Lecture 1
.Introduction of the Oral Medicine
Dr.wisam rasool
.College of Dentistry. University of Alkut
Oral medicine is a dental specialty that bridges the traditional areas of
health between dentistry and medicine. International descriptions reflect this
and oral medicine is defined as "the dental speciality placed at the interface
between medicine and dentistry and is concerned with the diagnosis and
management of (non-dental) pathology affecting the oral and maxillofacial
.region
Oral medicine specialists provide clinical care to patients with a wide "
variety of orofacial conditions, including oral mucosal diseases, orofacial pain
syndromes, salivary gland disorders, and oral manifestations of systemic
diseases. There is a growing need to implement this specialty globally: due to
the rapid progress in both medicine and dentistry, and to the growing percentage
of senior citizens in many countries, the adequate diagnosis and treatment of
.oral diseases will become even more complex in the future
Oral medicine is concerned with clinical diagnosis and non-
surgical management of non-dental pathologies affecting the orofacial
.region (the mouth and the lower face)
Many systemic diseases have signs or symptoms that manifest
in the orofacial region. Pathologically, the mouth may be afflicted by
many cutaneous and gastrointestinal conditions. There is also the
unique situation of hard tissues penetrating the epithelial continuity
.(hair and nails are intra-epithelial tissues)
.Example conditions that oral medicine is concerned with are
lichenplanus, Behçet's disease and pemphigus vulgaris. Moreover, it
involves the diagnosis and follow-up of pre-malignantlesions of the oral cavity,
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such as leukoplakias or erythroplakias and of chronic and acute pain conditions
such as paroxysmal neuralgias, continuous neuralgias, myofascial pain, atypical
.facial pain, and migraines
Another aspect of the field is managing the dental and oral condition of
medically compromised patients such as cancer patients suffering from related
oral mucositis, bisphosphonate-related osteonecrosis of the jaws or oral
pathology related to radiation therapy. Additionally, it is involved in the
diagnosis and management of dry mouth conditions (such as Sjögren's
syndrome) and non-dental chronic orofacial pain, such as burning mouth
syndrome, trigeminal neuralgia and temporomandibular joint disorder ,So in
order to get an accurate diagnosis of the patient we have to take adequate
history from the patient by the followings sequins Introduce yourself, identify
your patient and gain consent to speak with them. at first we start with the age
.of the patient
The age of the patient is important in the following major problem
:including chronic and recurrent condition from the earlier adult stages like
Degeneration bone and joint disease that affected the TMJ ●
Chronic brain syndrome ●
,Malnutration, mental disorder ●
Drugs. This because the old patients have a related changes in the ●
pharmadynamic and pharmakinetic of the drugs also the drug to drug reaction,
drug –food reaction all of these will alter the absorption,distribution,
.metabolism,exertion.Other changes include
Bone and cortical trabecular bone decreased as a result it will be more potential ●
for osteoporotic fractures
Muscle. the number of the muscle fiber decreased atrophy as a result the ●
flexion of the joint decreased which lead to slowly muscle regeration
.increased auto immune diseases ●
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Changes in theJoints include
Cartilage erosion.1
Calcium deposit increased.2
Water in cartilage decreased.3
Osteoarthritis increased.4
Other changes
dentin decreased ●
gingival retraction ●
bone density lost ●
the papilla of the tongue decreased which lead to taste change ●
taste threshold for salt and sugar increased ●
salivary secretion decrease ●
potential loss of the teeth ●
While other changes on the mucosal surface
increase in the potential infection on the mucosal surface ●
malignancy incidence ●
response to acute infection reduced ●
potential recurrence of latent herpes zoster ●
also the immune system changes
secretary immunoglobulin IgA decline ●
thymus gland involved ●
thymopoietin decreased ●
lymphoid tissue decreased ●
antibody production impaired ●
T. lymphocyte decreased ●
autoantibody increased ●
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.SEX.2
Malignant melanoma the incidence is increasing in male ●
Mucous membrane pemphigoid ,cicatrical pemphigoid more in female ●
Epulis and pregnancy epulies occur in female because of the circulating ●
estrogen are highest
S.C.C more in males●
mucocele more in female●
Presenting complaint (PC).3
History of presenting complaint (HPC).4
The dentist should gain as much information about the specific
:complaint.Site
?Where exactly is the pain
?Onset: When did it start, was it constant/intermittent, gradual/ sudden ●
?Character:What is the pain like e.g. sharp, burning, tight ●
?Radiation: Does it radiate/move anywhere ●
Associations: Is there anything else associated with the pain e.g. sweating, ●
vomiting
?Time course: Does it follow any time pattern, how long did it last ●
?Exacerbating/relieving factors: Does anything make it better or worse ●
?Severity: How severe is the pain, consider using the 1-10 scale ●
Past medical history (PMH) .5
Gather information about a patients with other medical problems
Drug history (DH).6
Find out what medications the patient is taking, including dosage and
how often they are taking them e.g. once-a-day, twice-a-day,… etc. At this point
.it is important idea to find out if the patient has any allergies
Family history (FH). 7
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A family health history (also referred to as a family medical history, a
family history, or medical family tree) is a compilation of relevant information
about medical conditions affecting a patient and his/her close family members.
