Oral Medicine #2

Sorry for being late , I didn’t have the slides and the doctor said she’ll put them on the E-learning website , but unfortunately she didn’t (( till now ))  so I didn’t put the picz and the tables that were present in the slides.

So sorry for that 

Last week we talked about the oral mucosa and the normal structure of the oral mucosa, and at the end of the lecture we talked about the forms of medications we use in oral medicine . 1st we talked about the normal appearance of the oral mucosa , the normal changes or what changes we expect to see when the patient get older , and about other abnormal changes & how do they look like and how can you see them in this light !!!  and how can you see them in the clinic . We talked about treatment options ,the systemic medications and the topical ones ,creams & ointment ,and about the pastes (the orabase) because we use them a lot in oral medicine , and Why do we use steroids in oral medicine ??To reduce the immune response , we use them for allergic reaction , when I have an exaggerated immune response I use the steroids . Today , we are going to talk about special investigations

from the patient , sometimes we mange to know, The reasons for his pain we can get to a conclusion for what the problem is , but most of the times we need to examine the patient, so Taking history and examination are basics .

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complaint just by taking the history like for example: When he describe the

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When we have a patient in the oral medicine clinic, 1st we take the history

And after the history taking and the examination is done we should do further investigations like : – – – – –

Radiographs Blood examination . Biopsy . Microbial investigations. Allergy patch testing .

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Imaging techniques .

When do we need to use the blood examination !! If we saw any signs and symptoms that are suggestive for hematological abnormalities like : if the patient looks pale so 1st you’ll think the patient might have anemia so we do blood test to check if there is anemia or not , sometimes the reduced iron level in the blood is presented clinically in a recurrent oral ulcers , usually they are idiopathic but sometimes when the patient noticed that they become more frequent or very sever in this case it give us a clue that there might be a problem or a predisposing factor, and he should go immediately and check the blood level, The iron level , vit B12 level ,because sometimes decrease in these measures will increase the frequency in recurrent oral ulcers , Also persistence sore or dry mouth we should check for the anemia presence .

antifungal and you expect this infection should be healed in one week, And the patient didn’t respond to the medications , you’ll start thinking about the reasons why he is not responding to the medications , you’ll start to think about depression in the immunity , so I’ll do blood testing and check for the WBC’s count , to figure out what’s the reasons that the patient is not responding to the treatment .

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the patient came back and u noticed that there is still a fungal infection, and

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If the patient is having a fungal infection , you prescribed for him

You should check the Bleeding tendency too , like when the patient report that the last time he had an extraction, he had bleeding for a couple of days ,and he had to go back to the dentist and do suturing and it couz him a lot of trouble. So , if I want to do an extraction to a patient, I need to check that the bleeding time is okay the PT , PTT and all the measures should be normal . And if there is anything in the medical history indicate that the patient has a problem like he is anemic or used to be anemic in the case you need to follow this up with the patient and do the blood test .

Blood test includes: –

Hematological investigations

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The CBC , blood film , these are the basic standers of hematological investigations.

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Ferritin and iron levels , vit B12 , we do these when we suspect there is a deficiency like recurrent oral ulcer and sore mouth as we said .

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Coagulations screening .

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erythrocytes sedimentation rate .

it’s non specific guide for an abnormality like the patient is having a chronic infection or acute one , immune disease ,the ESR well be elevated . in the this test they do a centrifugation for the erythrocytes and rate the blood cells where they flow down in the tube when it increased, which means

Biochemical investigations only when needed , like blood glucose for example: when you have a patient that have a sever periodontal disease , and his oral hygiene is okay

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WBL’s which is an indication for an infection.

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the blood become more viscose , which mean there is lots of cells or lots of

we’ll start think of other systemic factors that causing this deterioration in his periodontal status, and one of the most causing factor is diabetes mellitus , or the patient is complaining of xerostomia , parestheia, ulceration and sensations in the mouth ,we do this test . –

urea and creatinine, if we suspect renal failure.

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liver function test .

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calcium and phosphate and alkaline phosphates in metabolic bone diseases like paget's disease, if we want to check for some abnormalities we do those testing.

Immunological investigations Includes: –

rheumatoid factor, if your patient came complaining of pain in the TMJ, it’s very tender and it’s not the only complaint but he is complaining of pain in all of his joints , so we check the rheumatoid factor , and if it’s +ve ,than we need to refer the patient to rheumatologist to follow this up .

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Antinuclear factor.

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SSA and SSB antibodies.

immunological disease .

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The C1 esterase inhibitor, we use this test for angioedma and for viral infection, if we suspect a viral infection we check for the viral antibodies if they are present in the serum.

