Download Diagnosis in oral surgery

ORAL SURGERY
Lec.1
Third
grade
Dr. Noor Sahban
Diagnosis in oral surgery
Oral and maxillofacial surgery:
It is one of the dental specialties dealing with the management of diseases, injuries
and defects of human jaws and associated structures.
Diagnosis in oral surgery:
Oral diagnosis is the art of using the scientific knowledge to identify the oral
diseases and also to distinguish one disease from another.
In oral surgery practice, dentist is often faced with the diagnosis of the following
conditions:
1. Dental and facial pain
2. Swelling (lump, mass)
3. Ulcers
4. Injuries (dental, facial bones)
5. Tempromandibular joint (TMJ) problems
6. Facial deformity (cleft lip and palate)
7. Medically compromised patients
Case history (case sheet):
It’s the description of past events and related information that contributes to the
assessment of the patient’s health, during which the dentist observes the patient
and note any abnormality. These observations are then supplemented by a careful
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and thorough clinical examination of these abnormalities and systems indicated by
the patient’s history.
Component of case history:
1.
History taking.
2.
Clinical examination.
3.
Investigations (radiographs and laboratory tests).
4.
Interpretation and final diagnosis.
5.
Treatment plan.
 History taking:
The art of taking an accurate case history is probably the most important step in
the diagnosis of the medical and surgical condition. History taking must be
systematic using special set or sequence during which the dentist listen to the
patient’s story and list the symptoms in order of severity or importance.
Symptoms: a subjective problem that the patient describes like pain,
parasthesia.
Signs: (objective) an abnormal presentation detectable by the dentist
like swelling, ulcer.
 Objective of taking history:
1.
To provide dentist with information that may be necessary for making
diagnosis.
2.
To establish good or positive provisional relationship with patient;
which affects cooperation and confidence.
3.
To provide information about patient’s systemic health which may be
greatly affect the treatment plain and prognosis and disease that could be
transmitted to dentist, his staff or other patient.
4.
It serves as legal document.
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 Component of history taking:
a) Biographic data:
Include patient’s name, gender, age, address, phone no. and occupation. These
information may aid or contribute to the diagnosis since some medical problems
have a tendency to occur in a particular age group, gender or race. The patient
occupation may be associated with a particular disease or may influence the type
of therapy.
b) Chief complaint (CC):
It’s the reason for the patient’s visit. The chief complaint is best stated in patient’s
own words in a brief statement of the problem (e.g. pain, swelling, ulcer,
numbness, clicking, bleeding...etc). This statement helps the dentist establish
priorities during history taking and treatment planning. In addition, having patients
formulate a chief complaint encourages them to clarify for themselves and the
dentist why they desire treatment.
c) History of present illness:
The patient should be asked to describe the history of the present complaint or
illness, particularly its first appearance, any changes since its first appearance, and
its influence on or by other factors.
The most common symptom that causes the patient to seek dental aid is toothache.
A very detailed history of the pain should be taken which include the following
information:
1. Date of onset and duration: whether any incident may played some part in
the cause of the pain (like blow to the jaw, recent dental treatment…etc.)
2. Location of the pain: the patient points to the place where pain id felt using
his finger.
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3. Timing of the attacks of pain during the day: pulpal pain often prevents
or disturbs sleep, in acute peridontitis the pain worse at meal time.
4. Character of pain: sharp, dull, throbbing, stabbing, burning, mild,
continuous, intermittent, all these objectives can be applied to the pain in
different pathological process which may help in the diagnosis. (in acute
pulpitis, the pain is sharp and sever, in dental abscess the pain is dull,
throbbing and sever with tooth tenderness, in acute maxillary sinusitis the
pain is dull, throbbing and continuous).
5. Radiation: the patient is asked to demonstrate the course of the pain with
his finger. Pain may be felt in sites other than that of the causative lesion
and this type called “referred pain”, like pain of pericoronitis radiate to the
ear. (Pain is never referred across the midline).
6. Precipitating factors: e.g. pulpal pain often precipitated by thermal and
osmotic stimuli (hot, cold, sweet), antral pain by bending, periodontal pain
often precipitated by biting and chewing although the earliest stages of
acute periodontitis many patients obtain relief by biting on the affected
tooth.
