Diagnosis and management fo oral medicine and oral surgery: problems

Question 1

Steps to diagnosis

Answer 1

History
Examination
Diagnosis or differential diagnosis
Special tests and investigations
Refine/ modify diagnosis
Management strategy

Question 2

History is to gain info about

Answer 2

The condition
Previous experience of dentistry
Health of pt
-management, oral manifestations of systemic conditions, iatrogenic disease
Family history
Social history

Question 3

history for recurrent oral ulcers

Answer 3

Onset
How many
How often
Size
Shape
Healing time
Areas affected
Max ulcer-free period
Effect on quality of life
Previous treatment
Family history?
Genital ulcers?
Skin rashes?
GI problems?
Joint problems, eye problems?
Relevant medical history?
Relevant drug history?
Recent smoking cessation?
Association with menstrual cycle?
Impact of stress?

Question 4

Crop of ulcers is called

Answer 4

Herpetiform

Question 5

Why is PMH important

Answer 5

Oral disease may be a manifestation of a systemic disease (e.g. oral ulceration in inflammatory bowel disease)
Oral disease may be iatrogenic (e.g. oral ulceration due to nicorandil)
Management of oral disease may be affected by systemic disease (e.g. systemic treatment and pregnancy or liver disease or even arranging a biopsy of a patient with bleeding disorder)

Question 6

Extra-oral examination

Answer 6

General appearance
Symmetry / swellings
Lymph nodes
TMJ and muscles

Question 7

Intra-oral examination

Answer 7

Mucosa
Lubrication
Oral hygiene
General dental condition

Question 8

Differential diagnosis of white areas with some erythema

Answer 8

Lichen planus

Oral dysplasia

Question 9

Investigations

Answer 9

Tissue sampling

Biopsies

Question 10

When to do biopsies? (5)

Answer 10

To confirm the diagnosis (e.g. oral lichen planus)
To exclude other pathologies (e.g. oral epithelial dysplasia)
When we are not sure of the diagnosis (e.g. white patch – frictional keratosis? Lichen planus? Chronic hyperplastic candidosis? Dysplasia?)
When we remove a lump (e.g. mucocele, polyp – the tissues are sent for histopathological examination)
When a lesion changes (e.g. known lichen planus plaque becomes speckled)

Question 11

Types of biopsies (4)

Answer 11

Inicisional
Excisional
Core
Fine needle aspiration

Question 12

When to do blood tests (4)

Answer 12

To check there is no underlying condition leading to the oral disease (e.g. anaemia or haematinic deficiency leading to mouth ulcers or uncontrolled hyperglycaemia leading to oral candidosis)
To monitor the condition (e.g. Sjogren’s syndrome patients developing lymphoma)
To ensure it is safe for a patient to receive the treatment (e.g. prior to commencing systemic immunosuppressants to control severe erosive oral lichen planus)
To monitor it is safe to continue the treatment (e.g. systemic immunosuppressants)

Question 13

Types of blood tests (6)

Answer 13

Haematology (e.g. full blood count)
Clinical chemistry (e.g. liver and renal profiles)
Coagulation (e.g. INR)
Immunology (e.g. autoimmune profile)
Microbiology/virology (e.g. syphilis, HIV)
Special clinical chemistry (e.g. tumour markers, enzymes)

Question 14

Vacutainers (2)

Answer 14

There are different vacutainers .Sometimes several tests can be done from the same tube, but sometimes one test requires more than one tube.

Question 15

Other special investigations (6)

Answer 15

Imagining – radiographs, CBCT, ultrasound, MRI, sialography
Oral rinses, swabs
Sialometry
Shirmer’s
Dental – probing, percussion, vitality
Clinical – e.g. applying a pressure with a glass slide on a suspected vascular lesion to see if it blanches.

Question 16

Who’s responsibility is it to ensure the results are checked and appropriate action is taken?

Answer 16

The requesting clinician

Question 17

Factors to consider when presented with xerostomia (4)

Answer 17

Underlying medical problems
Drug therapy
Auto-immune disease
Candida infection

Question 18

Immediate aim for the consultation (6)

Answer 18

Make a working diagnosis and arrange special tests if required to confirm it
Address patient’s concerns and reassure if appropriate
Inform the patient of the diagnosis, if possible, and discuss it in detail. Give patient information leaflet.
Consider patient’s discomfort and dysfunction – pain relief (e.g. benzydamine hydrochloride mouth rinse in oral ulceration)?
Educate – smoking and alcohol, diet, oral hygiene, dental follow up
Can the problem be easily solved (e.g. adjusting dentures, smoothening a sharp filling/cusp)?

Question 19

Short-term management (6)

Answer 19

Reassure if appropriate
Educate about the condition and management
Address risk factors
Can the oral disease be managed with medications (e.g. steroid mouth rinses for oral ulcers)?
Do we need to do more investigations?
Arrange adequate follow up

Question 20

Long-term management (5)

Answer 20

Reassure if appropriate and address patient’s concerns
Educate about the condition and management, and self-monitoring
Address risk factors – smoking, alcohol, betel products, poor diet
What can be done to control the condition? E.g. use of steroid mouth rinses prn to manage oral ulceration, systemic immunosuppressants to control severe erosive oral lichen planus.
Who and how will be following the patient up? GDP? Educate the patient and involve the GDP.