Oral pathology

course# 75303301
The Faculty of Dental medicine
Third year
2023/2024
4 points
Instructors:
Dr. Omar Imran
Dr. Hasnaa’ Makkawi
 Important notes:
Learning materials:
1) Cawson’s Essentials of Oral Pathology and Oral Medicine, E.W. Odell 9th edition.
2) Oral Pathology Clinical Pathologic Correlations, Joseph A. Regezi, 6th edition.

Course evaluation:
• Quizzes 5%
• Assignments and oral presentations 15%
• Midterm exam 30%
• Final exam 50%

Attendance:
• Course attendance is mandatory.
 Course outline

Introduction to oral
pathology.

Hard tissues Soft tissues Odontogenic and

Salivary gland
pathology (epithelial, mucosa Infectious lesions Neoplastic lesions non-odontogenic
diseases and
(osseous) and submucosa) neoplasms tumers

Disorders of tooth
development and
caries white lesions

Odontogenic and non pigmented and red

odontogenic cysts lesions

TMD Inflammatory jaws

lesions ulcerative lesions

Vessiculo- bullous
lesions
Introduction to oral
pathology
Text book
Cawson’s essentials of oral pathology
Chapter 1
 Principles of investigation, diagnosis and
treatment
• A detailed medical and dental history
• Clinical examination
• Extraoral
• Intraoral
• Investigations selected for specific purposes
Taking a History

• Demographic details (age, gender, the family and social history

ethnic group and occupation)
• Medical history
• History of the present complaint
• The dental history
• Consent
The Art of Medical History Taking

• Gaining rapport, eliciting useful

information.
• Introduce yourself and greet the
patient by name.
• Listening ‘actively’
• Be culturally aware.
• Act courteously and respectfully,
maintain professional detachment.
• Put patients at their ease, be
empathic
The Art of Medical History Taking
• targeted incisive questions ( thorough knowledge of the disease)
✓patients should speak at some length and to gain confidence
✓‘open’ question
✓ avoid leading questions
✓Explain the need for specific questions if asked
✓Summarize your findings back to the patient for confirmation of
meaning (mirroring)
✓mental and emotional state of the patient should be assessed Assess
the patient’s expectations from treatment.
Types of questions:
patients own words,
Tell me /avoid interruptions
gives them confidence
Open: about the
and quickly generates extract the most relevant
pain
rapport

.
What does Specific information Restricts the patients
Closed: the pain feel opportunities to Talk
like? Helps focus on the complain

Does the pain feel like

Leading:
an electric shock?
Medical history, why?
• Importance of medical history :
- aids the diagnosis of oral
manifestations of systemic disease
- ensures that medical conditions
and medications that affect dental
or surgical treatment are identified
- How to take medical history?
• Verbal medical history
• printed questionnaire
Medicolegal
Questions in a medical history
• Are you taking any medicines, medications or tablets at present?
- Potential interactions
- Potential oral adverse effects (ex: bisphosphonates)
- Immunosuppression (steroids)

Have you ever been in hospital for any illnesses or operations?

Indicates severe health problems
Malignant disease, chemotherapy, radiotherapy and immunosuppression
Anesthetics, bleeding problems or other medical complications

Do you have, or have you had, any problems with your heart or past rheumatic fever?
Risk of angina, myocardial infarct or other cardiac emergency in the dental
Surgery Potential anesthetic problem Possible predisposition to infective
Endocarditis, depending on defect. ( need of prophylactic antibiotics??)
 Do you have, or have you had, hepatitis or jaundice?
Infection control risk for hepatitis B and C.
Coagulation defect, metabolic defect can contraindicate
Prescription of some drugs

Have you ever had epilepsy or other fits or faints?

vasovagal attack vasovagal attack, medication…

Do you have diabetes?

hypoglycaemic collapse
hyperglycaemia infection,
particularly candida but also
bacterial and periodontal disease
Dry mouth may result from dehydration

Do you have high blood pressure?

