Treatment Planning And Oral Diagnosis
Posted by John Doe at Dental Assistant on February 2, 2012.
Categories: Dental Secrets
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40. What are the major causes of pigmented oral and perioral lesions?
Pigmented lesions are due to either endogenous or exogenous sources. Among endogenous sources are melanoma, endocrine-related pigmentation (such as occurs in Addison's disease), and perioral pigmentation associated with intestinal polyposis or Peutz-Jegher's syndrome. Exogenous sources of pigmentation include heavy metal poisoning (e.g., lead), amalgam tattoos, and changes caused by chemicals or medications. A common example of medication-related changes is black hairy tongue associated with antibiotics, particularly or bismuth-containing compounds, such as Pepto-Bismol.
41. Do any diseases of the oral cavity also present with lesions of the skin?
Numerous diseases can cause simultaneous lesions of the mouth and skin. Among the most common are lichen planus, erythema multiforme, lupus erythematosus, bullous pemphigoid, and pemphigus vulgaris.
42. What is the appearance of the skin lesion associated with erythema multiforme?
The skin lesion of erythema multiforme looks like an archery target with a central erythema tous bullseye and a circular peripheral area. Hence, the lesions are called bullseye or target lesions.
43. A 25-year-old woman presents with the chief complaint of spontaneously bleeding gingiva. She also notes malaise. On oral examination you find that her hygiene is excellent. Would you suspect a local or systemic basis for her symptoms? What tests might you order to make a diagnosis?
Spontaneous bleeding, especially in the face of good oral hygiene, is most likely of systemic origin. Gingival bleeding is among the most common presenting signs of acute leukemia, which should be high on the differential diagnosis. A complete blood count and platelet count should provide data to help to establish a preliminary diagnosis. Definitive diagnosis most likely requires a bone marrow biopsy.
44. A 45-year-oh, overweight man presents with suppurative periodontitis. As you review his history, he tells you that he is always hungry, drinks water almost every hour, and awakens four times each night to urinate. What systemic disease is most likely a cofactor in his periodontal disease? What test(s) might you order to help you with a diagnosis?
The combination of polyuria, polyphagia, polydipsia, and suppurative periodontal disease should raise a strong suspicion of diabetes mellitus. A fasting blood glucose test is the most efficacious screen.
45. A 60-year-old woman presents with the complaint of numbness of the left side of her mandible. Four years ago she had a mastectomy for treatment of breast cancer. What is the likely diagnosis? What is the first step you take to confirm it?
The mandible is not an infrequent site for metastatic breast cancer. As the metastatic lesion grows, it puts pressure on the inferior alveolar nerve and causes paresthesia. Radiographic evaluation of the jaw is a reasonable first step to make a diagnosis.
46. What endocrine disease may present with pigmented lesions of the oral mucosa?
Pigmented lesions of the oral mucosa may suggest Addison's disease.
47. What drugs cause gingival hyperplasia?
- Phenytoin
- Cyclosporine
- Nifedipine
48. What is the most typical presentation of the oral lesions of tuberculosis? How do you make a diagnosis?
The oral lesions of tuberculosis are thought to result from the presence of organisms brought into contact with the oral mucosa by sputum. A nonhealing ulcer, which is impossible to differentiate clinically from carcinoma, is the most common presentation in the mouth. Ulcers are most consistently present on the lateral borders of the tongue and may have a purulent center. Lymphadenopathy also may be present. Diagnosis is made by histologic examination and demonstration of organisms in the tissue.
49. What are the typical oral manifestations of a patient with pernicious anemia?
The most common target site in the mouth is the tongue, which presents with a smooth, dorsal surface denuded of papillae. Angular cheilitis is a frequent accompanying finding.
50. What is angular cheilitis? What is its cause?
Angular cheilitis or cheilosis is fissuring or cracking at the corners of the mouth. The condition typically occurs because of a localized mixed infection of bacteria and fungi. Cheilitis most commonly results from a change in the local environment caused by excessive saliva due to loss of the vertical dimension between the maxilla and mandible. In addition, a number of systemic conditions, such as deficiency anemias and long-term immunosuppression, predispose to the condition.
51. What is the classic oral manifestation of Crohn's disease?
Mucosal lesions with a cobblestone appearance are associated with Crohn's disease.
52. List the oral changes that may occur in a patient who is receiving radiation therapy for treatment of a tumor on the base of the tongue.
- Xerostomia
- Osteoradionecrosis
- Cervical and incisal edge caries
- Mucositis
53. A patient presents for extraction of a carious tooth. In taking the history, you learn that the patient is receiving chemotherapy for treatment of a breast carcinoma. What information is critical before proceeding with the extraction?
Because cancer chemotherapy nonspecifically affects the bone marrow, the patient is likely to be myelosuppressed after treatment. Therefore, you need to know both the patient's white blood cell count nd platelet count before initiating treatment.
54. What oral findings have been associated with the diuretic hydrochlorothiazide?
Lichen planus has been associated with hydrochlorothiazide.
55. Some patients believe that topical application of an aspirin to the mucosa next to a tooth will help odontogenic pain. How may you detect this form of therapy by looking in the patient's mouth?
Because of its acidity, topical application of aspirin to the mucosa frequently causes a chemical burn, which appears as a white, necrotic lesion in the area corresponding to aspirin placement.
