Sorry for being late , I didn’t have the slides and the doctor said she’ll put

them on the E-learning website , but unfortunately she didn’t (( till now )) 
so I didn’t put the picz and the tables that were present in the slides.

So sorry for that 

Last week we talked about the oral mucosa and the normal structure of the
oral mucosa, and at the end of the lecture we talked about the forms of
medications we use in oral medicine .

1st we talked about the normal appearance of the oral mucosa , the normal
changes or what changes we expect to see when the patient get older , and
about other abnormal changes & how do they look like and how can you see
them in this light !!!  and how can you see them in the clinic .

We talked about treatment options ,the systemic medications and the

topical ones ,creams & ointment ,and about the pastes (the orabase)
because we use them a lot in oral medicine , and Why do we use steroids in
oral medicine ??To reduce the immune response , we use them for allergic
reaction , when I have an exaggerated immune response I use the steroids .

Today , we are going to talk about special investigations

When we have a patient in the oral medicine clinic, 1st we take the history

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from the patient , sometimes we mange to know, The reasons for his
complaint just by taking the history like for example: When he describe the
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pain we can get to a conclusion for what the problem is , but most of the
times we need to examine the patient, so

Taking history and examination are basics .

And after the history taking and the examination is done we should do
further investigations like :

– Radiographs
– Blood examination .
– Biopsy .
– Microbial investigations.
– Allergy patch testing .
– Imaging techniques .

When do we need to use the blood examination !!

If we saw any signs and symptoms that are suggestive for hematological
abnormalities like : if the patient looks pale so 1st you’ll think the patient
might have anemia so we do blood test to check if there is anemia or not ,
sometimes the reduced iron level in the blood is presented clinically in a
recurrent oral ulcers , usually they are idiopathic but sometimes when the
patient noticed that they become more frequent or very sever in this case it
give us a clue that there might be a problem or a predisposing factor, and he
should go immediately and check the blood level, The iron level , vit B12 level
,because sometimes decrease in these measures will increase the frequency
in recurrent oral ulcers , Also persistence sore or dry mouth we should
check for the anemia presence .

If the patient is having a fungal infection , you prescribed for him

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antifungal and you expect this infection should be healed in one week, And
the patient came back and u noticed that there is still a fungal infection, and
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the patient didn’t respond to the medications , you’ll start thinking about the
reasons why he is not responding to the medications , you’ll start to think
about depression in the immunity , so I’ll do blood testing and check for the
WBC’s count , to figure out what’s the reasons that the patient is not
responding to the treatment .
You should check the Bleeding tendency too , like when the patient report
that the last time he had an extraction, he had bleeding for a couple of days
,and he had to go back to the dentist and do suturing and it couz him a lot of
trouble.

So , if I want to do an extraction to a patient, I need to check that the

bleeding time is okay the PT , PTT and all the measures should be normal .

And if there is anything in the medical history indicate that the patient has
a problem like he is anemic or used to be anemic in the case you need to
follow this up with the patient and do the blood test .

Blood test includes:

– Hematological investigations
– The CBC , blood film , these are the basic standers of hematological
investigations.
– Ferritin and iron levels , vit B12 , we do these when we suspect there
is a deficiency like recurrent oral ulcer and sore mouth as we said .
– Coagulations screening .
– erythrocytes sedimentation rate .

it’s non specific guide for an abnormality like the patient is having a chronic
infection or acute one , immune disease ,the ESR well be elevated .

in the this test they do a centrifugation for the erythrocytes and rate the
blood cells where they flow down in the tube when it increased, which means
the blood become more viscose , which mean there is lots of cells or lots of
WBL’s which is an indication for an infection. Page
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Biochemical investigations

only when needed , like blood glucose for example: when you have a patient
that have a sever periodontal disease , and his oral hygiene is okay
we’ll start think of other systemic factors that causing this deterioration in
his periodontal status, and one of the most causing factor is diabetes
mellitus , or the patient is complaining of xerostomia , parestheia, ulceration
and sensations in the mouth ,we do this test .

