This new edition has been fully revised to bring dental students fully up to date with the latest advances in oral medicine. Divided into five sections, the book. This book, written by world authorities in the field, is a comprehensive, up-to-date guide to the specialty of Oral Medicine, which is concerned with the diagnosis. Impact of Oral Health on Interprofessional Collaborative Practice, An Issue of Dental Clinics of North America. Leslie Halpern. Sep $ Add to Cart.
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Reactive hyperplasia of the lymphoid tissue at the postero-lateral borders of the tongue re- sulting in a swelling can sometimes be mistaken for lymphoma. Size The size of the localized swelling should be measured and recorded. Statements such as large, medium or small or comparison with eggs, peanuts and so on, should be avoided.
Some benign tumours of the jawbones can grow to an enormous size over a period of time. Acute inflammatory swellings e. Swellings caused by chronic odontogenic infection may be localized and do not involve large areas.
Colour and Temperature The surface of the vascular swelling such as haemangioma may be red, blue or purple depend- ing upon the amount of reduced haemoglobin present in the vessels and the depth of the layer of the skin or mucous membrane through which the tumour is seen.
In swellings caused by extravassated blood haematoma , the pigments from red blood cells may produce a range of colours from red to dark blue and brown. Most swellings caused by melanoma exhibit brown or black colour. Skin nodules containing lipids called Xantho- mas , which are often seen on the skin around the eyelids in hyperlipidaemia are yellow in colour. Lipoma on the other hand may show slight yellow colour. In children eruption cysts frequently present blue coloured swelling coronal to the erupting tooth.
Neuroectodermal tumour of infancy is char- acterized by the presence of brown to black pig- ment melanin on its mucosal surface. Nodular swelling of traumatic neu- roma of the oral soft tissues which is a reactive lesion involving the nerve is almost always pain- ful. Cystic swellings of the jawbones are usually painless unless they are secondarily infected.
Crepitus Swellings of the jawbones due to fracture may elicit Crepitus on palpation. In a large ameloblas- toma Crepitus may be felt due to thinning of the cortical plates.
Movement A swelling may be either attached to or free from the surrounding structures such as bone, skin or muscle. Fixation to deeper structures is also a feature of malignant tumours. Nodular mucosal swellings can be attached to the underlying structures either by a broad base sessile or by means of a narrow pedicle pedunculated.
In the neck region, the presence or absence of movement of a swelling during normal body movements gives a clue as to the nature of the swelling. For example, most thyroid gland swell- ings goitre move with the act of swallowing whereas invasive thyroid carcinoma swelling may be immobilized due to the fixation to surround- ing structures. Very large goiters may also be immobilized during swallowing because they occupy all the available space in the root of the neck.
Carotid body tumour in the neck cannot be moved by the examinee vertically; only lateral movement is possible. The term thrill is used to denote the palpable vibration accompanying a vascular murmur or pulsations. Biopsy of these lesions should not be attempted in the dental clinic. Surface Texture The surface of a swelling may vary from uni- formly smooth to grossly irregular. Important clues pointing to the probable pathological process of the lesion can be derived from the surface texture. Margin Margins of the swellings may show variations.
Cervical lymph node enlargement due to regional metastasis of oral squamous cell car- cinoma is one such example. Other Methods Depending on the probable cause and nature of the swelling e. Examination of Swellings Inspect the mass carefully, noting any change in the colour or surface characteristics. Palpate gently to elicit any tendemess and any change in the temperature. Proceed with palpation in order to define the site and shape of the swelling. Determine whether the mass is pulsatile or not.
This is assessed by keeping the palpating hand still for a few moments on the swelling. Fixation of the deeper structures is assessed by attempting to move the swelling in different directions. Fluctuation is best performed and confirmed in two planes fingers on vertical and horizontal planes. Auscultate for vascular bruits and other sounds using a stethoscope. Transillumination if required can be carried out by pressing the lighted end of a pen torch into one side of the swelling.
