at 370 for a period of 72 hrs
 The media contains:
o Bactopeptone 20g
o Dextrose 20g
o Sodium chloride 5 g
o Agar 16 g
o Bromocresol green 0.02 g

38. Colour change
blue/green to yellow
Caries activity
24 hrs high
48 hrs medium
72 hrs slight
No colour change for
more than 72 hrs
immune

39. salivary reductase test
 Measures the activity of salivary enzyme
reductase
 Diazoresorcinol indicator is used
colour time score Caries activity
colourless 30 s 5 Extremely conducive
red 30 s 4 Highly conducive
red 15 min 3 Moderately conducive
orchid 15 min 2 Slightly conducive
blue 15 min 1 Non conducive

40. Salivary buffer capacity
 10 ml of stimulated saliva – pH of the saliva is
adjusted to 7 by addition of lactic acid or base
 Lactic acid is then added until pH is 6
 The amount of lactic acid needed to reduce pH
from 7 to 6

41. Fosdick calcium dissolution test
 25 ml of gum stimulated saliva – placed in an
8 inch sterile test tube
 Tube is sealed + shaken for 4 hrs
 Analysed for calcium content
 Enamel dissolution increases as the caries
activity increases

42. Diseases of the Pulp

43.  Pulp Vitality Tests
1. Thermal
- Heat
- Cold
2. Electric
3. Test Cavity
 Pulse oximetry
 Laser Doppler Flowmetry
 Fistulous Tracking

44.  Heat Test
 Hot water
 Hot Burnisher
 Gutta percha

45.  3 mm of the end of the stick of gutta percha is heated in
a flame for 2 seconds and is applied to the suspected
tooth
Precautions:
 Tooth surface is lightly coated with vaseline to prevent
the sticking of gutta percha
 First a normal contralateral tooth should be tested and
then the affected tooth is tested

46.  Observations:
 No response – necrosis, gangrene, chronic abscess
 Mild to moderated response – normal pulp
 Painful response which subsides after the removal of
stimulus - reversible pulpitis
 Painful response which continues even after the removal
of stimulus – irreversible pulpitis, acute alveolar abscess,
acute pulpitis

47. Cold Test
 Ice
 CO2 snow
 Ethyl Chloride spray

48.  Excess cold may cause pulpal damage or crazing lines
in the enamel
 Begin with the most posterior tooth and proceed towards
the anterior teeth because such sequence will prevent
melting of ice water from dripping in a posterior direction
and possible excitation of non tested tooth by giving
false response

49.  Observation:
 No response – non vital or false negative
Examples of negative response:
o Calcification of immature opening
o Recent trauma to the tooth
o Patient is premedicated
 Moderate response – normal pulp
 Painful response which subsides immediately after the
stimulus is removed – reversible pulpitis/ hyperemia
 Painful response which may remian after removal of stimulus
– irreversible pulpitis
 In case of hyperemia there may be a quick response and in
chronic pulpitis may be a delayed response

50. Electric pulp test
 Pulp testers are designed to elicit response by
electrical excitation of neural elements in the pulp
 Technique:
 Describe the test to the patient in such a way that will
reduce anxiety and will eliminate a biased response
 Isolate the area of teeth to be tested with cotton rolls
and saliva ejector and air dry all the teeth
 Apply an electrolyte on the tooth electrode and place it
against the dried enamel of the crowns on the
occlusobuccal or incisolabial surface

51.  It is important to avoid contacting any restoration in the
tooth or the adjacent gingival tissue with the elctrolyte or
the elctrode or else this would cause a false and
misleading response
 Retract the patients cheek away from the tooth electrode
with the free hand
 When this hand contacts with the patients cheek, it
completes the electrical circuit
 Turn the rheostat slowly to introduce minimal current into
the tooth and increase the current slowly
 Ask the patient to indicate when sensation occurs by
using such words as tingling or warmth
 Record the result according to the numeric scale on the
pulp tester

52.  Accuracy depends on
 Accuracy of apparatus
 State of mind of the patient whether the patient is
apprehensive or relaxed
 Individual threshold response
 Patient under sedative medication
 Recently erupted teeth with incomplete root fromation
 Recently traumatized teeth
 Teeth with extensive restoration and a pulp protecting
base

53.  False positive response:
o Conductor/electrode
contact with a large metal
restoration or the gingiva
o Patient anxiety
o Liquefaction necrosis
o Inadequate isolation
o Multirooted tooth