7. Reliving factors: is the pain controlled by analgesics, this will give idea
about the nature and severity of the pain.
8. Associated signs and symptoms: like swelling, unpleasant taste, trismus,
fever, etc.
9. Relevant medical history: a history of previous “nervous breakdown” is
often obtained from patients complaining from psychosomatic origin or who
posses low pain threshold, angina pain may be felt in the mandible.
10. Therapy: type and dose, effectiveness.
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d) Medical history
It is the description of the patient’s health status from the birth to the moment that
the patient enters the dentist’s office. It is usually divided into past diseases,
characteristic infection, hospitalization, allergies, and current medical treatment.
An accurate medical history is the most useful information a dentist can have
when deciding whether a patient can safely undergo planned dental therapy and
anticipating how a medical problem might alter a patient’s response to planned
anesthetic agents and surgery.
e) Review of systems
The medical review of systems is a sequential, comprehensive method of
obtaining patient symptoms on an organ-by-organ basis. It may reveal
undiagnosed medical conditions. This review of systems when conducted by the
dentist before oral surgery should be guided by pertinent answers obtained from
the history.
For example, the review of the cardiovascular system in a patient with a history of
ischemic heart disease includes questions concerning chest discomfort (during
exertion, eating, or at rest), palpitations, fainting, and ankle swelling. Such
questions help the dentist decide whether to perform surgery at all or to alter the
surgical or anesthetic methods.
The review of systems includes: cardiovascular system, respiratory system, central
nervous system, gastrointestinal system, genitourinary system, endocrine system,
musculoskeletal system.
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f) Past dental history:
It’s a summary of past dental care, unusual experiences, hygiene practices and
attitude toward dental care. We ask the patient:
• When was the last visit to the dentist and why?
• Any difficulties and complications?
g) Family medical history
It consists of the health status of the family members; this may reveal risk factors
for patients as well as the possibility of inherited illnesses such as diabetes,
ischemic heart disease, hemophilia.
h)The social history
It should include information regarding any habits such as tobacco, alcohol, or
illicit drug use. These habits may adversely affect healing and also may increase a
patient’s risk for undergoing a planned surgical procedure.
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ORAL SURGERY
Lec. 2
Third
grade
Dr. Noor Sahban
Diagnosis in oral surgery
 Clinical examination:
Careful history taking should be followed by a thorough and systematic clinical
examination that focuses on the oral cavity and, to a lesser degree, on the entire
maxillofacial region. It provides diagnostic information about the patient without
the use of complex technical devices. It has two aspects (Extraoral and Intraoral).
The diagnostic instruments include:
1. Dental mirror.
2. Dental probe.
3. Dental tweezers.
The clinical examination usually involves one or more of the following four
primary means:
1. Inspection (visualization):
In the oral and maxillofacial regions, inspection should always be performed. The
dentist should note facial symmetry and proportion, eye movements and
conjunctival color, nasal patency on each side, the presence or absence of skin
lesions or discoloration, and neck or facial masses. A thorough inspection of the
oral cavity is necessary, including the oropharynx, tongue, floor of the mouth, and
oral mucosa.
2. Palpation:
It is a physical examination method that relies on the sense of touch. Palpation
allows the dentist to examine structures deep to the surface and notice
characteristics such as tenderness, compressibility. It is important when examining
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temporomandibular joint (TMJ) function, salivary gland size and function,
presence or absence of enlarged or tender lymph nodes, and induration of oral soft
tissues, as well as for determining pain or the presence of fluctuance in areas of
swelling.
There are three methods of palpation:
 Bimanual palpation: performed with both hands, using one hand to
manipulate the tissues while the other hand to support the structures
from the opposite side such as examining the content of the floor of the
mouth.
 Bi-digital palpation: same as the previous only done by using two
fingers. It is used for examining thinner tissues such as the lips.
 Bilateral palpation: it’s effective method for examining bilateral
structures at the same time and compare between them such as
examining the lymph nodes or parotid gland.
3. Percussion:
It is the technique of gentle tapping of the tissue or the dentition with a finger or
the handle of a dental mirror, the examiner listen to the sound and observes the
response of the patient. Percussion is often used to test teeth and paranasal sinuses.