This is to be carried out in a dark room. Aspiration of the contents of a swelling e. In healthy subjects palpable cervico-facial lymph nodes are often detected. The submental, submandibular, pre-auricular, tonsillar, supraclavicular and deep cervical nodes are examined from behind the patient. Lymph nodes located at the back of the neck and poste- rior triangle, and those at the posterior auricular and occipital region are examined from the front of the patient.
When lymphadenopathy of un- known local cause is detected, it is important to determine whether the liver and spleen are also enlarged. Ulcers may or may not be symptomatic. In accessible parts of the head and neck, patients usually notice ulcers. Occasionally, however, painless ulcers on the inaccessible parts of the oral cavity may remain unnoticed by the patient. Questions to be asked regarding ulcers are as follows: Where was the Ulcer First Noticed?
Location of the ulcer is an important indicator of the nature of the pathology. Attention to the Ulcer? Was it pain? Is it painful? Aphthous ulcers generally heal in one—two weeks. Has it changed shape? Has it recurred on the same or other site?
Such as trauma, colds, etc. Pemphigus vulgaris Peeling of the epithelium e. Fever e. If so, try to assess the severity and type of injury. Examination of an Ulcer Inspection Size and Shape Traumatic ulcers may be of variable size and shape. Those caused by sharp cusps of the molars for example often tend to conform to the shape and size of the offending tooth cusp.
Tuberculous ulcers are generally oval in shape. When multiple ulcers coalesce, an irregular ulcer outline may be seen. Syphilitic ulcers are generally circular or semi- circular in the initial stages. These may become serpigenous creeping with a wavy margin at a later stage. Carcinomatous ulcers are irregular in siie and shape. Some may be small whereas those that have been present for a longer time may be large in size.
Recurrent aphthous ulcers are small and round with a red halo around them. Traumatic ulcer is generally single. Ulcers derived from pre-existing vesiculo- bullous lesions can be multiple in number. Those of acute necrotizing ulcerative gingivitis are multiple. Aphthous ulcers are generally located on the non—keratinized areas of the oral cavity e.
Malignant ulcers may occur anywhere in the oral cavity. Most common sites, however, include buccal mucosae, alveolar sulcus, and lateral borders of the tongue. A malignant ulcer on the posterior part of the dorsum of the tongue is extremely rare.
Ulcers of the basal cell carcinoma are common on the face around the canthus of the eye and generally do not occur intra-orally. Syphilitic ulcers occur at the site of the tissue contact with the causative organisms during the sexual act.
Chancres are common on the Vermil- ion of the lip. Gummatous ulcers are generally located on the palate followed by the tongue. Ulcers developing from the vesiculo—bullous lesions can be located anywhere in the mouth although the majority of these are seen on the non-keratinizing mucosa.
Ulcers of acute necrotizing ulcerative gingivitis are typically located on the gingival papillae. Edge not the Margin of an Ulcer The edge of an ulcer can show any of the following features: Undermined edge This is commonly seen in a tuberculous ulcer. Punched out edge This is a feature of the gummatous ulcer. In this situation the edge drops down at right angles to the surface.
Sloping edge Traumatic ulcers that show signs of healing present sloping edges. Raised edge Basal cell carcinomas of the skin show a raised and pearly—white beaded edge of the ulcer. Adenocarcinomas also present everted edges. In these categories the fast growing malignant ulcer edges heap up and spill over the normal mucous membrane or skin and produce everted edges. This shows the following features: A black coloured floor may indicate malig- nant melanoma.
Discharge A healing ulcer will show scanty serous discharge. A spreading and infected ulcer may show purulent discharge. Tuberculous and malignant ulcers A red halo seen around the recurrent aphthous ulcers is a char- acteristic feature. In some cases the surrounding area of an ulcer may show pigmented spots or patches as in ulcers of malignant melanoma.
Paloation Tenderness An acutely inflammed ulcer is acutely tender e. Tuberculous ulcers and syphilitic ulcers may be mildly tender. Neoplastic ulcers are generally non-tender unless they are secondarily infected. Careful palpation of the edge and surround- ing tissue of the ulcer gives important clues to diagnosis. For example, induration hardness of the edge of an ulcer is a sign of carcinoma.
