Reproduced from Brook P, et al. However, where AP movement is required, a lateral skull radiograph will back up the clinical assessment of skeletal pattern and help to determine the degree of difficulty. Serial lateral skulls aid assessment of growth.
If a landmark is hard to see, block off the rest of the film so that only that area is illuminated. By convention, the most prominent image should be traced, i. There are many commercial programs of varying complexity and cost to facilitate cephalometric analysis and Rx planning.
If SNA significantly i or d this could be due to the position of nasion, in which case an additional analysis should be used, e. Wits analysis. It is important to remember that the ANB difference is not an infallible assessment of skeletal pattern as it assumes incorrectly in some cases that there is no discrepancy in the cranial base and that A and B are indicative of basal bone position.
When a cephalometric tracing seems at odds with your clinical impression it is worth doing another analysis which avoids reliance on the cranial base, such as a Wits analysis. Before deciding on a Rx plan it is helpful to consider what factors have contributed to a particular malocclusion, e. The relative contribution of the maxilla and mandible to the skeletal pattern may indicate possible lines of Rx; e.
CBCT scans are increasingly available and used instead of radiographs in many cases. For a good discussion of the pros and cons see reference. Functional occlusal plane Fig. Then possible solutions and their relative risks and benefits can be considered.
This gives a starting point around which to plan Rx. The first step is to decide if the lower arch is sufficiently crowded to warrant extractions. In some cases, movement of the LLS is indicated but these are the province of the specialist, e. If in doubt, refer for advice. This will give an indication of the space required and the amount and type of movement necessary.
Should extractions be indicated in both arches, mechanics are often easier if the same tooth is extracted in the upper as in the lower. These decisions should be made based on available evidence of efficiency, predictability, minimal risks, and minimal patient cooperation. In orthodontic Rx, the resistance to unwanted tooth movement is called anchorage and also needs to be considered when planning Rx. Retention of the final result should be included in the Rx plan and the need for compliance with wearing retention appliances explained to the patient.
If a compromise plan is chosen by the patient, this should be recorded in the consent process. Rx planning is the most important, and most difficult, part of orthodontics. Further reading S. Littlewood et al. Later, pressure from the developing canines on the roots of 2 2 results in their being tilted distally and spaced.
The majority of Es erupt so that their distal edges are flush. Often, infraocclusion can impede eruption or cause palatal eruption of the successor tooth. It is wise to seek an orthodontic opinion in this instance. Indicative of crowding. Spontaneous disimpaction rare after 8yrs. Can try dislodging 6 by tightening a piece of brass wire round the contact point with E over several visits.
Appliances to break the habit may help, but most children will stop when they are ready. However, this is no reason to delay the start of Rx for other aspects of the malocclusion. This is also seen when a C is prematurely exfoliated by an erupting 2. If Es are lost, the 6 will migrate forward. This is particularly marked if it occurs before eruption of the permanent tooth, so if extraction of an E is unavoidable try to defer until after the 6s are in occlusion and do not balance or compensate.
Further reading M. They also give best chance of spontaneous improvement especially if extracted just as the 3s are appearing, but if appliance therapy is planned, defer until the canines have erupted. FAs are required, especially in the lower arch.
If 5s are hypoplastic or missing there may be no choice. Early loss of an E will often lead to forward movement of the 6 and lack of space for 5s. In the upper arch this results in 5 being displaced palatally and provided 4 is in a satisfactory position, extraction of 5 on eruption is advisable. In the lower arch, 5s are usually crowded lingually.
Extraction of lower 4 is easier and will give lower 5 space to upright spontaneously. Even so, may still require appliance therapy to align 8 on eruption. In the upper arch, extraction of 7 is often limited to facilitating distal movement of the upper buccal segments. If not, avoid extraction of 6 in affected quadrant. There is a greater tendency for mesial drift in the maxilla, therefore, the timing of loss of 6 is less important.
If the upper arch is crowded, 3 may be squeezed buccal to its normal position, in which case space needs to be created for its alignment. Usually 4 is the tooth of choice for extraction and, if so, this should be carried out just as 3 is about to erupt. Where 2 and 4 are in contact, extraction of 4 alone will not provide sufficient space to accommodate 3 so consider extracting 3. Less commonly, 3 may develop well forward over the root of 2. In this case, orthodontic Rx to align 3 will be prolonged.
