October University for Modern Sciences and Arts

FACULTY OF DENTISTRY
ORAL DIAGNOSIS
OMD411

BY
Prof. Dr. Fatheya Zahran
The Best Of British Higher Education In The Best Environment
 CONTENTS
Pages
 Oral Diagnosis 1
 Patient’s History: 5
- Identification data 7
- Chief Complaint 10
- History of chief complaint 11
- Pain as Chief Complaint 16
- Ulcer as Chief Complaint 26
- Swelling as Chief Complaint 29
- Burning Sensation 31
- Paraesthesia and Numbness 31
- Bleeding as Chief Complaint 32
- Other Common Complaints 33
- Dental History 35
- Health History 38

 Clinical Examination 46
- Examination Methods 46
- Extraoral Examination 51
- Intraoral Examination 70

 Laboratory Investigation 87
- Haemogram 87
- Hemostasis 91
- Tests for Diabetes mellitus 98
- Liver Function Tests 103
- Kidney Function Tests 106
-Biopsy 107
- Microbiological Tests 111

 References 115
 ORAL DIAGNOSIS
INTRODUCTION
Oral diagnosis is the art of using scientific knowledge to identify oral disease
processes and to distinguish one disease from another.

Oral diseases refer to diseases either localized in the oral cavity or those
which appear as oral manifestations of systemic diseases.

Types of Oral Diagnosis:

1) Comprehensive oral diagnosis:
It is done for the patients requiring total dental care. It entails the listing of
all dental problems (performing a "problem list") comprising all oral findings
that require dental treatment (caries, exposure, edentulous areas, etc...) then a
comprehensive dental treatment plan can be designed to achieve optimal oral
functions.
Any comprehensive diagnostic procedure should include:
1- History taking.
2- Clinical examination (extra- and intra-oral).
3- Laboratory investigations (if needed).
2) Emergency diagnosis:
The immediate diagnosis of the patient's complaint that requires
immediate attention and management by the dentist (acute dental pain, accidental
fractures,…).
The emergency interferes with obtaining adequate history or full clinical
examination (only the area of chief complaint).
3) Spot (snap) diagnosis:
In simple cases where rapid diagnosis can be achieved perfectly, based on
minimal data e.g. palatal ulcer + history of eating hot pizza = diagnosis of pizza
burn.
4) Differential diagnosis:
It is the collection and categorization of data to develop a list of two or more
different diseases having common primary clinical presentation (though different
in etiology).

1
This presentation may be in the form of:
- Change in color : i. White lesions, or white and red lesions
ii. Pigmented lesions (red, yellow, brown, …)
- Loss of mucosal integrity in the form of ulcers or erosions.
- Soft tissue swelling (fibroma, lipoma, ….)
- Bony lesions.
The most likely lesion is put on top of list (presumptive diagnosis, according
to clinical impression) then through history, clinical examination and special
investigations (if needed), final diagnosis can be reached by "exclusion".

White lesion Red and white lesion

Brown lesion Ulcers

Soft tissue swelling Bony lesion

2
5) Tentative (working or provisional) diagnosis:
It is primary, uncertain diagnosis before all diagnostic data are assembled.
Final or definitive diagnosis is then reached by confirming the tentative diagnosis
or changing it according to: either: response to treatment (+ve or – ve) or : result
of diagnostic aid e.g. biopsy.

6) Definitive (final) diagnosis:

It is the final diagnosis based on accurate appraisal of all available data (case
history, clinical examination and special investigations) that point clearly to a
specific disease entity.

Some Definitions Used:

Technical aid (diagnostic aid)
Any technique or special instrument used to help the establishment of a
diagnosis such as pulp testing procedures, biopsy, radiographs, blood analysis,
urine analysis, … etc.

Symptoms and signs:

All findings can be grouped as either symptoms (subjective) or signs
(objective).
Symptoms (subjective):
Symptoms are complaints that are described and reported by the patient and
can not be detected by the examiner. For example, pain, sensitivity to hot or cold,
altered taste, parasthesia, nausea and past occurrence of bleeding or swelling.
Signs (objective findings):
Objective findings are the changes or deviations from normal that can be
detected by the examiner. For example, discoloration of teeth or soft tissues,
swelling, tenderness to palpation and abnormal consistency of a part.
Obviously some overlap between subjective and objective findings is
possible. Common conditions such as discoloration, bleeding and mobility of
teeth are noticed by both the patient and dentist. Also, a patient may report
feeling hot and feverish (symptom) and have a measurable fever (39ºC) detected
by the examiner (sign).

3
Prognosis
Prognosis is to guess the final outcome of the disease. It is the prediction of
the duration, course and termination of the disease and the likelihood of its
response to treatment. Prognosis is usually expressed in general terms as
―excellent‖, ―good‖ or ―Poor‖.
Prognosis must be determined before the treatment is planned. It depends on
the patient’s attitude, his oral hygiene and desire to retain his natural dentition. It
also depends on condition of teeth, costs as well as experience and technical skill
of the operator.

4
 I- PATIENT’S HISTORY

A History Serves the Following:

1- To discover complaints about oral structures.
2- Recognition of underlying medical problems which is important in :
a- Prophylactic measures may be necessary for the safety of patient and
clinician.
b- Unusual reaction to drugs can be discovered.
c- Referral to a physician may be necessary.
3- To detect any complications associated with previous dental treatment.
4- To detect any diseases running in the family that may be of dental significance
or may be a potential threat to the patient during dental treatment.
5- To provide information about oral hygiene methods of the patient , patient’s
diet, and any habits such as smoking .

Methods for Obtaining a Patient's History

1. Printed questionnaires.
2. Patient interview.
3. Combination of both.
It is obvious that a combination of the direct interview and the printed
questionnaire would make use of the advantages of each and tend to minimize
their disadvantages.

Methods of Presenting Questions During the Diagnostic Interview:

1. Open -ended questions
Open-ended questions urge the patient to be a narrative. The patient should
be allowed to respond fully to the question with few interruptions from the
dentist. For example ―Can you tell me about your surgery that was performed last
year?‖. The question will direct the patient to describe the entire topic.

5
2. Closed-ended questions
Simple and specific answers are expected for closed-ended questions. After
the answer is given the clinician quickly proceed to the next question. The patient
answer is limited to a small single sentence or even Yes or No For example:
- Do you smoke?

3. Leading questions
Leading is a technique, which suggests the answer within the question.
For example; the dentist may suspect that recurring morning headache described
by the patient is caused by bruxism. The dentist asks: ―Do you grind your teeth
during sleep?‖.

4. Indirect questions
Indirect question is a way of revealing information beyond what is
requested by the question. An example of indirect questions is to give
information about the manifestation of a systemic disease e.g. ―have you had
chest pain especially following exertion‖. If the answer is ―Yes‖ it may reveal
heart problem.

5. Loaded questions:
A loaded question is considered a variant of the indirect approach in which
an emotional element is inserted into the phrasing to get the patient’s attention.
For example ―With the problems you have , do you think it might be best to
extract all of your teeth ?‖. Non-verbal responses such as nervous shifting of
position or negative facial expressions may reveal the response of the patient to
this type of indirect questions.

6. Contradiction questions:
The contradiction question states inconsistent information and allows the
patient to resolve the contradiction. For example; ―Since you said that you do
not have epilepsy, is there another reason for you to be taking a medicine that is
usually prescribed to control seizures?‖

6
Items of History:
A- Identification data
B- Chief complaint
C- History of chief complaint
D- Health history
E- Past dental history

A- Identification data ( the administrative chart)

Recording of routine data of the patient such as code number, name, age,
sex, marital status , occupation , address , etc …..

Significance of components of the administrative chart

1 – Code number
Code number is essential for record keeping and retrieval of the patient’s file.

2 – Name
Patient’s full name and how he or she prefers to be addressed should be
recorded. Patient’s name is important for:
 Record keeping and retrieval of the file.
 Better communication between the dentist and the patient.
3 – Date of birth (patient’s age)
Age is important as certain diseases occur generally in certain age groups
and rarely in others. For example :
 Primary acute herpetic gingivostomatitis, moniliasis, measles and
mumps occur commonly in childhood.
 Squamous cell carcinoma, atrophic and degenerative changes are
common in old age.
4 – Sex (gender)
Recording the sex of the patient is important particularly in those who carry
names that could be taken for both sexes e.g. Esmat.

7
 Also, some diseases are common in males e.g. leukoplakia and carcinoma
of the lip, while females more frequently suffer from the manifestations of iron
deficiency anemia and carcinoma of the breast.

5 – Birth place
Birthplace is important to detect diseases acquired in childhood (endemic
diseases) such as
 Dental fluorosis occurs in areas drinking water from wells.
 Bilharziasis is of common occurrence in Egyptian villages.

6 – Race
A race is a genetically determined population group having the same criteria
regarding skin color, hair characters and shape and form of the body and head as
well as facial features.
Race is important, as certain diseases are dominant in certain races. For
example :
 Blond race is liable for skin carcinoma, which is rare in Africans and
dark skinned individuals.
 Negroes are more susceptible to Burkitt’s lymphoma.
 Jews are more liable to develop pemphigus vulgaris.

7 – Address
Address may help in throwing light about the patient’s social and home
background. Patients living near factories are liable for pulmonary diseases. Also,
in absence of a phone number, the address may be useful for recalling the patient.

8 – Phone number
The telephone number of home, office and mobile is important for recalling
the patient. Also, rapid recalling of the patient is of special importance during
taking oral biopsy when malignancy is suspected.

8
9- Occupation
In some instances, the diagnosis of some diseases will be based on the
knowledge of the patient’s occupation or the nature of his work. Occupational
diseases are generally defined as those characteristic of a certain field of human
activity and resulting from the effect of the harmful factors of the working
environment. For example:
 Industrial use and manufacture of acids may produce tooth erosion,
discoloration and decalcification of the enamel as well as
inflammation of the mucosa.
 Lead intoxication may occur in workers in battery factories, while
mercury intoxication may occur in workers in fluorescent lamp
manufactures. These heavy metals may form dark metallic line on the
patient’s gingiva.
 Cancer of the mouth and tongue may occur in industrial workers with
tar and arsenicals. Cancer lip may appear following contact with tar
and after prolonged exposure to solar rays.
 Cervicofacial actinomycosis is likely to occur in individuals
concerned with cattle.
10- Marital status
Psychological stress of some married people should be taken into
consideration. It may exacerbate or predispose to certain oral diseases such as
lichen planus and aphthous ulceration. Also, the marital status may be a source
of infection in certain diseases such as T. B., AIDS, and other viral infections.

11- Parent or guardian name and address

A parent or guardian, such as a grandparent or a relative, must provide the
patient history for a child or legally disabled adult. It is critical to ascertain who
can give consent for treatment, and who will be responsible for payment of fees.

12- Physician name and address

In some instances, the only dependable source of information may be the
patient’s physician. Medical consultation may be unavoidable to obtain an
adequate patient history.

9
B- Chief Complaint
The underlying cause for the patient’s visit to the dentist is known as the
chief complaint. It is recorded in the patient’s own words and in chronological
order if the patient has more than one complaint.

Common oral chief complaints include:

1- Pain.
2- Sores (ulcers).
3- Swelling .
4- Burning sensation.
5- Paraesthesia and numbness
6- Bleeding.
7- Hypersensitivity with thermal changes.
8- Loose teeth.
9- Occlusal problem.
10- Delayed tooth eruption.
11- Xerostomia (dry mouth).
12- Ptyalism (too much saliva).
13- Bad taste.
14- Halitosis (bad odor).
15- TMJ problems.
16- Esthetic problems.

N.B. Patients may come to the dental clinic having no chief complaint:.
Regular check up (notation – no chief complaint)
Some patients are accustomed for regular recall appointments usually for
routine dental care and treatment of all dental needs.
Referred patient
The most common type of referred patients is the referral from a general
practitioner to a specialist for a specialty level care such as the referrals to an oral
surgeon, periodontist, endodontist, orthodontist...etc. In these cases, the complaint
of the patient was previously diagnosed by the former dentist and the specialist
should concentrate his effort to treat only the complaint for which the patient is
referred.

10
C- History of chief complaint
Learning more about the chief complaint is the "History of the Present
Illness."
Once it is known why a patients seeks care, it is important to learn as much as
possible about the condition that brought her/him to the dentist. How long has the
condition been present? Is there pain? What events initiated the condition? These
are but a few questions that may be asked to obtain a history of the condition
(history of present illness).

[1] Onset Character

Date
- Sudden (abrupt)
(a) Character of onset: - Gradual
- Insidious
(1) Acute inflammatory
Sudden onset = condition e.g. Acute dentoalveolar
abscess, erythema multiforme
or

(2) Allergic conditions

Gradual onset = (1) Chronic inflammatory conditions

(2) Neoplastic lesions

Insiduous onset:
The patient discovers the lesion by chance, and can’t give a precise answer
regarding its onset, such lesions include:
(1) Congenital malformations
(2) Developmental anomalies
(3) Physiologic conditions e.g. racial pigmentation.

(b) Date of onset:

Should be recorded in day, month and year. When compared to date of
presentation, the duration can be deduced.

11
[2] Duration:
Recorded is hours, days, weeks, months, years, including periods of
remissions and exacerbations.

 Short duration (hours – days) : characteristic for acute conditions.

 Weeks–months: characteristic for chronic conditions and
neoplastic lesions ( if with large size  malignancy is suspected)
 Years: characteristic for chronic conditions and benign neoplasms

[3] Character and severity :

Severity: (Mainly of pain) : This will be affected by pain threshold of

patient and may be described as : mild, moderate or severe.

Character ( of pain ) : may be

(1) Throbbing pain means fluid accumulation e.g.: pus accumulation in
acute dento alvealar abscess
(2) Lancinating, stabbing, shooting or electric shock like pain: pain of nerve
origin e.g. herpes zoster, post herpetic neuralgia and paroxysmal
trigeminal neuralgia..
(3) Interference with sleep and work: Acute dental pain e.g. acute pulpitis.

[4] Location and site:

 Location : is the anatomical area : tongue, cheek, gingiva,

etc..
 Site: is the specific area in an anatomical location e.g. lateral
aspect of the tongue
N.B. Sometimes pain may be referred from its origin to a remote area.

[5] Course:

Could be recorded as:

Progressive: (increasing in severity) e.g. tumours, acute inflammatory lesions.
Regressive ( decreasing in severity) e.g. self drained abscess.
Recurrent, intermittent, remission and exacerbation

12
Recurrent Intermittent Remission/Exacerbation
* One lesion heals * It is the same lesion, * Lesion is present all the
and a similar one with signs and time, signs are present and
appears in the symptoms the change is in the severity
same site or disappearing then of symptoms.
another site reappearing
* Patient is * Patient is completely * During remission no or less
completely free free from signs and severe symptoms,
from signs and symptoms between reappearing with
symptoms between attacks exacerbation
attacks
* Frequency well * Frequency of attacks * Frequency well separated
separated (weeks, is within very short e.g. seasonal.
months, years) period of time e.g.
within the same day
e.g. RAU, - e.g salivary gland e.g. lichen planus
erythema stone, accompanied
multiforme by intermittent gland
swelling, at meal
times
Paroxismal trigeminal
neuralgia attacks
[6] History of recurrence:
The history of previous occurrence of the lesion may be of importance in
diagnosis, e.g. RAU, eryhthema multiform.
[7] Distribution:
(A) The lesion may be (1) Solitary e.g. traumatic ulcer
or (2) Multiple: Multiple lesions are either:
i) Unilateral e.g. Herpes Zoster or
ii) Bilateral lesions which are either symmetrically distributed e.g. lichen
planus or in assymetrical (random) fashion e.g. erythema multiforme.
(B) Lesions may be restricted to one region of the oral cavity e.g. anterior part as
1 ry herpetic gingivostomatitis or posterior part as herpangina.
(C) The lesions may be restricted to the oral cavity or distributed both extra and
intra orally.
Intra oral only e.g. traumatic ulcer, RAU
Extra + intra-oral e.g. dermatologic diseases with oral manifestations as
lichen planus, lupus erythematosus.

13
Unilateral ulcers of Herpes zoster Single aphthous ulcer

Intra-oral lesion of lichen planus Extra-oral lesion of lichen planus

(bilaterally symmetrical on cheeks) (violaceous flat topped & polygonal )

[8] Precipitating factors and relation to other activities:

Pain may increase by eating, swallowing, sleeping, cold or hot drinks:
which are then called "precipitating factors" (ppt).
According to ppt factors diagnosis could be guessed:
e.g. Any exposed dentin will lead to sensitivity with thermal changes
specially cold, e.g. carious lesions, exposed root dentin
Differentiation should then be done between pain which stops as the
stimulus disappears and pain that persists.
On the other hand, pain with mastication is related to disease in the
supporting structures e.g. periodontal disease, periapical abscess.

14
Relation to other activities:
Sometimes pain may accompany activities not related to the oral cavity:
 Pain on exertion referred particularly to left mandibular region indicates
cardiac condition.
 Pain in upper teeth increasing with leaning downwards indicates maxillary
sinusitis.
 Pain with sleeping may indicate accumulation of edema fluid leading to
pressure on nerve endings.

[9] Relieving factors:

Factors which relieve chief complaint e.g. rest, medications as simple
analgesics, vasodilators or morphine should be noted. Also, dental pain relieved
by cold water or conversely by hot fomentation.
[10] Associated phenomena:
These are manifestations associated with the complaint: eg
● Fever (hyperpyrexia with acute abscess).
 Prodrome of fever, malaise, lymphadenopathy
1 ry herpetic gingivostomatitis
 Foetid odour + pain + bleeding gingiva + mild fever +
lymphadenopathy ANUG
[11] Previous medication:
Mouth washes, analgesics, antibiotics, previously used by the patient, and
their effect on c/c., as well as duration of treatment should be noted. e.g.
 Mouth wash: patient may use anti inflammatory mouth wash as
benzydamine hydrochloride, if pain is relieved, therefore pain is of
gingival origin, if not, therefore it is of dental origin.
 Antibiotics: if c/c. is relieved or better, therefore it is due to
bacterial infection.
 Mild analgesic: if pain is relieved, therefore the condition is not
severe
Also: sometimes previous medication is the cause of c/c: e.g.
 long term antibiotics or cortisone  oral candidosis.