4. Auscultation:
It is the process of listening to the internal sounds of the body usually using a
stethoscope. The dentist uses auscultation primarily for TMJ evaluation.
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Extraoral examination:
It is done by inspection, palpation and auscultation when needed. It focuses on the
head and neck area, although examination of other region may give significant
information. It includes the following:
 Facial form, color and symmetry:
Observe the color of face, conjunctiva and sclera. Symmetry, position and
contour of the orbits, pupil alignment, midline position of the nose and the
resting position of the mouth (lip competence).
 Yellowish discoloration of the skin and sclera caused by jaundice. It
occurs due to abnormally high blood levels of the bile pigment,
bilirubin. This may be caused by hemolysis (extensive lyses of red
blood cells) and liver diseases.
 Faint bluish discoloration of the skin and mucous membrane
(Cyanosis) due to increase in the amount of reduced hemoglobin in
the capillaries.
 Pale skin: this may occur in case of anemia, shock (dangerously low
blood pressure), low blood sugar, syncope or fainting.
 Lymph nodes (L.N.):
Lymph nodes in the head and neck (fig. 1) should be examined by palpation and
note any enlargement or tenderness.
* The submental nodes drain the lower lip, the lower incisor area, the tip of the
tongue and part of the floor of the mouth.
* The submandibular nodes drain much of the face, the mouth and the anterior
two-thirds of the tongue excluding the tip.
* The upper anterior cervical nodes are usually involved from the face and the
pharynx.
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 Facial, sublingual, submandibular and cervical L.N. can be felt more easily
when the patient relaxes with his neck flexed, the soft tissue of the region
are firmly palpated with finger tips and rolled over a bony surface such as
the lower border of the mandible in case of submandibular L.N., the facial
group of lymph nodes is situated just in front of the lower attachment of the
masseter muscle. In younger patients particularly, they frequently become
enlarged and tender as a result of dental infection.
** Multiple tender, mobile and compressible nodes with in a regional group
results from an active infection with in the tissues drained by that group.
** Firm, non tender and mobile nodes that is palpable typically reflects sclerosis
that has been caused by previous infection.
** Multiple firm and non tender nodes that are fixed or attached to surrounding
structures is characteristic of regional metastasis of malignant neoplastic disease.
Fig. 1: Lymph node distribution in the head and neck with its pattern of drainage
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 Swelling (if present):
The size, shape, attachments and consistency of any swelling present should be
noted. The response of tissue to pressure by palpation can suggest the composition
of the structure or swelling:
 Fluctuant: it’s the property of yielding to pressure by palpating fingers so
as to suggest that the area being felt contains fluid. When an abscess, for
instance, has fully developed, it tends to become fluctuant. It should be
examined in two planes at right angle to each other (the examining finger
applying pressure between two watching fingers, the presence of fluid can
readily be detected by the watching fingers).
 Bony hard: like rigid sensation of bone which means that this structure is
calcified.
 Indurated: means hardness but without the sensation of calcification (like
squeezing a dense, solid rubber ball) it’s the feature of many malignant
neoplasms.
 Firm masses: yield more to pressure than do indurated tissues (minimal
shape alteration of the structures occurs in contrast to compressible tissues).
Many benign neoplastic and hyperplastic enlargements are firm.
 Compressible: it’s relatively non specific term indicting that pressure
significantly alters the shape of the structure.
 Doughy: indicate that the structure deforms with a degree of resistance
suggesting semisolid contents, then returns slowly to the original shape.
Some cysts are characterized by this consistency.
 Spongy: the structure offers minimal resistance to pressure and quickly
regains the original contour after the pressure is released. Highly vascular
lesions give this sensation.
 Pitting response to pressure indicates that the structure offers minimal or
moderate resistance and then slowly regains the original contour after the
release of the pressure. Edema often produces this response.
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 Collapsing: refers to an easily compressible enlargement that remains
deformed after the release of the pressure this implies that the contents of
the structure have been displaced. Expression of pus from the abscess is
common example.
 Tempromandibular joint function:
Routine assessment of jaw function consists of four elements:
1. Palpation of the TMJ:
Pain or tenderness of TMJ during palpation is one of the most reliable
indications of joint inflammation. The dentist insert the little finger in the
external auditory canal, the patients is asked to open and close while the
examiner apply pressure on the joint, a distinct depression should be felt
during opening as the condylar head translate forward. The movement of
both joints is normally synchronized. Click, crepitus, or jump during
opening suggests dysfunction.