If the arch is crowded, it may be simpler to extract 3 and align remaining teeth. In the maxilla, 3 is usually transposed with 4, and in the mandible, the lateral incisor is more commonly involved. Rx options include alignment of teeth in transposed position, extraction of the most displaced tooth, or correction if transposition of root apices is not complete. Interceptive extraction of C has long been advocated to facilitate an improvement of a displaced 3 but there is currently no robust evidence to support this approach.
If the canine is only very slightly palatally displaced or impacted between 2 and 4, provision of space should result in eruption. Provided no evidence of cystic change or resorption, removal of 3 can be left until GA required, e. Patient must understand that C will eventually be lost, necessitating a prosthesis. Becker et al. Peck et al. Parkin et al. Again, 3 will require removal in due course. Sequence is to arrange exposure, and allow tooth to erupt for 3 months, and then commence orthodontic traction to move tooth towards arch.
FAs are required. Prognosis is i by avoiding damage to PDL and if root formation is not complete. If the distance between the maxilla and the mandible is sufficiently i such that even if incisors erupt to their full potential they do not meet, an AOB will result Fig.
Tongue thrusts are usually adaptive and can maintain an AOB due to a habit even after the habit has stopped. Most operators leave the TADs in situ during initial months of retention to continue intrusive forces and offset relapse. Extrusion of the incisors is unstable. For more severe cases, the only alternative is surgery. Further reading D. Class III cases. Class III malocclusions occur in association with the whole range of vertical patterns.
Xbites are a common feature, due to the more forward position of the mandible relative to the maxilla. If so this i prognosis for correction of incisor relationship. Some patients with more severe skeletal Class III opt for alignment, accepting incisor relationship rather than proceeding with surgery. Can occur in isolation or as part of a syndrome. Submucous cleft of the palate is often missed until poor speech noticed, as overlying mucosa is intact.
In repaired clefts maxillary growth is d AP, transversely, and vertically. Teeth adjacent to cleft are often displaced. Also i incidence of hypoplasia and delayed eruption. Centralization of care and audit of outcome gives better results. Some surgeons do a Vomer flap at same time.
Bilateral lips are closed in either one or two operations. Deferring repair until patient is older d growth disturbance, but speech development is adversely affected. To aid surgical access and improve outcome, usually need to expand collapsed arches and align the upper incisors prior to grafting.
FAs are usually used and care is required not to move roots of adjacent teeth into cleft. Ideally, if 2 missing, Rx should aim to bring 3 forward to replace it, thus avoiding a prosthesis. If nasal revision surgery is planned then this should be carried out after bony surgery.
A proportion of cleft patients will have a skeletal discrepancy that is too severe for conventional surgical movements. In addition, advancement of the maxilla may, by bringing forward the soft palate, adversely affect speech.
In these cases, anterior teeth are aligned using either brackets and wires on the teeth or with clear aligners. Dietrich et al. Lindhe et al. See also Journal of Clinical Periodontology. This was presented at EuroPerio9 in Amsterdam in June Box 5. Periodontal health, gingival diseases, and conditions Periodontal and gingival health.
Gingivitis: dental biofilm induced. Periodontitis Necrotizing periodontal diseases. Periodontitis as a manifestation of systemic disease. Other conditions affecting the periodontium Systemic diseases or conditions affecting the periodontal supporting tissues.
Mucogingival deformities and conditions. Traumatic occlusal forces. Classification of periodontal disease Box 5. Gingival diseases A. Plaque induced 1. Without local contributing factors.
With other local contributing factors. Gingival disease modified by systemic factors. Gingivitis associated with blood dyscrasias, e. Gingivitis modified by medications. Gingival disease modified by malnutrition. Chronic periodontitis Localized. Aggressive periodontitis Localized. Periodontitis as a manifestation of systemic disease V. Abscesses of the periodontium VII. Periodontitis associated with endodontic lesions VIII. Developmental or acquired deformities and conditions International Workshop for a Classification of Periodontal Diseases and Conditions.
The only risk factors included in the World Workshop paper were diabetes, specifically unstable diabetes, and smoking. While the World Workshop on the Classification of Periodontal Diseases has been widely accepted, the British Society of Periodontology BSP felt that it was too complicated to be used in its raw form in general practice in the UK and set up a working group to look at how this new system could be implemented in UK general practice.
This simpler system mirrors the style of the original document but simplifies the staging and grading elements of the diagnosis to allow for easier use in general practice Box 5. Overt infection occurs when there are local or systemic predisposing factors, therefore the prime tenet of management is to look for and treat these factors. Occasionally symptomless, but more commonly cause discomfort on eating and also may cause a burning sensation and bad taste.