15
I- Pain as Chief Complaint:
Pain is the most common symptom for which patients seek help .
Causes of oral or maxillofacial pain :
1- Diseases of teeth and supporting tissues .
2- Oral mucosal diseases .
3- Diseases of the jaw .
4- Pain in the edentulous patient .
5- Postoperative pain .
6- Pain induced by mastication .
7- Referred pain .
8- Neurological diseases .
9- Psychogenic ( atypical ) facial pain .

Pain from teeth or supporting tissues:

May be due to :
1- Pulpal disease .
2- Pulpoperiapical disease .
3- Gingival and periodontal disease.

a) Pulpitis:
Pulpitis is usually the cause when hot or cold food or drinks trigger the
pain. It is also the main cause of spasmodic, poorly localized attacks of pain
which may be mistaken for a variety of other possible causes. The pain of acute
pulpitis is of a sharp lancinating character peculiar to itself, impossible to describe
but unforgettable once experienced. Recurrent attacks of less severe, subacute or
chronic pain, often apparently spontaneous, suggest a diseased and dying pulp.

b) Acute Periapical Periodontitis:

Pain form acute periapical periodontitis should be readily identifiable as
there is precisely localized tenderness of the tooth in its socket. Radiographs are
of little value in the early stages but useful after sufficient destruction shows itself
as loss of definition of the periapical lamina dura. In other cases, acute
inflammation may supervene on chronic, and a rounded area of radiolucency is
seen.

16
c) Lateral, Periodontal Abscess
The tooth is tender in its socket, but is usually vital and there is deep
localized pocketing. Occasionally both a periodontal and periapical abscess may
form together on a non-vital tooth with severe periodontal disease, or a
periodontal abscess may be precipitated by endodontic treatment when a reamer
perforates the side of the root.
Pain from mucosal lesions:
Ulcers generally cause soreness not pain, however, deep ulceration may cause
severe aching pain. Examples are:
 Carcinoma causes severe pain when nerve fibers become involved.
 Herpes zoster causes severe aching that may be mistaken for toothache.
Painful Jaw Diseases:
 Fractures
 Osteomyelitis
 Infected cysts
 Malignant neoplasms
 Sickle cell infarcts

With the exception of fractures and osteomyelitis which depend in their

diagnosis on clinical presentation and radiographic picture, diagnosis depends on
biopsy and histological examination.
Pain in Edentulous Patients:
 Denture trauma
 Excessive vertical dimension
 Diseases (enumerated earlier) of the denture-bearing mucosa
 Diseases of the jaws
 Teeth or roots erupting under a denture
Traumatic ulcers, usually the consequence of over-extension, often cause
trouble with a new denture. After the denture has been relieved, these ulcers heal
within 24-48 hours.
Lack of freeway space due to excessive vertical dimension of the dentures
prevents the mandible and masticatory muscles from reaching their natural rest
position. This causes the teeth to be held permanently in contact. Aching pain is
usually felt in the fatigued masticatory muscles, but the excessive stress imposed
on the denture-bearing area sometimes causes pain in this region. Very

17
occasionally patients seem unable to tolerate dentures, however carefully they are
constructed and complain of such symptoms as gripping, burning, or drawing pain
particularly under the upper denture. These symptoms are not associated with any
physical changes and are psychogenic.
A painful swelling of the jaw in the edentulous patient is probably most
often due to an infected residual cyst.
Malignant tumours are very much less common but must be considered.
As they cannot be reliably distinguished from cysts and other benign conditions
by radiography alone , histological examination is therefore essential.
Osteomyelitis of the jaws in edentulous patients must be considered
virtually only in those who have had radiotherapy to this region. In such patients
denture ulceration can allow infection to penetrate and set up persistent painful
chronic osteomyelitis of the ischemic bone.
Retained roots or rarely, late eruption of buried teeth beneath a denture
become painful as they reach the surface, causing the mucosa to be pinched
between them and the denture. This trouble will be obvious on clinical or
radiographic examination, as are the late effects of a healed malaligned fracture.
Postoperative Pain:
 Alveolar osteitis (dry socket)
 Fracture of the jaw
 Damage to the temporomandibular joint
 Osteomyelitis
 Damage to nerve trunks or involvement of nerves in scar tissue.
Pain induced by Mastication:
 Diseases of teeth and supporting tissues
 Diseases of the temporomandibular joint
 Pain dysfunction syndrome
 Temporal arteritis
 Trigeminal neuralgia (rarely)
 Salivary calculi
The common dental cause for pain on mastication is apical periodontitis,
but any conditions which causes the tooth to be tender in its socket, whether it be
a lateral periodontal abscess or occasionally, maxillary sinusitis can cause this
symptom.

18
 Open contact between teeth as the case with proximal caries leading to
forceful impaction of food interdentally is one of the most common causes of pain
during mastication.
The least common cause of pain during eating is organic disease of the
temporomandibular joint. Fractures and dislocations of the temporomandibular
joint are usually obvious from the history, their effects on the occlusion and the
radiographic changes.
Pain dysfunction syndrome usually causes dull, aching pain, often
associated with clicking sounds from the joint, episodes of locking and some
limitation of opening in varying combinations. However , no pathology can be
revealed in the TMJ . Young women are predominantly affected and there is
typically a strong neurotic element.
The typical manifestation of temporal (giant-cell) arteritis is headache.
However, it is also a cause of masticatory pain and should be considered
particularly in patients over middle age with this symptom. The pain is due to
ischaemia of the masticatory muscles, caused by the arteritis.
The characteristic pain of trigeminal neuralgia is occasionally triggered by
mastication. Trigeminal neuralgia may then be misdiagnosed as dental or due to
pain dysfunction syndrome.
Calculi, particularly when obstructing the parotid duct, can cause pain
when salivation is triggered by eating. Hence the history of the relationship of the
pain to stimulation of salivation is distinctive.
Pain from Extraoral Disease (Referred Pain):
 Diseases of the maxillary antrum
Acute sinusitis
Carcinoma, particularly when it involves the antral floor
 Diseases of salivary glands
Acute parotitis
Salivary calculi
Sjogren’s syndrome
Malignant neoplasms
 Diseases of the ears
Otitis media
Neoplasms in this region
 Myocardial infarction

19
 Antral disease can cause pain felt in the upper teeth but a sinus radiograph
should provide the diagnosis. Acute sinusitis is the most common paranasal
disease that causes facial pain but antral carcinoma is rare.
Mumps is a common cause of pain from and swelling of the parotid
glands. In children the diagnosis is usually quickly made on clinical grounds. In
adults the diagnosis may not be immediately suspected and occasionally, these
patients think they have dental disease.
Suppurative parotitis is uncommon but may be a complication of dry
mouth. Acute parotitis may therefore be seen as a complication of Sjogren’s
syndrome or irradiation damage to the glands. Sjogren’s syndrome itself can
occasionally cause parotid pain and swelling of the glands.
Swelling rather than pain is usually the first symptom of malignant tumors
of salivary glands. Parotid gland tumors can also cause facial palsy and finally
ulceration and fungation.
Myocardial infarction usually causes constricting or crushing pain
substernally but pain may radiate down the inside of the left arm or up into the
neck or jaw. Rarely cardiac pain is felt in the jaw alone. This pain can come on at
any time at rest or during exercise. The clinical picture is variable but in typical
cases the patient is obviously anxious , pale and sweating with a rapid pulse and
low blood pressure.

Neurological Diseases:
a) Trigeminal Neuralgia:
Typical Features of Trigeminal Neuralgia:
 Pain confined to the distribution of one or more divisions of the
trigeminal nerve.
 Pain is paroxysmal and very severe
 Trigger zones in the area
 Absence of objective sensory loss
 Absence of detectable organic cause.
The pain is paroxysmal, severe, sharp and stabbing in character but lasts
only seconds or minutes and may be described as like lightning. However, attacks
may sometimes be quickly recurrent at short intervals. Stimuli to an area (trigger
zone) within the distribution of the trigeminal nerve can provoke an attack.

20
Common stimuli are touching, draughts of cold air or tooth-brushing.
Occasionally mastication induces the pain.
There are no objective signs. Either the second or third division of the
trigeminal nerve is usually first affected, but pain soon involves both. The first
division is rarely affected and pain does not spread to the opposite side. Less
typical features of trigeminal neuralgia which make diagnosis difficult are more
continuous, long-lasting, burning or aching pain with absence of trigger zones,
and extension of the pain beyond the margins of the trigeminal area, though not to
the opposite side.
A careful search should be made for diseased teeth, though pain of this
severity is unlikely to be due to dental disease. An inflamed pulp can cause stabs
of severe pain in its early stages, but the pain changes in character and soon
becomes more prolonged. Pulpitis can usually also be identified as tooth- ache by
most patients and is felt to be different in character from pain in the face due to
neuralgia.
b) Glossopharyngeal Neuralgia:
This rare condition is characterized by pain similar to that of trigeminal
neuralgia but felt in the base of the tongue and fauces on one side. It may also
radiate deeply into the ear. The pain, which is sharp, lancinating and transient, is
typically triggered by swallowing, chewing, or coughing. It may be so severe that
patients may be terrified to swallow their saliva and try to keep the mouth and
tongue as completely immobile as possible.
c) Post herpetic Neuralgia:
Up to 10% of patients who have trigeminal herpes zoster, particularly if
elderly, may develop persistent neuralgia. The pain is more variable in character
and severity than trigeminal neuralgia. It is typically persistent rather than
paroxysmal. The diagnosis is straightforward if there is a history of facial zoster
or if scars from the rash are present.
d) Intracranial Tumors:
Pain resembling trigeminal neuralgia can rarely be caused by intracranial
tumors. Features suggesting an intracranial lesion are associated sensory loss
especially if associated with cranial nerve palsies.
e) Bell’s Palsy:
Bell’s palsy is a common cause of facial paralysis. It probably results from
compression of the facial nerve in its canal as a result of inflammation and
swelling. A viral infection, particularly herpes simplex, is suspected as the cause.

21
Either sex may be affected usually between the ages of 20 and 50 .Pain in the jaw
sometimes precedes the paralysis or there may be numbness in the side of the
tongue. Though this disease is uncommon in dental practice, its recognition is
important as early treatment may prevent permanent disability and disfigurement.
Function of the facial nerve is tested by asking the patient to perform
facial movements. When asked to close the eyes, the lids on the affected side
cannot be brought together but the eyeball rolls up normally, since the oculomotor
nerves are unaffected. When the patient is asked to smile, the corner of the mouth
on the affected side is not pulled upwards and the normal lines of expression are
absent. The wrinkling around the eyes which accompanies smiling is also not seen
on the affected side and the eye remains staring. The patient cannot blow his
mouth .
The affected part of the face sometimes also contracts involuntarily in
association with movement of another part. There may, for example, be twitching
of the mouth when the patient blinks. More uncommon is unilateral lacrimation
(crocodile tears) when eating. The majority of patients with persistent denervation
develop contracture of the affected side of the face. Watering of the eye
(epiphora) due to impaired drainage of tears, or occasionally to excessive and
erratic lacrimal secretion, may remain particularly troublesome.

Psychogenic (atypical) Facial Pain:

Features Suggestive of Psychogenic (atypical) Facial Pain:
 Women of middle age or older mainly affected
 Absence of organic signs
 Pain often poorly localized
 Description of pain may be bizarre
 Delusional symptoms occasionally associated
 Lack of response to analgesics
 Unchanging pain persisting for many years
 Lack of any triggering factors
 Sometimes good response to anti-depressive treatment

It must be emphasized that the diagnosis of psychogenic facial pain is a

diagnosis by exclusion but it is important to try to recognize the condition,
however limited diagnostic methods may be. The symptoms cause real enough
suffering to the patient and should, if possible, be relieved. It is also important to
avoid unnecessary surgery.

22
 Pain is usually not provoked by any recognizable stimulus such as hot or
cold foods or by mastication. Despite the fact that the pain may be said to be
continuous and unbearable, the patient’s sleeping or even eating may be
unaffected. Analgesics are often said to be completely ineffective, but some
patients have not even tried them, despite the stated severity of the pain.
Objective signs of disease are absent. Although teeth have often been
extracted and diseased teeth may be present, none of these can be related to the
pain. As a consequence, treatment of diseased teeth does not relieve the
symptoms.
Other signs of emotional disturbance are highly variable. Some patients
are more or less obviously depressed; some of them mention, in passing,
difficulties they have had, for instance, at work with their colleagues.
Others may complain how miserable the pain makes them. Others
may complain of bizarre (delusional) symptoms such as ―slime‖ in the
mouth or ―power‖ coming out of the jaw.
Burning Mouth Syndrome:
Features Suggestive of “Burning Mouth Syndrome”:
 Middle-aged or older women are mainly affected
 No visible abnormality or evidence of organic disease
 No haematological abnormality
 Pain typically described as ―burning‖
 Persistent and unremitting soreness without aggravating or
relieving factors, often of months or years duration; no response to
analgesics.
 Bizarre patterns of pain radiation inconsistent with neurological or
vascular anatomy.
 Sometimes, bitter or metallic taste associated.
 Associated depression, anxiety or stressful life situation.
 Obsession with symptoms which may rule the patients life.
 Constant search for reassurance and treatment by different
practitioners.
 Occasionally, dramatic improvement with antidepressive
treatment.

23
 In this distressing and troublesome condition, symptoms may affect the
whole mouth or only the tongue may be sore. This complaint has many features in
common with atypical facial pain and may be a variant of it. Clinical features may
suggest psychogenic factors.

Psychogenic Dental Pain (Atypical Odontalgia):

This is a less common variant of atypical facial pain. Pain is often
precisely localized in one tooth or in a row of teeth. Which are said either to ache
or to be exquisitely sensitive to heat, cold, or pressure. If dental disease is found,
treatment has no effect, or if, as a last resort, the tooth is removed, the pain moves
to an adjacent tooth. Again, if no organic cause can be found and treatment is
ineffective, psychiatric assessment is needed. Early diagnosis is essential to avoid
over treatment and serious dental morbidity.

24
 According to origin: pain may be:
(1) Somatic
(2) Neurogenous or neurogenic
(3) Psychogenic
(1) Somatic pain: Due to noxious stimulation of normal neural structures that
innervate body tissues.
(2) Neurogenic pain: due to pathology or abnormality in the neural structures
themselves (within the nervous system), i.e.
neuropathy.

Neuritis (inflammation in nerve trunk)

Neuropathy
Neuralgia Paroxysmal pain along the nerve distribution,
may be due to vascular spasm, CNS disease or of unknown etiology.
(3) Psychogenic pain : due to psychic stress.
Somatic pain Neurogenic Pain Psychogenic Pain
- Usually acute - Usually chronic ?
- Cause is apparent (usually - No cause is usually apparent - No apparent causes
inflammation) (except with neuorotropic
viruses infection e.g. Herpes
zoster)
- Throbbing,..aching, sharp, - Lancinating, electric - No specific Character
mild, moderate shock like , stabbing
- May be progressive in severity - Constant in severity - Bizarre pattern (variable
in severity)
- Localized at affected region and - Localized to affected nerve - No localization; vague,
may cross mid line distribution and not crossing crossing anatomical
mid line boundaries e.g. bilateral
- May be referred to neighbouring - Not referred - Referred to abnormal
or opposing structures ( same locations
side).
- No trigger zones - There may be trigger zones - No trigger zones.
(½ inch sign of trigeminal
neuralgia)
_ _ - History of psychic stress
or antidepressant drug
(1) Pulpal pain (1) trigeminal neuralgia
(2) Pain from supporting structures (2) viral neuralgia
(3) Pain from mucosal lesions

25
II- Ulcer as Chief Complaint
Onset
a- Primary ulcer (not preceded by vesicles)
 Traumatic ulcer
 Aphthous ulcer
b- 2 ry ulcer to vesiculobullous lesion
 Viral ulcers
 Pemphigus vulgaris
 BMM pemphigoid
 Bullous pemphigoid
 Bullous erosive lichen planus
Also onset may be:
a- Sudden :
 Erythema multiform
 ANUG
 Traumatic ulcer
b- After prodrome
 Viral ulcers.
 Aphthous ulcer

Duration:
Short (disappears within 2-3 weeks spontaneously or with non- surgical
treatment):
 Traumatic ulcer
 Viral ulcers
 Minor aphthae .

Prolonged (persistent):
 Major aphthous
 Pemphigus vulgaris
 Malignant
Course:
Exacerbation and remission:
 Bullous erosive lichen planus
 BMM pemphigoid

26
History of Recurrence:
 Aphthous
 Recurrent intra oral herpes
 Erythema multiforme
 Behcet’s syndrome

Previous medication:
 Drugs to which patient is allergic  allergic stomatitis.
 Erythema multiforme
 Cytotoxic drugs.
Associated phenomena:
Pain :
 + ve in aphthous, traumatic, viral and erythema
multiforme ulcers
 - ve in malignant ulcers (early), but later there may
be severe pain due to invasion of nerves.
 -ve in gummatous ulcer
 Pain + bleeding + foetid adour  ANUG
Location / Site:
Tongue:
 Tip: T.B,
 Postrolateral: more prevalence of malignant ulcers.
 Dorsal : gummatous ulcer
Keratinized Mucosa:
 Recurrent intra oral herpes
 BMM pemphigoid
Non Keratinized Mucosa:
 Minor aphthous
 (usually) pemphigus
On both keratinized and non Keratinized:
 1 ry herpetic gingivo stomatitis
 Major aphthous ulcer
 Malignant ulcer.

27
Distribution:
Intra Orally:
 Solitary: traumatic ulcer, aphthous ulcer (usually)
 Multiple :
(1) Unilateral : Herpes zoster
(2) Bilateral
a) Symmetrical lesions: bullous erosive lichen planus
b) Randomly distributed: may be :
 More in anterior part of mouth: 1 ry herpetic gingivostomatitis
 More in posterior part herpangina , acute L.N. pharyngitis.
 Anywhere (ant. /post): multiple aphthous ulcers, erythema
multiform
Some oral ulcers are accompanied by extra oral lesions:
 Herpes zoster
 Lichen planus
 Muco cutaneous ocular syndromes (Steven Johnson, Behcet’s,
Reiter’s).
 Autoimmune ulcers: pemphigus, bullous pemphigoid, BMM
pemphigoid.
Each characteristic extra oral lesion will help to differentiate the condition.

