Practical oral medicine 2

Practical Oral Practical Oral Medicine 2Medicine 2

Ahmed A. Abdelazim

10 Marks over the following:1-Cardiovascular diseases2-Endocrine diseases3-Infectious diseases:a)AIDSb)Hepatitis4-Oro-facial pain5-Tongue diseases

1- 1- Cardiovascular Cardiovascular

diseasesdiseases

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

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 :

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 :

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 :

Case 1This 65-year-old male This 65-year-old male

patient suffers during patient suffers during the dental treatment the dental treatment from Pain in the left from Pain in the left arm and shoulder, he arm and shoulder, he also gave a history of also gave a history of previous attacks that previous attacks that resolved resolved spontaneously spontaneously

1- Diagnosis ?1- Diagnosis ?

2- Management ?2- Management ?

Case 2A patient presented to A patient presented to Your clinic giving a history Your clinic giving a history Of taking this drugOf taking this drug

1- What is the 1- What is the Scientific name ofScientific name ofThis drug ?This drug ?

2- Its Uses ?2- Its Uses ?

3- Common side 3- Common side Effect of this drugEffect of this drug

Case 370-year-old patient gave70-year-old patient gaveA history of severe chestA history of severe chestPain and a heart attack thatPain and a heart attack thatOccurred 2 years agoOccurred 2 years agoAnd he was taken to theAnd he was taken to theHospital 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 ?

Case 4A 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 from occurring again ?

Case 5

Mention Uses ofThis drug

Case 6Case 6During 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 for MI patients before dental procedures ?

Case 7During 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- Diagnosis2- Management ?2- Management ?

Case 8This patient presented toYou suffering from persistentSevere headache, and also Reported the presence ofDental pain without thePresence of caries orPeriodontal disease(Odontalgia)

1- Possible DiagnosisAnd how to confirm ?

2- Write 3 drugs taken by these patients

Case 9After 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 for similar patients before extraction ?

Case 10

1- Diagnosis2- Describe it and mention 2 diseases

associated with it ?

Note

Clubbing of fingers

35-Clubbing finger

Case 10Female 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 her if the proper drug wasn’t administered ?

Case 11This patient presented withBluish discoloration of his handsAnd bilateral lower limb edemaTogether with distention of The neck veins. He wanted toExtract his lower incisors

1- Diagnosis

2- Discuss emergencySituations possible withThis patient and theirmanagement

Note

Digoxin (Digitalis) is usedBy heart failure patients

Side effects Gag reflex

Note

Nifidepine (Calcium antagonist) cause generalized gingival enlargement

2- Endocrine diseases

Case 1This patient presents withChronic fatigue, tiredness andHypotension and melanin Hyperpigmented macules onThe skin and vermilion border

1- Diagnosis

2- Explain the reason of hyperpigmentations ?

NoteMoon’s face in Cushing

Buffalo hump

Case 2A 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 ?

Case 3A patient came to your clinic suffering from badly broken down

upper right first molar that requires extractionIn history taking: the patient admitted taking prednisone for 6

years in treating rheumatoid arthritis

1- Dental Management of this patient

2- Explain why ?

Case 4This female patient who is taking Daily steroid for several years lostHer consciousness with a rapidDrop in blood pressure. She alsoBecame mentally confused andNot responsive to the dentist

1- Diagnosis ?

2- Dental Management ?

Case 550 years old patient came to your clinic for operative

restoration of his mandibular second molar toothHistory revealed taking daily steroid (6 mg prednisone) for 3

months

How to avoid the occurrence of adrenal Crisis in this patient ?

Case 6During 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 for this patient ?

Case 7This patient presents with severeAphthous ulcers on his lips andOral mucosa. You decided to startA steroid therapy taken orallyFor the management of theOral 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 ?

Case 855-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 random blood glucose level ?

2- What is the proper treatment ?

Case 9During 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 ?

Case 104 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 most probable diagnosis is:The most probable diagnosis 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

Case 11Female 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 ?

Case 121- Name ThisEye phenomenon

2- It occurs with …………………..

Exophthalamus in Hyperthyroidism

Case 13This patient presented withPuffiness of his face andLips also macroglossia wasSeen intra-orally.The patient is very tired andObese and shows signs of edemaallover his body.His skin is cold and very dry

1- Diagnosis ?2- How to confirm it ?3- Possible complication during dental treatment

3-Infectious 3-Infectious diseasesdiseases

AIDSAcquired immune

deficiency syndrome

Important to Know

Atrophic Candidiasis

Chronic Herpes Simplex infection with lesions on tongue and lips.