In infancy, widespread oral candidosis can be associated with a livid facial rash and an associated nappy rash. Rx: a variety of topical formulations such as nystatin and miconazole are available, but provide only limited benefit. Fluconazole and itraconazole are very effective. Chlorhexidine mouthwash is an effective adjunct to Rx. Most antifungals especially the azole group, interact with a number of drugs including warfarin and statins.
It is painful and exacerbated by hot or spicy foods. The oral mucosa has a red, shiny, atrophic appearance and there may be coexisting areas of thrush. Aetiology is multifactorial with local and systemic precipitating factors, e. Therefore, FBC and haematinics should be investigated. Clinically, red, cracked, macerated skin at angles of the mouth, often with a gold crust. Rx: miconazole cream, which is active against all three infecting organisms. Rx needs to be prolonged, up to 10 days after resolution of clinical lesion, and carried out in conjunction with elimination of any underlying factors.
Mupirocin cream applied to the anterior nares helps eradicate sources of Staphylococcus aureus. Oral candidosis candidiasis Fig. It is seen in patients using inhaled steroids and smokers.
Some patients have lesions in the centre of the dorsum of tongue and palate kissing lesions. Rx only if symptomatic as discomfort can be improved with topical antifungals, but the appearance cannot. Exclude haematinic deficiency and diabetes.
It typically presents as a white patch on the oral commissural buccal mucosa bilaterally or dorsum of tongue. Although there is an i risk of malignant change, the initial approach after ensuring the diagnosis microbiologically and histopathologically is to eradicate the candidal infection. Candidal hyphae can be seen in the superficial layers of the epidermis, one reason why eradication is so difficult. Rx: systemic antifungals such as fluconazole and itraconazole are indicated.
Often associated with iron, folate, and vitamin B12 deficiency, and smoking, which should be corrected. Most lesions will resolve after such Rx; if not, reassess degree of dysplasia and surgical excision may be indicated. Patients should be encouraged to stop smoking. Start at childhood or adolescence.
Prodromal discomfort may precede painful ulcers. Rx: prevent superinfection with chlorhexidine mouthwash and relieve pain simple analgesics, benzydamine mouthrinse. It is important to look for and treat any underlying deficiency or coexisting pathology FBC, haematinics, vitamin B12 and red cell folate, serum antiendomysium, and transglutaminase assay.
Associated with tissue destruction and scarring, and any site in the mouth and oropharynx may be affected. There is an even higher association between major aphthae and gastrointestinal and haematological disorders. They are also seen in AIDS. Seldom a cyclical pattern. Commoner in older females. Rarely, they merge to form a large ulcer which heals with scarring. Rx: as for minor aphthous ulceration. All organs of the body can be affected.
In the UK a prevalence of 0. It is a disease of young adults, more common and more severe in males. It is associated with HLA subtype. Recurrent aphthous stomatitis ulcers Fig. Oral signs are frequently the first manifestation of autoimmune diseases.
Dentists can play an important role in the detection of autoimmune pathologies. Managed in consultation with rheumatologist. Rx: ophthalmic referral if eye involved. Direct immunofluorescence is performed on a fresh biopsy specimen.
Indirect is performed on a serum sample. Autoimmune in aetiology, there are circulating autoantibodies to epithelial desmosome tonofilament. Rupture leaves a large superficial, easily infected ulcer. The first identifiable lesions are quite often found in the mouth, especially on the palate, although these are usually seen as ulcers because the bullae break down rapidly.
Rarely, it may be drug induced or paraneoplastic. The pemphigus can be easily confused with other disorders that present lesions like aphthae, lichen planus, candidiasis, and pemphigoid. Other methods are by histology and direct or indirect immunofluorescent techniques biopsy samples need to be fresh.
Newer therapies include biologic agents rituximab and calcineurin inhibitors appear promising. The titration of circulating antibodies is carried out to evaluate the progress of the disease.
Other variants are subepithelial. A group of uncommon bullous conditions that are inherited with an autosomal dominant or recessive pattern. Skin blisters due to mild trauma, leading to scarring and disfigurement. Great care should be taken to prevent IO lesions during dental Rx. Simplex type is due to mutations in the K5 or K14 gene, leading to disruption of basal cells and formation of bullae.