– urea and creatinine, if we suspect renal failure.

– liver function test .
– calcium and phosphate and alkaline phosphates in metabolic bone
diseases like paget's disease, if we want to check for some
abnormalities we do those testing.

Immunological investigations

Includes:

– rheumatoid factor, if your patient came complaining of pain in the

TMJ, it’s very tender and it’s not the only complaint but he is
complaining of pain in all of his joints , so we check the rheumatoid
factor , and if it’s +ve ,than we need to refer the patient to
rheumatologist to follow this up .

– Antinuclear factor.

– SSA and SSB antibodies.

we use these to check for Sjogren syndrome , there are immunological tests
and we are testing for the presence of the antibodies that is causing the Page
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immunological disease .

– The C1 esterase inhibitor, we use this test for angioedma and for viral
infection, if we suspect a viral infection we check for the viral
antibodies if they are present in the serum.
You’ll find the normal values on the book, it’s good to know the mine findings
, the hemoglobin , the WBC’s , RBC’s , the blood film when there is a
Microcytic anemia or Megaloblastic anemia ,and what causes them .

Microcytic anemia caused by iron deficiency ,while Megaloblastic anemia by

vit B12 deficiency .

Endocrine function test

When a patient with orofacial symptoms caused by hormonal disturbances

Like diabetes , Addison's disease, we can notice pigmentations of brownish
macula’s , increased in the production of melanocytes and the under
production of the corticosteroids , so when we see those signs on the oral
cavity ,we have to refer the patient or we can check these tests like
checking the cortisol level.

patients on steroids is another example , if I’m giving the patient systemic

steroids for a long duration like in autoimmune diseases, we need to check if
there is a suppression on the corticosteroids hormone and the patient
should be always under monitoring ,or maybe the patient is already having a
endocrine disease ,he is diabetic or he is using steroids or for any other
reason like Cushing syndrome and the signs are obvious on the patient than
you need to do the testing to make sure that it’s safe to do the dental
treatment for this patient .

one of the tests that is very useful for us in oral medicine is using the
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Toluidine blue dye test
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this dye has a very high affinity to the DNA , when there is abnormal
lesions on the oral cavity and you want to take a biopsy for this lesion , you
want to take the most representative part of the lesion to send it to the lab
for examination , you can’t judge or guess which one is more representative ,
the toluidine blue dye will help you to figure out which one is , because this
dye goes directly to the DNA , and as you know when there is a cancerous
activity there will be increased in the cell division rate , so there is lots of
nuclei ,like 2or 3 nuclei in one single cell because of the repeated cycle of
division , this areas with very high activity will be stained with the toluidine
blue dye .

for example here (plz refer to the slides)

this is the whole lesion on the tongue and we were not sure which site we
select for the biopsy , using the toluidine blue dye suggest this area , than I
can take my biopsy within this blue area .

this is how we use it : ( refer to the slides for the picz ) “sorry” 

Like this lesion as you see it occupies all the cheek, I used the toluidine blue
dye and put it on the cheek , the buccal mucosa ,Than I washed this dye
using acid , than I asked the patient to rinse his mouth with water , the blue
dye will be removed from the tissues and stay within the area with high
activity and cell division and by that I know this region is a good choice for
biopsy .

One of the student ask a question but unfortunately I couldn’t hear it but
the answer was:

Particularly In our country they hate biopsy , the biopsy is equivalent for
cancer , so sometimes you need to do biopsy not to exclude cancer but to
know what is the diagnosis like in pemphigus and pemphigoid or any immune
mediated diseases ,and u need to do a biopsy to confirm your diagnosis .