28
III-Swelling as Chief Complaint :
The following entities should be considered:
1- Inflammation and infection.
2- Cysts.
3- Retention phenomena.
4- Inflammatory hyperplasia.
5- Benign and malignant tumors.
Diagnosis will depend on the history obtained:
Onset
- Sudden:
o Acute inflammation
o Allergic condition
- Gradual:
o Chronic inflammatory condition.
o Neoplasm
o Salivary gland disease
o Bony lesion
Duration
Short: Hours, days:
o Acute inflammation
Long: Months, years:
o Chronic inflammation
o Benign neoplasms
Course
Progressive: Acute inflammation
Neoplasms
Regressive: Self-drained abscess

Intermittent:Salivary gland stone (repeated swelling with meals and relief

in between meal times).
Exacerbation and remission: Chronic periapical abscess

History of recurrence may imply chronicity e.g. acute exacerbations of chronic

periapical abscess.

Distribution:
 Unilateral : Acute dentoalveolar abscess
 Bilateral : Mumps, allergy.

29
Associated Phenomena:
 Fever: Acute inflammation
 Pain + ve with acute inflammation
- ve with neoplastic lesions
 Salty taste: Cyst
Previous Medication:
 Drugs to which the patient is allergic
 Antibiotics: if giving good response, thus swelling
is caused by bacterial infection.
Location and Site:
According to the tissue constituents, various neoplastic growths will be
recognized. Also; periapical, periodontal and gingival abscesses can be usually
differentiated by their site in relation to the vestibule and gingiva.

30
IV- Burning Sensation
Usually felt in the tongue, but may involve anywhere in the oral cavity. It
may be due to:
1- Superficial mucosal lesions such as viral and fungal infections, thinning or
erosion of surface epithelium, etc ..
2- Xerostomia.
3- Anemia.
4- Vitamin deficiency.
5- Diabetes mellitus.
6- Fissured tongue.
7- Psychosis/neurosis.
8- Burning mouth syndrome.

V– Paraesthesia and Numbness

Usually felt in the lip, but may involve anywhere in the oral cavity. It may
be due to:
1-Vitamin deficiency.
2- Pressure on the mandibular nerve such as neurofibromatosis.
3- Injury to the trigeminal nerve.
4- Trauma from anesthetic needles and following surgical procedures.
5- Diabetes mellitus.
6- Pernicious anemia.
7- Syphilis.
8- Prolonged use of some medications such as streptomycin, sedatives,
tranquilizers and hypnotics.

31
VI- Bleeding as Chief Complaint
It’s either spontaneous or due to trauma, etc..

Local causes Systemic causes

1- Periodontitis 1- Blood vessel wall abnormality

2- Trauma a- Scurvy (Vit C deficiency)
3- Post-operative infection b- Hereditary Hemorrhagic
Telangiectasia (H.H.T)
2- Platelet disorders:
a- Thrombocytopenia
b- Aspirin (long duration)
3- Clotting disorders:
(coagulation deficiency)
a – Hemophilia
b – Antiocagulant therapy
c – Liver disease
4 -Fibrinolytic pathway activation
Anticoagulant therapy

Evaluation of the case before management:

Based on the history of bleeding disorder, examination and lab.
investigations patients may be classified into three categories:

1) Patients at Low Risk:

A. Patients with no history of bleeding disorder, normal examination and
normal bleeding parameters.
B. Patients with non specific history of excessive bleeding but with normal
bleeding parameters (normal platelets count, PT, PTT and bleeding time
rule out clinically significant bleeding disorder).These patients can be
managed by normal protocol.

32
2)Patients at moderate risk:
Examples are patients on anticoagulant therapy or on chronic aspirin
therapy.

A. Patients on anticoagulant therapy and a PT in the therapeutic range (1.5-2

times the control value).
B. Patients on chronic aspirin therapy. In these patients we have to modify the
therapeutic regimen before elective dental therapy.

3) Patients at High Risk:

A. Patients with known bleeding disorders, thrombocytopenia,
thrombocytopathy and clotting factors defects.
B. Patients without known bleeding disorders who were found to have
abnormal platelets count, PT, PTT or bleeding time.
Dental management of these patients requires close coordination of care
with the patient's physician or hematologist and hospitalization is often
advised.

Other Common Complaints:

Loose Teeth loss of supporting bone or the resorption of roots may result in loose
teeth and may indicate the presence of any of the following
1. Periodontal disease
2. Trauma
3. Normal resorption of deciduous teeth
4. Pulpoperiapical lesions
5. Malignant tumors
6. Benign tumors that may induce root resorption (chondromas,
myxomas, hemangiomas)
7. Histiocytosis X
8. Hypophosphatasia
9. Familial hypophosphatemia
10. Papillon-lefevre syndrome
11. Acquired immunodeficiency syndrome (AIDS)

33
Bad Taste a complaint of bad taste may result from any of the following:
1. Aging changes
2. Heavy smoking
3. Poor oral hygiene
4. Dental caries
5. Periodontal disease
6. Acute necrotizing ulcerative gingivitis (ANUG)
7. Diabetes
8. Hypertension
9. Medication
10. Psychoses
11. Neurologic disorders
12. Decreased salivary flow
13. Uremia
14. Intraoral malignancies

Halitosis although this is more frequently classified as an objective symptom,

patients may come with it as a complaint . It may be due to:
1. Poor oral hygiene
2. Periodontal disease
3. Third molar opercula
4. Decayed teeth
5. ANUG
6. Oral cancer
7. Spicy food
8. Tobacco use
9. Nasal infection
10. Sinus infection
11. Tonsillitis
12. Pharyngeal infections or tumors
13. Gastric problems
14. Diabetes
15. Uremia

34
D. Dental History
The dental history provides the dentist with reliable information about the
patient’s dental hygiene practices, attitude towards dental care and the nature of
past dental treatment as well as any complications related to previous dental
procedures.
Components of Routine Dental History:

(1) Attitude of the patient towards his previous dentist and/or treatment:
The patient’s perception of a former dentist is likely to become the
attitude toward the current dentist unless the patient is carefully managed.
Negative comments about a previous dentist or previous dental treatment often
reveal potential attitude problem such as unsatisfactory doctor patient
relationship or unsatisfactory cost.

2) Past Dental Care:

The frequency of past oral health care can be an important predictor for
the patient’s compliance with the new treatment recommendations. Attitude of
most patients towards dental care can be summarized as one of the three forms:
A – Routine dental care
Implies regular recall appointments and regular treatment of most dental
needs.
B – Episodic dental care
Implies less than comprehensive dental care and an irregular pattern of
recall examinations.
C – Symptomatic dental care
Implies that the patient has generally consulted a dentist for relief of pain
without regular attention to dental health.

3) Periodontal Therapy
Regular periodontal care as well as past periodontal therapy and type of
treatment the patient had received (scaling, occlusal adjustment, gingivectomy…
etc) are of value in the evaluation of periodontal condition and prognostic
sequence.

35
4) Local Anaesthesia
History of common problems that have emerged when the patient
received local anaesthesia including general anxiety, syncope (fainting), allergy
and unwanted reaction to anaesthetic agent may alert the dentist about the
possible serious complications that he may face during injection of local
anaesthesia or indicates the use of general anaesthesia.

5) Extraction
History of fractured tooth during extraction or excessive hemorrhage,
infection and delayed wound healing following extraction should be recorded
and evaluated before proceeding with additional surgery.

6) Missing Teeth
The dentist should establish the reason for any unerupted or missing teeth,
including the exact time at which they were removed.

7) Filling Restorations
Knowing the age of restorations may yield important perspectives on the
quality and success of previous work, the patient’s oral hygiene as well as the
prognosis for new work.

8) Root Canal Fillings

Endodontically treated teeth are fragile and liable for easy fracture or
fracture during extraction. It should be covered with crown. Moreover, failure of
endodontic therapy may lead to periapical pathosis which needs further
interference from the dentist.

9) Removable Prosthetic Appliance:

History of partial or complete dentures including length of time of
wearing , type and design of the appliance as well as any modifications such as
fracture, relining, rebasing or addition of teeth should be recorded. Also,
personal care of the appliance as well as soreness, burning sensation or
sensitivity to denture base material should be reported.

36
10) Fixed Bridges
Satisfactory design, type of prosthesis, length of service, comfort and
personal care should be established.

11) Orthodontic Therapy

Past orthodontic treatment including nature of the appliance, removable
or fixed and its duration should be reported. It is important to establish whether
the patient has had any surgical procedures necessary for success of treatment
such as extraction or orthognathic surgery. Also, the effect of therapy on
periodontal condition, personal care and received treatment during the period of
orthodontic therapy should be evaluated.

12) Surgical Procedures:

Past surgical procedures in and about the mouth other than extraction,
nature of tissue removed, the manner in which it was removed, complications
and possible recurrence should be established.

13) TMJ Therapy

Night guard, TMJ splint or other types of treatment should be reported.

14) Radiographs
Pre-existing recent panoramic and/or intra-oral radiographs may exclude
the need for further exposure for radiation.

37
E- Health History
The health history has four components. The health history is composed of
1) Past and present medical history,
2) A review of systems,
3) Social history, and
4) Family history

1) Past and present medical history

While the identification of medically complex patients is the goal of
obtaining a medical history, it has the added benefit of establishing rapport and
communication between dentist and patient. While rare patients view the process
as either intrusive or irrelevant, most appreciate the concern for their well-being
and their safety.
Many medically complex patients do not identify themselves as such.
While some patients immediately and forcefully announce that they are medically
complex, others do not. There is, therefore, great need for a standard approach to
identify medically complex patients. While there are variations, the most common
and most logical first step in identification is to have all patients complete a
standard health questionnaire which is the quickest, most accurate, and most
standard method.
Standard health questionnaires are available from professional societies.
Although a dentist can construct her/his own health questionnaire, it makes little
sense to do so. Excellent expert-constructed forms are readily available from the
American Dental Association (ADA) and other professional organizations.
Dentists who use these forms are, therefore, in the mainstream of dental practice.
Certainly, practitioners should be encouraged to add or reword questions on the
ADA-type forms to fit special needs.
It must be understood that obtaining a health history does not end with
administration of a health questionnaire. To the contrary, it serves only to elicit
basic information that must be checked and expanded during the patient interview.
It is also important that the history be updated annually and to be repeated every
five years.

38
(A) Who Are Medically Complex Patients?
They are:
- Patients with a known medical condition
- Patients with an undetected medical condition
- Patients recovering from a medical condition
- Patients taking medication
- Patients following a special diet
- Patients in need of special dental care.
- Patients that may transmit infection
Patients with a Known Medical Condition
Some patients know that they have a serious medical condition. These
patients have been diagnosed and treated by a physician and are likely to
continue under a physician's care. However, they may require special
precautions and/or pre-medication before any kind of dental treatment. Also,
some systemic conditions have oral manifestations. Examples include:
Diseases that may require patient’s hospitalization during dental treatment:
1. Leukemia: there is liability for excessive bleeding and infection.
2. Hemophilia: there is liability for excessive bleeding and patient
should receive anti-hemophilic globulin.
3. Addison’s disease: there is liability to develop adrenal crisis (fatal) .
4. Uncontrolled hyperthyroidism: there is liability to develop thyroid
crisis (fatal).
Diseases that require premedication before dental treatment :
1- Patients at risk for infective endocarditis: these need prophylactic
antibiotics administration. They include :
- Rheumatic heart disease.
- Prosthetic heart valves.
- Heart surgery.
- Mitral valve prolapse.
- Congenital heart disease.
- Systemic lupus erythematosus.
- Arteriovenous shunt.
2- Diabetes mellitus: these need prophylactic antibiotics administration +their
anti-diabetic drugs .

39
Diseases that may Require Precautions During Dental Treatment:
1- Coronary heart diseases:
- Angina pectoris.
- Myocardial infarction.
2- Hypertension.
3- Heart failure.
4- Renal failure.
5- Immunologic disorders .
6- Epilepsy.
7- Allergic diseases such as bronchial asthma.
8- Liver diseases and biliary tract obstruction.

Diseases that give oral manifestations :

They include:
- Vitamin deficiency: angular cheilitis, glossitis.
- Anemia: pallor, atrophy of tongue coating.
- Leukemia: ulceration, gingival enlargement, bleeding.
- Agranulocytosis: ulceration, infection.
- Skin diseases such as:
 Lichen planus
 Lupus erythematosus
 Erythema multiforme
 Pemphigus vulgaris
Patients With An Undetected Medical Condition:
Some patients are unaware that they have a serious medical condition.
Some patients who do not have a physician or who have not visited a physician
for some years may not know that their medical condition could be aggravated by
dental treatment. By being alert to the signs and symptoms of important medical
conditions, by assessing vital signs, and by appropriate referral to a physician, a
dentist may uncover an important medical condition that could endanger general
health and safety during and following dental treatment. An orderly review of
systems (as discussed later) will be of great help.

40
Patients Who Have Recovered From a Medical Condition:
Patients who have recovered from a medical condition may be at risk.
In some circumstances, a patient who has recovered from a disease or surgery
may be predisposed to a medical complication from dental treatment. For example,
patients who have recovered from cardiac valve replacement surgery are
predisposed to acquiring infective endocarditis. It is important that dentists know
of such possibilities and determine whether their patients have the underlying
medical conditions that can cause them.

Patients Taking Medications:

 Use of medications may complicate dental treatment: Some medications
cause physiologic changes that may cause complications during or
following dental treatment. As one simple example, patients who regularly
take aspirin to prevent blood clots are susceptible to prolonged bleeding
after oral surgery.
 Use of medications may provide clues about a patient's medical status:
A history of medication use may provide a clue to the presence of an
underlying medical condition affecting dental treatment. For example :
- Dilantin indicates epilepsy.
- Nitroglycerine indicates angina pectoris.
- Anticoagulants indicate myocardial infarction.
- Nifedipine indicates hypertension.
- Diuretics indicate hypertension and/or heart failure.
- Digitalis indicates heart failure.
- Carbamazepine (tegretol) indicates neuralgia.
- Carbimazole indicates hyperthyroidism.
 Use of medications may produce oral manifestations: such as :
- Dilantin used in treatment of epilepsy and nifedipine used in treatment
of hypertension may produce gingival hyperplasia.
- Drugs that contain salts of heavy metals such as bismuth and gold used
in treatment of some skin diseases and mercurial diuretics used in
treatment of hypertension may produce metallic intoxication and
stomatitis.
- Cytotoxic drugs and antimetabolites used in cancer chemotherapy may
produce oral ulceration, bleeding and increased tendency for infection.

41
  Drugs may need certain adjustment and special management before
and during dental procedures : such as :
- Steroid therapy.
- Anticoagulants e.g. heparin or dicumarol.
 Drug interaction may occur between medications taken by the
patient & those prescribed or given by the dentist
- Barbiturates and tranquilizers potentiate hypotension in patients
receiving antihypertensive drugs. So, the dose of barbiturates and
tranquilizers should be reduced.
- Antidepressants containing monoamine oxidase (MAO) inhibitors
and received by some hypertensive patients may intensify the
action of barbiturates. So, barbiturates should not be given for
patients receiving MAO inhibitors.
- Monoamine oxidase inhibitors potentiate the action of adrenaline.
So, adrenaline should not be given for patients receiving MAO
inhibitors.
- Tetracycline chelates with antiacid and with iron salts. So, when
tetracycline is prescribed it should be taken two hours after the
antiacid or the iron therapy.
 Use of medications may produce allergic and adverse reactions .
Any complications caused by any drug should be recorded with details
including:
- The name of the drug.
- Route of administration.
- The nature of the reaction.
- Chemical structure of the drug to avoid cross-reaction between
similar drugs such as sulpha and ester type of anaesthesia.
Patients Following A Special Diet
Special diet may give an idea about a patient’s medical status. For
example, low fat diet may be prescribed to patients with diabetes mellitus and\or
atherosclerosis, whereas low sodium diet is often prescribed to patients with
arterial hypertension.

42
Patients In Need Of Special Dental Care
1- Patients may need special dental care prior to receiving medical care.
Patients scheduled for cancer chemotherapy or radiotherapy may need to
have careful evaluation of their dental status.
2- Patients may need special dental care to prevent serious medical condition.
For example the elimination of periodontal and periapical disease may
prevent infective endocarditis after heart catheterization.
Patients Who May Transmit Disease
Patients with infectious diseases may complicate dental treatment.
Infectious diseases as viral hepatitis (B & C), herpes, HIV, syphilis and active
tuberculosis are increasing. Patients with such diseases need to be managed in a
way that:
1- Prevents transmission of infection to dentist, dental personnel and other
patients.
2- Prevents further damage to them.

(B) History of Infections and Immunizations:

The history of characteristic infections such measles, herpes simplex as
well as immunizations may be significant for the dentist. Past infection or
previous immunization can exclude the specific infectious diseases from
diagnostic consideration of a new infection.
(C)History of Hospitalization/Surgery:
Any past hospitalization or surgical procedures, together with any
accompanying complications or blood transfusion should be reported .This will
reveal:
- The patient’s ability to tolerate surgical stress.
- The cause of hospitalization or surgery, e.g. facial injury,
malignancy.
- Patient’s exposure to infection.
(D) History of radiotherapy
Radiotherapy for treatment of malignancy may have complications on
oral and paraoral structures.
Complications of radiotherapy include:
- Radiation mucositis and Candidosis.
- Fibrosis of salivary glands, ascending parotitis and xerostomia.
- Loss of taste sensation.