No cure and Rx is symptomatic and preventive. Invariably develops during eating and can be alarming to the patient. Most common in elderly. Steroid inhalers may predispose. Soft palate, cheeks, and tongue most common sites. Presents as mucous membrane bullae which rupture and heal with scar formation. Rare to see skin bullae. Conjunctiva may be affected and if scarring occurs can lead to loss of vision, therefore regard oral signs as a warning to prevent ocular damage.
The mucous membrane pemphigoid is a chronic disease that requires a continuous Rx strategy although the prognosis is benign. Rx: topical steroids, systemic steroids with or without azathioprine, methotrexate, or dapsone. Refer to ophthalmology.
Subepithelial bullae form which are firm and less likely to break down than those in pemphigus; it is due to autoantibodies IgG to the epithelial basement membrane. Rx: dapsone may be used both diagnostically and therapeutically. Bullous lichen planus is a rare variant in which subepithelial bullae form and break down, leaving large erosions. The dystrophic autosomal recessive form is most likely to present with oral manifestations and appears shortly after birth.
Associated with bullae formation after minor trauma to skin or mucosa; these break down leaving painful erosions. Dentine may be affected leading to hypoplasia and high susceptibility to caries. Healing is with scarring, resulting in difficulty in eating, speaking, and swallowing as scar tissue limits Vesiculo-bullous lesions—subepithelial movement. Skin involvement can lead to destruction of extremities and may be overtaken by carcinomatous change. Prognosis varies widely depending on type.
Phenytoin and steroids may help some varieties. Trigger agents can be identified in half of the cases and these include drugs carbamazepine, penicillins, NSAIDs , infection HSV, mycoplasma pneumonia , pregnancy, malignancy, sunlight, and chemicals such as perfumes and food additives.
There is usually a fever. Hospitalization may be required in severe forms for supportive therapy with IV rehydration. Biopsy; virological studies to exclude herpes; aciclovir may be needed if it is related to herpes. Improve OH with 0. Severe form: Rx with steroids and azathioprine. Minor form: Rx with topical steroids.
May be variant of dermatitis herpetiformis. May be localized due to trauma or neoplasia or widespread hereditary or systemic. It appears as asymptomatic diffuse, soft, uneven thickening of the superficial layer of the epithelium, which characteristically has no definite boundary and may affect any part of the mouth.
Histology shows hyperplastic epithelium with gross intraepithelial oedema. Usually noticed in second decade of life, although developmental in origin.
Rx: reassurance. It is managed by removal of the source of the friction, which will generally allow complete resolution of the lesion. There is little evidence that these patches are premalignant and they resolve on stopping smoking. Active disease must be treated; however, this will not resolve the area of leucoplakia, which has a propensity to undergo malignant change. White patches Fig.
Risk of malignant change. Oval, benign, white patches on tongue are common. Clinicians often wrongly diagnose such lesions as oral leucoplakia and treat simply. Lesions nearly always recur and turn malignant. Clinicians should treat these lesions aggressively because they can progress to SCC or verrucous carcinoma. May result from implantation at time of restoration or from broken filling. May be palpable but often not. If asymptomatic, diagnose and reassure.
Analogous to a mole. Mostly harmless. Most commonly seen on vermilion border of lips and palate. Exhibits an i risk of malignant transformation. Mehanna et al.
Recent survival data suggests that the UK has the best survival figures for diagnosed oral cancer at all stages. Most common in sixth and seventh decades, however there appears to be an increasing incidence in younger patients and those who do not use tobacco. It is estimated that the risk of developing lip cancer doubles every miles nearer the equator.
Immunosuppression, e. Patients may present with a history of a neck lump as a result of metastatic spread to cervical lymph nodes. Pain is usually a late feature.
Referred otalgia is a common manifestation of pain from the tongue or oropharyngeal cancer. The ulcer is described as firm with raised edges, with an indurated, inflamed, granular base and is fixed to surrounding tissues.
The presence or absence of extracapsular spread of tumour in metastatic cervical nodes is the most important single prognostic factor. Characteristically shows invasion of deep tissues with cellular pleomorphism and i nuclear staining. The presence of a lymphocytic response may have prognostic value, as does the manner of invasion pushing or spreading. Can spread via local infiltration or lymphatic system cervical nodes , and late spread via bloodstream.
Oral cancer Fig. Historically, inadequate radiotherapy has been reported to induce more aggressive behaviour. The tongue is a peculiar muscular organ covered with specialized sensory epithelium and the lips form the interface between skin and mucosa. Rx: frenectomy.