Induration of a milder degree can be felt on the edges of syphilitic and gummatous ulcers. Base of an Ulcer The base of an ulcer refers to that part on which the ulcer rests. In Carcinomatous ulcers the base is indurated hard. Chronic ulcers tend to show a milder degree of induration. Healing ulcers such as major aphthae also often show induration. Depth of an Ulcer The depth of an ulcer may be shallow or deep. Most traumatic ulcers are shallow. This de- pends on the degree of trauma.
Major aphthous ulcers may often be deep. Malignant ulcers may be deep, often reaching the underlying tissues such as bone.
Punched out ulcers of acute necrotizing ulce- rative gingivitis may often be deep. Ulcers arising out of vesiculo—bullous lesions are generally shallow. Bleeding in an Ulcer Bleeding of an ulcer on slight touch may be a common sign in malignancy.
Healing ulcers with granulation tissue may also show minute bleeding if the area is disturbed. If the crust of the lip as in erythema multiforme is removed the exposed part may show bleeding of a milder degree.
Loss of sensation around an ulcer may be a sign of nerve lesion as in cases of lepromatous leprosy. Association with the Regional Lymph Nodes Examination of an ulcer should include the examination of the regional lymph node.
In acutely inflammed ulcers regional lymph nodes are generally enlarged and tender. In tuberculous ulcers regional lymph nodes become enlarged, matted and mildly tender. In primary and secondary syphilitic oral ulcers cervical lymph nodes are palpable. In gummatous ulcers the lymph nodes are generally not involved. Other Important Aspect: If an ulcer is clinically suspected to be due to syphilis, thorough search elsewhere in the body should be carried out. Chest, abdominal and neck examination is to be carried out if the ulcer is suspected to be of tuberculous origin.
Routine hematological examination is essential in most cases of ulcers. Examination of urine to rule out diabetes is necessary when healing of an ulcer is delayed. If discharge is present, bacteriological exami- nation of the ulcer must be carried out. If tuberculosis is suspected Mantoux skin test is to be performed.
Sus- pected malignant ulcers must be biopsied at the edge of the ulcer and a portion of the normal appearing tissue should be included in the biopsy specimen. Histopathological opinion of the tissue must be sought as soon as possible. Exfoliative cytology is often used in suspected malignant ulcers but this must be followed by a biopsy and histopathologic report.
Imaging techniques. These have become in- creasingly useful in situations such as malignancy. Suggested Further Reading 1. Bates, Barbara Lippincott, Philadelphia. I-lalstead, C. Physical Evaluation of the Dental Patient. The C. Mosby Company, St. Coleman, G. Principles of Oral Diagnosis.
Mosby Year Book Inc. With the medically compromised patient population on the increase, the need for dental practitioners and students to be aware and knowl- edgeable of the applications of clinical labora- tory investigations in dentistry has become very real. How useful are the Clinical Laboratory Investigations? Clinical laboratory investigations are useful in: Screening Tests Screening test results provide evidence of disease.
In most instances the patient may be asymptom- atic. Examples of screening tests include blood glucose estimation for screening diabetes and haematocrit values for anaemia.
Screening tests must be sensitive which means that the test is per cent positive when a person has the disease. Often however, positive results are recorded when the person has a disease other than the one for which the screening test is For example, VDRL serologic test for syphilis may give positive result for patient who has had recent vaccination or acute viral infections.
Screening tests therefore should not be used for the purpose of confirmatory diagnosis. Ideally in these tests, per cent of normal persons would give negative results. The former is a screening test, which is carried out to screen antibodies to the protein components of the virus. The latter, on the other hand, detects individual viral proteins.
The dental practitioner can collect the samples from the patient in the clinic and send them to the appropriate sections of the clinical laboratory. Depending on the clinical circum- stances, the clinician may also send the patient to the laboratory with requests for appropriate in- vestigations. It is essential that the clinician is aware of the different functional units or sections of the clinical laboratory to which samples or the patients from dental clinics are sent.