43
 - Increased incidence of periodontal disease.
- Radiation caries and hypersensitivity of teeth.
- Fibrosis of the masticatory muscles.
- Osteoradionecrosis
(E) Pregnancy (in females):
Only emergency treatment is performed in the first and late third trimesters.
The middle trimester is the safest. Radiographs should be avoided unless it is
necessary with certain precautions. Administration of drugs should be limited
and those having teratogenic effect should be avoided.
(F) Other Conditions
Lines are provided for the answer to the following question: "Do you have
any other conditions not already mentioned?"
(2) Review of systems (ROS)
Survey of a patient's health by major body systems is the "Review of
Systems”.
Usually each system has its unique disease symptomatology that is not duplicated
elsewhere. In order not to miss anything of significance, an orderly review of
systems is essential. Examples of questions used in ROS are as follows:
Do you have or you ever had?
- Short breath, dyspnea on exertion, heart murmur , swollen ankles , pain
over the hear, pain in chest on exertion , fast or irregular beating of the
heart , palpitation may reveal heart trouble.
- Nervousness, loss of weight, tremors of hands and tongue, intolerance of
hot weather, excessive sweating, insomnia and tachycardia may reflect
hyperthyroidism.
- Excessive urination (polyuria), excessive thirst (polydipsia) and excessive
appetite (polyphagia) associated with weight loss are the characteristic
presentation of undiagnosed diabetes mellitus.
- Constant fatigue may be the only symptom of anemia.
- Unusual progression of infections affecting the mouth, GIT, gut, skin …
etc, with common involvement of the regional lymph nodes and recurring
characteristic oral ulceration may indicate disease of white blood cells.
Dentist’s role is not the definitive diagnosis of systemic illness. His role is
limited to assessment of the need for medical referral when undiagnosed or
uncontrolled disease is suspected.

44
 (3) Social History
Learning about a patient's personal habits is the "Social History."
A history of cigarette smoking or heavy alcohol use may suggest a predisposition
to oral malignancies.

(4) Family History

Sometimes a history of family illness may indicate diseases to which the
patient may be predisposed. It is common for physicians to ask their patients
about parent health or death to determine the risk for familial diseases which
involve two categories:
 Hereditary or familial diseases (e.g. diabetes , colon cancer, ischemic heart
disease).
 Infectious diseases (e.g. TB, hepatitis). The health status of family members
living together may uncover a patient's potential exposure to these .

45
 II-CLINICAL EXAMINATION

Examination Methods

The common techniques of examination are:

1- Observation
2- Inspection
3- Palpation
4- Percussion
5- Probing
6- Auscultation
7- Olfaction.

Observation: "...an act or instance of noticing or perceiving." Observation refers

to examining the patient from afar. As a patient enters the operatory the dental
practitioner should observe her/his general appearance and her/his general
physical status.

Inspection: "...the act of inspecting or viewing, especially carefully or critically."

During the examination, particularly the soft tissue part, the operator must look at
the features of, for example, a lesion up close. This close, careful, examination is
called inspection.

Through inspection we examine:

1- Colour: Usually the oral mucosa is pale pink, it is affected by :
a) White colour of the covering stratified squamous epithelium ,
keratin (if present) and collagen bundles in the underlying
connective tissue . Any increase in the thickness of these structures
(e.g. hyperkeratosis , acanthosis ,…..etc ) increases the pallor of the
mucosa in varying degrees to the extent of reaching a frank white
colour (white lesions) .In contrast , their decrease (e.g. epithelial
atrophy) causes redness of the mucosa .
b) Red colour of the vasculature of the connective tissue ; as the oral
epithelium is translucent it reflects the colour of this vasculature,
giving the pale pink colour. If the vascularity decreases (e.g.
anemia) a whitish colour is obtained .If vascularity increases (e.g.
inflammation) there is redness.

46
 c) Degree of fixation to underlying structures:
Loosely attached tissues are more translucent to underlying
structures.Attached gingiva is firmly attached and thus appears
more pale. Hard palate: firmly attached to underlying structures
together with the presence of areas of adipose tissue and heavy
keratinization so it appears very pale in colour. On the other hand ,
the vestibule, soft palate and free gingiva , being loosely attached
appear more red in colour.
d) The presence of melanin brown pigmentation
e) Yellowish discoloration due to lipopigments or jaundice

2- Surface Texture
Usually the oral mucosa looks smooth except for the attached gingiva
which when dry shows stippling (orange peal appearance) and the rugae area of
the palate which appears pebbled.
The surface of pathologic lesions may appear
a) Smooth (masses that arise in tissues beneath the lining mucosa).
b) Papillomatous (lesions that arise in epithelium as papilloma, warts,
verrucous carcinoma ).
c) Ulcerated (break in surface epithelium continuity).
d) Necrotic.
e) Flat or raised surface:
o Macule (discolored: brown, red, ….). It is flat lesion due to lack
of cell proliferation (hyperplasia) or increase in cell size
(hypertrophy).
o Nodule or papule: Surface is raised due to hyperplasia
hypertrophy.
o Pustule: Pus-filled nodule or papule.
3- Contours:
The diagnostician should be familiar with normal contours in and around
the oral cavity e.g.
o Facial symmetry
o Nasolabial fold (appears normally as depression).
4- Aspiration:
If any lesion contains fluid: This fluid can be aspirated and inspected:
o Straw – coloured fluid with cholesterol crystals = cyst.
o Pus = infected lesion or abscess.

47
5- Transillumination may be used, it is a visual diagnostic method that relies
on the passage of light through relatively thin, translucent tissues.
Transillumination can demonstrate the accumulation of fluid and pus within
the maxillary sinus. The patient is placed in a darkened room and an intense
light source is placed intraorally with the patient’s lips closed around the
probe.The tissues overlying the normal maxillary sinus exhibit a dull glow,
while congestion or abnormal soft tissues within the sinus block the diffusion
of light. The frontal sinus can be similarly examined by placing the light
source inferior to the supra orbital ridge at the nasal aspect of the orbit. It can
be also used to visualize proximal caries in anterior teeth

Palpation: "...the act of examination by touch, especially for the purpose of

diagnosing disease or illness." Touching a part of a patient -- a structure or a
lesion, for example -- is known as palpation. This procedure is of particular
importance in the soft tissue portion of the physical examination.
Palpation Techniques:
A. Bidigital palpation:
It is the manipulation of the tissues using the two fingers of one hand. It
is used for thin tissues such as lips.
B. Bimanual palpation
It is the manipulation of the tissues using the two hands or two fingers of
both hands. It is used for examination of cheeks, floor of the mouth and
soft tissue swellings to detect presence of fluids ( fluctuation test ) .
C. Bilateral palpation
It is the simultaneous manipulation of the symmetrical structures to
detect a difference from one side to another. It is used for examination of
T.M.J, lymph nodes and parotid glands.
From palpation:
1- The shape, size, consistency and anatomic location of the suspected lesion
can be estimated.
2- The presence of tenderness usually indicates inflammation and is revealed
by the patient’s response when pressure is applied.
3- Lesions are considered well delineated if palpation reveals separation from
adjacent tissues or diffuse if this distinction is difficult to discern.

48
 4- Independent lesions are mobile relative to adjacent tissues during
manipulation, while resistance to movement suggests fixation.
5- Palpation of lesions that contain blood (e.g. haemangioma) causes the red
lesion to become pale or blanch. The use of a glass slide to compress the
lesion while observing the area is called diascopy and may demonstrate this
feature. Release of pressure allows refilling of the vessels and a rapid
return of the red color. Red lesions produced by extravasation of blood into
the connective tissue do not blanch during palpation.
6- Bimanual palpation helps to detect the presence of fluids inside soft tissue
lesions (fluctuation test).
7- Surface temperature .

Percussion: "...the striking or tapping of the surface of a part of the body for
diagnostic or therapeutic purposes." Occasionally, it is necessary to tap on a tooth
to determine if periapical disease is present. This tapping act is known as
percussion.

Two types of percussion can be applied:

1- Teeth percussion
Percussion of the teeth is performed by striking the cusp or incisal edge
of each tooth with a gentle but firm blow with the blunt end of no.17 explorer or
similar light instrument, the blow should be directed in the long axis of the tooth.
- During percussion on teeth the examiner should be aware of:
1. The feel of the blow.
2. The sound produced.
3. The reaction of the patient.
A sound tooth with healthy periodontium will ―feel‖ firm and resistant
and will produce solid sound on percussion, while teeth with periodontal disease
and sufficient bone destruction will ―feel‖ soft or will not be resistant to
percussion and produce a dull sound. The presence of inflammation within the
periodontal tissues will lead to tenderness (patient feels pain) during percussion .
2- Soft tissue Percussion:
This method of percussion is of value in observing muscle reflex
mechanism, muscle tenderness, hypertonicity of the muscles of mastication
and demonstration of Chvostek’s sign (in latent tetany tapping over the facial
nerve in front of the ear causes twitching of the facial muscles).

49
Probing : "...the use of a slender device to examine a narrow tract or cavity" The
dental probe may be :
1-Sharp (explorer) used to:
o Detect carious cavities.
o Test local anaesthesia
o Explore sinus tract
o Explore deposits on tooth surface
2-Blunt (periodontal graduated probe) used to :
o Detect periodontal pockets
o Measure periodontal pockets

Auscultation: "...the act of listening, either directly or through a stethoscope or

other instrument, to sounds within the body as a method of diagnosis." Other than
listening to the functioning temporomandibular joint with a stethoscope,
auscultation is of limited use in dental physical examinations.

Olfaction:" the sense of smell occasionally contributes to diagnostic

information." As:
o Foetid odour of bacterial infection in necrotic teeth, abcesses
and ANUG
o Garlic or bad odor of chronic periodontitis.
o Acetone odor in diabetic patient with ketoacidosis .

50
 EXTRAORAL EXAMINATION

Extraoral examination recommended for the average general practice in dentistry

consists of:
1) Observation of general appearance
2) Inspection and palpation of the head and neck
3) Observation of other parts of the body
4) Measurement of vital signs.
Patient's general appearance:
A great deal can be learned by observing patients in the waiting room, as
they enter the operatory, as they sit in the dental chair, as they talk during the
interview, and as they leave. These observations should include the following:

Dress and Grooming -- Observe the level of care in dress and grooming. Sick or
disturbed patients often let these external appearances deteriorate.

Agility and Energy -- Observe the presence or absence of energy and enthusiasm.
The degree to which patients are alert and aware of their surroundings may
indicate the absence or presence of disease. Similarly, the facility with which
patients are able to sit, stand, and walk may also indicate their general state of
health. Also, observe the patient’s weight; overly obese individuals may be
afflicted with one of several systemic diseases.

Demeanor -- Observe the patient's behavior towards dental treatment, towards

family members, and towards office staff. Presence of nervousness or abnormal
response to ordinary events may indicate psychological disorders or, at the very
least, future management difficulties.

Breathing -- Observe whether or not patients have difficulty in catching their

breath after walking from the waiting room and sitting in the dental chair. If they
cannot talk for several minutes after being seated, it may indicate the presence of
serious underlying cardiac and/or pulmonary disease.

Odors -- Observe any unusual body odors. Tobacco and alcohol odors are
common and may indicate potential systemic disease (lung/oral cancer or liver
cirrhosis). Acetone breath may indicate that a patient suffers from uncontrolled

51
diabetes mellitus. Putrefied breath odor may indicate oral or pulmonary infections.
Generally unpleasant body odor may speak about a patient's grooming habits.

Walking pattern (Gait) -- Gait is the manner of walking and most gait
abnormalities relate to neuromuscular disability from injury , stroke or
degenerative neuromuscular diseases. The different gaits may be named as
follows:
 Waddling gait in paget’s disease. To walk with short steps that tilt the body
from side to side
 Circumduction gait: in hemiplegia (semicircular lateral swing of the affected
leg).
 Tabetic gait: Tabes dorsalis refers to neurologic degeneration of tertiary
syphilis and results in an ataxic gait with a tendency for the patient to watch the
feet to compensate for lost proprioception.
 Ataxic gait: irregular, wide-distanced walk common in alcohol intoxication.
 Parkinsonian gait: consists of limited stride, hanging arms and rapid steps.

Inspection and Palpation of the Head and Neck

Inspection and palpation of the face may reveal important diseases.
Dental practitioners operate very close to a patient's face. Given the proximity,
there is ample opportunity to observe the eyes, skin, and other facial parts.

Eyes -- Some diseases manifest with eye changes.

- Hyperthyroidism is often accompanied by bulging eyes (exophthalmos);

- Jaundice may appear first as yellow sclera.
- Osteogenesis imperfecta and dentinogenesis imperfecta are accompanied by
blue sclera .
- Multiple sclerosis, neurosyphilis or neoplasm cause ptosis which is dropping
of upper eye lid and inability to open the eye completely. It is due to paralysis
of levator muscle supplied by third occulomotor nerve.
- In neurosyphilis the eye pupil only reacts to location and fails to react to
light (Argyll Robertson pupil).
- Facial nerve paralysis (Bell’s palsy) causes inability to close eye lids and
leads to constant excessive irritation, lacrimation and dryness.
- Congenital syphilis ( together with saddle nose and Hutchinson’s teeth) ,
hereditary benign intra epithelial dyskeratosis and vitamin A deficiency are all

52
 accompanied by localized or diffused dull cloudy or opaque areas over the
cornea referred to as ―Interstitial keratitis”.
.Skin -- Observe and inspect the skin of the face for obvious lesions. Basal cell
carcinoma and melanoma are common in the skin of older people. Observe the
skin elsewhere for bruises, ecchymoses, jaundice, or cyanosis. These changes may
indicate presence of serious underlying diseases.
Nose--Dentist’s examination of the nose is usually limited to superficial
inspection of the surface of the nose and nares, any changes in color, size, shape
might be interrelated to oral lesions. The following might be affected:
 Size enlargement occurs in cases of acromegaly & rhinoscleroma.
 Shape: Depression of the nasal bridge known as saddle nose is common in
congenital syphilis, infantile myxodema, sickle cell anemia and following
trauma.
 Colour Persistent redness occurs in chronic alcoholism, liver cirrhosis and
systemic lupus erythematosus.
 Function nasal obstruction due to polyps, deviated nasal septum or nasal
discharge diverts the patient to mouth breathing with it’s harmful effects
on the periodontium.

Ears--Inflammation of the ears can produce symptoms similar to those of

tempromandibular dysfunction and inflammatory dental conditions.

Swellings, Asymmetries, Anomalies -- Observe the face for obvious swellings of

the parotid glands, the thyroid gland, or the jaws. Look for palsy of the face or
other obvious asymmetries. Also note any obvious developmental defects such as
cleft lip.

Causes of facial Asymmetry:

(1) Congenital Defects:
a) Facial hemi-atrophy or hypertrophy of superficial tissue, muscle & bone.
b) Mandibular condyle hypoplasia due to intrauterine or birth trauma.
c) TMJ ankylosis , the mandible moves to affected side
d) Mandibular body or ramus hyperplasia , the mandible moves to unaffected
side

(2) Traumatic:
a) Zygomatic process fracture which leads to infra orbital ridge depression.

53
(3) Inflammatory:
a) Abscess
b) Cellulitis
c) Cyst
(4) Muscular:
a) Atrophy of facial musculature following prolonged facial nerve
paralysis.( Bell’s palsy)
b) Hyperplasia of masseter in clenching habit.
c) Patients using only one side in chewing.
(5) Neoplastic:
Ameloblastoma, lipoma, osteoma……..etc.
(6) Salivary glands:
- Inflammatory as mumps or neoplastic.

Parotid and

Submandibular Glands -- The parotid and submandibular glands should be

palpated to disclose any growths in their substance. Are they enlarged or tender?

54
Sometimes Specific Face Patterns may be Noticed and Imply Certain
Diseases:
Characteristic Face Patterns
1- Acromegalic face (hyperpituitarism in adulthood)
The features are coarse due to bulged eye brow ridges, enlarged mastoid,
zygomatic, nasal, frontal and malar processes. The mandible is prominent
and protruded ( prognathism) with spaced and protruded teeth. The soft
tissues of the nose ,ear and lips are also enlarged.
2. Moon face: in Cushing disease ( supra renal cortex hyperfunction)
The face is rounded, flushed & obese due to cortisol over production causing
redistribution of the fat in the body.
3. Hyperthyroid face: moist skin, protruded eye balls, nervous muscle
movement and high temperature.
4.Congenital syphilis face: saddle nose, rhagades, interstitial keratitis.
5. Nephrotic face: puffy, pale with baggy eyelids due to retention of
fluids.
6. Scleroderma face: ―mask face‖, where smiling, whistling & other
expressions are difficult. The skin is very tight. This may be big problem
in dental treatment
7. Mongoloid face: the patient has particular face pattern and criteria as slanted
eyes, broad flat nose, large tongue, scanty hair& stupid expression.
8. Adenoid face: this is a special case in which the patient is suffering in the
early life from a soft tissue mass obstructing the nasal breath (polyps). The
expression appears stupid, the mouth is usually open, the nostrils are pinched
while the lips may be thick. The dental arch is narrow and the teeth protrude as
well as high palatal vault. Mouth breathing is a chief sign, the voice has a nasal
tone as well as snoring during sleep.

55
 Observation, inspection, and palpation of the neck may reveal important
diseases:
The structures of the neck should be observed, inspected, and palpated. Enlarged
lymph nodes may indicate the presence of serious disease. An enlarged thyroid
gland indicates disease in that structure. Distention of the veins passing through
the neck may indicate congestive heart failure.

Examination of Cervico-Facial Lymph Nodes:

I. Precervical group
A. Inner circle:
1. Palatine tonsils.
2. Pharyngeal tonsils
3. Lingual tonsils.

INNER CIRCLE
LN

56
B. Outer circle
1. Submental lymph nodes.
2. Submandibular lymph nodes.
3. Parotid lymph nodes (Preauricular) .
4. Mastoid lymph nodes (Posterior auricular).
5. Occipital lymph nodes.

II .Cervical Group
1. Anterior cervical lymph nodes
2. Superficial cervical lymph nodes
3. Deep cervical lymph nodes
4. Supraclavicular lymph nodes.
(peritracheal-perilaryngeal)
(anterior & posterior).
(anterior & posterior).

Upper deep
Cervical
SUB LN
MANDIBULAR

LN

LOWER deep
Cervical
LN

57
 SUB MENTAL
LN

ANT CERVICAL
(PRETRACHEAL)
LN

Thyroid G

ITHMUS OF THYROID

Lymphatic Drainage:
Pre-cervical group
Inner circle lymphoid tissue around pharynx
i) Palatine at the mucous membrane of the lateral wall of the pharynx between
palatoglosal & palatopharyngeal arches, large in children.
ii) Pharyngeal at the mucous membrane of the roof and posterior pharyngeal
wall.
iii) Lingual lymphoid aggregations mostly at dorsolateral and dorsopharyngeal
aspects of posterior 1/3 of the tongue. Less frequent on ventral surface of the
tongue, floor of the mouth, palate or cheek mucosa.
The palatine, pharyngeal and lingual tonsils are called lymphatic ring of
Waldyer. Their function is the protection against ingested & inspired bacteria.