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and we are testing for the presence of the antibodies that is causing the

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we use these to check for Sjogren syndrome , there are immunological tests

You’ll find the normal values on the book, it’s good to know the mine findings , the hemoglobin , the WBC’s , RBC’s , the blood film when there is a Microcytic anemia or Megaloblastic anemia ,and what causes them . Microcytic anemia caused by iron deficiency ,while Megaloblastic anemia by vit B12 deficiency .

Endocrine function test When a patient with orofacial symptoms caused by hormonal disturbances Like diabetes , Addison's disease, we can notice pigmentations of brownish macula’s , increased in the production of melanocytes and the under production of the corticosteroids , so when we see those signs on the oral cavity ,we have to refer the patient or we can check these tests like checking the cortisol level. patients on steroids is another example , if I’m giving the patient systemic steroids for a long duration like in autoimmune diseases, we need to check if there is a suppression on the corticosteroids hormone and the patient should be always under monitoring ,or maybe the patient is already having a endocrine disease ,he is diabetic or he is using steroids or for any other reason like Cushing syndrome and the signs are obvious on the patient than you need to do the testing to make sure that it’s safe to do the dental treatment for this patient .

this dye has a very high affinity to the DNA , when there is abnormal lesions on the oral cavity and you want to take a biopsy for this lesion , you want to take the most representative part of the lesion to send it to the lab for examination , you can’t judge or guess which one is more representative , the toluidine blue dye will help you to figure out which one is , because this dye goes directly to the DNA , and as you know when there is a cancerous

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Toluidine blue dye test

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one of the tests that is very useful for us in oral medicine is using the

activity there will be increased in the cell division rate , so there is lots of nuclei ,like 2or 3 nuclei in one single cell because of the repeated cycle of division , this areas with very high activity will be stained with the toluidine blue dye . for example here (plz refer to the slides) this is the whole lesion on the tongue and we were not sure which site we select for the biopsy , using the toluidine blue dye suggest this area , than I can take my biopsy within this blue area . this is how we use it : ( refer to the slides for the picz ) “sorry”  Like this lesion as you see it occupies all the cheek, I used the toluidine blue dye and put it on the cheek , the buccal mucosa ,Than I washed this dye using acid , than I asked the patient to rinse his mouth with water , the blue dye will be removed from the tissues and stay within the area with high activity and cell division and by that I know this region is a good choice for biopsy . One of the student ask a question but unfortunately I couldn’t hear it but the answer was: Particularly In our country they hate biopsy , the biopsy is equivalent for cancer , so sometimes you need to do biopsy not to exclude cancer but to know what is the diagnosis like in pemphigus and pemphigoid or any immune mediated diseases ,and u need to do a biopsy to confirm your diagnosis .

or not , so if there is no area stained with toluidine bule , you know it’s not conclusive but you can say it appears that there is no high activity of cell division but you can’t be sure without a biopsy , so this is might be away to convince the patient either to do a biopsy , or you may think to leave it for a while and ask the patient to come back for a review .

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there is anything sinister, anything serious that you need to take the biopsy

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If the patient denied the biopsy this might be an indicator for you that if

Of course using the toluidine blue it’s not alternative for a biopsy ,it’s not another way , it’s just for you to help you to get to a clinical judgment , For what would be your advice to the patient ,is it an argent biopsy !! or the patient can comeback for review after a while .

The indications for biopsy –

Lesions which has neoplastic or pre-malignant features like :

Leukoplakia , erthroplakia , non healing ulcer , these are some of the premalignant lesions or highly suspicion lesions , so when there is red or white lesion unexplained by friction or by irritation , than you need to take a biopsy for this lesion to make sure what it is .

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Persistent lesions of uncertain etiology. Some times when we notice a white lesion in the oral cavity , we try to eliminate any causes like : sharp tooth edge , and ask the patient to come back after a week , and if lesion is still there and didn’t heal , than this will be an indication to take a biopsy to get to a diagnosis .

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Persistent lesion failed to response to treatment Like Candida infections , sometimes the fungal infection is presented as a white lesion and it doesn’t go away by wiping the lesion ,in this case we prescribe an antifungal medication to the patient and ask him resolve and the mucosa will get back to normal and in some patient it take a biopsy to check if there is any abnormalities in the cells .