Haematology Haematology deals with investigations of abnormalities of the cells of the blood, their precursors and of the haemostatic and clotting mechanisms. The main purpose of these examinations is to detect and identify the microorganisms that are responsible for the causation of various diseases. Antibiotic sensitivity tests also come under the scope of microbiology.
Biochemistry Also called chemical pathology, this discipline deals with investigations of the metabolic abnor- malities of the body in disease states. Immunologyl S erology Immunology deals with the detection of abnor- malities in the immune system.
The primary role of serology is to diag- nose infectious disease by observing the presence of an antibody in the patient that resulted from infection or entry of the pathogen antigen into the body.
The semi-quantitative measure of the amount of antibody present in the serum is called a titer. The application of immunological techniques to other branches of investigative pathology is also possible.
An oral histopathologist microscopically examines appro- priately stained tissue sections obtained from biopsy procedures. Biopsies are commonly per- formed and these tissue sampling procedures are carried out in dental clinics. Cytopathology This literally means the study of abnormal cells.
The clinician collects a sample of abnormal cells from lesional tissue scrapings or by means of needle aspirations. Cells are then stained and studied by light microscopy. Electron microscopy is not used commonly for diagnostic purposes in dental practice. Often, a dental practitioner is faced with the- dilemma as to what investigation to order in a given clinical situation. Undoubtedly, clinical laboratory investigations are an extension of the clinical examination.
The plan of investigation therefore should be decided from the facts gathered by history-taking and physical and other such as radiographic examinations.
Such conditions may be diagnosed by subjecting appropriate samples from the patients to certain clinical laboratory tests. There is a wide range of laboratory investiga- tions available today.
The following investigations are available to the practising dentist. Some are commonly used: Laboratory investigations should not be carried out as a routine. They must be selective and done only when indicated. In general, investigations become necessary when: El Oral diseases may be closely associated with a systemic disorder. CI Those patients with surgical risk require surgery under general anaesthesia. CI Genetic or heritable basis of disease or disorder is suspected.
The identification of the offending microbiological agent is crucial. El The response or sensitivity of the microbial agent to antibiotics is to be determined. Some microorgan- isms may show resistance to certain antibiotics. D The follow-up of a patient by monitoring the natural history of a disease or treatment is necessary.
Specimens also called samples for investiga- tions can be collected either in the clinic by the dental practitioner and sent to the laboratories or in the clinical laboratory by trained technicians. In dental practice however only a few of these are of relevance. The cycle begins with the patient who consults a clinician because of signs and symptoms pointing to an infectious disease. An appropriate specimen for culture must be collected and a transport medium selected that would maintain the viability of any pathogenic organism during the transit.
The specimen must be material from the actual site of the infection and should be collected with minimum of contamination from adjacent tissues or secretions. Throat swabs for strepto- coccal screening for example should be taken from the peritonsillar fossae while avoiding contact with the parts of oropharynx.
Deep oro- facial abscesses must be aspirated. In general, samples collected from swabs are inferior in collection of material as compared to those from aspiration procedures. Swabs must be placed in a transport medium or a moist container to prevent drying and death of bacteria.
The use of swabs for recovery of anaerobic bacteria is discouraged, rather aspiration with a needle and syringe is recommended. In either case, specimens once collected should not be exposed to ambient oxygen. Transport contain- ers for this purpose are available commercially. Time delay between collection of specimen and inoculation of media should be kept to a mini- mum.
This is critical. Whenever possible, cul- tures should be obtained before the administration of antibiotics. In order to avoid breakage during transport by mail to distant laboratories, sterile propylene or polyethylene containers may be used particu- larly if the sample is sent for recovery of myco- bacteria and fungi.
Observations made on the identity of the pathogen may be conveyed to the clinician im- mediately. One or more culture media are selected. Success with any viral diagnostic method is contingent upon proper specimen collection and transportation. Specimens for culture and direct antigen detection should be obtained during the active stage of the disease when viral shedding is the highest.