Enlargement of this group causes dysphagia,

58
Outer Circle:
I) Occipital drain posterior part of scalp.
II) Mastoid drain parietal region of scalp.
III) Parotid drain lateral part of frontal region, middle ear & lateral aspect of the
eyelid.
IV) Submandibular (submaxillary) drain :
 Medial part of frontal region.
 Medial part of eye lid
 Nasal, cheek & upper lip skin cover
 Gum of lower jaw
 All upper and lower teeth
 Floor of the mouth
 Lateral anterior 2/3 of the tongue
 Lateral part of lower lip
V) Submental drain middle portion of the lower lip and tip of the tongue.
Cervical Group:
I) Superficial Cervical (anterior & posterior chains)
 Below parotid gland, associated with the external &
anterior jugular vein.
 Drain external ear and angle of the jaw.
II) Anterior Cervical (Pretracheal-Prelaryngeal)
 It lies on the isthmus of the thyroid gland, on cricothyroid
ligament & 2 or 3 lymph nodes are embedded at the back of
thyroid gland.
 It drains larynx, trachea & thyroid gland
III) Deep Cervical (upper & lower groups)
 It is the largest, most numerous & most important LN in the
head and neck.
 It extends from posterior belly of digastric muscle to the
sternum, under sternomastoid in relation to the carotid
sheath.
 Drainage :
- All pre-cervical & superficial cervical L.N drain into
the deep cervical.
- Deeper structures drain into the deep cervical.
- Deep cervical drains also Maxillary gums, hard palate &
posterior 1/3 of tongue

59
Examination of the submandibular LNs can be carried out by bilateral
palpation from behind the patient. Alternatively, it can be done (each side
separately) from in front while the patient is tilting the head towards the examined
side for muscle relaxation. In both ways, four fingers of the examiner’s hand(s)
roll the LNs together with the overlying skin against the lower border of the
mandible. The submental LNs are similarly examined from in front of the patient
by rolling them with the overlying skin against the inner aspect of the mandibular
symphasis

Palpation of the anterior superficial cervical LNs is carried out while patient is
turning away from the examined side to stretch the muscles .Finger tips of
examiner are moved along the anterior border of sternomastoid muscle while the
thumb makes counter pressure along the posterior border. To examine the
posterior chain, the finger position is reversed.
Palpation of deep cervical LNs is difficult as they are imbedded underneath the
sternomastoid. However, when they get enlarged they bulge out along the anterior
and posterior borders of the muscle and can be palpated while patient tilts the
head towards the examined side to relax the muscle and the examiner can force
his finger tips beneath its borders.

60
It should be noted that:
- Normally lymph nodes are unpalpable
- If enlarged and palpable this is known as lymphadenopathy.
- If inflamed this is known as lymphadenitis.
The following points should be gained during examination of LN
- Being solitary or multiple
- Unilateral or bilateral
- Localized or generalized
- Discrete or matted ( fused )
- Painful, tender or painless on palpation.
- Consistency ( soft, firm or hard )
- Fixation to underlying structure
- Draining area.
LNs are usually
- Tender, soft (or firm) and discrete in acute infections.
- Firm without tenderness in chronic infections.
- Firm and matted in malignant lymphoma.
- Soft and matted in TB (known as scrofula).Later they open with a
sinus or get calcified
- Painless, stony hard and fixed in metastases.

Cervio-facial Lymphadenopathy:
Dental and periodontal infections are by far the most common causes of cervical
lymphadenopathy .however, other possible causes include life-threatening
diseases such as carcinomatous metastases or lymphomas. In HIV infection,
lymphadenopathy is one of its most common features. Cervical lymphadenopathy
without an obvious local cause is therefore a warning sign that must not be
ignored.

61
Important causes of cervico-facial lymphadenopathy
Infections
Bacterial
- Dental, tonsils, face or scalp infections
- Tuberculosis
- Syphilis
- Cat-scratch disease
Viral
- Herpetic stomatitis
- Infectious mononucleosis
- HIV infection

Parasitic
- Toxoplasmosis

Possibly infective
- Mucocutaneous lymph node syndrome (kawsaki’s disease)

Neoplasms
- Primary
o Hodgkin’s disease
o Non-Hodgkin lymphoma
o Leukaemis –especially lymphocytic
- Secondary
o Carcinoma-oral salivary gland or nasopharyngeal
o Malignant melanoma
o Other mesenchymal tumours
Miscellaneous
- Sarcoidosis
- Drug reactions
- Connective tissue disorders

62
Investigation of cervical lymphadenopathy
History
- Is there a history of a systemic illness?
- Has there been any contact with infectious disease (e.g HIV or
syphilis )?
- Has there been an animal scratch?
- Are there recurrent fever, lassitude, sweats or anaemia to suggest
Hodgkin’s disease?
- Do any symptoms (e.g epistaxis or hoarseness) suggest a
nasopharyngeal cause ?
- Are any drugs (especially phenytoin ) being taken?
Examination
- Check the temperature
- Identify the node and its drainage area
- Check carefully for dental, other oral, pharyngeal, or other skin
causes in the area
- If a possible primary cause is found (e.g. an oral ulcer) it should be
biopsied
- If no local cause if found, consider ENT referral for a
nasopharyngeal cause
- Examine the other side of the neck. Bilateral lymphadenopathy
suggests a lymphatic cause

Special investigations (as appropriate)

- Blood picture (leukaemia? glandular fever?)
- Chest radiograph for mediastinal nodes (e.g. Hodgkin’s disease,
sarcoidosis)
- Serology (glandular fever, toxoplasmosis, HIV)
- Angiotensin –converting enzyme and calcium levels (sarcoid)
- Mantoux test (tuberculosis)
- Fine needle aspiration (primary or metastatic neoplasm,
tuberculosis)
- Thyroid scan and function tests for unsuspected thyroid tumor
- Biopsy of nasopharynx and tonsils if needle biopsy of the node
shows malignancy
- Biopsy of node itself is a last resort. Send fresh material for
myobacterial culture.

63
Examination of the Temporo-mandibular Joint:
The temporomandibular joints connect the mandible to the temporal bones at both
sides .

The temporomandibular joint should be palpated along with the parotid glands. It
is customary to have the patient open and close the mouth as the condyles are
being felt. Any cracking, grinding (crepitus), tenderness or other abnormality
should be noted.
The TMJ, masticatory muscles & teeth function as one unit in coordinated manner.
- Disturbance of any one of them will be reflected on the other
components.
- Examination of TMJ will include: examination of TMJ,
masticatory muscles & the teeth.

(A) TMJ Examination

1. Inspection Examination of TMJ and face should begin by:
a. Observing the degree of symmetry of the mandible and face.
b. Observing the path of excursion of mandible during opening and
closing.
2. Palpation
a. While standing infront of the patient, bilateral palpation should be
carried out.
b. The bulb of index fingers is placed slightly anterior and below external
auditory meatus.
c. Palpate through external auditory canal with the little fingers (the bulb
of fingers of fingers facing anteriorly because of the S shape of the
canal).

64
 d. Ask patient to perform function movement (open, close, protrusive
the and lateral movement) & then watch, feel or hear:
1. Undue movement of the condyle.
2. Clicking sounds [this can be detected also by auscultation]
3. Pain on slight pressure from the palpating fingers when the mouth is
fully opened.
4. Deviation of the mandible during opening & closing the mouth.
5. Degree of mouth opening (normal 40 – 55 mm).
- Pain on palpation may indicate:
a. Internal joint derangement.
b. Inflammation of TMJ.

N.B. If acute pain arises during palpation via external auditory canal this may
indicate otitis externa.
- Clicking sound may indicate
a. Internal joint derangement.
b. Dysfunction of masticatory muscles.
- Jaw deviation or limitation of mouth opening: may indicate muscle spasm.

(B) Muscles of Mastication:

Temporalis Muscle :
Palpate over the temporal region of the skull. A fan-shaped
muscle covered by a fascia sheet. The large fan-like portion attaches to the side of
the skull and the smaller tapering portion attaches to the coronoid process of the
mandible. The temporalis muscle maintains the rest position of the mandible
when the person is upright. This muscle is activated during end to end and centric
occlusal biting positions, and pulls the mandible back in retrusive position
Masseter Muscle :
Quadrilateral muscle that covers most of the lateral aspect of the ramus of the
mandible. A portion of the parotid gland, the parotid duct, transverse facial artery
and branches of the facial nerve lie superficially to the muscle. The masseter
elevates the mandible during the centric occlusion, moves the mandible to the side
in lateral excursions, and retrudes the mandible when in protrusion.
- Originates from the lower portion of the zygomatic arch.
- It inserts on the lateral surface of the angle and coronoid process of the mandible.

65
- This muscle has a deep and superficial portion.
- It can be located when the jaws are forcibly closed.
- Palpation of the masseter muscle include:
1. Palpation of the origin.
2. Palpation of the insertion.
3. Palpation of the body with the thumb & index finger of one hand and the
index finger of the other hand

Procedure
1. Ask the patient to clench the teeth firmly together (muscular contraction).
2. The examining finger is run up the anterior border of the masseter intra-orally,
counter pressure being exerted from the external surface.
3. When the examining finger reaches the zygomatic origin of the masseter
muscle, tenderness become more evident and is shown by the patient’s
reaction, & this is a common feature of myofacial pain dysfunction
syndrome.
4. A similar test should be carried out on the opposite side.

The Internal Pterygoid Muscle:

1. It originate from the medial side of the lateral pterygoid plate and the
tuberosity of the maxilla, where it cannot be palpated.
2. The muscle inserts on the lower medial surface of the ramus of the
mandible where it can be palpated.

Procedure
1. The anterior part of the insertion can be palpated by inserting the index
finger at a 45-degree angle in the floor of the mouth near the base of the
relaxed tongue.
2. The opposite hand can be used extra-orally to palpate the posterior and
inferior portions of the insertion.
3. The body of the muscle can be palpated by moving the index finger upward
against the muscle to near its origin on the tuberosity.
- Muscle tenderness is also a feature of myofascial pain dysfunction
syndrome.

The External pterygoid muscle:

- Originates in two parts:

66
 1. Greater wing of the sphenoid bone.
2. The lateral surface of the pterygoid plates.
Insertion:
1. On the neck of the condyle.
2. The articular disc of the TMJ through capsule.
Procedure:
1. The muscles palpated by using the index or little finger and placing it
lateral to the maxillary tuberosity and medial to the coronoid process.
2. The finger presses upward and inward and a painful response can be
determined.
3. Since this is uncomfortable for the patient, the response requires
evaluation.
(C) Examination of Occlusal Relationship of Teeth:
- The examiner should pay particular attention to:
1. Missing teeth particularly molars or premolars (lack of posterior
support).
2. Presence of wear facets.
3. Evidence of bruxism (gross occlusal attrition).
4. Occlusal disharmony.
5. Poorly articulating or unsatisfactory dentures.
Observation of Other Body Parts:
Observation of other body parts may reveal important diseases.
Hands -- Observe the hands for skin changes mentioned above. Also note the
presence of clubbing of the fingers and cyanosis or hemorrhage under the
fingernails. These changes are indicators of serious underlying disease.
Abnormality of finger nails may reveal systemic diseases:-
 Clubbing of nails and fingers (koilonychia)--advanced cardiovascular
or cardiopulmonary dysfunction.
 Spoon-shaped nails with dull color--- iron deficiency.
 Bluish discoloration--- early sign of cyanosis due to inadequate blood
oxygenation or peripheral circulation.
 Pitted or linear defects--- severe recent illness.
 Hyperkeratosis of palms and soles—Papillon Le Fevre syndrome.

Legs and Ankles -- If they are exposed, observe the ankles and legs for signs of
swelling. Swollen ankles may indicate the presence of dependent edema, a
hallmark of congestive heart failure.

67
Abdomen -- Observe whether or not the abdomen is obviously enlarged compared
with other body parts. An enlarged abdomen in an otherwise slender person may
indicate the presence of ascites, a hallmark of serious underlying disease (e.g.
advanced liver disease).

Measurement of Vital Signs:

Blood Pressure Measurement:
Indirect blood pressure measurement is a reliable, easily-mastered procedure.
Usually, however, blood pressure is measured by a simple non-invasive indirect
technique, a procedure that can be implemented by patients, technicians, dental
assistants, dental hygienists, and dentists alike. This indirect procedure requires
three devices: 1) a stethoscope, 2) a pressure cuff, and 3) a pressure gauge (the
sphygnomanometer). It measures pressure in the brachial artery in the antecubital
fossa.

Several blood pressure readings should be taken. It is recommended that several

readings be taken over a 30 minute period. Between readings it is usual to talk to
the patient (conduct the medical history) leaving the cuff in place. By the time the
third reading is taken, the patient will no doubt feel more relaxed producing a
more reliable resting blood pressure reading. For obese individuals it may be
necessary to place the cuff on the lower arm and listen to Korotkoff sounds at the
wrist (radial artery).

Pulse Measurement
Measuring pulse is usually done at the wrist. In dentistry, there are three locations
where determination of heart rate by "taking a patient's pulse" can be measured:
1) the radial artery at the wrist, 2) the carotid artery in the neck, and 3) the
brachial artery in the antecubital fossa. Patients are used to having their pulse
taken at the wrist; therefore, a dentist taking a pulse at this location should meet
with acceptance. The radial artery can be felt at the thumb side of the inside wrist.
The pulse should be measured with two fingers: the middle and ring fingers, or
the middle and index fingers. It should never be felt with the thumb as the
operator's own thumb pulse may interfere with obtaining the patient's pulse.
While it is desirable to count the pulse for a full minute, it is customary to count it
for 15 seconds and then multiply the result by four. It is also common to measure
a patient's pulse by palpating the carotid artery in the neck. This pulse can be felt
by locating the thyroid cartilage (Adam's apple) and then moving laterally toward
the sternocleidomastoid muscle until the pulse is felt. Again, the middle and ring

68
or index fingers should be used. Once the pulse is located, it is counted just as at
the wrist. It is uncommon to take the pulse in the antecubital fossa. However,
special circumstances may require it. Once the pulse is located here, the procedure
outlined above is used.

Measurement of Temperature, Weight, and Height

Body Temperature -- While it is certainly appropriate to measure body
temperature orally, it may not be necessary to do so routinely unless, of course, an
infection is suspected. Normal oral temperature is 98.6 oF. (37oC.). Temperature is
measured by placing a thermometer under the tongue for several minutes. It is
important that the thermometer be sterile. Disposable thermometers are available.

Body Weight -- While abnormal thinness or heaviness may indicate serious

underlying disease, it is not feasible to weigh patients in the typical dental office.
Instead, it is sufficient to estimate whether or not the patient is over or
underweight and to ask two questions: 1) "What is your current weight?" and 2)
"Has your weight changed significantly over the last two years?"

Body Height -- Here again, it is not usual to measure a patient's height in the
typical dental office. Instead, it is sufficient to ask the patient: "What is your
height?" or "How tall are you?"

69
 INTRA-ORAL EXAMINATION

When examining the oral cavity and dentition you must wear gloves, have
good light, use sterile instruments (eg. dental mirror / gauze / tongue depressor)
and position the patient in a comfortable position.
Although the patient may be aware of one specific area of disease, other
areas of the mouth may be involved. To ensure that no area is overlooked, an
orderly approach to examination should be undertaken.

The intra-oral examination is classified into:

1. General appraisal of the patient's oral health and chief complaint area.
2. Examination of oral soft tissues and bony hard structure (mandible,
maxilla, and hard palate).
3. Examination of teeth.
4. Examination of the gingiva and periodontal supporting structures.
General appraisal of the patient's oral health and chief complaint area.
1) General inspection of the area of chief complaint
2) Presence of deposits, e.g. soft deposits (dental plaque and food debris)
hard deposits (calculus), stains (intrinsic and extrinsic). The extrinsic
(chromogenic bacteria, food, and beverages as well as smoking, …….etc)
and the intrinsic (Mottled enamel, amelogenesis imperfecta, tetracycline
staining etc……).
3) Prevalence of caries, including rampant caries.
4) Prevalence of periodontal disease.

70
 5) Missing teeth (edentulous areas), impacted teeth and retained deciduous
teeth.
6) Supernumerary teeth (mesiodens – paramolar – distomolar).
7) Presence of restorations and appliances (crown and bridge restorations,
prosthetic, and orthodontic appliances………etc).
8) Presence of halitosis.
9) Salivary flow ; Is the mouth dry or not?
I- The lips and labial mucosa

Start by examining the lips. The upper lip should

be grasped gently between the thumbs and index
fingers of both hands.
While inspecting the surfaces described below,
palpate the lip for submucosal masses. First
inspect the red portion (vermilion) for surface
lesions. Then, by everting the lip, similarly examine the labial mucosa, labial
vestibular mucosa, and anterior gingiva -- again noting any abnormalities. Upon
reaching the corners of the mouth (commissure), continue the eversion, inspection,
and palpation of the lower lip (vermilion, labial
mucosa, vestibular mucosa, and anterior gingiva).
Bidigital palpation reveals submucosal uniform
consistency and thickness. Firm, submucosal
nodules that are less than 1cm in diameter can be
palpated within the lips due to the presence of the
minor salivary glands.
The labial frenum normally appears as a slender, midline band, it is weblike
attachment at the height of the mucolabial vestibule. A small nodular ―tag‖ of
tissue that appears attached to the frenum is a common finding.
Its level of attachment should be beyond the attached gingiva to avoid
conveying the pull action of labial muscles to the marginal gingiva which would
result into gingival recession. Also a fibrotic thick frenum helps to form diastema
between central incisors.

71
 Instruct the patient to smile or whistle to detect the integrity of the 7 th cranial
nerve. Also watch the patient while speaking, in case of facial nerve paralysis
there might be some dropping of the angle of the mouth.

Lips should be examined for evidence of disease. Large lips may be an

expression of variation of normal or due to angioedema, neoplasms, cretinism,
acromegaly, cheilitis glandularis apostomatosum, cheilitis granulomatosum
(included in Melkerson - Rosenthal syndrome).

Angioedema (allergy): sudden diffuse swelling, firm and non-pitting.

Usually only one lip is affected but occasionally the whole face is involved.