54.  False negative response:
o Patient premedicated with analgesics,narcotics, alcohol
tranquilizers
o Inadequate contact of electrode with the enamel
o Recently traumatized tooth
o excessive calcification in the canal
o Dead batteries or forgotten to turn the pulp tester
o Recently erupted tooth with an immature apex
o Partial necrosis
o Clinician wearing surgical gloves
o Presence of pulp protecting materilasunder restoration
o Patients high pain threshold

55.  Disadvantages:
o No indication is given of the state of vascular supply
which would give a more reliable measure of the vitality
of the pulp
o Readings taken from posterior teeth may be misleading
since the chances of presence of some combination of
vital and non vital root canal pulps
o Cannot be used on crowned teeth
o False positive readings may be due to stimulation of
nerve fibres in the periodontium
o False positive in liquefaction necrosis may be seen due
to transmission of current from the liquid

56. Test cavity
 The preparation of a test cavity has been suggested as a last
resort in a tooth where no other means can ascertain the pulp
status
 Cutting into dentine using a high or low speed bur without
local anaesthetic may give some indication of whether the
sensory element of the pulp is still functioning although it is
unlikely that this procedure would provide any more
information than thermal and electric pulp sensibility tests
 Whilst the defect made in the tooth can be repaired with
restorative dental materials, this method is nonetheless
considered invasive and irreversible
 A consideration must be made for the apprehensive patient,
as it is likely that he or she may react nervously and confound
the response
 Hence, test cavities are not generally recommended as a
means of testing pulp sensibility.

57. Tooth Slooth
Cracked Tooth Syndrome
When the patient bites on a cotton applicator or rubber wheel the
fracture segments may separate and the pain may be reproduced at
the initiation or release of the biting pressure

58. Laser Doppler Flowmetry
 Research into the application of laser Doppler
flowmetry to traumatized teeth has been extensive
 Other applications have been reported in paediatric
dentistry, as an aid in the differential diagnosis of
nonodontogenic periapical pathosis and to assess pulp
blood flow
 The aim of this technique is to objectively measure the
“true” vitality of the pulp (i.e., the pulp blood flow rather
than its sensory function) without invasive procedures
such as intravital microscopy and gas desaturation

59.  This electro-optical technique uses a laser source that is
aimed at the pulp, and the laser light travels to the pulp
using the dentinal tubules as guides
 The backscattered reflected light from circulating blood
cells is Doppler-shifted and has a different frequency to
the static surrounding tissues

60. Pulse Oximetry
 Compared to laser Doppler flowmeters, pulse oximeters are
relatively inexpensive and commonly used in general
anaesthetic procedures
 The term oximetry is defined as the determination of the
percentage of oxygen saturation of the circulating arterial blood
 Oxygenated haemoglobin and deoxygenated haemoglobin are
different in colour and therefore absorb different amounts of red
and infrared light
 The pulse oximeter therefore utilises probes emitting a red and
an infrared light to transilluminate the target vascular area, which
allows the photodetector to identify absorbance peaks due to
pulsatile blood circulation, and thereby calculate the pulse rate
and oxygen saturation level (SaO2)

61. PART 2

62. Periodontal disease

63.  Periotemp
 Halimeter
 Periotest
 Plaque disclosing agents
 Perioscopy
 Fremitus test

64. PERIOTEMP
 The PERIOTEMP measures elevated
temperatures in the periodontal pocket
surrounding the teeth
 If an elevated temperature reading is
detected , this equates with the degree of
inflammation that is occurring at a specific
gingival site
 This inflammation directly relates to the
presence of periodontal disease

65. HALIMETER
 These machines measures the level of sulfide gas
found in a persons breath
 But, it has certain drawbacks in clinical
applications, some of the common sulfides such
as mercaptan are not easily recorded and can be
misrepresented in test results
 The halimeter is also very sensitive to alcohol, so
one should avoid drinking alcohol or using alcohol
containing mouthwashes for atleast 12 hrs prior to
being tested

66. ELECTRONIC NOSE
 The electronic nose was developed in order to mimic the
human olfaction.
 It consists of arrays of sensors which are able to
generate electrical signals in response to either simple
or complex volatile compounds present in the gaseous
sample.
 Essentially, e-nose consists of three major parts:
 Sample Delivery System.
 Detection System.
 Computing system.