Herpetic whitlow

Linear gingival erythema

Linear Gingival erythema

- Mild pain- Responds poorlyTo conventionalTreatmentHIV periodontal Triad:1- HIV associated gingivitis1- HIV associated gingivitis2- HIV associated periodontitis2- HIV associated periodontitis3- HIV associated Necrotizing gingivitis & 3- HIV associated Necrotizing gingivitis &

periodontitis periodontitis

Linear gingival erythema

Linear gingival erythema

Linear Gingival Erythema

Necrotizing Ulcerative Periodontitis

Squamous cell papilloma

Squamous cell papilloma

(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

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

(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)

(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

(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

(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

Case 1This HIV + patient presented to theOral Medicine department sufferingFrom asymptomatic corrugated White lesion on the lateral borderOf the tongue.The patients says he feels gagging Because of the lesion and complainedOf its bad appearance.

1- Diagnosis ?

2- What is the causative organism ?

3- Mention other diseases showing the same lesion?

Case 2This 66-year-old AIDS patients presented to yourClinic suffering from extremely painful ulcers,Erosions and crusts on his face, cheeks and ears

The patient reported the presence of the lesionsFor 3 months now

1- Diagnosis ?

2- Causative organism ?

3- Management ?

Case 3A 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 causativeOrganism ?

Case 4This 40-year-old patient Who gave a history ofIV drug abuse for severalYears, presented with manyDeep painful ulcers on Her upper and lowerLip that aren’t healingAnd are chronic

1- Diagnosis ?

2- What underlying disease you suspect ?3- Management ?

Case 1This 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 ?

Case 250-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 ?

Case 3This 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 ?

Case 4This 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

Management of MFPDS1. 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 .

Case 5A 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 ?

Tongue diseases Tongue diseases and disordersand disorders

ExaminationExaminationInspectionInspection

B- Palpation B- Palpation BidigitalBidigital Consistency Consistency

C- Function evaluationC- Function evaluation

Tongue Tie

Tongue deviation

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

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

Treatment

• Tricyclic antidepressant

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

Disorders of taste dysgeusia

• Viral infections• Candidiasis• Malnutrition• Neoplasms• Xerostomia• Metabolic disturbance• Drugs• Radiation• Zinc deficiency

COMMON LESIONS

Normal variations

Varicosities

Foliate papillae

They are occasionally mistaken fortumors or inflammatory disease

Developmental lesions

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

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………

MicroglossiaMacroglossia\Fissured tongue

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

Black hairy tongue

Brown hairy tongue

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

1. What is the clinical diagnosis

2. What are the predisposing factors?

3. What is the treatment?

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

Hemangioma of the lateral aspect of the tongue

Lingual thyroid

Other lesions

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

OraI hairy leukoplakia, Diagnosis

•DNA in situ hybridization•Biopsy

CandidiasisPseudomembranous

• Etiology• Predisposing factors• Classification• Treatment

Median rhomboid glossitis• Median rhomboid

glossitis - atrophic disorder of the tongue secondary to chronic candidiasis

Atrophic (erythematous) candidiasis

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.

Leukoplakia

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

EARLY SQUAMOUS-CELL CARCINOMA OF THE LATERAL

BORDER OF THE TONGUEEARLY SQUAMOUS-CELL

CARCINOMA OF THE FLOOR OF THE MOUTH

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.

• 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.

Traumatic ulcerSource of trauma should be identified

Case 11-What is the clinical diagnosis ?2-What are the predisposing factors ?

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 ?

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 abscess1-What is the most likely diagnosis ?2-How can you confirm your diagnosis clinically ?3-What is the appropriate treatment ?

Case 4A 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 ?

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 ?

Case 6These tongue changes were discovered accidentally during routine examination of the oral cavity. The patient reported that both his sons have the same lesions1-What is the most likely diagnosis ?

Case 7

This lesion was observed clinically, but with no pain

1-What is the diagnosis ?

Case 81) What is the differential diagnosis ?2) How can you confirm your diagnosis ?

Case 9A 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 ?

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 ?

Case 11A 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 ?

Case 12

This patient reported the presence of this lesion since early childhood

What is the Probable diagnosis ?

Good Luck