Benign tumours e. Surgical reduction of the tongue may be indicated. Commoner in Down syndrome patients than average population. More common in smokers and people with poor OH and hyposalivation.
Involves the rapid appearance and disappearance of atrophic areas with a white demarcated border on the dorsum and lateral surface of the tongue, giving it the appearance of moving around the tongue surface. It is due to temporary loss of the filiform papillae. Familial pattern is common. Main causes of glossitis are iron deficiency anaemia, pernicious anaemia, candidosis, Abnormalities of the lips and tongue vitamin B group deficiencies, and lichen planus.
Sore, but clinically normal tongue is a common problem and often psychogenic in origin; however, the first line of Rx is to exclude any possible organic cause, e. It may be an allergic reaction to benzoates toothpaste ingredient or tomatoes. A patch test for allergens may be indicated. Intralesional steroids, e. May be associated with granulomatous cheilitis.
Lip swelling, and gingival and palatal nodules occur. CXR: hilar lymphadenopathy. Ask an ophthalmologist to exclude uveal tract involvement. Rx: steroids, intralesional or systemic. Common causes are lip licking, and exposure to wind or sunlight. It is also a manifestation of viral illness. Rx: lip salves. Usually an identifiable cause. Lip, neck, floor of mouth swelling, and swelling of feet and buttocks.
Precipitated by trauma. Diagnosis from family history, bloods: low C4, normal C3, and absence of C1 esterase inhibitor activity. Prophylaxis: long term, tranexamic acid; short term, danazol. It is often stimulated by touching a trigger point in the distribution of the trigeminal nerve. Patients may refuse to shave or wash the area which stimulates the pain although, strangely, they are rarely woken by it.
It is thought to be a sensory form of epilepsy, although some cases are due to vascular pressure or nerve demyelination intracranially. Injection of LA can break pain cycles and be useful diagnostically. Other useful drugs are gabapentin and pregabalin. It affects the glossopharyngeal nerve, causing an intense paroxysmal shooting pain on swallowing. There may be referred otalgia. Again, carbamazepine is the drug of choice.
Bilateral neuralgic symptoms indicate demyelination until proven otherwise. The pain is localized to the temporal and frontal regions and usually described as a severe ache, although it can be paroxysmal.
The affected area is tender to touch. Major risk is involvement of retinal arteries, with sudden deterioration and loss of vision; underlying pathology is inflammatory arteritis. Biopsy shows the arterial elastic tissue to be fragmented with giant cells.
Temporal artery biopsy helpful only if positive as negative result does not exclude the Facial pain diagnosis due to the possibility of skip lesions. Rx: aim is to relieve pain and prevent blindness with the use of systemic prednisolone. Most sufferers describe alcohol intolerance. Rx: O2 inhalation effectiveness in acute attack is diagnostic , NSAIDs, ergotamine or sumatriptan, intranasal lidocaine. Pizotifen is used prophylactically. Acute and chronic forms are recognized.
The acute form presents with pain and responds to acetazolamide. Will need ophthalmological referral. Differs from trigeminal neuralgia in that different neurological signs and symptoms in time and place are evident from the history. Eye pain retrobulbar neuritis is associated. MRI reveals features of demyelination of neural tissue.
Constitutes a large proportion of patients presenting with facial pain. Bizarre or grossly exaggerated descriptions of pain. Pain is described as deep, constant ache or burning and there are no relieving or exacerbating factors. Sleeping and eating are not obviously disturbed, despite continuous unbearable pain. Most analgesics are said to be unhelpful, although many will not have tried adequate analgesia.
No objective signs are demonstrable and all investigations are essentially normal. After exclusion of any possible organic cause, tricyclic antidepressants, gabapentin, or pregabalin can help.
Related to atypical facial pain. Patients may complain of altered or bad taste. A burning sensation usually crosses the midline. With experience the patient type often becomes obvious.
Rx: reassurance, patients are often cancerophobic. Tricyclic antidepressants are frequently prescribed by clinicians. Rx: steroids improve chance for full recovery if Rx early within 3 days of onset. Protect cornea with eye pad. Combining aciclovir with steroid or aciclovir alone does not appear to improve recovery over steroid alone.
Pain is associated with herpes zoster virus in the facial nerve. Systemic aciclovir and steroids improve recovery. McMillan et al. The oral lesions persist longer than the skin lesions.
It affects females more commonly than males at the ratio of Lichenoid reactions are an unwanted reaction to some systemic drugs and may also be related to amalgam restorations.