Antihypertensive drugs cause dry mouth, gingival hyperplasia,
lichenoid reactions, burning mouth and taste loss.
Risk of interaction with some vasoconstrictors in local anesthetic
Anesthetic risk Patients may faint from hypotension after rising from
a supine position for dental treatment
Have you ever been anemic?
aphthous ulcers, candidiasis, glossitis and burning mouth

Do you have any allergies …?

ask specifically about penicillin and other
drugs including local anesthetic
Reveals atopic patients prone to allergy

Have you ever had any problems stopping bleeding after a cut or surgery?
Hemorrhage
Avoid aspirin
Anticoagulants interact with drugs prescribed for oral conditions and
prolong bleeding after surgery

Do you smoke?
carcinoma
atheroma, hypertension and cardiac disease
Associated with oral red and white lesions
potentially malignant disorders
For female patients, is there any chance you might be pregnant?
X-ray exposure Pregnancy modulates healing and is association with
remission in aphthous stomatitis and predisposes to pyogenic granuloma
and gingivitis.

Are you otherwise generally fit and well

Do any diseases run in your family?

Is there anything else about your health you would like to tell me?

The Dental History
• Past dental history very
important
• Chief compliant
• Essential for the diagnosis of
dental pain or to exclude teeth
as cause of symptoms in the
Head and neck region.
• Patient previous exposure to
anesthesia
• Psychological trauma
• The nature of pain if present
• Toothache and its mimics
• • Toothache
• • Pulpitis
• • Periapical periodontitis
• • Fractured cusp/tooth
• • Dentine hypersensitivity
• Mimics of toothache
• • Prodromal herpes zoster
• • Postherpetic neuralgia
• • Trigeminal neuralgia
• • Neuropathic pain after trauma or central nervous
• system disease
• • Maxillary sinusitis
• • Temporal arteritis
• • Migrainous neuralgia
• • Otitis media
• • Referred pain of angina pectoris
• • Referred pain of temporomandibular joint myofascial
• pain dysfunction
• • Atypical odontalgia / facial pain
History of the present complaint
• Record the description of the complaint in the patient’s own words
• Elicit the exact meaning of those words
• Record the duration and the time course of any changes in symptoms or
signs
• Include any relevant facts in the patient’s medical history
• Familial and genetic disease that is running or inherited in the family.
• Note any temporal relationship between them and the present complaint
• Consider any previous treatments and their effectiveness
• Check previous investigations to avoid their unnecessary repetition
Features required in a pain history
Characteristic Informative features
Character Ache, tenderness, dull pain, throbbing, stabbing, electric
shock. These terms are of limited use, but information on
the constancy of pain is useful
Severity Mild – responds to mild analgesics (e.g.
aspirin/paracetamol) Moderate – unresponsive to mild
analgesics Severe – disturbs sleep
Duration Time since onset. Duration of pain or attacks
Nature Continuous, periodic or paroxysmal If not continuous, is
pain present between attacks
Initiating factors Initiating factors
Exacerbating and relieving factors Record all and note especially hot and cold sensitivity or
pain on eating as they suggest a dental cause
Localization The patient should map out the distribution of pain if
possible. Is it well or poorly defined? Does it affect an area
supplied by a particular nerve or artery? Is the distribution
of the pain consistent with anatomy?
Referred pain Try to determine whether the pain could be referred
History-taking needs to be tailored to the
individual patient.
 CLINICAL EXAMINATION
• Extraoral
• Oral examination
1) Soft tissues
2) Teeth
Extraoral Examination