67. The Cyranose
320 is a
handheld
“electronic
nose”
developed by
Cyrano
Sciences of
Pasadena,
California.

68. PERIOTEST
 Projects a rod against the implant or abutment using a
magnetic pulse at a certain speed
 The apparatus measures the deceleration time needed
before the rod comes to a standstill
 This is transformed in an arbitrary unit, which reflects
the rigidity of the bone-to-implant continuum
 Values should be below +7, the minimum, with the
most rigid being -8
 Osseointegrated implants are thought to demonstrate
an increased rigidity over time

69. Plaque disclosing agents
 Dental plaques are relatively invisible
 Certain agents(dyes) may be used to make the
supragingival plaques visible and such agents are
called disclosing agents
 Erythrosin tablets are dissolved into a solution or
chewed to dissolve in the mouth
 It stains the plaque area red but also may stain
soft tissues
 It is the most widely used disclosing agent.

70.  On application fluorescein dye stains the plaque yellow
 It does not stain the soft tissues
 But special light is required to see the stained plaque
 It is more expensive
 A solution containing a combination of two dyes(two
tone dyes) is used
 Mature plaques are stained blue, while new plaques are
stained red
 iodine containing solutions:They have been used as
disclosing agents but have the disadvantage of causing
a high incidence of allergic reactions
 Also have unacceptable taste hence not preferred

71. Perioscopy
 Perioscopy is a procedure that uses a miniature dental
endoscope with advanced video, lighting and
magnification technology that enables us to diagnose
and treat areas below the gingiva non-surgically
 A miniature camera is attached to a tiny probe and then
gently placed subgingivlly. The images are immediately
displayed on a chairside video screen for the clinician
 The dental endoscope provides up to 48 times
magnification, disclosing minute details under the
gingiva that, before the advent of this technology, might
easily be missed.

72.  Perioscopy allows the clinician to see, accurately and
effectively treat periodontal and other dental conditions,
which might otherwise go undetected and ultimately
undermine your oral health and perhaps even affect your
overall well-being
 Perioscopy is a great new tool in the preservation of
natural teeth and the fight against periodontal disease

73. MALOCCLUSION

74.  Habits
Mouth breathing
1. Butterfly Test
2. Water in mouth test
3. Double sided mouth mirror

75. Tests for Mouth Breathing:
1. Mirror test: A double sided mirror is held between the
nose and the mouth. Fogging on the nasal side of the
mirror indicates nasal breathing while fogging towards
the oral side indicates mouth breathing.
2. Cotton test: (Butterfly test): A butterfly shaped piece
of cotton is placed over the upper lip below the nostrils.
If the cotton flutters down it indicates nasal breathing.
This test can be used to detect unilateral nasal
blocking.
3. Water test: The patient is asked to fill his mouth with
water and retain it for a period of time. While nasal
breathers accomplish this with ease, mouth breathers
find the task difficult.

76. TMJ AND MUSCLES OF MASTICATION

77. Gnathodynamometer
 A gnathodynamometer (or occlusometer) is an
instrument for measuring the force exerted in closing the
mouth
 A bimeter gnathodynamometer is one with an adjustable
central-bearing point
 As per the inventor's design study, the instrument works
well "in measuring maximal bite force and masticatory
efficiency of incisor and molar teeth, respectively."

78. Electromyography
 The use of EMG biofeedback supplemented with
visual and tactile components of biofeedback can
be an effective approach in treatment of the pain
and dysfunction associated with TMDs
 By establishing an autogenic relaxation and
normal muscle firing of the masticatory muscles
through practice and integrating several forms of
closed-loop feedback, this technique can result in
long term relief of TMD symptoms

79. SALIVARY GLAND DISEASES

80. 1. Sialometry
2. Saliva Buffering capacity/pH
3. Lip stick sign
4. Tongue blade

81.  Sialometry
 Salivary flow rates
 Individual major salivary glands
 Whole saliva is the mixed fluid contents of the mouth.
 Unstimulated whole saliva flow rates of < 0.1 mL/min
and
 Stimulated whole saliva flow rate’s of < 1.0 mL/min
 Abnormally low and indicative of marked salivary
hypofunction.