Usually the oral lesions are bilateral and posterior in the buccal mucosa; it is not seen on the palate but can, however, affect the tongue, lips, gingivae, and floor of mouth.
The most common oral lesion is a lacy reticular pattern of hyperkeratotic epithelia seen bilaterally on the buccal mucosa. Desquamative gingivitis is a common variant affecting the gingivae. The skin lesions affect the flexor surfaces of the arms, and wrists and legs, and are particularly common on the shin as purple papules with fine white lines Wickham striae overlying them.
Lichen planus can last for months or years. It is essentially benign; however, some controversy exists about the risk of malignant transformation in erosive forms of lichen planus. Rx: biopsy may be indicated to exclude dysplasia or malignancy; if there are lichenoid eruptions, the implicated drugs should be identified and avoided if possible.
Reassurance for asymptomatic reticular lesions. Clinical photographs and repeat biopsy may be indicated. This results in very easy bruising and bleeding of skin as well as oral mucosa.
Rx: aimed at the symptoms. Rarely, pannus formation within the joint may occur. The association with the presence of antinuclear factor is more common in females. Antinuclear antibodies are present. The demonstration of intact adjacent tissues towards given lesions through histological and immunohistochemical confirmation is still the standard criterion for a definitive diagnosis.
Arthritis and anaemia frequent, but all major organ systems may be affected. Lip lesions in women may be premalignant. Butterfly rash may be present. Eating becomes difficult due to immobility of underlying tissues, and dysphagia occurs due to oesophageal involvement.
Autoantibodies are present. Rx: a combination of cyclophosphamide and steroids may help in early disease; penicillamine has always been used but has numerous unwanted effects. May occasionally present with mouth ulcers and soreness of tongue, palate, or gingiva. Although children also present with ulceration, they are more likely to show weight loss, weakness, fatty diarrhoea, and failure to thrive.
Other findings are glossitis, stomatitis, and angular cheilitis. Rx: haematological and gastrointestinal investigations are required, blood picture, and haematinic assay. Vitamin B12, folate, iron d should be corrected. Gastrointestinal symptoms predominate. Arthritis, uveitis, and erythema nodosum also occur. Topical steroids and systemic sulfasalazine are used in Rx. Most of these patients are managed by gastrointestinal specialists. Orofacial granulomatosis is probably a variant.
Painful oral lesions seem to respond well to topical steroids or simple excision but Rx is aimed at the systemic disease. Probable aetiology is as a hypersensitivity response to certain foods, additives such as benzoates, etc.
Rx: specific to the local problem; e. Most beneficial Rx is to identify and avoid the irritant factors. Sialosis is another association. Oral manifestations of gastrointestinal disease Fig. Atrophic glossitis was formerly the commonest oral symptom of anaemia but is less often seen now. The sore, clinically normal tongue burning tongue is sometimes a manifestation or even precursor of anaemia.
Other oral problems include bleeding and petechial haemorrhage even with minimal trauma , gingival swelling, ulceration, and mucosal pallor. Prevention of superinfection with chlorhexidine mouthwashes and aggressive appropriate Rx of infections which arise are of real help.
Commonest as idiopathic thrombocytopenic purpura ITP in children. Palatal petechiae or bruising may be seen. Palatal petechiae are also seen in glandular fever, rubella, HIV, and recurrent vomiting. Oral signs include enlargement of the tongue and lips, spacing of the teeth, and an i in jaw size, particularly the mandible resulting in a Class III malocclusion.
Adrenocortical hypofunction. Classically, causes melanotic hyperpigmentation of the buccal mucosa. Facial acne and skin atrophy is also seen. Note a need for steroid prophylaxis. In adult hypothyroidism, puffiness of the face and lips also occurs, but there are no particular oral changes.
Ocular proptosis characteristic of Graves disease. Rx of hyperthyroidism with carbimazole is a rare cause of oral ulceration. Caused by hyperplasia or adenoma of the parathyroids. Xerostomia and thrush are prominent features of ketoacidosis.
Sialosis is sometimes seen as a late feature of diabetes. Burning mouth may be a presenting feature, and oral or facial dysaesthesia may reflect the peripheral neuropathies seen in diabetics. There is a tendency to slower healing following surgery.
Some females have recurrent aphthae clearly associated with their menstrual cycle, and several symptoms, usually burning tongue or mouth or general soreness of the tongue or mouth, have been described during the menopause.