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Conformation of the clinical diagnosis and lesions causing to the patient extreme concern . Sometimes the patient is really concerned about growth , Like fibroepithelial polyp , you know it’s a fibro- epithelial polyp but you can’t find the causing for this irritation which leads to this growth , but the

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doesn’t , in this case it might be a pre-malignant lesion so we have to

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to come back after one week ,in most of the patient the infection will

patient is not happy to have this growth within his mouth , either because it irritating for him being inside his mouth , or because he is really concerned and want to get rid of it !!  in this case we might do a biopsy . Different methods of biopsy –

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We have brush biopsy. Incisional biopsy. Excisional biopsy. Punch biopsy. Fine needle aspiration (FNA). This is the set you need to take a biopsy (back to slides) We need topical anesthesia, and the most important think is that you don’t inject the anesthesia very close or within the lesion because this will destroy the tissue that you want to examine. So you’ll inject the anesthesia away from the lesion but in area that the analgesic or the anesthetic will reach the region where are you going to take your biopsy. You need the container where you should put the specimen, and you need a form to write down your provisional diagnosis , the patient name ,age , file number, and to write down from where you took the biopsy , and draw the shape and size of the lesion and how it appear clinically .

tweezers or any other instrument, because if you did it’ll destroy the mass or will destroy the lesion , in this case the alternative way is to use the sutures ,you just put the suture in the middle of lesion and do the incision and get the specimen , put it in the container and send it to the lab .

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grab the over growth tissue or the lesion, and you can’t use the

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Of course we need suturing, sometimes even if you want to catch or

• Brush biopsy Very simple method, but it’s not very accurate as the incisional or the excisional biopsy. The idea behind it, is for example here (refer to the slides of the picz) this patient we suspected something wrong here, a white lesion on this lower lip , we can do a brush biopsy , using like this brush , just scraping over this lesion to take samples of the cells that present in the lesion . You need to be a little hard to get to the deep parts of lesion, and you’ll know you are doing it in the right way if you noticed bleeding or some blood oozing from the surface where you got your biopsy, if there is no bleeding or any blood on the sample side. that means your sample isn’t correct , and what you got in your sample will be just epithelium from scraping the surface , when using this way you don’t need to give the patient any type of anesthesia, it’s like you are creating erosions not a cut on the mucosa. Here there is a brush, you spread it on the slide and you need an expert on the cytology to examine these cells if they are normal or if there is any abnormality . For example here , you can notice there is the nucleus ratio to the cytoplasm is very huge , and this an indication for abnormal changes in the cells . This method is very simple , the patient will accept it , the problem is cancerous cell because you took the wrong cells , and you gave the So again it’s not an alternative, but it’s another way just to double check that if there is anything wrong , if you noticed any abnormality on the cells this will give you the information that you need to do a biopsy to confirm your diagnosis .

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patient an indication that everything is okay while it’s not .

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with the false +ve and false –ve results , it’s very often you miss

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Incisional biopsy

Here we take parts of the lesion not the whole of it , and again we have to select the most representative sits if the lesion , maybe we can use the toluidine blue to guide us where is the most representative sits , and it’s a good practice to do the biopsy this way take it like a wedge shape this will help to reduce of the trauma and it’ll be easier for suturing . Another good practice is to take parts of the normal tissue , and this normal tissue will allow you to compare or to make sure where you are exactly in the slide , so we take the borders of the normal tissue and parts of the abnormal tissue .

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Excisional biopsy

We take out the whole lesion when we use this way , we use it when the lesion is small in size and I can take the whole of it , and again you have to take it with a safety margins, so I can see in the slides there is a safety margins where the tissue should be normal , around the lesion or around the abnormal area , so that I can be sure that I did take all the abnormal lesion in my biopsy .

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Punch biopsy

It’s another type of biopsy , it have the same concept but we are using to make the incision or to take the biopsy , and most of the patients one click and you’ll take out the sample .

• Fine needle aspiration (FNA)

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prefer this way because you won’t cut the incision with a scalpel , just

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this punch to take or to grab a piece , we don’t need to use the scalpel

If there is cyst of there is collection of pus, I can aspirate amount of this fluid and send to the lab to check what is the content of the cyst We use it for the thyroid enlargement to check this growth if it’s a mass or a cyst containing a fluids or an abscess. For some diseases taking a biopsy is not adequate, like for example here in pemphigus or pemphigoid, to diagnose those diseases we use immunofluorescent stains , these diseases are immune mediated , there is an increase in IgG,and this IgG is affecting the whole cells as you can see here , all cell membranes are affected with these antibodies . What we do is we use an antibody for this antibody which is circulating around the cells , and this antibody is fluorescently labeled , and the anti-antibody will bind here and will be obvious under UV light , we can see all cell are affected we can diagnose the patient with pemphigus . In this one here we did exactly the same, we know there is an increase in the immune antibody IgG , but here they are presented mainly in the basement membrane in the basal cell layer , by dyeing this section with anti-antibodies which contain a fluorescent dye, it’ll attach only to the cells that are present in the basal cell layer where the antibodies are present .

infection , for bacteria is swab and culture , and than you can know the type of bacteria , we can do testing for sensitivity by doing a sensitivity test to select the most appropriate antibiotics for this bacteria , if there is a pus present In cyst like lesion we can just aspirate and do a culture to know the type of bacteria and to select the appropriate type of antibiotics .