Any developmental abnormalities should be recorded such as double lip,

cleft lip or lip pits which are unilateral or bilateral depressions or pits on the
vermilion surface of either lips, commonly on the lower lip.
Other lesions on the lips :
a- Angular cheilitis (candidal infection & low vertical dimension), angular
cheilosis (vitamin deficiency & protein deficiency).
b- Rhagades in the form of scar lines around the vermilion border in
congenital syphilis.
c- Herpes labialis.
d- Smoker’s patch.
e- Mucocele, mucous retention cyst.
f- Bloody crusted lip [Erythema Multiform].
g- Localized chronic discoid lupus erythematosis.
h- Contact allergy due to mouth washes, cosmetics, food. …..etc.
i- Lichen planus {white striation in papular form, ulcer in bullous erosive
form }:
j- Actinic keratosis (solar keratosis)
k- Focal epithelial hyperplasia (Heck’s disease or human papilloma virus).

72
 Angular cheilitis Herpes labialis

II – Buccal Mucosa:

Starting on one side or the other, palpate the

cheeks for submucosal masses. As with lips bidigital palpation of the buccal
mucosa may reveal nodularity due to presence of the minor salivary glands or
deeply seated lesions. Bidigital & bimanual palpation are carried out to
determine the consistency , flexibility & pliability of the cheek or buccal
mucosa. The buccal mucosa must be supported from out side by the four
fingers of one hand and the index finger of the other hand running inside the
buccal mucosa in different directions to palpate any deeply seated lesion in the
same time to examine the pliability, firmness & induration of the mucosa as it
occurs e.g. in cases of leukoplakia, submucous fibrosis, scleroderma . Direct
light onto the buccal mucosa; inspect it for surface lesions. Similarly, inspect
the buccal vestibular mucosa and the buccal gingivae.

On the mucosal surfaces look for signs of

inflammation (redness /swelling etc), ulceration, pigmentation and lesions. If any
lesions are present describe them in terms of their site, size, shape & contour.

73
Normal variation appear as whitish ridge of tissues opposite the occlusal plane of teeth,
known as linea alba buccalis, which can be faint, accentuated or even sometimes absent.
Also, apposite the 2nd upper molar a fleshy swelling may be present covering the orifice
of stenson’s duct (of the parotid gland) , known as parotid papilla, it should not be
mistaken for a pathologic lesion.

Common lesions:
- White lesion e.g. frictional keratosis, leukoplakia, candidiasis, aspirin
burns, smoker keratosis, papular lichen planus.
- Ulcerative lesions: e.g. traumatic ulcer, aphthous ulcer, intra-oral herpes
simplex
- Pigmented lesions e.g.: Blood dyscrasias (petechia, ecchymosis) which
give dark red to bluish coloration, melanoma, amalgam tattoo.
- Warty lesions e.g. viral warts.
- Papilloma
- Neoplastic lesions seen as swelling or ulcer.

III- Buccal Vestibule:

Inspection :
The buccal vestibule can be inspected by retracting the cheeks while the
mouth is opened and then asking the patient to occlude the teeth. The buccal and
labial vestibules are visualized to demonstrate their superior and inferior
extensions and symmetric contours. Any loss in depth (sulcus obliteration) or
change in bone contour should be evaluated.

Palpation:
The facial surfaces of the maxilla and mandible are palpated to identify
typical elevations or depressions in the contour of the bone.
The palpation of the buccal vestibule can be done by slowly sliding the tip
of the finger along the alveolar surfaces at the periapical level to identify the
tenderness or enlargement of periapical inflammatory lesions. Also signs as egg
shell crackling or fluctuation should be noticed.

74
 IV- The Tongue and Floor of Mouth
The dorsal surface of the tongue normally exhibits a relatively uniform
pale pink colour and a uniform rough surface texture consisting of numerous
filliform papillae which appear as small whitish, hair like projections. They may
become quite elongated (hairy tongue) or very short (atrophic tongue). Scattering
among them are the larger fungiform papillae. They are more prominent at the
lateral border and tip, they are red in colour Approximately 10-14 larger
circumvallate papillae are responsible for the nodular, irregular contours in the
posterior region of the dorsal tongue surface. They are round, have a groove
around them , this groove contains the openings of Von Ebner glands and also
contains taste buds.
The median groove or fissures on the dorsal surface is referred to as
fissured tongue and is a common anatomic variation.
The ventral surface of the tongue appears vascular and smooth with the
exception of the lingual frenum and the thin webbed projections of the plica
fimbriata lateral to the frenum.

Normal tongue coating is formed of:

Papillae on the dorsal surface of tongue, food debris, desquamated
epithelial cells, fibrin & bacteria. Normally tongue coating increase in the
morning as salivary flow decreases during sleep & then decreases while chewing
food & speech with normal flow of saliva.
A) Increase in tongue coating : may be caused by :
Drugs (H2O2, Na perborate) mouth breathing, febrile illness, excessive
vomiting, dehydration, smoking and stomach upset.
B) Decrease in tongue coating: [Atrophy of tongue coating]: may be caused
by :
- Nutritional deficiency (anemia, malnutrition, vit. B12 deficiency,
alcoholism, malabsorption, iron deficiency and Plummer Vinson
syndrome).
- Drugs as chemotherapy, antibiotics.
- Diseases as in atrophic lichen planus .
- Peripheral vascular changes as with :
 Obliteraton of small vessels secondary to diseases
(submucous fibrosis, scleroderma).
 Micro angiopathy (diabetes mellitus).
 Endarteritis obliterans (syphilitic bald tongue).
 Vasculis (SLE).

75
Nerve supply of the tongue :
The extrinsic and intrinsic muscles are innervated by the hypoglossal (12th
cranial) nerve with the exception of palatoglossus and glossopharyngeus; which
are innervated through the pharyngeal plexus.
The lingual branch of the trigeminal (5th cranial) nerve transmits general
sensation from the anterior two thirds of the tongue, also bearing within its fibres
of the chorda tympani branch of the facial nerve (7 th cranial), these fibres carry
special taste sensations from the anterior two thirds of the tongue.
The glossopharyngeal (9th cranial) nerve carries general sensation and
special taste sensation from the pharyngeal surface (posterior third).
Proprioceptive sensation of the tongue muscles is transmitted by the
hypoglossal nerves.

Common Lesions of the Tongue :

Geographic tongue, fissured tongue, aphthous and traumatic ulcers, bald
tongue, hairy tongue, fibroma, hemangioma, leukoplakia, lichen planus, median
rhomboid glossitis (candidal infection), herpes, syphilis, squamous cell carcinoma,
granular cell myoblastoma, lingual thyroid, lingual varices and ankyloglossia
(ventral surface).

76
 Geographic tongue Fissured tongue

Enlargement of the Tongue Occurs in:

Haemangioma, lymphangioma, amyloidosis, lingual abscess, angioneurotic
edema, actinomycosis.
Tongue thrusting is the positioning of the tongue between the anterior teeth
during swallowing, speaking or at rest. Appliances & myofunctional therapy are
both used to control this habit.
Examination of the Tongue:
Ask the patient to stick the tongue out so that you can examine the dorsal
surface. You should be able to identify cirucumvallate papillae. These are raised
areas which form a V -shape and lie at the junction between the anterior two
thirds and the posterior one third of the tongue.

Leaving the mouth for an instant, pick up a piece of

sterile gauze. After asking the patient to extend the
tongue out of the mouth, gently grasp the end of it
with the gauze (to keep it from slipping). Extending
the tongue a little further (prevent the ventral
surface from being cut on the lower teeth), palpate
it between the thumb and index finger of the free
hand (bidigitally) to detect deeply seated lesions . Inspect the dorsum for surface
lesions and abnormalities in tongue coating.

77
 Move the tongue gently to one side inspecting the
lateral surface from tip to base (lingual tonsils) for
lesions. The lateral surface of the tongue is an area
of high risk for oral cancer. Move the tongue to the
other side to inspect the remaining lateral surface.

Finally the patient should be asked to touch the roof

of the mouth with the tip of the tongue so that the
ventral surface of the tongue can be examined.
Notice the lingual veins (sometimes they appear
distended and tortuous ,forming lingual varices),
the lingual frenum and the projections at the
junction between the frenum and the floor of the
mouth (carencula sublingualis), where the ducts of the sublingual and
submandibular salivary glands open .

With the tongue in this position it is possible to

inspect the floor of the mouth for surface lesions.
Remember that oral cancers often occur in these
areas: they are areas of high risk. With the tongue
still raised, inspect the lingual gingiva for surface
lesions. The lingual aspect of the mandible can be
also examined by inspection and palpation for any
mucosal lesions or periapical tenderness. The mandibular torus (pl. tori) are
bilateral bony prominences seen lingual to the lower canines and/or premolars
region.
Common Lesions of the Floor of the Mouth:
Mucous retention cysts, ranula, salivary stones, Ebbing Tide
leukoplakia,…etc.

78
 V- The Submandibular and Sublingual Salivary
Glands

Place a finger of one hand in the floor of the mouth

and press upward on the outside against it with the
four fingers of the other hand ( bimanual palpation )
in an effort to palpate for masses or stones within
the submandibular and sublingual salivary
glands. This may be difficult because of the
contraction of the mylohyoid muscles.

At the same time, the outer hand can feel if the

enlargement was confined to the submandibular
lymph nodes

VI. Hard Palate:

Indirect inspection of the hard palate using the mouth mirror provides
detailed inspection of the surface. Instead, direct vision is accomplished from the
submental perspective with the patient’s mouth open wide and the head hyper
extended. The direct vision approach provides better visualization of the posterior
palatal contours for evaluating symmetry of the region.
The normal palatal mucosa appears pale pink and homogenous in colour.
The palatal rugae of the anterior hard palate typically present a folded, corrugated
appearance that is symmetric without fissuring between the prominences. An
incisive papilla is seen as a soft tissue protuberance, just posterior to the maxillary
central incisors. From that part, median palatine raphe extends posteriorly,
separating the hard palate into two halves.

Palpation:
The palatal alveolus is palpated at periapical level for tender foci or hard
bony enlargement at the midline, called maxillary torus (torus palatinus). Any
abnormal sensation detected by palpation such as egg shell crackling or
fluctuation should be recorded.
Common Lesions of the Hard Palate:
Stomatitis nicotina eruptions which could be seen as raised yellowish
white rings around the openings of the minor salivary glands, which look like red

79
dots (umblicated appearance). Other lesions that could be noticed include cleft
palate, thermal burns (e.g. pizza burn), cysts and minor salivary glands tumors.

VII- The Back of the Mouth

Directing light onto the soft palate, inspect it and the uvula for surface
lesions. It is usually necessary to use the back of the mouth mirror to gently
depress the tongue. To prevent a gag reflex, encourage the patient to breath
naturally through the nose, not the mouth. The mucosa of the soft palate typically
appears reddish pink with prominence of the underlying vascularity. The soft
palate of older individuals may appear somewhat yellow as a consequence of an
increased proportion of submucosal fat tissue. The soft palate normally appears
loose and mobile .
Directing light to the right and left, inspect the tonsillar pillars for surface
lesions. Now, depressing the tongue while the patient says "aah," inspect the
posterior pharyngeal wall for surface
lesions. At the same time, the elevation
of the uvula symmetrically during saying
―aah‖ shows the functional elevation of
the soft palate, while blowing through
the nose with the nostrils compressed
demonstrates its muscular depression.

The structures that encircle the

posterior mouth -- soft palate, tonsillar pillars, and posterior pharyngeal wall -- are
areas where oral squamous cell carcinoma ("oral cancer") frequently exists. These
structures, then, are high risk areas for development of this disease.

Palpation of the soft palate causes gagging and is not routinely performed
unless an abnormality is observed visually. Palpation can then be accomplished
by using a single finger to quickly strike laterally from the midline. The normal
soft palate is spongy and homogeneous to palpation without nodularity.

Common lesions of the soft palate Herpangina, herpes zoster, recurrent aphthous
ulcers, petechiae and ecchymosis, pseudo membrane formation as in diphtheria.
Also, occasionally the median raphe may extend posteriorly and divide the uvula
(bifid uvula).

80
Examination of Teeth:
The following should be considered in the examination of teeth:-
1 . Colour and stains
2. Size
3 . Form and structure
4. Number.
5 . Restorations
6 . Mobility
7 . Contact relationships
8 . Caries
9 . Functional contours
10. Fractures
11. Attrition, erosion or abrasion.
12. Vitality
13. Occlusion
14. Quality of oral hygiene
The Colour of permanent teeth may show considerable variations from white,
grayish, to yellowish hue or tinge that become darker as individuals become older.
Primary teeth are generally bluish white. The inherent colour is determined by
the translucency and thickness of the enamel and the colour of the underlying
dentin.

Change in Colour May be:

- Generalized: may result from incorporation of pigmented materials
during dental development.
- Symmetric colour abnormality limited to teeth that form
simultaneously and normal appearance of teeth that calcify at other
times: suggests severe illness during development.
- Discolouration of a single tooth: usually reflects pulpal necrosis.
Alterations in colour of teeth may be due to extrinsic or intrinsic stains. The
extrinsic stains could be due to tobacco and cigarette smoking, drinking beverages
or eating coloured foods, chromogenic bacteria and other coloured materials
placed within the mouth.
The intrinsic discolouration is usually due to developmental disturbances
during tooth formation like amelogenesis and dentinogenesis imperfecta or dental
fluorosis with mottling of enamel. Discolouration may also result from intrinsic
pigments as cases of:

81
 - Tetracycline staining of teeth.
- Porphyria: the teeth become dark red and under ultraviolet lamp
they fluoresce giving a brilliant crimson.
- Erythroblastosis fetalis occurs due to hemolytic jaundice causing
the teeth to become blue or green.
The number, Size, form and Structure of Teeth:
Examination reveals the number of erupted teeth in the mouth
- Extracted teeth: the patient’s history may suggest why certain
teeth were extracted e.g. because of decay, periodontal
destruction or other causes as trauma.
- Edentulous areas should be examined radiographically for the
presence of impacted or unerupted teeth.
- Anomalies in number include supernumerary or impacted teeth,
and complete or partial anodontia.
- Anomalies in shape or form include fused teeth, gemination,
Dense in dent, Hutchinson’s teeth, mulberry molars,
odontomas, hypoplastic defects and accessory cusps. Also
fractures, attrition or wear due to bruxism, erosion or abrasions
should be noted.
- Anomalies in size include macrodontia and microdontia. An
abnormally small tooth which is whiter in colour than other
teeth is often a retained deciduous tooth.
- Restorations like fillings, inlays or crowns have to be carefully
checked for proper contour, broken restorations, overhanging
margins and open margins
Carious Lesions:
Periodic and regular examination of the teeth is indicated for all
individuals regardless of their ages. Carious lesions develop frequently in pits,
fissures, developmental grooves of the occlusal surfaces and in the proximal
surfaces of teeth. Less frequently smooth surfaces like buccal or lingual are
affected. Numerous cavities may reflect the absence of routine dental treatment in
recent years, increased vulnerability to decay, or both. Exceptional vulnerability
to decay indicates that careful examination for easily overlooked lesions such as
cervical cavities is necessary.
- The examination should be done by combining clinical and radiograghic
techniques.

82
 - The initial lesion of dental caries is seen as an opaque or white spot, which
would later be cavitated, pigmented or stained.
- The explorer has to be fine and sharp, otherwise many areas of occlusal or
proximal decay may be overlooked.
- The examination should begin with a specific tooth and proceed
systematically throughout the arches. All surfaces of a tooth should be
examined before moving to the next tooth.
- Manipulation of the explorer and sufficient pressure to push the explorer
tip into soft decayed tooth structure will result in a ―catch or hang‖.
- Interproximal probing should be done by placement of the explorer tip
immediately apical to the contact in such a way that pressure can be
directed axially and slightly superior. Too much superior angulations will
result in a false ―catch‖ sensation from wedging the probe within the
embrasure.
- Mobility:
In order to test for mobility, the tooth to be examined is held firmly
between the handle of one metallic instrument and the side of one finger or
between the handles of two metallic instruments. Then, it should be attempted to
move the tooth in all directions, while observing the mobility from an occlusal or
incisal view.
Mobility is usually graded clinically according to the ease and extent of
tooth movement as follows:
Grade I: Slightly more than normal.
Grade II: Moderately than normal
Grade III: Severe mobility faciolingually and /or mesiodistally,
combined with vertical displacement.
An automated device called the Periotest is a compact handheld device
that measures tooth mobility by delivering repeated mechanical impulses. Any
mobility is automatically recorded by a microprocessor that controls the device.
Vitality:
Vitality of any tooth can be detected by:
(1) Inspection, (2) Pulp testing either electrical or thermal and
(3) Periapical radiographs.

83
1 – Inspection:
- Teeth with non vital pulps change colour towards gray to black or bluish
black if not treated endodontically soon after pulp death.
- The tooth injured by a severe blow may immediately change colour
towards red or blue due to intrapulpal hemorrhage then the colour may
become darker as the pulp becomes necrotic.
2 - Pulp Testing:
Electric Pulp Testing:
It is used to determine the presence or absence of vital nervous tissue
within a pulp chamber. A painful response to the stimulus denotes vitality. The
one advantage of the electrical test over the application of hot material is the fact
that the controlled stimulus can be applied in a gradually increasing degree by
means of sensitive rheostats to avoid excessive pain. Discoloured teeth, fractured
teeth, and deep carious lesions or restorations may indicate the need for testing.
Pulp testing gives varying responses in teeth of the same individual,
depending on the resistance of the teeth, condition of the pulp and efficiency of
the electric tester.
Unipolar high-frequency electrical testers are widely used with the
following precautions:
 We must explain the nature of the test to the patient before starting.
 Dry the teeth and then apply the electrode to be placed on sound
tooth structure.
 The electrode should never be placed near the gingiva or on
metallic fillings to avoid false reading.
 Electric pulp tests must not be used in patients with cardiac pace-
makers.
Thermal Pulp Testing:
a) Cold test: A piece of ice or small ball of cotton sprayed with ethyl chloride
is usually used.
b) Hot test: A heated cylindrical stick of gutta percha provides a reasonable
source of heat.
A tooth with painful pulpitis will give an earlier, more severe, and
prolonged painful response to both thermal tests than the adjacent normal teeth.