It should be remembered, however, that there are profound psychological changes at this time of life in many women, and these symptoms may be a manifestation of atypical facial pain rather than a direct hormonally mediated effect. Maxillary lesions affect skin of cheek, upper lip and side of nose, nasal mucosa, upper teeth and gingiva, and palatal and labial mucosa. The palatal reflex may be lost. Mandibular lesions affect skin of lower face, lower teeth, gingivae, tongue, and floor of mouth.
Lesions of the motor root manifest in the muscles of mastication. Taste sensation is not lost in such lesions, although other sensations from the tongue are. The motor branch is tested by moving the jaws against resistance. A blink should be elicited by stimulating the cornea with a wisp of cotton wool corneal reflex. It is tested by having the patient raise their eyebrows, screw their eyes shut, whistle, smile, and show their teeth.
Upper and lower motor neurone lesions can be distinguished because the forehead has a degree of bilateral innervation and is relatively spared in upper motor neurone lesions.
Taste is tested using sour, salt, sweet, and bitter solutions. If taste is intact, flow from the submandibular duct can be assessed by gustatory stimulation. Test hearing to assess stapedius. Psychogenic causes include hyperventilation syndrome and hysteria. Combination lesions can be caused by amyotrophic lateral sclerosis of the cord. Apparent paralysis may occur in myasthenia gravis Oral manifestations of neurological disease where abnormally i fatigue of striated muscle causes ptosis and diplopia.
Therapeutic paralysis may be induced for facial spasm, using botulinum toxin injected locally. Horner syndrome results in ptosis, enophthalmos sunken eye , miosis constricted pupil , and anhidrosis of facial skin d sweating due to sympathetic impairment. Muscular dystrophy may present with ptosis and facial paralysis. Phenothiazines and metoclopramide are notorious for causing dystonic reactions in young women and children.
Bizarre attacks of trismus due to masseteric spasm have been ascribed to metoclopramide. Erythematous early , hyperplastic, pseudomembranous late , and angular cheilitis in young people most common oral feature of HIV. It is a predictor of a bad prognosis and possible development of lymphoma.
Often characterized by linear gingival erythema, an intense red band along the gingival margin. Occurs in young, otherwise healthy mouths. It is pathognomonic if seen in a young male who is not receiving immunosuppression. Rx: radiotherapy, intralesional vincristine, or local excision. Cervical nodes particularly commonly affected. Facial manifestations of their use include a severe facial lipoatrophy. The finding of an enlarged node or nodes in children is relatively common and can be reasonably managed by watchful waiting.
Was there any constitutional upset when the lump appeared? Has it been getting bigger progressively or has it fluctuated? Is it painful, and how long has it been present? Examine systematically, feeling the submental, facial, submandibular, parotid, auricular, occipital, deep cervical chain, supraclavicular, and posterior triangle nodes. Differentiating between the submandibular salivary gland and node can be a problem, made simpler by palpating bimanually; the salivary gland can be felt moving between the external and internal fingers.
Supraclavicular nodes are more liable to be due to an occult tumour in the lung or upper gastrointestinal tract, whereas posterior triangle nodes are more liable to be haematological or scalp skin in origin.
If a node is palpable, note its texture, size, and site, and whether it is tender to touch or fixed to surrounding tissues. Examine axillary and inguinal nodes, liver, and spleen. Specific blood tests such as serology for EBV, CMV, cat scratch disease, and toxoplasmosis may be required according to the history. If access for examination is limited, examination under anaesthesia EUA is indicated.
MRI and CT scanning will confirm the presence, shape, size, and presence of necrosis within nodes and may reveal an occult tumour.
Cervicofacial lymphadenopathy Fig. If of recent onset, ask whether it was preceded by blistering. Are the ulcers multiple? Is any other part of the body affected and have similar ulcers been experienced before? Blistering with lesions elsewhere in the body suggests erythema multiforme or hand, foot, and mouth disease. Under a denture or other appliance suggests traumatic ulceration. Pain is often a late feature of oral carcinoma and the fact that an ulcer may be painless never excludes it from being a potential cancer.
What is it? The problem being addressed is pain in the preauricular area and muscles of mastication with trismus, with or without evidence of internal derangement of the meniscus. Multiple theories put forward regarding occlusion, trauma, stress, habits, and joint hypermobility. This is compatible with the observed high association with depression, back pain, tension headache, migraine, irritable bowel syndrome, and fibromyalgia.