82.  Collection Devices
 Whole Saliva
1. Graduated tube
2. Salivette®.Absorbent cotton
 Individual Saliva
1. Carlson-Crittenden
2. Lashley’s cup

83. Collection Methods
1. Draining method
1. Spitting method
2. Suction method
3. Absorbent method

84. Salivary Stimulants
 Chewing unflavored gum base
 paraffin wax
 rubber band
 2% citric acid to the tongue at regular intervals

87.  Diagnosis of xerostomia may be based on evidence
obtained from the patient's history, an examination of the
oral cavity and/or sialometry, a simple office procedure
that measures the flow rate of saliva
 Xerostomia should be considered if the patient
complains of dry mouth, particularly at night, or of
difficulty eating dry foods
 When the mouth is examined, a tongue depressor may
stick to the buccal mucosa
 In women, the "lipstick sign," where lipstick adheres to
the front teeth, may be a useful indicator of xerostomia

88. Lacrimal function

89. Lacrimal function
1. Schirmers Test
2. Rose Bengal dye test
3. Tear Film Breakup time

90. Schirmers Test
 The purpose of this test is the measurement of the total
(reflex and basal) tear secretion
 To minimize reflex tearing, the eyes should not be
manipulated before starting this test
 There is no contraindication to this test
 The materials used are commercially available Whatman
no. 41 filter paper strips 5 mm wide × 30 mm in length,
known as Schirmer tear test filter strips
 The patient is seated in a dimly lit room, and the filter
paper strips are folded 5 mm from the end

91.  The folded end is placed gently over the lower palpebral
conjunctiva at its lateral one-third
 The patient keeps the eyes open and looks upward
 Blinking is permissible
 After 5 minutes the strips are removed and the amount
of wetting is measured from the folded end
 If the strips are completely wetted before 5 minutes,
they may be removed prematurely
 A normal patient will wet from 10 to 30 mm in 5 minutes;
this is age dependent and decreases after the age of 60
years, but is rarely less than 10 mm in 5 minutes

92.  Measurements greater than 30 mm at 5 minutes indicate
that reflex tearing is intact but not controlled and,
therefore, are of little diagnostic value
 Between 10 and 30 mm of tear secretion may be
normal, or basal secretion may be low but compensated
for by reflex secretion
 Values less than 5 mm on repeated testing indicate
hyposecretion of basic tearing
 There is a 15% chance of diagnostic error in this test

93.  More than 10 mm of moisture on the filter
paper after 5 minutes is a sign of normal tear
production. Both eyes normally release the
same amount of tears.

94. Rose Bengal dye test
 The purpose of this test is to ascertain indirectly the
presence of reduced tear volume through detection of
damaged epithelial cells
 The eye is anesthetized topically with proparacaine
0.5%. Tetracaine or cocaine may give false-positive tests
because of their softening effect on corneal epithelium.
 One drop of 1% rose bengal solution or a drop from a
saline-wetted rose bengal strip is instilled in each
conjunctival sac
 Rose bengal is a vital stain taken up by dead and
degenerating cells that have been damaged by the
reduced tear volume, particularly in the exposed
interpalpebral area

95.  This test is particularly useful in early stages of
conjunctivitis sicca and keratoconjunctivitis sicca
syndrome
 A positive test will show triangular stipple staining of the
nasal and temporal bulbar conjunctiva in the
interpalpebral area and possible punctate staining of the
cornea, especially in the lower two-thirds
 False-positive staining may occur in conditions such as
chronic conjunctivitis, acute chemical conjunctivitis
secondary to hair spray use and drugs such as
tetracaine and cocaine, exposure keratitis, superficial
punctate keratitis secondary to toxic or idiopathic
phenomena, and foreign bodies in the conjunctiva

96.  The stain will also color mucus and epithelial debris,
which may mask the results
 Certain patients who are normal will show some positive
staining to rose bengal on the cornea
 Because of this, conjunctival as well as corneal staining
should be present before the diagnosis of
keratoconjunctivitis sicca is made

97. Tear Film break-up time (TFBUT)
 This measures the interval between the individual’s last
complete blink and the break-up of his or her tear film
 This simple test involves the use of a slit-lamp, set on a
bright light setting with a cobalt blue filter:
 Instil fluorescein into the lower fornix.
Ask the patient to blink several times and then stop.
 Measure the time between the last blink and the first
appearance of a dark spot on the cornea (formation of a dry
area) on the otherwise continuously stained tear film.
A tear break-up time of less than 10 seconds suggests a dry
eye.

99. Phenol Red Test
 A cotton thread impregnated with phenol red
dye is used. Phenol red is pH sensitive and
changes from yellow to red when wetted by
tears.
 The crimped end of a 70mm long thread is
placed in the lower conjunctival fornix.
 After 15 seconds, the length of the colour
change on the thread - indicating the length of
the thread wetted by the tears -is measured in
millimetres.

100.  Wetting lengths should normally be between
9mm and 20mm. Patients with dry eye have
wetting values of less than 9mm.