84
3 - Periapical Radiograph:
Periapical pathosis may be detected if infection has extended from the
infected pulp to the periapical region.
IX. Examination of the Periodontium:
The examination of the periodontium includes: 1) Inspection of the
gingiva, 2) Palpation and 3) Probing of the gingival sulcus for any pathologic
deepening associated with periodontal disease.
Inspection of healthy gingiva reveals uniform, noncompressible contours
with typical, homogenous pink colour and stippling. Signs of inflammation
include erythema, edema, bleeding, exudates expressed by palpation….etc
 Full mouth periapical radiographs and posterior bite-wing radiographs for
loss of continuity of lamina dura and height of the alveolar crest of bone
may be valuable.
 The use of periodontal chart is also useful in which informative data of the
depth of periodontal pocket tooth, mobility, level of bone around the teeth,
malpositioned and lost teeth, plaque and calculus index as well as bleeding
index can be recorded.
Gingiva:
The gingival tissues should be examined for:
1. Colour.
2. Form.
3. Contour.
4. Consistency.
5. Texture.
6. Level of attachment.
7. Depth of crevice.
Examination Procedure:
Inspection
The examination of the gingiva should begin with a systematic inspection
from the junction of the alveolar mucosa to the free gingival margin. Any
alteration of the normal color should be recorded. The inspection should also
include the signs of altered form. Normally the marginal gingiva should have a
knife edge . The form may be altered by disease or past therapy. Gingival
enlargement may be diffuse or localized; the areas involved should be
recorded .Contour of the attached gingiva , in the form of festooning due to inter-
dental grooves should be noted .Any gingival recession (localized or generalized)

85
should be recorded. The presence of soft debris, plaque, stains and calculus
should be noted (main etiological factors of any gingival disease). When the
gingival is dry , its surface is matt and stippling is evident .
Palpation:
Palpation of the gingiva should be systematically carried out to determine
the resilience, texture and status of the underlying tissues. Areas of tenderness,
friable tissues, loss of normal texture, exudated pus and soft spongy tissue should
be noted. The ball of the index finger is placed along the lateral aspect of the
marginal gingiva, and pressure is applied in a rolling motion towards the crown.
Probing and Charting:
The level of the attachment and the position of the free gingival margin
should be measured relative to the cemento-enamel junction as a first step. The
examiner should probe the depth of all the gingival crevices to determine whether
they exceed the clinically acceptable limit of 3 mm. in depth or not. The actual
measurement is made from the free gingival margin to the base of the crevice of
periodontal pocket.
The most suitable instrument for measuring the depth of periodontal
pockets is a very thin, calibrated periodontal probe, it should be straight, resilient
with a blunt end.
The probe must be inserted carefully parallel to the long axis of the tooth
to gain the deepest penetration possible without penetrating the gingival tissues or
epithelial attachment. Ledges of calculus, enamel pearls, variations in the
cemento-enamel junction may feel like the base of the crevice and may confuse
the inexperienced examiner so special attention is required. Six readings from the
following places should be recorded: Mesiobuccal, midbuccal, distobuccal,
distolingual, midlingual and mesiolingual.
Full delineation and tracing of the periodontal pockets is essential, and it is
important to determine if the base of the pocket involves the bifurcation or
trifurcation in posterior teeth or not.
Furcation Involvement:
A furcation involvement exists when periodontal disease has caused bone
resorption and connective tissue attachment loss in the bifurcation or trifurcation
of a multirooted tooth.

86
 III. LABORATORY INVESTIGATIONS
Haemogram
(Complete Blood Count)
It Includes:
 Red blood cell count (RBC/mm3)
 Haemoglobin concentration (Hb%)
 Total white blood cell count (WBC/mm3)
 Differential white blood cell count
 Platelet count
 Sedimentation rate.

Red Blood Cell Count

Normal:
 Males 5.5 1 milions/mm3
 Females 4.8 1 millions/mm3
 Increased (more than 6.5 milions/mm3)
 Decreased (Erythrocytopenia (anemia)
 R.B.Cs = less than 4 millions/mm3
Decreased production: (e.g. aplastic anemia, bone marrow disease, renal
disease).
 Decreased RBC
 Decreased reticulocyte count (normally: 1-2% of R.B.Cs, count)
 No or little change in RBCs morphology (normocytic,
normochromic) anemia.
Decreased maturation (e.g.: pernicious anemia, folic acid deficiency anemia,
iron deficiency anemia).
 Decreased RBC count.
 Increased reticulocyte count
 Change in RBC morphology (macrocytic anemia in pernicious and
folic acid deficiency anemias, microcytic anemia in iron deficiency
anemia).
 Increased destruction /loss: e.g.: hemolytic anemias, hemorrhage
 Decreased RBC count
 Increased reticulocyte count (bone marrow is actively producing
immature forms to compensate the loss of RBCs)

87
  In cases of anemia due to increased blood loss: no changes are
observed in RBCs morphology.
 In hemolytic anemias certain morphologic changes are observed
e.g. sickle shaped RBCs in Sickle cell anemia. Also: Fragments of
RBCs are seen (Schistocytes).
Total White Blood Cell count (WBC/mm3)
 Neutrophils:
 1st defense line against bacterial infection
 Eosinophils:
 Defence against parasitic infection
 Has role in allergic disease.
 Basophils:
 Has a role in allergic disease
 Lymphyoctes:
 B-cells → plasma cells → antibody immunity→ humoral
immunity
 T-cells → cell-mediated immunity
 The total WBC count:
 In normal adults: 4,000-11,000/mm3
 In children: slightly higher
 WBC disorders:
 Quantitative (abnormal number)
 Qualitative (poorly functioning cells)
Differential Count:
Absolute %
Neutrophils
 Segmented 0-2000/mm3 60-70%
 Bands 3000-6000/mm3
Basophils 0-100 /mm3 0-1%
Eosinophils 100-700/mm3 1-3%
Lymphocytes 1000-4000 mm3 20-35%
Monocytes 100-900/mm3 2-6%

88
Changes in Neutrophil Count:
Increase (Neutrophilia)
 Acute bacterial infection
 Sterile inflammation (as that
associated with tissue necrosis in
cases of burns and myocardial
infarction)
 Myeloid(myelogenous) leukemia
Changes in Lymphocytes Count:
Increase (Lymphocytosis)
 Chronic infections
 Lymphocytic leukemia
 Some viral infections
e.g. mumps
Changes in Eosinophils Count:
Increase (eosinophilia)
 Allergic disorders
 Parasitic infestations
 Drug reactions
 Hodgkin’s & non Hodgkin’s lymphomas
 Chronic myelogenous leukemia
89
Decrease (neutropenia)
 Decreased production as in
 Aplastic anemia
 Cytotoxic drug therapy
 B12 and folate deficiency
 Idiopathic neutropenia
 Bone marrow depression after
irradiation.
 destruction as in hypersplenism
 Peripheral use as in overwhelming
bacterial, fungal or rickettsial
infections.
 Infection with some viruses
Decrease (Lymphocytopenia)
 Aplastic anemia
 Renal failure and uremia
 Immunodeficiency disorders
e.g. HIV infection (AIDS)
Decrease (eosinopenia)
 Aplastic anemia
 Typhoid
Changes in Monocytes Count :

Increase (monocytosis) Decrease (monocytopenia)

 Chronic infections (e.g. TB)  Aplastic anemia
 Infectious mononucleosis
 Bacterial endocarditis
 Malaria
 Monocytic leukemia

Platelet Count:
 Platelets function is mainly related to hemostasis: so both number and
function are important.
 Normal platelet count: 150,000-500,000/mm3.
  In number = thrombocytopenia (<150,000/mm3)
 20,000-50,000: Bleeding occurs only with trauma and surgery
 Less than 20,000: spontaneous bleeding may occur
 Less than 5,000: profuse spontaneous hemorrhage occurs.
  In number = thrombocytosis or thrombocythemia (may reach
1,000,000/mm3)
 Bleeding occurs with thrombocytosis due to abnormal function despite the
increase in number.
Changes in Platelets Count :
Thrombocytosis occurs in
Thrombocytopenia Occurs in
 Idiopathic  Idiopathic
 B12 and folate deficiency  Secondary to diseases as
 Secondary to drugs polycythemia
 Secondary to disease e.g. multiple
myeloma,infectious
mononucleosis
 Hypersplenism
 Blood dilution by recurrent
transfusions

90
 Hemostasis
Three Mechanisms Cooperate in Hemostasis:
1) Blood vessel contraction and integrity
2) Platelets: adhesion, aggregation and release phenomena
3) The clotting cascade.

Thus Bleeding Tendency may Result From:

1) Increased blood vessels fragility (tested for by Hess test)
2) Platelet deficiency or dysfunction
Tested for by:
a) Platelet count
b) Bleeding time
c) Clot retraction
d) Specific tests for platelet function.
3) Coagulation mechanisms disorders
Tested for by:
a) Clotting time
b) Prothrombin time (PT)
c) Partial thromboplastin time (PTT) & activated partial thromboplastin
time (APTT) .
d) Coagulation factors assays.

91
Laboratory Investigations Related to Hemostasis and Blood Coagulation:
I. Testing Capillary Function:
Hess Test (Tourniquet test):
When the venous flow is obstructed, and the capillary walls are not normal,
blood will get extravasated from the capillaries leading to peticheal hemorrhage.
Technique:
- Sphegnomanometer cuff applied on the arm.
- Raise the pressure to a value between systolic and diastolic pressure and
maintain that level for 5 minutes.
- Watch the number of petechiae appearing on the forearm within an area of a
circle 1 inch in diameter.
- > 10 petechiae means increased capillary fragility.
II - Testing Platelet Function:
1 ) Platelet count : as before.
2 ) Bleeding time:
It is a good test of platelet function because it measures directly the end
point of this function which is the cessation of bleeding.
i ) Duke method: in which bleeding from a pricked ear lobe is measured
Normal bleeding time by this method is 2-4 min. However, it is not a very
satisfactory method.
ii ) Ivy method
- A standardized skin wound is made on the forearm, while a
sphegnomanometer cuff is applied on the upper arm and pumped to 40 mm
Hg pressure. (A finger prick may also be used).
- Blood is blotted every 30 seconds from the wound with filter paper until
bleeding stops.
Bleeding Time is then Measured by:

- Bleeding time = no. of blots

2
- Normal bleeding time by this method = 2 - 9 minutes (average 5 minutes).

92
 - Bleeding time is prolonged in:

 Thrombocytopenia
 Thrombocytosis
 Thromboasthenia (deficient platelet aggregation: Glanzmann’s disease).
 Thrombocytopathy (deficient platelet adherence: Bernard-Soulier
syndrome).
 Aspirin therapy (and other non steroidal anti-inflammatory drugs): these
drugs inhibit platelet aggregation and their release reaction.
 Uremia.
3 ) Specific Tests for Platelets Function:
a ) Platelet Adherence:
- Fresh blood is passed over glass beads (to which normal platelets
adhere).
- Not less than 20% of platelets should be found adherent to the beads.
- This no. is decreased in:
 Thrombocytopathy
 Thrombocythemia
 Uremia
b ) Platelet Aggregation: (using aggregometer).
ADP, Collagen, thrombin and epinephrine cause aggregation of normal
platelets.When citrated platelet-rich plasma is exposed inside the aggregometer to
any of the previous materials, the measurement of light transmission inside the
apparatus gives the measurement of platelet aggregation.
 Decrease in: thromboacthenia, aspirin therapy.
c) Platelet Factor 3 Activity.
Platelet factor 3 is produced by platelets during the release reaction and
helps in blood coagulation.
d) Detection of anti platelet antibodies (autoimmune thrombocytopenia).

93
4) Clot Retraction:
Retractozyme produced by platelets leads to clot retraction, starting from 30
minutes after normal blood clotting, becoming apparent at 1 hr. and is complete
after 24 hrs.
Decreases in: * Thrombocytopenia.
* Thrombocyte dysfunction.
III. Testing the Clotting Factors:
1) Clotting (coagulation) time (Lee- White time). ―The time taken by freshly
collected blood to form a firm clot.
It is a non specific test for the intrinsic and common pathways, which is not
sensitive to minor clotting factor deficiencies.
Technique:
- Put blood in a capillary glass tube 1 mm in diameter and put it in
warm water bath (37oC).
- Every 30 seconds a short portion of the tube is broken off till fibrin strands
are found to connect the broken edge.
- Calculate the time from blood collection till fibrin is formed (normally 10 -
15 minutes).
The test time is prolonged in the deficiency of any clotting factor except
factors III, VII, XIII.
2) Partial thromboplastin time (PTT) and Activated partial thromboplastin
time (APTT):
These tests detect abnormalities in the intrinsic and common pathways.
They measure the efficiency of factors:
XII (Hageman factor)
XI (Plasma thromboplastin antecedent)
X (Stuart - Prower factor)
IX (Christmas factor)
VIII (antihaemophilic globulin)
V (Labile factor)

94
II (prothrombin)
I (fibrinogen)
Deficiency of any of these factors causes prolonged PTT and APTT.
a) Partial thromboplastin time: (PTT)
Patient’s citrated plasma (i.e. deficient in Ca++) that is poor in platelets +
Phospholipid extract from brain tissue (partial thromboplastin) + known amount
of Ca++ fibrin formation
Normal time = 60 - 85 Seconds.

b) Activated partial thromboplastin time (APTT):

In addition to the PTT procedure, kaoln (clay-like substance) is added to
activate factor XIII (fibrin stabilizing factor).
Normal time = 35 - 50 Seconds.

3) The one-stage Prothrombin time (Quick method ) [PT]

It is the time required for oxalated or citrated plasma to clot in the presence
of added factor III (tissue thromboplastin), and Ca ++.

Citrated plasma + tissue thromboplastin + Ca++ (known amounts) 37oC clotting .

Normal value = 12 - 15 Seconds.
The result is then converted into the “International Normalized Ratio” (INR)
by dividing the obtained value by a standard normal value:
INR = PT of patient/PT of control.
Normally it should be 1 or about. No oral surgery should be attempted if
INR exceeds 2.
It measures the extrinsic and common pathways. Thus it measures the
efficiency of:
Factor VII (Stable factor) in addition to X, V, II and I
Thus the deficiency of any of these factors leads to prolonged PT.
( it is not prolonged in haemophilia)
The most common causes for its prolongation are: anticoagulant drugs and
liver disease

95
 4) Factor assays:
Here there is precise identification of the deficient factor.
 Method: By adding all other factors except the one to be tested.
 Results are expressed in % of concentration.
< 40% is considered abnormal. This could be applied to all factors except
fibrinogen (Factor I). Instead, it is quantified in plasma.
 Normal factor I level in plasma = 200 - 400 mg/dl.
It is Decreased in:
- Advanced liver disease
- Disseminated intravascular coagulation
- Congenital hypofibrinogenomia.

International Nomenclature for Blood Coagulation Factors and their more

common Synonyms
Factor Synonym
I Fibrinogen
II Prothrombin
III Tissue Thromboplastin
IV Calcium
V Labile Factor, Proaccelerin, Accelerin, Ac Globulin
VII Stable Factor, Proconvertin. Serum Prothrombin Conversion Accelerator (SPCA)
VIII Antihemophilic Globulin (AHG), Antihemophilic Factor (AHF)
IX Plasma Thromboplastin Component (PTC), Christmas Factor
X Stuart - Prower Factor
XI Plasma Thomboplastin Antecedent (PTA).
XII Hageman Factor
XIII Fibrin-Stabilizing Factor

96
 INTRINSIC EXTRINSIC
PATHWAY PATHWAY

XII XIIa

XI XIa

IX IXa Tissue Factor (III)
+VII

+VIII Ca 2+
Phospholipid
Ca2+

X Xa

(prothrombin) II II a
+V. Phospholipid
Ca2+
conversion 
 catalytic action Fibrinogen (I) Fibrin

COMMON PATHWAY

PTT tests this pathway to fibrin formation PT tests this pathway to fibrin formation

The relationship between intrinsic and extrinsic blood coagulation systems

97
 Tests for Diabetes Mellitus
1) Test Paper Strips:
Commercially available reagent strips used to detect glucose in urine
(Clinistix) or blood (Dextrostix) can be employed in the clinic by the dentists to
identify suspected diabetic patient or patient with diabetic coma. To use
Dextrostix (more accurate than clinistix):
 Finger prick blood on paper strip wash after 1 minute.
 The colour change is then compared with the standard chart supplied with
the strips.
2) Blood Glucose Level:
Diagnosis of diabetes mellitus depends on the presence of:
Symptoms which include polyuria, polydipsia , polyphagia or unexplained
weight loss .
Plus positive findings from any two of the following tests on different days.
a) Casual or random plasma glucose concentration ≥200 mg/ dl
(Casual is defined as any time of the day without regard to time since last
meal.)
b) Fasting plasma glucose (FPG).
Fasting is defined as no caloric intake for at least 8 hours
Categories of FPG include:
 FPG < 110 mg/dl =normal fasting glucose
 FPG> 110 mg/dl and < 126 mg/dl = impaired fasting.
 FPG > 126 mg/dl =provisional diagnosis of DM.
c) Post-challenge plasma glucose (PCG)
(2 hours after the administration of a standard 75 g oral glucose load)
For the 2 hrs post-challenge glucose, sustained values > 200 mg/dl are
considered diagnostic for DM.
d)Postprandial glucose (PPG)
(2 hours after the patient’s regular breakfast).
Categories of 2 hours post-prandial glucose (2h PPG) include:
 2h PPG < 140 mg/dl = normal glucose tolerance.
 2h PPG > 140 mg/dl and < 200 mg/dl=impaired glucose tolerance.
 2h PPG > 200 mg/dl = provisional diagnosis of DM.

