This document contains 11 cases related to various cardiovascular, endocrine, infectious diseases and orofacial pain conditions. Case 1 describes a 62-year-old male smoker with diabetes, hypertension and chest pain who is found to have generalized gingival enlargement. Case 6 describes a 55-year-old female who had a past heart attack and is bleeding severely during a tooth extraction, requiring tests for myocardial infarction patients before dental procedures. Case 10 asks for the diagnosis of a condition associated with clubbing of the fingers and mentions two associated diseases. The document provides details for managing patients with various medical conditions in a dental setting and determining appropriate treatment approaches. It discusses evaluating risk factors and potential

1. Practical OralPractical Oral
Medicine 2Medicine 2
Ahmed A. Abdelazim

2. 10 Marks over the following:
1-Cardiovascular diseases
2-Endocrine diseases
3-Infectious diseases:
a)AIDS
b)Hepatitis
4-Oro-facial pain
5-Tongue diseases

3. 1- Cardiovascular1- Cardiovascular
diseasesdiseases

4. 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

9. 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 :

10. 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 :

11. 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 :

12. Case 1
This 65-year-old maleThis 65-year-old male
patient suffers duringpatient suffers during
the dental treatmentthe dental treatment
from Pain in the leftfrom Pain in the left
arm and shoulder, hearm and shoulder, he
also gave a history ofalso gave a history of
previous attacks thatprevious attacks that
resolvedresolved
spontaneouslyspontaneously
1- Diagnosis ?1- Diagnosis ?
2- Management ?2- Management ?

13. Case 2
A patient presented toA patient presented to
Your clinic giving a historyYour clinic giving a history
Of taking this drugOf taking this drug
1- What is the1- What is the
Scientific name ofScientific name of
This drug ?This drug ?
2- Its Uses ?2- Its Uses ?
3- Common side3- Common side
Effect of this drugEffect of this drug

14. Case 3
70-year-old patient gave70-year-old patient gave
A history of severe chestA history of severe chest
Pain and a heart attack thatPain and a heart attack that
Occurred 2 years agoOccurred 2 years ago
And he was taken to theAnd he was taken to the
Hospital 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 ?

15. Case 4
A 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 fromoccurring again ?

16. Case 5
Mention
Uses of
This drug

17. Case 6Case 6
During 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 forMI patients before
dental procedures ?

18. Case 7
During 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- Diagnosis
2- Management ?2- Management ?

19. Case 8
This patient presented to
You suffering from persistent
Severe headache, and also
Reported the presence of
Dental pain without the
Presence of caries or
Periodontal disease
(Odontalgia)
1- Possible Diagnosis
And how to confirm?
2- Write 3 drugs taken by these patients

20. Case 9
After 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 forsimilarpatients before
extraction ?

21. Case 10
1- Diagnosis
2- Describe it and mention 2 diseases
associated with it ?

22. Note

23. Clubbing of fingers

24. 35-Clubbing finger

25. Case 10
Female 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 herif the proper
drug wasn’t administered ?

26. Case 11
This patient presented with
Bluish discoloration of his hands
And bilateral lower limb edema
Together with distention of
The neck veins. He wanted to
Extract his lower incisors
1- Diagnosis
2- Discuss emergency
Situations possible with
This patient and their
management

27. Note
Digoxin (Digitalis) is used
By heart failure patients
Side effects 
Gag reflex

28. Note
Nifidepine (Calcium antagonist)  cause
generalized gingival enlargement

29. 2- Endocrine
diseases

30. Case 1
This patient presents with
Chronic fatigue, tiredness and
Hypotension and melanin
Hyperpigmented macules on
The skin and vermilion border
1- Diagnosis
2- Explain the reason of hyperpigmentations ?

31. Note
Moon’s face in Cushing

34. Buffalo hump

36. Case 2
A 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 ?

37. Case 3
A patient came to your clinic suffering from badly broken down
upper right first molar that requires extraction
In history taking: the patient admitted taking prednisone for 6
years in treating rheumatoid arthritis
1- Dental Management of this patient
2- Explain why ?

38. Case 4
This female patient who is taking
Daily steroid for several years lost
Her consciousness with a rapid
Drop in blood pressure. She also
Became mentally confused and
Not responsive to the dentist
1- Diagnosis ?
2- Dental Management ?

39. Case 5
50 years old patient came to your clinic for operative
restoration of his mandibular second molar tooth
History revealed taking daily steroid (6 mg prednisone) for 3
months
How to avoid the occurrence of adrenal Crisis in this
patient ?

40. Case 6
During 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 forthis patient ?

41. Case 7
This patient presents with severe
Aphthous ulcers on his lips and
Oral mucosa. You decided to start
A steroid therapy taken orally
For the management of the
Oral 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 ?

42. Case 8
55-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
randomblood glucose level ?
2- What is the propertreatment ?