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If the patient denied the biopsy this might be an indicator for you that if
there is anything sinister, anything serious that you need to take the biopsy
6
or not , so if there is no area stained with toluidine bule , you know it’s not
conclusive but you can say it appears that there is no high activity of cell
division but you can’t be sure without a biopsy , so this is might be away to
convince the patient either to do a biopsy , or you may think to leave it for a
while and ask the patient to come back for a review .
Of course using the toluidine blue it’s not alternative for a biopsy ,it’s not
another way , it’s just for you to help you to get to a clinical judgment , For
what would be your advice to the patient ,is it an argent biopsy !! or the
patient can comeback for review after a while .

The indications for biopsy

– Lesions which has neoplastic or pre-malignant features like :

Leukoplakia , erthroplakia , non healing ulcer , these are some of the pre-
malignant lesions or highly suspicion lesions , so when there is red or
white lesion unexplained by friction or by irritation , than you need to
take a biopsy for this lesion to make sure what it is .

– Persistent lesions of uncertain etiology.

Some times when we notice a white lesion in the oral cavity , we try to
eliminate any causes like : sharp tooth edge , and ask the patient to
come back after a week , and if lesion is still there and didn’t heal ,
than this will be an indication to take a biopsy to get to a diagnosis .

– Persistent lesion failed to response to treatment

Like Candida infections , sometimes the fungal infection is presented
as a white lesion and it doesn’t go away by wiping the lesion ,in this
case we prescribe an antifungal medication to the patient and ask him
to come back after one week ,in most of the patient the infection will

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resolve and the mucosa will get back to normal and in some patient it
doesn’t , in this case it might be a pre-malignant lesion so we have to
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take a biopsy to check if there is any abnormalities in the cells .

– Conformation of the clinical diagnosis and lesions causing to the

patient extreme concern .
Sometimes the patient is really concerned about growth , Like fibro-
epithelial polyp , you know it’s a fibro- epithelial polyp but you can’t
find the causing for this irritation which leads to this growth , but the
 patient is not happy to have this growth within his mouth , either
because it irritating for him being inside his mouth , or because he is
really concerned and want to get rid of it !!  in this case we might do
a biopsy .

Different methods of biopsy

– We have brush biopsy.

– Incisional biopsy.
– Excisional biopsy.
– Punch biopsy.
– Fine needle aspiration (FNA).

This is the set you need to take a biopsy (back to slides)

We need topical anesthesia, and the most important think is that you
don’t inject the anesthesia very close or within the lesion because this
will destroy the tissue that you want to examine.
So you’ll inject the anesthesia away from the lesion but in area that
the analgesic or the anesthetic will reach the region where are you
going to take your biopsy.
You need the container where you should put the specimen, and you
need a form to write down your provisional diagnosis , the patient
name ,age , file number, and to write down from where you took the
biopsy , and draw the shape and size of the lesion and how it appear
clinically .

Of course we need suturing, sometimes even if you want to catch or

grab the over growth tissue or the lesion, and you can’t use the Page
8
tweezers or any other instrument, because if you did it’ll destroy the
mass or will destroy the lesion , in this case the alternative way is to
use the sutures ,you just put the suture in the middle of lesion and do
the incision and get the specimen , put it in the container and send it
to the lab .
• Brush biopsy
Very simple method, but it’s not very accurate as the incisional or the
excisional biopsy.
The idea behind it, is for example here (refer to the slides of the
picz)
this patient we suspected something wrong here, a white lesion on this
lower lip , we can do a brush biopsy , using like this brush , just
scraping over this lesion to take samples of the cells that present in
the lesion .
You need to be a little hard to get to the deep parts of lesion, and
you’ll know you are doing it in the right way if you noticed bleeding or
some blood oozing from the surface where you got your biopsy, if
there is no bleeding or any blood on the sample side. that means your
sample isn’t correct , and what you got in your sample will be just
epithelium from scraping the surface , when using this way you don’t
need to give the patient any type of anesthesia, it’s like you are
creating erosions not a cut on the mucosa.
Here there is a brush, you spread it on the slide and you need an
expert on the cytology to examine these cells if they are normal or if
there is any abnormality .
For example here , you can notice there is the nucleus ratio to the
cytoplasm is very huge , and this an indication for abnormal changes in
the cells .
This method is very simple , the patient will accept it , the problem is
with the false +ve and false –ve results , it’s very often you miss
cancerous cell because you took the wrong cells , and you gave the Page
9
patient an indication that everything is okay while it’s not .
So again it’s not an alternative, but it’s another way just to double
check that if there is anything wrong , if you noticed any abnormality
on the cells this will give you the information that you need to do a
biopsy to confirm your diagnosis .
• Incisional biopsy
Here we take parts of the lesion not the whole of it , and again we
have to select the most representative sits if the lesion , maybe we
can use the toluidine blue to guide us where is the most
representative sits , and it’s a good practice to do the biopsy this way
take it like a wedge shape this will help to reduce of the trauma and
it’ll be easier for suturing .
Another good practice is to take parts of the normal tissue , and this
normal tissue will allow you to compare or to make sure where you are
exactly in the slide , so we take the borders of the normal tissue and
parts of the abnormal tissue .