98
3) Glucose Tolerance test:
It is an accurate method for detection of the response of the pancreas to a
measured oral or I.V. dose of glucose.
Advantages:
1 ) Detects patients prone to develop diabetes ( border line patients)
2 ) It can differentiate between diabetes mellitus and other causes of high
glucose level as hyperthyroidism.
Disadvantages:
1 ) Time consuming (2 - 3 hrs).
2 ) Expensive ( 5 readings of blood glucose level).
3 ) Exhausting for the patient .
Procedure:
1 ) 3 days of unrestricted (high carbohydrate ) diet + physical exercise.
2 ) 10 - 16 hours of fasting (nothing except water).
3 ) Fasting blood sample is taken.
4 ) A measured dose of glucose is administrated either:
Orally : 75 gm glucose in solution or
I.V. : 0.5 mg glucose /kg body wt.
5) Blood samples are taken at ½ hour intervals for 2-3 hours, thus
giving 5 - 7 samples:
 But usually: ½ hr, 1 hr , 2 hr , then 3 hr. samples are taken.
Normal Results: Fasting = ~ 100 mg /dl.
½ hr. = 120- 160 mg / dl.
1 hr. = 160 mg /dl. 1
2 hr. = <120 mg/dl

180
160
140
120
100
80
60
40
20
0
0 hr 1/2 hr 1 hr 2 hrs 3 hrs

99
4) Urinary Glucose:
Glucose can be detected in urine using Benedict or Fehling Solution.
But: this can be used only as a screening test (due to its simplicity), but not
a very definitive test as false negative results are usual.

5) Glycosylated Haemoglobin (HbA1C):

Normally, Hb in RBCs gets glycated gradually to form HbA1C. The greater
the severity of hyperglycemia, the higher the % of H bA1C.
Normal value ≤7%
In controlled diabetics = 9 - 12 %
In poorly controlled diabetics ≥13 %
[It gives an idea about hyperglycemia in the last 3 months].
6) Ketoacidosis
It is a condition related to the disturbance in protein and fat metabolism in
liver. The accumulation of the products of fat metabolism results in acidosis
(Ketone bodies: acetoacetates, beta-hydroxybutyrate and acetone).

Measurement of Severity of Ketoacidosis Can be Done by:

 Examining blood bicarbonate levels, since bicarbonate constitutes the
main plasma buffer system and becomes depleted during ketoacidosis.
 Low plasma pH
 Presence of acetone and glucose in urine.

100
7) Self assessment tests
a) Colorimetric Method:
Dextrostix or clinistix can be easily utilized by the patient.
b) Photometric Method:
Blood is applied to cover the test strip area and the strip is inserted in
the meter. Results are digitally displayed after 12 seconds.

101
 Blood Chemistry

Tests to check Tests to check Tests for patients with

Liver function Kidney function multiple Jaw bone
lesions

 Alkaline  Bloodurea  Alkaline

Phosphatase enzyme nitrogen phosphatase
(not very specific)  Creatinine enzyme
 Serum transaminases leveland  Serum Ca
 Serum bilirubin creatinine  Serum P
 Blood glucose level clearance
 Blood urea nitrogen  Uric acid

102
 Liver Function Tests
(1) Alkaline Phosphatase Enzyme Level:
 Normal values of serum alkaline phosphatase:
 1-4 Bodansky units/dl
 3-13 King-Armstrong units/dl
 Detection of its level is not very specific test for liver function as it is
elevated in other conditions.
 The activities in which alkaline phosphatase is included arise from
 Bone,
 Intestine,
 Liver and
 Placenta
Thus, its level increases in:
 Increased bone activity or turn over:
 Growing children
 Healing fractures
 Hyperparathyroidism
 Metastases to bone
 Paget’s disease
 Osteomalacia
 Pregnancy
 Liver disease
 Parenchymal liver disease (leads to moderate increase in alkaline
phosphatase level (not exceeding double the normal)
 Obstructive liver disease (leads to severe increase around 10 times
normal).
 In case of parenchymal liver disease:
 There is increased synthesis of the enzyme by hepatocytes and biliary
tract epithelium.
 In case of obstructive liver disease:
 Because alkaline phosphatase is excreted normally in bile, biliary
tract obstruction will lead to its regurgitation back into the blood.
2) Serum Transaminases (Aminotransferases)
 SGOT (Serum glutamic-Oxaloacetic transaminase) = AST (aspartate
aminotransferase). Normal = 8-40 Karmen units/liter
 SGPT (Serum glutamic – Pyruvic transaminase) = ALT (Alanine
amino transferase). Normal = 5-25 karmen units/liter.

103
  These two enzymes are present in large amounts in:
 Liver
 Heart
 Kidney
 Skeletal muscles.

 Thus, acute destruction of any of these organs leads to increase in their

serum levels. However, it should be noticed that:
 SGOT (AST):
- Its elevation is pronounced in both myocardial
infarction and liver disease.
-
 SGPT (ALT):
- While SGPT (ALT) increase is more specific for liver
disease (as it is found primarily in the liver).
-
 Highest levels of these enzymes are found in conditions causing extensive
hepatic necrosis, e.g. severe viral hepatitis (particularly in the early phases)
where it may reach 1000-2000 U/liter.

 While lesser values are encountered in chronic liver disease and liver
cirrhosis (only reaches 50-100 karmen U/liter).

(3) Serum bilirubin:

 Bilirubin is a bile pigment
 Normal serum value= 0.3-1 mg/dl
 Increases due to:
  production (due to  R.B Cs destruction).
 Lack of excretion in bile and its regurgitation back into the blood
(obstructive liver disease).
 Parenchymal liver disease.
 Jaundice (yellowish discolouration of sclera, skin and oral mucosa)
appears when bilirubin level exceeds 2-3 mg/dl.

(4) Blood Glucose Level:

Usually liver function derangement is accompanied by diabetic glucose
tolerance test abnormality or even frank diabetes. This is due to decreased. Uptake
of glucose by the liver and  glucose storage as glycogen → leading to
hyperglycemia.

104
 (5) Blood urea nitrogen (BUN):

 Normal level = 5-25 mg/dl

 Normal urea metabo lic pathway:

Protein metabo lism

deaminat ion
Amino acids Keto acids
In liver
+
Ammo nia absorbed fro m Ammo nia
intest ine in the liver

Urea

Excreted via the kidney

 In  liver function:
 Less urea is produced → decreased BUN level
 In  kidney function:
 Less urea is excreted → increased BUN level

(6) Serum Albumin:

In end-stage liver disease, the liver fail to synthesize albumin leading to
hypoalbuminemia.

105
N.B.:
 Besides blood chemistry:
 Sonography can show bile ducts abnormalities (e.g. gal stones)
abnormal structures or masses in the liver.
 Percutaneous needle biopsy of the liver is a safe, simple valuable
method for the diagnosis of liver disease.
 To confirm that abnormal liver function is due to viral infection specific
tests are carried out to detect:
 HBV antigens and anti HBV antibodies.
 HCV antigens and anti HCV antibodies.
 Polymerase chain reaction (PCR) is a laboratory method used to amplify
the amount of viral antigens in blood so that its detection could be much
easier.
 Importance of liver function tests in dentistry:
 Liver function is important for synthesis and conjugation of most
clotting factors (bleeding tendency).
 Liver function abnormality may be due to infective hepatitis (viral)
which endangers the dentist and other patients.
 Drugs prescribed and local anaesthetics administered to patients with
liver disease should be watched for hepatotoxic effect and drug
metabolism by the liver.
Kidney Function Tests
(1) Blood Urea Nitrogen (BUN):
(2) Uric acid Level:
 Normal value = 2.5 -8 mg/dl
 Increases in:
 Gout
 Renal failure
 Leukemia or lymphoma
(3) Serum Creatinine / Creatinine Clearence:
 Normal serum creatinine = 0.3-1.2 mg/dl
 Increases in renal failure: It is kept steady in serum through excretion via
the kidney and its rate of excretion is known as creatinine clearance.
 Creatinine clearance is the most frequently used measure of renal function.
 Normal: Male = 100-140 ml/min
Female = 80-120 ml/min
Decreases in renal failure

106
 Biopsy
Definition:
Biopsy is the microscopic examination of tissues removed from the living
body to reach a definite diagnosis.
Indications:
1. When careful examination fails to reach the diagnosis.
2. To recognize precancerous lesions.
3. Lesions which present clinical signs of malignancy.
4. Lesions that failed to respond to therapy in a limited period of time.
5. To differentiate between lesions.
6. As a general rule, when there is doubt do biopsy.

Rules of Biopsy:
1. These Data Should Accompany the Specimen :
The date of the biopsy; name, age and sex of the patient; the area
of the biopsy and a brief description of the clinical appearance of the
lesion and the associated symptoms, along with the tentative clinical
diagnosis.
1. Avoid iodine – containing surface antiseptics since they cause permanent
staining of certain tissue cells.
2. Avoid direct injection of anesthetic solution into the lesion.
3. Avoid routine use of electro-cautery. In suspected malignant lesions, however,
the electro-cautary may be the method of choice particularly when the entire
growth cannot be removed.
4. Avoid cutting from diseased to normal tissues to prevent implantation of
malignant cells. Incision should be directed always from the normal to the
diseased tissue, and more than one scalpel may be used.
5. Avoid areas of necrosis as it may not represent the lesion.
6. Avoid cutting into highly vascular or angiomatous lesions.
7. Avoid cutting into well encapsulated lesions.
8. Avoid piercing the periosteum in carcinoma near the bone to avoid spread of
the lesion.
9. Avoid crushing of the lesion with a tweezer.
10. Sufficient tissue should be removed.
11. The biopsy specimen should include clinically normal tissue for comparison.
12. Small lesions should be removed completely when the biopsy is taken.
13. Incisions should be deepened until the base of the lesion.

107
14. More than one specimen may be needed to represent large lesions.
15. One or more traction sutures may be placed through the lesion to
immobilize the tissues.
16. Inform the patient what you are doing.
17. The specimen should be placed in a large mouthed bottle to avoid
distortion of the lesion.
The bottle should contain a suitable fixing solution usually 10% formalin
and sent to the pathology laboratory.

The instrumentarium for

biopsy

In excisional biopsy :

An elliptical cut is performed to include the lesion and part of normal tissues .
The cut is deep enough to include the base of the lesion and part of the
underlying tissues. One or more traction sutures may be placed to immobilize
the tissues.

108
Types of Biopsy:

1. Excisional Biopsy:
Indicated in small lesions where the lesion is removed completely with
safety margins and acts as a biopsy specimen e.g. fibro-epithelial polyp and
pyogenic granuloma.

2. Incisional Biopsy:
Indicated in large lesions. A representative section at the margins with a
portion of adjacent tissue should be removed. Areas of necrosis should be avoided.

3. Aspiration Biopsy:
Indicated in fluctuant lesions, lymph nodes and cystic lesions. A large
gauge needle is used to obtain the fluid specimen.

4. Punch biopsy:
Indicated in inaccessible areas e.g. fauces. A portion of the lesion is
removed using a punch forceps.

5. Drill Biopsy:
Indicated in bony lesions e.g. fibro-osseous lesions. A hollowed steel drill
in the size of a large bur is used, it has cutting teeth at its end and mounted on a
straight hand piece. More than one specimen may be needed to represent the
lesion.

6. Exfoliative Cytology:
Exfoliative cytology is the study of the characteristics of superficial cells
that are removed or desquamated from various surfaces of the body. In fact, cells
exfoliated or collected from a surface may reflect many of the features of the
underlying tissues.
Technique:
Oral specimens may be collected by direct scraping of the area using a
moistened wooden tongue blade or metal spatula. The smear should be rapidly
spread over a glass slide which is immediately immersed in a fixative agent
composed of either 95% methyl alcohol or equal parts of methyl alcohol and ether.

109
Advantages and uses:
a. Minimal discomfort to the patient.
b. Ease of serial examination in long term study.
c. In evaluation of vesiculo-bullous lesions.
- Pemphigus to show Tzanck cell.
- Pemphigoid to show negative presence of acantholytic cells.
- In viral infections e.g. acute herpetic gingivostomatitis to show
multinucleated giant cells and ballooning degeneration of the nucleus.
d. In diagnosis of cancer, cytology may reveal cell changes at an early stage.
If abnormal cells are seen in cytology, a biopsy of the suspected area must
be performed to confirm the diagnosis.
e. Following treatment of oral cancer, periodic cytology may detect
suspicious or malignant cells before the reappearance of clinical signs.
f. The standard classification used in oral cytology report include:
Class 1 : Normal cells.
Class II : Some atypical cells, but no evidence of malignancy.
Class III : Changes in the nuclear pattern of intermediate nature.
Class IV : Suggestive of malignancy.
Class V : Obvious malignant changes.
A report of III, IV and V should be followed by biopsy.

Disadvantages and Limitations:

1. A negative cytology does not exclude the presence of cancer. The negative
results may be due to improper technique or presence of dysplasia in deeper
layers of epithelium.
2. A positive report may be misleading in certain tumors showing varying
degrees of differentiation.
3. A positive diagnosis should be followed by further confirmatory procedures
e.g. biopsy before the patient is subjected to major surgery or radiotherapy.
4. It is only useful when there are desquamated free cells to be examined. Some
serious lesions are not suitable for this kind of biopsy due to the intact external
surface and absence of desquamated cells .

110
 Microbiological Tests
When Bacterial, Fungal, Viral or Protozoal Infection is Suspected, Certain
Tests are Sometimes Needed:
In general, either the pathogen itself is detected or the body’s reaction
against it.
 Methods to identify the pathogen (in pus specimen, oral swab or
tissues):
 Microscopy.
 Culture technique.
 Biochemical methods.
 Immunologic (antigen) test.
 Testing Serum for Antibodies (Serologic Test)
 Level and class of antibody.
 Low level of IgG class will denote previous infection or
immunization.
 High level of IgG or IgM class (four –fold increase) will
denote active infection.
 Methods to test serum for antibodies.
 Serological testing of serum to detect and measure antibodies
is based on using certain antigen which binds antibodies
present in the serum. The reaction is evident by agglutination
or enzyme-linked immunosorbant assay (ELISA).
According to the Suspected Pathogen Utilized Techniques will Differ:
I- Bacteria:
 Smear.
 Morphologically bacteria can resemble cocci, bacilli, vibrios,
spirilla or spirochetes.
 The gram stain is most widely used.
 Zeil Neelson stain is used for acid-fast TB bacilli.
 Dark-field microscopy is effective in examining unstained living
bacteria e.g. T. pallidum.
 Culture identification.
 Incubation of the media may be anaerobic or aerobic according to
the pathogen to be demonstrated.

111
  Serologic tests.
e.g. Serologic Tests for Syphilis:
a) Nonspecific treponemal tests (Venereal Disease Laboratory
Research VDRL) which detects antibodies against cardiolipin.
b) Specific treponemal test: indirect immunofluorescent treponemal
antibody-absorption (FTA-ABS) test is the most commonly used
specific treponemal test.
 Other Laboratory Tests:
 PPD (Purified Protein Derivative) Skin Test:
Used for the diagnosis of TB, depending on type IV (delayed)
hypersensitivity to TB bacilli, where intradermal injection of protein extract of
killed TB mycobacteria in an infected person causes redness , swelling and
induration 48 hours after.

II- Fungi e.g. Candida Albicans:

a) Smear.
 In unstained smear Candida yeasts are small, oval seen as single
budding.
 Using Periodic Acid Schiff stain (PAS) Candida can be seen
attached to pseudohyphae.
b) Culture identification of Candida albicans.
 Candida grows on Sabouraud’s agar to give cream coloured
colonies.
c) Serologic test.
 Patients with candidosis demonstrate high antibody titre against the
fungus.
III- Viruses:
 Laboratory findings in HSV infection.
 Cytology: giemsa stain shows:
 Multinucleated giant cells, ballooning degeneration of the nucleus
and intranuclear inclusion bodies (Lipschutz bodies).
 HSV isolation: rabbit kidney culture is used.
 Antibody titers: within 3 or 4 days of the onset of symptoms there
are no detectable antibodies. Antibody to HSV begin to appear in a
week and reach a peak in 3 weeks.

112
  Laboratory Findings in Herpes Zoster
 Cytology is a rapid method of evaluation that can be used in cases
where the diagnosis is uncertain.
 The most accurate method of diagnosis is viral isolation in tissue
culture
 Demonstration of a rising antibody titer is rarely necessary for
diagnosis except in cases of herpes sine eruption.
 Laboratory findings in infectious mononucleosis (Epstein Barr virus)
 Leukocytosis with some atypical lymphocytes
 Non specific tests for the heterophil antibody include:
 Paul-Bunnell test and monospot test. These tests are based on
the presence of Ig in patient’s serum which can agglutinate
sheep and horse red blood cells (respectively).
 Specific antibodies against EBV.
 Hepatitis viruses
 Blood chemistry
 Serum aminotransferase enzyme activities alanine
aminotransferase and aspartate aminotransferase (ALT and
AST) are increased.
 Serum bilirubin levels are increased and bilirubin is present in
the urine.
 Serology
 Hepatitis B virus (HBV)
HBsAg:
 Presents in the incubation period, chronic infection and carrier.
 Disappears at recovery
HBe Ag:
 Presents in active disease process and it is indicative for high
infectivity
Anti-HBc Ag:
 Presents in:
- Acute stage (IgM)
- Chronic stage (IgG)
- After recovery (IgG)
Anti-HBsAg:
 It means lifelong immunization

113
Hepatitis C Virus (HCV)
Diagnosis of HCV infection is based on detecting anti-HCV IgG in
patient’s serum.
To detect the viral RNA itself, polymerase chain reaction (PCR) is applied
to amplify the amount of nucleic acid in order to be visualized.

 Human immunodeficiency Virus:

 Haematological Tests:
Tests which can be performed and provide useful information in HIV
disease include:
 Total and differential white cell count
 Platelet count.
 Flow Cytometry
Can reveal decrease in CD4 cells
 Serological Tests:
Most tests used to diagnose HIV infection are antibody tests. HIV
antibodies are detectable in the serum of nearly all infected persons within 3
months of exposure.
 Enzyme Immunoassays (EIA) to detect antibody.
 Western Blot Test.

114
References:

 Coleman G.C. &Nelson J.F. : Principles of Oral Diagnosis, Mosby, 1993.

 Cawson , R.A. & Odell , E.W. : Cawson’s Essentials of Oral Pathology &
Oral Medicine ,7th Edition , Churchill Livingstone, 2002.
 Pramod J.R. : Essentials of Oral Medicine , Jaypee , 2003.
 Wood , N.K. & Goaz P.W. : Differential Diagnosis of Oral and
Maxillofacial Lesions , 5th Edition ,Mosby, 2006.
 http://www.qub.ac.uk/cskills/Oral%20examination.htm

115