43. Case 9
During 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 ?

44. Case 10
4 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 m o st pro bable diag no sis is:The m o st pro bable diag no sis 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

45. Case 11
Female 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 ?

46. Case 12
1- Name This
Eye phenomenon
2- It occurs with
…………………..

47. Exophthalamusin Hyperthyroidism

48. Case 13
This patient presented with
Puffiness of his face and
Lips also macroglossia was
Seen intra-orally.
The patient is very tired and
Obese and shows signs of edema
allover his body.
His skin is cold and very dry
1- Diagnosis ?
2- How to confirm it ?
3- Possible complication
during dental treatment

49. 3-Infectious3-Infectious
diseasesdiseases

50. AIDS
Acquired immune
deficiency syndrome

51. Important to Know

61. Atrophic Candidiasis

84. Chronic Herpes Simplex infection with lesions on
tongue and lips.

85. Herpetic whitlow

99. Linear gingival erythema

100. Linear Gingival erythema
- Mild pain
- Responds poorly
To conventional
Treatment
HIV periodontal Triad:
1- HIVassociatedgingivitis1- HIVassociatedgingivitis
2- HIVassociatedperiodontitis2- HIVassociatedperiodontitis
3- HIVassociatedNecrotizinggingivitis &3- HIVassociatedNecrotizinggingivitis &
periodontitisperiodontitis

104. Linear gingival erythema

105. Linear gingival erythema

106. Linear Gingival Erythema

107. Necrotizing Ulcerative
Periodontitis

109. Squamous cell papilloma

110. Squamous cell papilloma

118. (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

119. (4)
CD 4 20 cells / ml
HIV viral load 120.000 copies/ ml

120. (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)

121. (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

122. (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

123. (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

124. Case 1
This HIV + patient presented to the
Oral Medicine department suffering
From asymptomatic corrugated
White lesion on the lateral border
Of the tongue.
The patients says he feels gagging
Because of the lesion and complained
Of its bad appearance.
1- Diagnosis ?
2- What is the causative organism ?
3- Mention other diseases showing the same lesion?

125. Case 2
This 66-year-old AIDS patients presented to your
Clinic suffering from extremely painful ulcers,
Erosions and crusts on his face, cheeks and ears
The patient reported the presence of the lesions
For 3 months now
1- Diagnosis ?
2- Causative organism ?
3- Management ?

126. Case 3
A 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 causative
Organism ?

127. Case 4
This 40-year-old patient
Who gave a history of
IV drug abuse for several
Years, presented with many
Deep painful ulcers on
Her upper and lower
Lip that aren’t healing
And are chronic
1- Diagnosis ?
2- What underlying disease you suspect ?
3- Management ?

129. Case 1
This 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 ?

130. Case 2
50-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 ?

131. Case 3
This 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 ?

132. Case 4
This 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

133. Management of MFPDS
1. 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 .

137. Case 5
A 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 ?

139. Tongue diseasesTongue diseases
and disordersand disorders

141. ExaminationExamination
InspectionInspection

142. B- PalpationB- Palpation BidigitalBidigital ConsistencyConsistency
C- Function evaluationC- Function evaluation
Tongue TieTongue deviation

143. 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

144. 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

145. Treatment
• Tricyclic antidepressant

146. 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

147. Disorders of taste
dysgeusia
• Viral infections
• Candidiasis
• Malnutrition
• Neoplasms
• Xerostomia
• Metabolic disturbance
• Drugs
• Radiation
• Zinc deficiency

148. COMMON LESIONS

149. Normal variations

150. Varicosities

152. Foliate papillae

153. They are occasionally mistaken for
tumors or inflammatory disease

154. Developmental lesions

155. 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

156. 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………

157. MicroglossiaMacroglossiaFissured tongue

158. 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

159. Black hairy tongue

160. Brown hairy
tongue
TREATMENT: Treatment consists of
brushing the tongue with a soft bristle
toothbrush . Surgical scraping.

161. 1. What is the clinical
diagnosis
2. What are the
predisposing factors?
3. What is the treatment?

162. 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

165. Hemangioma of the lateral aspect of
the tongue

167. Lingual
thyroid

168. Other lesions

169. 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

170. OraI hairy leukoplakia, Diagnosis
•DNA in situ hybridization
•Biopsy

171. Candidiasis
Pseudomembranous
• Etiology
• Predisposing factors
• Classification
• Treatment

172. Median rhomboid glossitis
• Median rhomboid
glossitis - atrophic
disorder of the tongue
secondary to chronic
candidiasis

174. Atrophic (erythematous) candidiasis

175. 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.

176. Leukoplakia
unilateral indurated white patch related to
the lateral surface of the tongue.

177. EARLY SQUAMOUS-CELL
CARCINOMA OF THE LATERAL
BORDER OF THE TONGUE
EARLY SQUAMOUS-CELL
CARCINOMA OF THE FLOOR OF
THE MOUTH

178. 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.

180. • 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.

181. Traumatic ulcer
Source of trauma should be identified

182. Case 1
1-What is the clinical diagnosis ?
2-What are the predisposing factors ?

183. 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 ?

184. 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 abscess
1-What is the most likely diagnosis ?
2-How can you confirm your diagnosis clinically ?
3-What is the appropriate treatment ?

185. Case 4
A 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 ?

186. 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 ?

187. Case 6
These tongue changes were discovered accidentally during
routine examination of the oral cavity. The patient reported
that both his sons have the same lesions
1-What is the most likely diagnosis ?

188. Case 7
This lesion was observed clinically, but with no pain
1-What is the diagnosis ?

189. Case 8
1) What is the differential diagnosis ?
2) How can you confirm your diagnosis ?

190. Case 9
A 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 ?

191. 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 ?

192. Case 11
A 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 ?

193. Case 12
This patient reported the presence of this lesion since early
childhood
What is the Probable diagnosis ?

194. Good Luck