56. What are the possible causes of burning mouth syndrome?
- Dry mouth
- Allergy
- Nutritional deficiencies
- Chronic infections (especially
- Diabetes mellitus fungal)
- Psychogenic factors
- Blood dyscrasias
- Medications
- Anemia
- Acid reflux from the stomach
- Latrogenic factors
- Hormonal imbalances
- Inflammatory conditions such as lichen planus
57. What is the most important goal in the evaluation of a taste disorder?
The most important goal in evaluating a taste disorder is the elimination of an underlying neurologic, olfactory, or systemic disorder as a cause for the condition.
58. What drugs often prescribed by dentists may affect taste or smell?
- Metronidazole
- Tetracycline
- Benzocaine
- Sodium lauryl sulfate toothpaste
- Ampicillin
- Codeine
59. What systemic conditions may affect smell and/or taste?
- Bell's palsy
- Cushing's syndrome
- Multiple sclerosis
- Diabetes mellitus
- Head trauma
- Sjogren's syndrome
- Cancer
- Radiation therapy to the head
- Chronic renal failure and neck
- Cirrhosis
- Viral infections
- Niacin deficiency
- Hypertension
- Adrenal insufficiency
60. What is glossodynia?
Glossodynia, or burning tongue, is relatively common. Although the problem is frequently related to local irritation, it may be a manifestation of an underlying systemic condition.
61. What questions should a clinician consider before ordering a diagnostic test to supple ment clinical examination?
- What is the likelihood that the disease is present, given the history, clinical findings, and known risk factors?
- How serious is the condition? What are the consequences of a delay in diagnosis?
- Is an appropriate diagnostic test available? How sensitive and accurate is it?
- Are the costs, risks, and ease of administering the test worth the effort? Matthews, et al: The use of diagnostic tests to aid clinical diagnosis. J Can Dent Assoc 61:785, 1995.
62. Distinguish among the accuracy, sensitivity, and specificity of a particular diagnostic test.
The accuracy is a measure of the overall agreement between the test and a gold standard. The more accurate the test, the fewer false-negative or false-positive results. In contrast, the sensitivity of the test measures its ability to show a positive result when the disease is present. The more sensitive the test, the fewer false negatives. For example, one problem with cytologic evaluation of cancerous keratotic oral lesions is that of 100 patients with cancer, 15 will test as negative (unacceptable false-negative rate). Consequently, cytology for this diagnosis is not highly sensitive. The specificity of the test measures the ability to show a negative finding in people who do not have the condition (false positives).
63. What is FNA? When is it used?
No, FNA is not an abbreviation for the Finnish Naval Association. It refers to a diagnostic technique called fine-needle aspiration, in which a needle (22-gauge) on a syringe is used to aspirate cells from a suspicious lesion for pathologic analysis. Many otolaryngologists use the technique to aid in the diagnosis of cancers of the head and neck. It seems to be particularly valuable in the diagnosis of submucosal tumors, such as lymphoma, and parapharyngeal masses that are not accessible to routine surgical biopsy. Like many techniques, the efficacy of FNA depends on the skill of the operator and experience of the pathologist reading the slide.
64. Which systemic diseases have been associated with alterations in salivary gland function?
- Cystic fibrosis 8. Thyroid disease
- HIV infection 9. Autoimmune disease
- Diabetes mellitus (Sjogren's)
- Affective disorder syndrome,myasthenia gravis, graft-vs.-host disease)
- Metabolic disturbances
- Sarcoidosis(malnutrition, dehydration
- Autonomic dysfunctionvitamin deficiency)
- Alzheimer's disease
- Renal disease
- Cancer
- Cirrhosis
65. What is PCR? Why may it become an important technique in oral diagnosis?
Polymerase chain reaction (PCR) is a technique developed by researchers in molecular biology for enzymatic amplification of selected DNA sequences. Because of its exquisite sensitivity PCR appears to have marked clinical potential in the diagnosis of viral diseases of the head and neck.
66. What conditions and diseases may cause blistering (vesiculobullous lesions) in the mouth?
- Viral disease
- Pemphigus vulgaris
- Lichen planus
- Erythema multiforme
- Pemphigoid
67. What are the most common sites of intraoral cancer?
The posterior lateral and ventral surfaces of the tongue are the most common sites of intraoral cancer.
68. What is staging for cancer? What are the criteria for staging cancers of the mouth?
Staging is a method of defining the clinical status of a lesion and is closely related to its future clinical behavior. Thus, it is related to prognosis and is of help in providing a basis for treatment planning. The staging system used for oral cancers is called the TNM system and is based on three parameters: T = size of the tumor on a scale from 0 (no evidence of primary tumor) to 3 (tumor> 4 cm in greatest diameter); N = involvement of regional lymph nodes on a scale from 0 (no clinically palpable cervical nodes) to 3 (clinically palpable lymph nodes that are fixed; metastases suspected; and M = presence of distant metastases on a scale from 0 (no distant metastases) to 1 (clinical or radiographic evidence of metastases to nodes other than those in the cervical chain). (tumor> 4 cm in greatest diameter); N = involvement of regional lymph nodes on a scale from 0 (no clinically palpable cervical nodes) to 3 (clinically palpable lymph nodes that are fixed; metastases suspected; and M = presence of distant metastases on a scale from 0 (no distant metastases) to 1 (clinical or radiographic evidence of metastases to nodes other than those in the cervical chain).
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