Viral transport medium should con- tain a buffered salt solution; protein stabilizer, pH indicator and antibiotics to inhibit unwanted bacteria.
Commercially available media are satis- factory for short-term 24 hours usage. Blood samples for virus isola- tion should be held at room temperature at all times. Viral cultures are set up the same day that specimens arrive in the laboratory. Collection of Blood Samples for Haematology Blood samples for haematological investigations are collected in three ways: Skin puncture 2. Venous puncture venous blood , and Heel is the preferred puncture site in infants.
Ear lobe can also be used as the puncture site. Veins used for venipuncture are veins of ante-cubital fossa; in particular median cubital or cephalic veins. Venipuncture method involves drawing of blood from the vein with the help of a sterile dry syringe. The disposable blood collecting tubes are preferred to the syringe. Arterial blood obtained by arterial puncture radial, brachial or femoral arteries is used to measure oxygen and carbon dioxide tension as well as blood gases.
Preparation of Blood When blood is drawn out of a blood vessel, it clots within minutes. Ifthe clinician wishes to study cellular components of the blood, it is important that the sample of blood is made avail- able unclotted. Collected sample therefore needs to be mixed with an anticoagulant that stops the process of clotting. Most anticoagulants except heparin remove calcium that is one of the essential factors required for the clotting process.
Heparin acts by destroying thrombin and thromboplastin that play a key role in the clotting process. EDTA is the anticoagulant of choice for most haemato- logical studies. Citrated blood is used for coagu- lation studies. Anticoagulated unclotted blood is known as whole blood. Fluid portion of the unclotted blood is called plasma. Plasma is used for coagulation studies. Fluid portion of the clotted blood is called serum. This is collected without any added chemical. Clotted blood is required for blood grouping and cross matching.
Serum is used for biochemical and serological studies. In order to obtain serum, blood is drawn by venipuncture and collected in a plain tube.
Specimen is allowed to clot for 30 minutes at room temperature and centrifuged at rpm for 10 nrinutes. Serum is then separated by means of a Pasteur pipette. Storage of Blood Specimen For red cell count, haemoglobin estimation, haematocrit estimation and total WBC count, and differential blood cell count, blood specimen can be refrigerated for a couple of hours. For platelet count and for bacterial cultures however, blood should not be refrigerated.
Serum can even be frozen for serological and biochemical studies to be carried out later. Refrigerated blood specimen must be brought to room temperature before subjecting it to haematological investigations as the cold specimen yields false values. Collection of Urine The urine specimen can be sent to laboratories for three different tests, namely: For reliable results, urine should be examined within 2 hours after collection.
An early moming specimen is desirable for most tests. Estimation of urobilinogen requires urine speci- men collected in the aftemoon 2 pm. For micro- biological studies culture , the urine sample should be collected in a sterile manner and inoculated within two hours. Some preservatives such as toluene, chloroform thymol and formalin are added to avoid the growth of microorganisms and to prevent changes in the constituents of urine.
Toluene is the preservative of choice. If the urine is to be subjected to pregnancy tests or microbiological studies, preservatives should not Urine sample may be refrigerated but should not be frozen.
Sputum Collection Sputum is coughed up from the throat and lungs. The patient is asked to spit the expectorate directly into the container provided. The jar should contain 25 ml acetylpyridium bromide 0. The lid must be screwed on and the bottle sent to the laboratory in a specially designed box.
The mouth is opened wide and a clean tongue depressor is used to depress the tongue. A pus sample from suppurative infections of the oro-facial region can be obtained by swabs or preferably by aspiration. All infection control measures should be strictly observed while collecting and transporting samples.
CI lfblood sample is obtained by venipuncture, it should be immediately placed in the appropriate container for the test required. Containers should be absolutely clean, sterile and dry.
Specimens should reach the laboratory in a fresh state. CI Specimens should be transported in the correct container. D Specimens are best taken by hand to the laboratory as soon as they are obtained.
