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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 1 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. 2 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. 3 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. 4 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. 5 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. 6 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 1 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. 2 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. 3 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 4 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. 5 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. 6 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. 7 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 8 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. 9 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. 10 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. 11 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. 12