• Excisional biopsy
We take out the whole lesion when we use this way , we use it when
the lesion is small in size and I can take the whole of it , and again you
have to take it with a safety margins, so I can see in the slides there
is a safety margins where the tissue should be normal , around the
lesion or around the abnormal area , so that I can be sure that I did
take all the abnormal lesion in my biopsy .

• Punch biopsy
It’s another type of biopsy , it have the same concept but we are using
this punch to take or to grab a piece , we don’t need to use the scalpel
to make the incision or to take the biopsy , and most of the patients Page
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prefer this way because you won’t cut the incision with a scalpel , just
one click and you’ll take out the sample .

• Fine needle aspiration (FNA)

If there is cyst of there is collection of pus, I can aspirate amount of
this fluid and send to the lab to check what is the content of the cyst
We use it for the thyroid enlargement to check this growth if it’s a
mass or a cyst containing a fluids or an abscess.

For some diseases taking a biopsy is not adequate, like for example
here in pemphigus or pemphigoid, to diagnose those diseases we use
immunofluorescent stains , these diseases are immune mediated ,
there is an increase in IgG,and this IgG is affecting the whole cells as
you can see here , all cell membranes are affected with these
antibodies .
What we do is we use an antibody for this antibody which is
circulating around the cells , and this antibody is fluorescently labeled
, and the anti-antibody will bind here and will be obvious under UV
light , we can see all cell are affected we can diagnose the patient
with pemphigus .
In this one here we did exactly the same, we know there is an increase
in the immune antibody IgG , but here they are presented mainly in
the basement membrane in the basal cell layer , by dyeing this section
with anti-antibodies which contain a fluorescent dye, it’ll attach only
to the cells that are present in the basal cell layer where the
antibodies are present .

Microbiological investigations
If you want to check for the presence of bacteria or virus of fungal Page
11
infection , for bacteria is swab and culture , and than you can know
the type of bacteria , we can do testing for sensitivity by doing a
sensitivity test to select the most appropriate antibiotics for this
bacteria , if there is a pus present In cyst like lesion we can just
aspirate and do a culture to know the type of bacteria and to select
the appropriate type of antibiotics .
For the fungal infection we use a swab and smear , we just take a
swab from the site of the infection , spread it on a slide and send it
for the lab , they will check for the presence of fungus in these cells .
as we said on the beginning of this lecture that some fungal infection
are not superficial but they are very deep and they might cause
dysplastic features in the cells , and in this case we need to take a
biopsy to know how dysplastic the cells are !! and if there is any
malignant changes or not .

One common way to diagnose fungal infection is just to try antifungal

treatment , if you suspect a fungal infection like you found a red
lesion on the mouth or in the palate and you suspect that this is a
fungal infection , just give the patient antifungal and ask him to come
back after one week and by that time it should be resolved , so if it’s
cute that’s it , it wasn’t fungal infection .