2. Palpation to identify tenderness of muscles of mastication.
3. Determination of maximal opening:
It’s accomplished by requesting the patient to open as wide as possible
without pain; normal dentulous adults can open approximately 35 mm or
three fingers or more without discomfort.
4. Observation of lateral deviation of the mandible during opening:
By looking down the patient face from a supra orbital position; and
watching the tip of the chin related to the tip of the nose during opening, the
dentist can identify lateral deviation. Deviation to one side typically
indicates degenerative joint disease on the side toward the patient deviates;
multiple deviations suggest degenerative joint disease of both joint.
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Intraoral examination:
Examination of oral soft tissue is accomplished by inspection and palpation. Oral
structures exhibit bilateral symmetry in most respects, any asymmetric contours or
variation in the uniformity of mucosal color or texture with in specific anatomic
regions suggests the possibility of an abnormality. It includes the following:
 Lips: extraoral surface of the lips normally appear pale pink and
homogenous in color, the common abnormalities of the lip include ulcer,
rough surface texture and homogenous white thickening.
 Buccal mucosa: it’s examined visually by having the patient open the
mouth slightly less than the maximal opening and then retracting the cheek
away from the teeth with a mirror, it has a deep homogenous pink color at
the level of the occlusal plane and more red vascular appearance at the
greatest extent of the mucobuccal vestibule.
 Buccal vestibule: it can be inspected by retracting the cheek with mirror
while the mouth is open and then ask the patient to bring the teeth nearly
together, the buccal vestibule are visualized and palpated to demonstrate
their superior and inferior extent and symmetric contour, the facial surfaces
of maxilla and mandible are palpated by slowly sliding the tip of the finger
along the alveolar surface at the periapical level to identify typical elevation
or depression in the contour of the bone and any tenderness or enlargement
of periapical inflammatory lesion.
 Hard palate: indirect inspection of the hard palate surface using the mirror,
direct vision provides better visualization of the posterior palatal contour in
evaluating the symmetry of the region. The normal palatal mucosa appears
pale pink and homogenous in color.
 Soft palate: it’s easily inspected during direct visualization of the hard
palate, depressing the tongue with a mirror is often necessary to fully
demonstrate the soft palate.
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 Oropharynx: its visualized directly while the tongue is depressed with the
mirror and the patient say “ah”
 Tongue: the dorsum of the tongue is best visualized by requesting the
patient to protrude the tongue while the mouth is open, the ventral surface is
examined visually by asking the patient to touch the palate with the tip of
the tongue while the mouth is open, the lateral border and posterior surface
of the tongue are examined by wrapping the tip of the tongue with a cotton
gauze and gently drawing out of the mouth and laterally. Bidigital palpation
of the tongue reveals its muscular consistency.
 Floor of the mouth: it can be visualized at the same time when the ventral
surface and lateral border of the tongue are examined.
 Periodontium: visual examination of healthy gingiva reveals a uniform non
compressible contour with typical homogenous pink color and stippling.
Healthy gingival sulcus depth normally expected to be in the range of 1-2
mm without bleeding or exudates during probing, greater depths suggests
apical displacement of the gingival attachment to the root surface.
 Teeth: examination of the quality of the oral hygiene, teeth present, general
extent of calculus could be done be inspection and palpation. In addition,
suspected teeth should be examined by
 Probing and percussion, note any signs of mobility, tenderness or
fracture.
 Vitality test of the pulp: it’s useful aid in diagnosis of the accused
tooth.
a. Thermal test (cold or hot): the teeth being examined should
be isolated and dried, then apply either a piece of cotton
soaked in ethyl chloride as a cold test, or warmed piece of
gutta percha or hot instrument as hot test. These tests may
have false positive response in case of pulpless tooth due to
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gaseous expansion within the closed pulp canal or in case
contact with gingival tissue occurs.
b. Electrical pulp testing: more refined method by using
electrical pulp tester in determining the vitality of tooth.
This test also may have false positive response if used with
the presence of pus in the pulp chamber and canal.