• look at the patient, before looking into the
patient’s mouth.
• Palpate the parotid glands
• Temporomandibular joints for clicks, crepitus or
deviation
• cervical and submandibular lymph nodes and
thyroid gland
• Lymphadenopathy ( infection, malignancies
lymphomas. Note the character (site, shape,
size, surface texture and consistency)
• examine the neck and the back of the head.
• Sinuses.
• Do not misdiagnose normal to diseased.
Intraoral examination
• Soft tissues
- systematic to include all areas of the mouth
including:
- Tongue ( lateral posterior anterior dorsum)
- Floor of the mouth
- Mucosa ( ulcerations, inflammation, lesion or
tumor)
- Palpation of accessible deeper tissues
(ex: submandibular glands)
- Muscular tone and tension
- Lips
- Gingiva crevice , attached gingiva
- Salivary glands ducts and salivary flow
- Visualize the oropharynx and tonsils.
Dental Examination
• periodontal health
• Number of teeth
• Caries
• restorative state
• tooth wear
• dental pain
• assessment of mobility and
percussion of teeth.
• Testing vitality of teeth ( false
positive false negative)
Medical examination
• Head and neck
• Hair
• Skin
• Eyes
• Cranial nerves function
 Investigations

• Screening and diagnostic tests

• Imaging
• Histopathology
• Biopsy
• Imaging
• Haematology, clinical chemistry and serology
• Microbiology
Sensitivity vs specificity of tests
• no test is completely accurate
• Sensitivity is when a test can correctly
identify a condition
• specificity determines whether it can
correctly exclude a condition.
• screening tests are used in population
screening and are only intended to
identify individuals who might have a
disease
• Diagnostic tests are required to have high
predictive values, and the more
significant the diagnosis, the higher the
predictive value must be.
• Positive for screening test will be referred
for diagnostic test
Imaging
• CBCT
• CT
• MRI
• Cephalometric
• Periapical
• Panoramic
• Ultrasound
• Positron emission tomography PET
Histopathology
• Strong diagnostic tool for diseases
of the mucosa, soft tissues and
bone.
• Biopsy is performed in the clinic
and sent to the pathologist with
the clinical feature and history
written in report
• The pathologist will report the
macroscopic and microscopic
features seen in the biopsy
• The interpretation will be based on
both
Types of biopsy
• Surgical biopsy (incisional or excisional)
- Fixed specimen for routine diagnosis
- Frozen sections for rapid diagnosis
- Fresh tissue for immunofluorescence, microbiological culture or molecular
analysis

• Fine needle aspiration biopsy

• Wide needle/core biopsy

Essential biopsy principles
Choose the most diagnostic or suspicious area, e.g. red
area when potential malignancy is suspected
• Avoid ulcers, sloughs or necrotic areas
• Give regional or local anesthetic – do not inject into
the lesion
• Include normal tissue margin if the lesion itself may be
friable or malignancy is suspected
• Specimen should preferably be at least 10 x 6 mm and
2 mm deep for mucosal disease, larger for large lesions,
smaller on muco-periosteum
• For mucosal disease, specimen edges should be
vertical, not beveled
• Design the sample shape and incision for easy primary
closure
• Before incising, pass a suture through the specimen to
control it and prevent it being swallowed or aspirated
by the suction
• For large lesions, several areas may need to be sampled
• Include every fragment removed for histological
examination
• Never open, incise or divide the specimen, always send
it intact
• Suture and control any post-operative bleeding
• Label specimen bottle with patient’s name and clinical
details
• Warn patient of possible soreness afterward. Give or
recommend an analgesic
• Check the histological diagnosis is consistent with the
clinical diagnosis and investigations
• Discuss with pathologist or repeat biopsy if diagnosis is
unclear or not understood
Other tests
• Immunofluorescent and
immunohistochemical staining
• Polymerase chain reaction and
quantitative polymerase chain
reaction analysis
• in situ hybridization and
fluorescent in situ hybridization
analysis
• Hematology, clinical chemistry
and serology microbiology
Reminders for microbiological investigation
• Always take a sample of pus for culture and antibiotic
sensitivity from bone and soft tissue infections before
giving an antibiotic
• Always take the temperature of any patient with a
swollen face, enlarged lymph nodes, malaise or other
symptom or sign which might indicate infection
• Culture of Candida from the mouth does not
necessarily indicate infection because this is a
commensal organism.
• Demonstration of hyphae in a
scraping of epithelial cells indicates active infection.
Interpreting investigations and
making a diagnosis and
treatment plan