For viral infection , it’s either I detect the antigen itself by

immunocytochemistry or by serology , we check for the antibodies
titer for this virus , if we found it very much elevated that means this
patient is infected with the virus , or we can use the new techniques ,
like using the DNA or the genome of the virus , they take a sample and
do the PCR which is a technique used to amplify the genome of the
virus , if it’s present that means the virus is present .

Another test we use in the clinic is the Page

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Allergy patch testing
What dose it test for , or what do we use it for ??
To check for type IV delayed hypersensitivity reaction , sometimes
the patient come to you complaining that he can’t tolerate the denture
, he had the denture like 2 weeks ago and he did wear it for 1 or 2
day’s and he can’t put them on again , cause when he put the denture
he feels like burning sensation , so one of the explanation will be
present of allergic reaction , to check for that If the patient is
allergic for the acrylic component monomer , or if it’s CR-CO we have
to check if this patient is allergic for any type of those metals or
alloys that involved in the prosthesis , so I do the allergic test ,and all
what I need to do is to put small amounts of this allergen for all the
materials that you suspect it might cause the allergy , and I use
another control like normal saline , put it on the patient hand and leave
it for 24 -48 hrs , and ask the patient to come back and than I check
if there is any presence for any allergic reaction Like in this pic
material number 3 caused allergic reaction , so I’ll confirm that the
patient is allergic for example to acrylic or any type of metal , or
amalgam.
For example if the patient has a leuconoid reaction, in Uk for example
The insurance well cover only amalgam fillings , it doesn’t cover
composite fillings and the patient came to the clinic complaining and
there is a leuconoid reaction and burning sensation , than we have to
do this test to confirm that he is allergic to amalgam and give him
report that this patient is allergic to amalgam , in this case is
replacement of the amalgam filling for a composite fillings was
covered by the insurance company .
So if we want to confirm if the patient is allergic to any type of
material we use this test .

Imaging technique
I’m not going to talk very much about it , because we are going to
cover these in radiology course  Page
13
But we use imaging techniques very often , almost all our patients we
need to have a radiographs for them , particularly if the problem is
affecting the jaws , we take periapical or bitewings for caries for
example ,Extra oral radiographs like the OPG’s to check for example
for a cyst , any retained root or any abnormality within the jaws .
Of course there is another type for the imaging techniques like
Sialography , we use it to check if there is any blockage or any
problems with the salivary glands , we inject a contrast media, to the
ducts , and have radiographs and follow and see if this media is going
smoothly through the canals of the ducts , this means that everything
is normal , if we find there is hazy or snow storm appearance or there
is a blockage in one of the ducts , this might lead us to the cause of
the problem , like the presence of a stone in the duct .
CT scans , ultrasounds , used particularly for TMJ problems
Magnetic resonance images (MRI) is good for soft tissues rather
than hard tissues .

After doing all this methods for diagnosis and after getting the
reports , in this case we can get to the final diagnosis so ..
1st we start with the 1- differential diagnosis when I do the history
taking and the examination , I’ll have a list of differentials diagnosis
For example like if I have a while lesion , Is it a hyperkeratosis !! or
leukoplakia , fungal infection .
Or if I have an ulcer I have again a list of differentials ,Is it a
recurrent oral ulcer!! , or immune mediated disease ulcer , is it a
cancer or traumatic ulcer .

Than I go to the 2-provisional diagnosis , which is the most likely to

be the cause , and finally I get to the 3- definitive diagnosis , when I
confirm my diagnosis according to the investigations that I did like
the biopsy or the tests that I have done to the patient . Page
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The end

Done by
Sukinah Al-fraid
 The doctor announce
You can find the lectures on the E-learning ( but I didn’t ) lol
Also the Essentials of Oral Medicine book and there is another
radiology book ( didn’t say the name of the book ) it has nice
illustration for bitewings and perapicals
You could get use of them because we use them a lot in oral medicine .

Feedbacks are more than welcome

Your colleague

Sukinah Al-Fraid
Peace out 

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