CI If specimens are mailed, they should be suitably packed and labelled: The correct anticoagulants should be used for chemical analysis or other blood tests.
D For serology, clotted blood with no additives in sterile containers should be sent. CI The correct transport media should be used for microbiological culture specimens. In A suitable preservative should be used if there is a delay in sending specimens to the laboratories. CI No chemical preservatives should be added to specimens when viral pathogens are suspected. All Usually the laboratories design their own request forms. It is essential that all details be clearly provided.
Preliminary details include name, address, hospital or clinic serial number, sex and date of birth of the patient. Other important details are: D Exact nature of the specimen: The clinician should be able to assess the false—negative results in non-quantitative test results such as cytology.
For quantitative test results as in biochemistry and haematology, the values are determined by the methods used and normal values may often vary from laboratory to laboratory. Communication with laboratory personnel becomes very impor- tant in these circumstances. It must also be re- membered that a value just outside the range of normal does not necessarily indicate abnormal- ity. Normal values are often established for the sex and age of the groups studied and for methods used in each laboratory.
Mosby YearBook Inc. Henry, J. Saunders Co. Mukherjee, K. Medical Laboratory Technology: Transmission can occur between individuals by direct contact but more commonly, it involves fornities, i. Patients, dentists, dental students, dental assis- tants, hygienists, steri—centre personnel, labora- tory and radiology technicians, secretarial staff, cleaning staff and dental engineers are all at risk from cross-infection and hence, must be pro- tected.
The primary goal of infection control in den- tistry is to reduce the risk of cross—contamination between patients and dental care providers. To ensure success, it is important to establish stan- dard infection control protocol and procedures 0 Know aspects of instrument sterilization and disinfection 0 Know different departmental infection control guidelines 0 Know dental laboratory guidelines of infection control 0 Know aspects relating to disposal of clinical waste that conform to universal precautions and are easily applied and highly effective.
Objectives of Infection Control D To protect members of the dental team and patients from contracting infections during dental procedures.
Compliance with the guidelines is extremely necessary in order for the above objec- tives to be met. Route of transmission is dependent on four factors: Table 3. For protection, dental health care workers can be vaccinated against the following: Vaccines for mumps, measles, poliomyelitis and whooping cough are usually taken during childhood.
Washing Hands Hands should always be washed thoroughly with a healthcare liquid soap. Cool rather than warm water should be used since the latter opens the skin pores. Hands should be rinsed and dried and cuts or abrasions covered with a waterproof dressing.
A two—minute washing at the beginning and end of the clinical session is recommended. Furthermore, a fifteen seconds washing between patients whenever gloves are removed drinking, calls. Hand washing facilities should be designed to avoid cross-contarnination at the scrub sink from water valve handles and soap dispensers. The use of 70 per cent isopropyl alcohol as an antiseptic to disinfect hands is endorsed.
Latex or vinyl gloves are recommended for use during patient examination and procedures. He is author and co-author of over scientific publications including several papers on oral cancer and potentially malignant diseases and of three books and nine book chapters on oral medicine. We are always looking for ways to improve customer experience on Elsevier. We would like to ask you for a moment of your time to fill in a short questionnaire, at the end of your visit. If you decide to participate, a new browser tab will open so you can complete the survey after you have completed your visit to this website.
Thanks in advance for your time. Skip to content. About Elsevier. Search for books, journals or webpages All Pages Books Journals. Paperback ISBN: Churchill Livingstone. Published Date: Page Count: Free Shipping Free global shipping No minimum order. Clearly describes and illustrates 76 oral conditions under standardized headings of clinical features, incidence, aetiology, diagnosis and management. Gives therapeutic protocols with associated flowcharts to correspond with the trend towards protocol-driven treatment.
Includes diagnostic flowcharts for major symptoms such as ulcers and red lesions, placed beside clinical photos to guide the reader systematically through the diagnostic process.
Provides step-by-step instructions on how to carry out biopsies and toluidine blue staining. English Copyright: