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Medical problems 1 4
1. Islam Kassem, BDS , MSc, MOMS RCPS Glasg,
FFD RCSI
Consultant Oral & Maxillofacial Surgeon
Medical Topics in
Orthodontics
ikassem@dr.com
2. 1- Patient assessment and medical history
2-Orthodontic management for diabetic
patients Orthodontic management of patient
with Cardiovascular emblications
3-Orthodontic management of Asthmatic
patients Orthodontic management of
patients with phschatic implications
4-Orthodontic treatment for geriatric
patients
ikassem@dr.com
5. 1- Lectures on
http://www.slideshare.net/islamkassem/n
ewsfeed
2-Readers
3-Medical problems in Dentistry Bu scully
ikassem@dr.com
6. 1- Patient assessment and
medical history
Importance of medical assessment
Step wise medical assessment
Common oral lesion
Cancer detection
Halitosis
Salivary disorders
ikassem@dr.com
12. Inspection
Scars
Lumps
Sinuses
Asymmetry
Stoma
Ask patient to swallow and protrude tongue
Ask patient to breathe deeply
Ask patient to count to ten
ikassem@dr.com
13. Palpation
Adequate exposure
Systematic
Develop system
From in front then mainly from behind
Submandibular area, both triangles
Supraclavicular area
ikassem@dr.com
16. Summary
See patient as a whole – don’t focus in on
one part of the body too soon
Be systematic
Adequate exposure
Be familiar with toys
Suggest further assessments
ikassem@dr.com
18. Oral Cancer Risk Factors
75% of all oral cancer cases are
related to tobacco use and/or
moderate/heavy alcohol use.
Human Papilloma Virus may be a
causative factor of oral cancer
ikassem@dr.com
19. Oral Cancer Risk Factors
Poor Oral hygiene and chronic
irritation (poor fitting dentures,
broken fillings).
HIV infection or compromised
immune system.
25% of oral cancers occur in people
that do not smoke or have other risk
factors.
ikassem@dr.com
20. Human Papilloma Virus and Oral
Cancer
The human papilloma virus (HPV) is a common virus
group that causes skin and mucosal infections.
There are over 80 types of HPV in humans.
Some types of HPV infect the mouth, throat, tongue and
tonsils.
The skin covering sexual organs can also be infected
with HPV.
The infection is manifested with skin ulceration and pain.
Infected skin can transfer the virus to other parts of the
body or other humans.
ikassem@dr.com
21. Human Papilloma Virus and Oral
Cancer
Warts are a form of HPV infection
Warts are small, cauliflower-type growths
on the skin.
Warts are usually painless, but can cause
some irritation, itching, or burning.
ikassem@dr.com
22. Human Papilloma Virus and Oral
Cancer
Some HPV types can cause cervical or oral cancer
The types associated with these cancers are: HPV-16,
HPV-18, HPV-31, and HPV-45.
HPV causes abnormal alteration and growth of the
infected mucosa covering the inner of the mouth
(dysplasia).
Dysplasia is not cancer, but it is a tissue change seen
prior to the formation of cancer.
The most dangerous types of HPV-- 16 and 18-- are
transmitted through sexual contact and are known to
cause up to 95% of cervical cancers.
– These two types have also been linked to oral cancer.
ikassem@dr.com
23. Human Papilloma Virus and Oral
Cancer
Human papilloma virus associated tumor
on the lip.
ikassem@dr.com
24. Who Can Get Oral Cancer?
Oral cancer is most common in:
Men
African Americans
Adults over 40 years old
Smokers and heavy drinkers
ikassem@dr.com
25. Early Detection is Key
5 Year Cancer Survival Rates
Localized 80%
Regional 50%
Distant 32%
26. Where to Start?
Early Detection starts with:
–Listen
–Look
–Feel
ikassem@dr.com
27. What Do You Need?
Oral cancer screenings will require the
following tools:
– Listen
Oral Screening form
– Look and Feel
Gloves
Gauze
Disposable mirror
ikassem@dr.com
28. Oral Screening Form
Make sure these items are included:
– Current or past tobacco use
– Age 40 or older
– Sore on lips, mouth, or cheeks that doesn’t heal in
two weeks
– Sore in throat or a feeling that something is
caught in the throat
– Numbness of the tongue or other area of the
mouth
– Swelling of the jaw that causes denture to fit
poorly or become uncomfortable
ikassem@dr.com
29. Oral Screening Form
– Persistent ear pain
– Hoarseness or voice changes
– A lump or mass in the neck, behind the ear or
under the jawbone
– Had or scheduled to have chemotherapy or
radiation treatment
– Sexually transmitted disease such as HIV or
Syphilis
ikassem@dr.com
31. Oral Cancer Screening
Ask the individual or patients whether
they have felt new lumps in the mouth,
head, neck, or behind their ears. Are
these lumps present on both sides of
the face or head? (Symmetrical
presence may be sign that the lump is
a normal structure.)
32. Oral Cancer Screening
Begin with the hairline
and look for any changes
in skin color, including
moles, lumps, bumps and
sores.
Both sides of the face
and neck should be the
same size, shape and
form. Feel the entire face
for lumps and numbness.
33. Oral Cancer Screening
Next, the neck exam:
Feel the front and
back of the large
muscles running from
the ears to the collar
bone.
Feel under the jaw
from the ears to the
chin.
34. Find the “Adam’s
Apple” and ask the
patient to swallow.
Feel for lumps and
soreness on both
sides to the
collarbone.
Oral Cancer Screening
35. Lymph nodes:
– Normally lymph nodes feel
like peas under our fingers
as we press the tissue
against the neck muscles
or jaw bone.
– A cancerous lymph node
will feel rubbery or hard to
touch, it can present as a
lump in the neck that does
not move when pressure is
applied
Oral Cancer Screening
36. Oral Cancer Screening
Next the patients’ lips
should be examined:
Squeeze the lip and
check for swelling,
tenderness and color
change
Pull the upper and
lower lips back and
look for sores or color
changes.
37. Oral Cancer Screening
Now the cheeks will be
examined:
Place the index finger
on the outside of the
cheek and the thumb
on the inside and gently
squeeze the cheek to
check for any swelling,
lumps or soreness.
Pull the patients’ cheek
back and look for color
changes such as red,
white or dark areas.
38. Oral Cancer Screening
Next the gums will be
examined:
Look on the inside
and outside of the
gums for lumps,
bleeding, or red and
white areas
Ask, “Are there any
sores that have not
healed for longer than
2 weeks?”
39. Oral Cancer Screening
Next the tongue will be
examined:
Ask the patient to place the tip
of their tongue on the roof of
their mouth to look for sores
under the tongue.
Using gauze pull the tongue to
the side and examine the top
and sides for color changes,
lumps or sores.
40. Oral Cancer Screening
Next the floor and roof
of the mouth will be
examined:
Feel the floor of the
mouth for lumps and
growths.
Use an index finger to
gently press against
the roof of the mouth
to feel for lumps,
swelling or soreness.
41. Oral Cancer Screening
The dentist should also examine other
tissues such as the lingual tonsil and may
perform other tests (such as brush biopsy)
ikassem@dr.com
43. Leukoplakia
Is a clinical term for a
white plaque that
cannot be removed
by scraping, and
cannot be classified
clinically or
histologically as
another disease
entity.
Some leukoplakias are
cancerous.
48. Lichen planus: a benign inflammatory
lesion. Typically this type of lacy white
plaque is seen bilaterally on the buccal
mucosa in a patient with lichen planus.
ikassem@dr.com
50. Candidiasis: yeast infection on the tongue
Candidiasis can present as a white plaque that
wipes off, leaving small bleeding points
underneath. The are may be painful or
sensitive.
ikassem@dr.com
51. Differential Diagnosis
Most red or white lesions, such as lichen
planus, should be assessed by biopsy.
There is no way to be absolutely certain
that these lesions are not cancer, so
biopsy is necessary.
ikassem@dr.com
52. Erythroplakia = Red Batch
Red lesions can be caused by processes such as
infection, trauma and inflammatory diseases.
An erythroplakia with no known cause/diagnosis is
more likely to undergo malignant transformation
than a white lesion
Speckled erythroplakia is a combination of
leukoplakia and erythroplakia
– 5I% of cases will show invasive carcinoma on biopsy
.
ikassem@dr.com
63. ikassem@dr.com
VITAL SIGNS
Blood pressure______ Pulse__________
Height_____ Weight____
Tobacco use: Never Former Current
Glasses of alcohol drinks per day:
1-2 3+
64. Prevention of Oral Cancer
Stop smoking or chewing tobacco.
Decrease use of alcohol (0-1 drinks/day).
Eat more fruits and vegetables.
See a dentist regularly.
Get screened- Early detection saves
lives.
ikassem@dr.com
65. Self-Determination Theory
Self-Determination Theory proposes that
behavior changes motivated by intrinsic
factors (e.g., inherently novel, enjoyable,
stimulating, self-driven, and satisfying) are
more sustainable than those produced by
extrinsic factors (e.g., coercion, external
reward, or fear) as well as those that are
amotivational.
People have to decide when and how to
change.
Your role is to assist people in the change
process, only if they choose to change after
receiving information that they choose to
hear from you.
ikassem@dr.com
66. Tobacco Use
The "5 A's" of a tobacco prevention program as
recommended by the Surgeon General
Expanded to include alcohol use in this lesson.
ikassem@dr.com
67. Tobacco Use
Ask
– Identify and document tobacco use status
for every patient at every visit. Identify
whether the individual is a heavy alcohol
drinker.
Assess
– Is the tobacco user willing to attempt to
quit? Is the individual willing to reduce
their consumption of alcohol?
ikassem@dr.com
68. Tobacco Use
Advise
– It is important to engage the user in an open
dialogue on what he thinks about tobacco use and
the impact on his/her health. Work towards a
position where the patient provides you with what
he or she should do.
Assist
– For the patient willing to attempt to quit, use
counseling and pharmacotherapy to help him or
her quit.
– For the patient willing to reduce alcohol
consumption, use counseling or refer to alcohol
addiction counseling programs in his/her area.
ikassem@dr.com
69. Tobacco Use
Arrange
– Schedule follow-up contact, in person or by
telephone, preferably within the first week
after the quit date or scheduled counseling for
reduction of alcohol use.
ikassem@dr.com
70. Advice about quitting
If your patient is worried about needing tobacco
to help wake up, get moving, and stay focused
on tasks, provide examples of other ways to feel
more energetic.
Encourage the patient to get enough rest,
exercise regularly (which will also reduce
cravings), take a brisk walk when feeling
sluggish, drink lots of cold water, and avoid
situations that lead to boredom.
ikassem@dr.com
71. Light or Low-Tar Cigarettes
“Light” cigarettes may actually be more
dangerous than regular cigarettes because
smokers may inhale more heavily or more
frequently or cover ventilation holes to get
the chemicals their bodies crave.
ikassem@dr.com
72. Barriers
Discuss barriers to quitting, set goals, and
devise a plan.
In addition, you may wish to assess whether the
patient sees him/herself as addicted to nicotine,
and recommend nicotine replacement or other
pharmacotherapy as appropriate.
ikassem@dr.com
74. Alcohol Counseling
Feedback to a patient by a primary care provider
about the results of the oral cancer screening
examination, clarification of the association between
excessive alcohol consumption and negative
consequences, and advice to reduce alcohol
consumption, are modestly effective in helping
patients with an alcohol problem.
Use the same principles followed in drafting
messages based on the stage of change.
Tailor your messages based on the stage of change
and the reasons for drinking.
ikassem@dr.com
77. Salivary Flow Rate (Xerostomia)
Saliva not only begins the digestive
process; it protects teeth by preventing
decay, regulating your mouth's acidity
level and keeping bacteria in your mouth
from running rampant.
But when saliva's lacking, plaque builds,
enamel erodes, cavities quickly form and
fungal growth runs rampant
ikassem@dr.com
78. Salivary Flow Rate (Xerostomia)
Diabetes and Dry Mouth
– Prevalence of dry-mouth symptoms
(xerostomia),
– Prevalence of hyposalivation
– Possible interrelationships between salivary
dysfunction and diabetic complications.
ikassem@dr.com
79. Self Report – Xerostomia
Does your mouth usually feel dry?
Do you regularly do things to keep your
mouth moist?
FOX QUESTIONNAIRE
– Do you have to sip liquids to aid in swallowing
foods?
– Does your mouth feel dry when eating a meal?
– Do you have difficulties swallowing dry foods?
– Does the amount of saliva in your mouth seem
too little?
.
ikassem@dr.com
82. Medication
Recent studies have shown that drugs called
Pilocarpine (Salagen™) and Cevimeline (
Evoxac™) can decrease your sensation of oral
dryness.
These drugs are generally taken 3 - 4 times a day,
after meals, and their effects usually last from 2 - 4
hours.
– The side-effects of these medications are generally
modest.
These drugs, combined with other methods to
stimulate the flow of saliva have had positive results
ikassem@dr.com
83. My Contact
ikassem@dr.com
You can get the
lectures form
http://www.slides
hare.net/islamkass
em/newsfeed
ikassem@dr.com