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If you want to check for the presence of bacteria or virus of fungal

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Microbiological investigations

For the fungal infection we use a swab and smear , we just take a swab from the site of the infection , spread it on a slide and send it for the lab , they will check for the presence of fungus in these cells . as we said on the beginning of this lecture that some fungal infection are not superficial but they are very deep and they might cause dysplastic features in the cells , and in this case we need to take a biopsy to know how dysplastic the cells are !! and if there is any malignant changes or not . One common way to diagnose fungal infection is just to try antifungal treatment , if you suspect a fungal infection like you found a red lesion on the mouth or in the palate and you suspect that this is a fungal infection , just give the patient antifungal and ask him to come back after one week and by that time it should be resolved , so if it’s cute that’s it , it wasn’t fungal infection . For viral infection , it’s either I detect the antigen itself by immunocytochemistry or by serology , we check for the antibodies titer for this virus , if we found it very much elevated that means this patient is infected with the virus , or we can use the new techniques , like using the DNA or the genome of the virus , they take a sample and do the PCR which is a technique used to amplify the genome of the virus , if it’s present that means the virus is present .

What dose it test for , or what do we use it for ?? To check for type IV delayed hypersensitivity reaction , sometimes the patient come to you complaining that he can’t tolerate the denture , he had the denture like 2 weeks ago and he did wear it for 1 or 2 day’s and he can’t put them on again , cause when he put the denture he feels like burning sensation , so one of the explanation will be

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Allergy patch testing

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Another test we use in the clinic is the

present of allergic reaction , to check for that If the patient is allergic for the acrylic component monomer , or if it’s CR-CO we have to check if this patient is allergic for any type of those metals or alloys that involved in the prosthesis , so I do the allergic test ,and all what I need to do is to put small amounts of this allergen for all the materials that you suspect it might cause the allergy , and I use another control like normal saline , put it on the patient hand and leave it for 24 -48 hrs , and ask the patient to come back and than I check if there is any presence for any allergic reaction Like in this pic material number 3 caused allergic reaction , so I’ll confirm that the patient is allergic for example to acrylic or any type of metal , or amalgam. For example if the patient has a leuconoid reaction, in Uk for example The insurance well cover only amalgam fillings , it doesn’t cover composite fillings and the patient came to the clinic complaining and there is a leuconoid reaction and burning sensation , than we have to do this test to confirm that he is allergic to amalgam and give him report that this patient is allergic to amalgam , in this case is replacement of the amalgam filling for a composite fillings was covered by the insurance company . So if we want to confirm if the patient is allergic to any type of material we use this test .

Imaging technique

But we use imaging techniques very often , almost all our patients we need to have a radiographs for them , particularly if the problem is affecting the jaws , we take periapical or bitewings for caries for example ,Extra oral radiographs like the OPG’s to check for example for a cyst , any retained root or any abnormality within the jaws . Of course there is another type for the imaging techniques like

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cover these in radiology course 

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I’m not going to talk very much about it , because we are going to

Sialography , we use it to check if there is any blockage or any problems with the salivary glands , we inject a contrast media, to the ducts , and have radiographs and follow and see if this media is going smoothly through the canals of the ducts , this means that everything is normal , if we find there is hazy or snow storm appearance or there is a blockage in one of the ducts , this might lead us to the cause of the problem , like the presence of a stone in the duct . CT scans , ultrasounds , used particularly for TMJ problems Magnetic resonance images (MRI) is good for soft tissues rather than hard tissues . After doing all this methods for diagnosis and after getting the reports , in this case we can get to the final diagnosis so .. 1st we start with the 1- differential diagnosis when I do the history taking and the examination , I’ll have a list of differentials diagnosis For example like if I have a while lesion , Is it a hyperkeratosis !! or leukoplakia , fungal infection . Or if I have an ulcer I have again a list of differentials ,Is it a recurrent oral ulcer!! , or immune mediated disease ulcer , is it a cancer or traumatic ulcer .

Than I go to the 2-provisional diagnosis , which is the most likely to be the cause , and finally I get to the 3- definitive diagnosis , when I

The end Done by

Sukinah Al-fraid

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the biopsy or the tests that I have done to the patient .

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confirm my diagnosis according to the investigations that I did like

The doctor announce You can find the lectures on the E-learning ( but I didn’t ) lol Also the Essentials of Oral Medicine book and there is another radiology book ( didn’t say the name of the book ) it has nice illustration for bitewings and perapicals You could get use of them because we use them a lot in oral medicine .

Feedbacks are more than welcome Your colleague

Sukinah Al-Fraid Peace out 

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