It does not, however, explain the cause in those patients who can identify no different levels of stress in their lives nor does it help explain the high incidence of internal derangement of the meniscus. Some patients may be clinically depressed but most are not.
This is due to the meniscus being displaced anteriorly on translation of the head of the condyle and then returning to its usual position the click. A lock is when it does not return. Do not create a problem where there is none! This is also the time to take a gentle but thorough social and family history to identify clinically depressed patients or those with significant stress. An information leaflet is helpful. The initial aim of a splint is to i show something is being done placebo ; ii d bruxism and joint load; and iii i the gap between condyle and fossa, whereby the disc may be freed.
Do not persist with ineffective Rx if symptoms have not improved within 3 months. There is also a misconceived reluctance among clinicians to use the tricyclics and related compounds.
Nortriptyline, dosulepin, and related compounds have been demonstrated to have analgesic and muscle relaxant effects independent of their antidepressant effect. In these cases, a hard diagnostic occlusal splint can be constructed for the mandible Tanner or for the maxilla Michigan , and should be made to give multiple even contacts in centric relation and anterior guidance. If pain is abolished while wearing the appliance, returns when it is removed, and is abolished on reinstitution, then occlusal adjustment by orthodontic, surgical, or restorative means is a reasonable option.
The first line which may be useful diagnostically and improve pain due to capsulitis is arthrocentesis or arthroscopy. This includes irrigation of the upper joint space, through which lysis and lavage of adhesions and synovial inflammatory mediators, and injection of steroids and LA can be performed.
The next line of surgical Rx includes open procedures such as meniscopexy, menisectomy, condylar shave, and eminectomy. However, the consensus dictates that the minimum of interference to the articulatory surfaces and the articular meniscus is carried out. Rarely, completely ruined joints will benefit from total joint replacement.
Gillison Nivolumab for squamous cell cancer of head and neck. N Engl J Med Hupp et al. Jones Facial Rejuvenation Surgery, Mosby. Mitchell and A. Shah Oral Cancer, Dunitz. In general, maxillofacial surgery is a postgraduate subject which has evolved from oral surgery, with foundations in medicine, dentistry, and surgery.
It was first conceived in Nebraska, subsequently developed by the ACS, and has now reached international acceptance. It is not the only approach but it is one which works. The principles of basic life support are included during trauma management and can be applied during emergencies in general dental practice. The first peak is within seconds to minutes of injury. Establish a patent airway and protect the cervical spine from further injury.
Inspect, palpate, and auscultate the chest. Count respiratory rate. Chest drain fifth intercostal space anterior axillary line if needed. Assess level of consciousness, skin colour, pulse and BP, manual pressure control of extreme haemorrhage. Establish ECG, seek help for operative control of bleeding if needed. Pupillary response to light, visual acuity. Prevent hypotension and hypoxia.
Remove all clothing to allow full assessment of injuries. Prevent hypothermia. Cervical spine film may help but the cervical spine should remain immobilized until fully assessed if the mechanism of injury suggests spinal trauma. Remember that isolated facial injuries rarely cause sufficient bleeding to induce hypovolaemic shock. Bleeding can cause pressure to the optic nerve and can cause blindness. Visual acuity must be checked. Most conscious patients can maintain a patent airway if the oropharynx is cleared.
Give all traumatized patients maximal O2 initially. Oral airways are not tolerated unless the patient is unconscious. Nasopharyngeal airways are only of value if they can be inserted safely and kept patent. If the patient is unconscious and the airway is obstructed, they should be intubated. Gunshot wounds and lacerated major vessels are exceptions which can cause extensive bleeding. Can they see? Assess and document visual acuity, can they count fingers?
Use a Snellen chart to formally document vision. If evidence of lost or decreasing visual acuity, request formal ophthalmological review. Although controversial, prophylactic antibiotics are used by many.
It was the concern that low levels of antibiotic in the CSF would only suppress signs of meningitis while selecting resistant organisms that prompted influential recommendations against prophylaxis. If in doubt admit. Place on, at least, initial hourly neurological observations most will need 15min observations initially. IV access and antibiotic. If teeth have been lost, ensure they are not in the chest CXR or soft tissues.
Change in the level of consciousness is the earliest and most valuable sign of head injury. A combination of the scales in Table It is a valuable handbook for any student, trainee, or qualified dentist treating patients in both a clinical and hospital setting. Reprints and Permissions. Oxford handbook of clinical dentistry, 7th edition.
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