It represents an essential component of a patient’s medical history, typically
obtained at the time of admission to a health care facility as one component of a
comprehensive patient assessment. Two features that distinguishes a family
health history from a patient’s medical history are that a family history extends
beyond enumeration of the patient’s major health problems to identify those
experienced by each member of that patient’s immediate family and its
indication of about the patients family history, e.g diabetes or cardiac history.
Find out if there are any genetic conditions within the family e.g. Polycystic
kidney disease, hematological diseases LIKE HAEMOPHILIA a family history
should go back at least 3 generation the nature of the relationships among
family members
autosomal recessive like sickle cell anemia ,alpha thalassaemia
autosomal dominant .neurofibromatosis ,myotonic
dystrophy ,Huntingtons disease
Social history (SH). 8
This is the opportunity to find out a bit more about the patient’s
background. Remember to ask about smoking and alcohol. Depending Also
.find out who lives with the patient
Smoking.Thereare lesions related to the smoking like leukoplakia nictonic
stomatities
Alcohol history the elevated of MCV mean corpuscular volume in the
absence of vitamin B 12 or folate deficiency or unexplained abnormal liver
function test
Review of systems (ROS ) .9
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Gather a short amount of information regarding the other systems in the
.body that are not covered in your HPC
:These are the main systems you should cover
CVS●
Respiratory●
GIT●
Neurology●
Genitourinary/renal system●
Musculoskeletal●
Psychiatry●
THE ART OF HISTORY TAKING
The basis of a true history is good communication between dentist and
patient. The patient may not be looking for a diagnosis when giving their history
.and the doctor's search for one under such circumstances is likely to be fruitless
The patient's problem, whether it has a medical diagnosis attached or not,
.needs to be identified
It is important for dentist to acquire good consultation skills which go
beyond prescriptive history taking learned as part of the comprehensive and
systematic. A good history is one which reveals the patient's ideas, concerns and
.expectations as well as any accompanying diagnosis
Often the history alone does reveal a diagnosis. Sometimes it is all that is
required to make the diagnosis. A good example is with the complaint of
headache where the diagnosis can be made from the description of the headache
and perhaps some further questions. For example, in cluster headache the
history is very characteristic and reveals the diagnosis without the need for
.examination or investigations
To obtain a true, representative account of what is troubling a patient and
how it has evolved over time, is not an easy task. It takes practice, patience,
understanding and concentration. The history is a sharing of experience between
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patient and dentist. A consultation can allow a patient to unburden himself or
herself. They may be upset about their condition or with the frustrations of life
.and it is important to allow patients to give vent to these feelings
Consultation skills
The skills required to obtain the patient's true story can be learned and go
beyond knowing what questions to ask. Indeed 'questions' may need to be
avoided, as they limit the patient to 'answers'.. There are many examples of
aspects of consulting which may assist history taking for dentist working with
.patients in all specialties
Complete the history by reviewing what the patient has told you. Repeat back
the important points so that the patient can correct you if there are any
.misunderstandings or errors
NOTE
During or after taking their history, the patient may have questions that
they want to ask you. It is very important that you don’t give them any false
information. As such, unless you are absolutely sure of the answer it is best to
say that you will ask your seniors about this or that you will go away and get
them more information (e.g. leaflets) about what they are asking. These
questions aren’t necessarily there to test your knowledge, just that you won’t try
.’and ‘blag it
What types of questions the dentist should ask the patient
Open questions .1
These are seen as the gold standard of historical inquiry. They do not
suggest a 'right' answer to the patient and give them a chance to express what is
on their mind. Examples include questions such as 'How are you?'. There are
other similar open questions but it may be effective just to let the patient start
.speaking sometimes
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Open questions can be used to obtain specific information about a
particular symptom as well. For example: 'Tell me about your pain' or 'How are
your water works bothering you?'. Open questions cannot always be used, as
sometimes you will need to delve deeper and obtain discriminating features
.about which the patient would not be aware
Questions with options .2
Sometimes it is necessary to 'pin down' exactly what a patient means by a
particular statement. In this case, if the information you are after cannot be
obtained through open questioning then give the patient some options to
.indicate what information you need
Technique must be used with care as there is a danger of getting the answer you
wanted rather than what the patient meant Try to avoid using specific medical
.terms such as
Burning type of pain If you can use an open question such as: what was
the pain is similar to?', rather than suggesting options, it is more likely to give
you a true picture of what the patient has experienced; however, sometimes
questions suggesting possible answers cannot be avoided.therefore never
describe the type of the pain to the patient who is complain from
neurological type of pain by describe the electrical stimulation on the
trigger area
Leading questions.3
These are best avoided if at all possible. They tend to lead the patient
down an avenue that is framed by your own assumptions. For instance, a male
patient presents with episodic ulceration pain. The dentist must know if he is a
smoker so you start asking questions that would help you to decide if it's
apthous. It is much better to ask an open question such as: 'Have you noticed
.'?anything that makes your pain worse
Have u any skin lesion,pain at the joint ,dry mouth ….etc
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Summarising
After taking the history, it's useful to give the patient a run-down of what
they've told you as the dentist understand it. For example: 'So, from what I
understand you've been losing weight, feeling sick, had trouble swallowing –
with ulceration of the tongue and the whole thing's been getting you down. Is
'?that right