101. PART 3

102. MUCOSAL LESIONS

103. 1. Vital Staining
2. Exfoliative cytology
3. Aspiration cytology
4. Brush Biopsy
5. Chemiluminescence
6. Fluorescence spectroscopy (FS)
7. Biopsy

104. VITAL STAINING
 Rationale
 Differential uptake of dye
 Affinity for Nucleic acids –
1. Methylene Blue,
2. Toluidine Blue,
3. Acridine
 Affinity for cellular Glycogen –
1. Lugol’s Iodine

105.  Vital Dyes
1. Toluidine Blue
2. Lugol’s Iodine
3. Acridine
4. Methylene Blue

106.  Composition
Toluidine blue solutions:
 Toluidine blue 1 g
 Acetic acid 10 cc
 Absolute alcohol 4.19 cc
 Distilled water 86 cc
 ph adjusted to 4.5
Lugols iodine solution:
 Iodine 2 g
 Potassium iodide 4 g
 Distilled water 100 cc

107. 1. Photograph untreated lesion
2. Application of 1% acetic acid withQ-tip (20 s)
3. Rinse with water
4. Apply toluidine blue 1% with Q-tip(10-20 s)
5. Decolorize with 2% acetic acid,Q-tip (20-30 s)
6. Photograph
7. Apply Lugol's iodine Q-tip (10-20 s)
8. Photograph

108. ACETIC ACID TOLUIDINE BLUE

109. Uptake of toluidine blue stain

110. Mechanism of action
 Toluidine blue, a cationic dye, binds with DNA or
nucleohsitone in two ways:
 One method is by intercalation, another by
stacking or aggregation
 The dye thereby attaches to the phosphate bonds
of DNA or nucleohistone
 The efficacy of the dye technique depends on the
amount of DNA present which relates to the
number and size of the superficially located nuclei
in the tissues to which toluidine blue is applied

111.  Negative results of staining do not rule out malignant
disease
 Positive result demands histologic verification

112. EXFOLIATIVE CYTOLOGY

113.  Exfoliative cytology is the study
of superficial cells which have
been either exfoliated or shed
naturally from mucous
membrane, renal tubules etc &
it also includes
 The study of those cells which
have been collected during
scrapping or pulled off
tissues surfaces and which
may also be found in body
fluids such as sputum, saliva
etc.

114.  The cells of the deeper layers are strongly
adherent to each other under normal
conditions.
 Loss of cellular cohesiveness
 Deeper cells may be exfoliated

115.  Indications
 Precancer
 Quick laboratory evaluation
 Multiple premalignant
 Extensive lesions.
 Post-operative or post irradiated malignant
lesions.
 Recurrent oral cancers
 Mass screening of oral cancers.
 Specific cells in non-malignant red-patches or
ulcerative lesions.
 Patients with malnutrition.

116.  Vesicular lesions.
 For the detection of sex chromosomes.
 For the study of the buccal mucosa in various anemias.
 Maturation of buccal mucosa during menstrual cycle.
 Certain benign hereditary skin lesions having their
representative oral manifestations.
 For the study of change of the oral epithelial cells
followed by chemotherapy.

117.  Contraindications:
 Deep seated lesions (both soft and hard tissue).
: Fibrous lesions
: Polypoid growth
: Non-ulcerative lesions
 No positive changes in the cells of the superficial layers
 Densely keratinized lesions
 Smooth surface lesions
 Lesions giving inadequate specimen sampling through
the adopted technique.
 Underlying blood dyscrasias.

118.  Wooden spatula
 Metal Spatula

119.  Fixation
1. Wet mount
2. Dry mount

120.  Staining
1. Papanicolaou stain
2. Gram Stain

121.  Interpretation
1. Class I -Normal cells
2. Class II - Some atypical cells
3. Class III - No definite evidence of
malignancy, but clearly aberrant cells are
present.
4. Class IV- Suggestive of malignancy;
5. Class V - Obvious malignant changes

122. CHEMILUMINESCENCE

123. ‘Chemiluminescence’ refers to the emission of light from a
chemical reaction.
Rationale:
 Following application of a cytoplasmic dehydration
agent such as an acetic acid solution, leukoplakic
lesions are seen with changes in refractile properties
that occur in atypical nonkeratinized squamous
epithelium due to an increased nuclear: cytoplasmic
ratio.
 Supplementing conventional projected incandescent
illumination with diffuse chemiluminescent light
(Vizilite) has been clinically shown to increase the
detection of biopsy proven squamous cell dysplasia.

124. Components
Vizilite 1% acetic acid solution
1. purified water
2. acetic acid
3. sodium benzoate
4. raspberry flavour
5. propylene glycol
6. alcohol.
Vizilite capsule /chemiluminescent light
stick
1. Outer flexible plastic capsule
containing Aspirin or acetyl salicylic
acid and an
2. Inner fragile glass vial containing
hydrogen peroxide.

125.  Procedure
 Apply Vizilite solution on mucosal surface
 Activation of light stick is by flexing it
 Inner fragile glass vial ruptures releasing the hydrogen
peroxide.
 The chemicals react to produce :
 Light of the blue-white colour (430 to 580 nm.)
 The light lasts for approximately 10 min

126. Interpretation
 Normal epithelium absorbs Vizilite; appears dark.
 Abnormal epithelium reflects Vizilite; appears white.
 Dysplastic nucleus becomes larger compared to the rest
of the cell reflects light and thus appears white

127. FLUORESCENCE SPECTROSCOPY (FS)

128.  When cells interact with light they become excited
and re-emit light of varying colours (fluorescence) and
this can be detected by sensitive spectrometers.

129.  Rationale
1. All tissues fluoresce due to the presence of fluorescent
chromophores (fluorophores) within them.
2. Fluorescence spectroscopy can detect these
substances - characteristic spectra - biochemical
changes
 Fluorophores detected include
1. NADH,
2. collagen,
3. elastin and
4. co-factors such as flavins (FAD, FMN).

130.  Fluorescence can occur as
1. Autofluoresence (if induced by UV light),
2. Laser induced
3. Topical or systemic application of 5-aminolaevulinic
acid (ALA)
 Measured By
1. Fluorescence spectroscopy
2. Raman spectroscopy
3. Elastic Scattering spectroscopy.

131.  Interpretation:
 Dysplastic and malignant tissues have increased red
fluorescence and decreased green fluorescence.
 Significant increase in the red/green fluorescence ratio is an
accurate predictor of dysplasia and malignancy.
 Malignant tissue also has a limited ability to metabolise
iron, so that an exogenous application of ALA will result in an
intracellular increase in protoporphyrin IX which increases
tissue fluorescence.

133. BIOPSY

134.  Biopsy is defined as the removal of tissue
from the living organism for the purpose of
microscopic examination and diagnosis
(Shafer).
 Bios – Life
Opsis – Vision
Biopsy - Vision of life.

135.  Major:
 Aspiration biopsy,
 Incisional biopsy,
 Excisional biopsy
 Minor:
 Punch Biopsy
 Needle Biopsy
 Drill Biopsy
 Trephine biopsy
 Exploratory Biopsy
 Curettage biopsy

136. USES:
 Adjunct in diagnosis.
 Confirm the diagnosis.
 Medico legal record .
 Determine the extent or margin of the disease.
 Rule out the possibility of malignancy
 Reassure cancerophobic or hypochondriacal patients.

137.  Indications
1. Lesion persisting for more than 2 weeks
2. Inflammatory lesion that does not respond
1. Local treatment after 10-14 days/
2. After removing local irritant.
3. Persistent tumescence
4. Interfere with local function (like fibroma).
5. Bone lesions.
6. Characteristics of malignancy.

138. Any lesion that has the characteristics of malignancy
like
 Erythroplakia (Red / speckled lesion)
 Ulceration
 Duration - more than 2 weeks.
 Rapid growth rate.
 Bleeding on gentle manipulation
 Induration of the lesion and surrounding tissue.
 Fixation to the adjacent structures.

139. Relative Contra indications:
 Inflammatory lesions.
 Normal anatomic and racial variations
 Compromised general health
 Proximity of the lesions to vital anatomic, vascular,
neural / ductal structures.
 Areas of difficult surgical access.

140. Absolute Contraindications:
 Pulsatile lesions
 Intra bony radiolucent lesions
 Pigmented lesions
 Lesions that are clinically obviously malignant should be
biopsied only in the facility that will assume continuum of
care.

141. BIOPSY TECHNIQUE:
 Area / areas - most representative of the disease
process.
 Deep narrow biopsies better rather than broad, shallow
ones.
 Specimen should include surrounding normal tissue.
 Elliptical sections with cuts converging to a V in the
underlying normal tissue

142. GENERAL COSIDERATION
 Biopsy specimen should include as much
tissue as possible.
 In large excisional biopsy specimens - Tag
the margins with sutures and notify the
pathologist of the location of the sutured
margins
 Suitable site for biopsy
Soft tissue lesion - border of the lesion Bony
lesions -centre of the lesion

143. CONSIDERATIONS IN SPECIFIC
LESIONS
 White and red mucosal lesions - multiple
portions must be sampled . In speckled red
and white lesions, both areas should be
included.
 Excisional biopsy - Pigmented lesions .
 Cystic lesions should be removed intact
without rupture
 Biopsy of a vesicle / a bulla should be
performed on a fresh, intact blister

145.  Aspiration Biopsy
Aspiration of Fluids from soft fluctuant
swellings

146. Aspiration Biopsy
 Use of a needle and syringe to penetrate a lesion for
aspiration of its contents.
 Although no tissue is obtained with aspiration, it is
included here because it is a biopsy in the broadest
sense of the word and it is used frequently for lesions in
and around the oral cavity.
 Inability to aspirate fluid / air indicates that the mass is
probably solid.
 Aspiration biopsy yields valuable information about the
nature of the lesion with little patient discomfort.

147. Advantages
 Simple and easy
 Non invasive
 Rapid
 Accurate in diagnosis
 Minimal patient discomfort.
 Cost effective
 Prevents false biopsy
 Less seeding of cells

148. Indications
 All lesions though to contain fluid (except
mucocele).
 Any intraosseous lesion before surgical
exploration to rule out a vascular lesion, which
could result in life threatening hemorrhage if
incised.
 Fluctuant mass in the soft tissues to determine
its content before definitive treatment.

149. Technique
 An 18-gauge needle is connected to a 5 / 10 ml syringe
 The area is anaesthetized and the needle is inserted into the
depth of the mass during inspiration
 The tip of the needle may have to be repeatedly repositioned
in order to locate a fluid centre
 For intra osseous lesions, if expansion and thinning of the
cortical plates has occurred, the needle may be firmly applied
directly through mucoperiosteum to the bone and twisted until
it perforates the cortical plate
 If this fails, a small mucoperiosteal flap may be elevated and a
bur used to penetrate the cortical plate
 The needle is then advanced through the cortical hole

150. ASPIRATION BIOPSY OF RADIOLUCENT LESIONS:
Any radiolucent lesion that requires biopsy should undergo
aspiration biopsy before surgical exploration, which
provides the dentist with valuable diagnostic information
regarding the nature of the lesion. For ex: aspiration of
brisk, pulsatile blood – vascular lesion; Straw-coloured
fluid – cyst; Air – traumatic bone cyst / maxillary sinus

151. Incisional biopsy:
Wedge shaped area of the tissue is removed

152.  Incisional Biopsy samples only a particular /
representative part of the lesion.
 If the lesion is large / have different
characteristics at different locations, more
than one area may need to be sampled

153. Indications
 Large, diffuse lesions- The important factor
here is the removal of just a portion of the
lesion, a representative fraction which affords
the pathologist a picture of both the aberrant
tissue in question and that of normal adjoining
tissue
 If the area under investigation appears
difficult because of its extensive size /
hazardous location / there is a great suspicious
of malignancy.

154. Principles
 A pie shaped / elliptical wedge is removed
with incisions on either side of the ellipse
coverage in a ‘V’ to join in deeper sub lesion
tissues and including both normal and
abnormal tissue.

155.  A sharp scalpel should be used to incise tissues.
 Electrosurgical equipment should be avoided.
 Two incisions forming an ellipse at the surface and
converging to form a V at the base of the lesion
provide a good specimen and leave a wound that is
easy to close.
 Incisions should be parallel to the normal course of
nerves, arteries and veins to preclude their injury.
 More than 1 incisional biopsy may be necessary if the
lesion’s characteristics vary from one area to
another.

156. Specimen Care
 After removal, the tissue should be
immediately placed in 10% formalin solution
(4% formaldehyde) that is at least 20
times the volume of the surgical specimen
 The tissues should be totally immersed in
the solution and should not be lodged on
the wall of the container above the level of
the formalin.