 Saliva: decrease or increase in saliva could be abnormal as in
 Xerostomia or dry mouth: it may be due to simple cause (anxiety,
dehydration) or more serious (salivary gland or duct disease, systemic
disorder like diabetes mellitus, chronic renal failure). Xerostomia
usually associated with increase in caries, periodontal disease and
infection as candidiasis.
 Ptylism or increased salivation: occurs due to Parkinson disease,
psychiatric disorders, drugs (cholinergic drugs usead in myasthenia
gravis), macroglossia, neurological lesions that cause facial and
lingual paralysis and disorders of pharyngeal function.
 Occlusion: the over bite and over jet between upper and lower anterior teeth
normally 2mm. any increase or decrease or malocclusion or crowding is
considered abnormal.
 Investigations:
Sometimes the dentist needs additional tests to clarify some aspects of the
diagnosis. These tests include:
 Radiographs: is one of the most frequently used investigations in oral
surgery. It provides information about hard and soft tissues that are hidden
from the eye and aid in the diagnosis and to evaluate the progress of the
disease. Some types of radiographs used are periapical, occlusal, extraoral
views like lateral oblique of the mandible, CT scan and MRI.
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 Physical investigations:
 Temperature: the normal value by mouth= 36.8 ̊ C with variation
between 0.5 and 0.75 ̊C in healthy individuals.
 Heart rate: normal adult value=72 beat/min.
 Respiratory rate: normal rate= 16-20/min.
 Blood pressure (BP): it is the pressure exerted by the blood on the
walls of the blood vessels.
 Normal adult value of systolic BP =120 mmHg.
 Normal adult value of diastolic BP: =80 mmHg.
 Higher than normal is (Hypertension), lower than normal is
(Hypotension).
 Biopsy: it is used to confirm the diagnosis of a lesion. Small specimen of
tissue
taken
from
the
lesion
and
submitted
to
microscopical
(Histopathology) examination. Biopsy could be Incisional, Excisional or
Exfolative cytology.
 Aspiration: aspiration of fluid from the lesion using a syringe may aid in
the diagnosis of the lesion. For example aspiration of pus indicates an
inflammatory process like abscess or an infected cyst, aspiration of yellow
fluid may indicates cystic lesion, aspiration of blood may indicates vascular
lesion like Hemangioma, …etc. aspiration is one of the methods used to
aspirate fluid from swelling for evaluation of the nature of the swelling
which may assist in the diagnosis.
 Clinical laboratory studies: like
 Glucose blood level (normal fasting less than 100mg/dl, normal
random less than 180 mg/dl).
 Bacteriology examination, Culture and sensitivity test.
 Hematological examination.
 Urine analysis.
 Blood chemistry and serological examination.
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 Diagnosis:
The collection of all information taken from history, clinical examination and
accessory investigations must be evaluated and analyzed to reach the final
diagnosis.
Diagnostic methods: it is the application of the scientific method to clinical
decisions, which consist of:
1. Collection of information: as case sheet.
2. Evaluation of information: organize the information and compare it with
basic knowledge such as anatomy and physiology and observation from past
clinical experiences.
3. Diagnostic decision: the dentist formulates opinions concerning the nature
of unusual finding; which is the explanation for an element of the patient’s
status that is most consistent with the available information.
4. Reassessment: reassessment of the abnormality after treatment (test the
diagnosis), good response confirm the diagnosis to some degree, while an
unexpected outcome suggests that the diagnosis may be incorrect.
 Treatment plan:
It is the formulation of strategy to solve as many of the patient’s dental problems
as possible. So every treatment plan must be designed to suit the dental, medical
and economic needs of the individual patient. Successful treatment planning must
be based upon a careful preoperative assessment of any difficulties which may be
encountered, any possible complications which might occur, together with both
the advantages and disadvantages of the treatment.
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In broad terms, there are three types of treatment in dentistry:
1. Expectant treatment or treatment by observation “reassurance” as in nonerosive lichen planus, benign hyperkeratosis, aphthous ulcer, hematoma.
2. Conservative treatment placement of a sedative dressing into carious
cavity or an infected socket, removal of calculus.
3. Radical treatment by means of surgery, extraction of tooth …etc.
In many cases the dentist will employ a combination of techniques during
treatment.
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