157. Other fixatives
 Formation 10%
 Monohydrate methylene glycol with monomeric
formaldehyde. Methanol (stabilizer) – affect
enzyme reaction
 Formic acid – increase on storage
 Formaldehyde reacts with end groups of
proteins to form cross-links between molecules
forming insoluble end product (amino, imino,
amido, peptide, hydroxyl carboxyl, sulphydryl

158. Excisional biopsy

159. Excisional Biopsy
 Excisional biopsy implies the removal of the
entire lesion in toto at the time the surgical
diagnostic procedure is performed
 A perimeter of surrounding normal tissue is
also excised to ensure total removal
 Complete excision may constitute definitive
treatment and entire lesion is made available
for pathological examinations

160. Indications
 Smaller lesions (less than 1cm in diameter),
which are appearing benign clinically.
 Any lesion that can be removed completely
without mutilating the patients.

161. Principle
 The entire lesion along with 2-3 mm of
normal appearing tissue is excised

162. Excisional biopsy of
soft tissue lesion
 Elliptical incision is made around the lesion,
staying at least 3mm away from the lesion.
 Incision is made deep enough to remove the
lesion completely.
 Incision is made convergent to depth of
wound to facilitate closure

163.  Punch Biopsy
It is used for the removal of small lesions
and in the removal of superficial
abnormalities.

164.  Punch biopsy is applicable to both incisional and excisional biopsy.
It is an alternative technique
 Indications:
 Total removal of small lesions
 Partial removal of superficial abnormalities
 Used on fixed tissue such as firmly attached palatal mucosa which
must heal by secondary intention regardless of the technique. But it
cannot be used elsewhere because it is impossible to close a
circular defect and at the same time, observe correct surgical
principles. For proper closure, additional peripheral tissue has to be
removed which can be removed initially with an elliptical incision
 Therefore a punch is basically a “Cookie Cutter” approach that
affords ease of application at the expense of proper surgical
technique and ideal wound healing.

165. Principles
 The punch is used in a twisting, circular motion to
create a clearly defined surgical margin to an
appropriate depth, after which the lesion is
undermined with a scalpel / scissors and removed
 The defect / fixed tissue is an open wound that
must heal by secondary intention. Punch sizes vary
from 2-6 mm in diameter

166. Fine Needle Aspiration
 It affords tentative diagnosis without direct
invasive surgical procedure.
 It is applied in deep-seated lesions not
amenable to surface biopsy. It includes deep
lesions of the soft palate, esophagus, head and
neck lymph nodes and space occupying lesions
of the salivary glands.
 This procedure is reserved for the clinician
assuming ultimate responsibility for definitive
care.

167. Uses:
 Any external lump that can be reached with a 4 cm needle
 Ultrasound guided FNA in staging patients with newly
diagnosed tumor
 Ultrasound guided FNA in irradiated patients with lesions
suspicious for tumor recurrence that cannot be localized by
palpation because of fibrosis (post radiation therapy)
 Lymph node cytopathology – Lymphoid hyperplasia,
infections, primary or secondary malignancy
 Assessment of nodal involvement of squamous cell
carcinoma, cysts, salivary glands tumors, soft tissues masses

168. BRUSH BIOPSY

169.  Advantages
1. Highly accurate method - pre-cancerous and
cancerous oral lesions.
2. Distinguish potentially harmful oral lesions
from other abnormalities
3. No topical or local anesthetic is required

171.  Rationale
1. Cells of the Deeper epithelial layers are more
diagnostic &
2. May not be shed off
 Procedure
1. Special circular brush
2. Moistened with water or the patient's saliva
3. Contact between the brush and the mucosal
surface with moderate pressure applied.
4. Rotated until pinpoint bleeding is noted

173. 1. Removed cells are transferred to a glass slide
2. Flooding the slide with (alcohol/propylene glycol)
3. Air-drying of the fixative
4. Stained with a modified Papanicolaou method
5. Scanned by an automated computer-driven
microscope system.

174.  Needle biopsy
Hollow needle is introduced into to the
swelling and a core of tissue is taken out for
histological examination.
 Drill Biopsy
This is performed by the apparatus
consisting of a small sharp cannula with in
which is attached a high-speed compressor
air drill.

175.  Trephine biopsy
Central or intra bony lesions like central
fibro-osseous lesions in the jaws.

176. References
1) Neville, B.W., Damm, D.D., Allen, C.M.,
Bouquot, J.E., “Oral and maxillofacial
pathology”, 2nd edition, Elsevier
publications, 2004, p: 40
2) Rajendran, R., Sivapathasundharam, B.,
“Shafer’s textbook of oral pathology”, 5th
edition, Elsevier publications, 2006, p:719-720
3) Ghom, A.G., “Textbook of oral medicine”, 1st
edition, Jaypee publishers, p:106

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178.  Newmann, Takei, Klokkevold, Carranza, “clinical
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