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‫بسم الله الرحمن الرحيم‬

The dr started the lecture by explaining that the Oral


Medicine (O.M) course is a 2 hours credit course divided
into one hour/week as a lecture & 3 hours clinic alternating
with the radio clinic. The location of the O.M clinic will
differ during the week days according to available clinics,
either the O.M clinic in the ground floor, the cons, or the
pedo clinic.
U will find the PowerPoint slides & the references for the
course on the university website "elearning.just.edu.jo",
search for the course by its name, then login using ur ID
number & ur password then u can download the lecs & the
references. The syllabus is also found on the website.
U can also find a PDF file for one of the books (the main
reference) & in other lec there will be other references, in
this case the dr will either upload it as a PDF file on the
website or she will give it as a handout to photocopy it.

Assessment & treatment of patients

The first two lecs will be filled with information as they


link between the O.M course & the Oral Pathology course;
so the dr will refer us to many chapters!!!
What is Oral Medicine?
It is the study & non-surgical treatment of:
1. Diseases affecting the oro-facial tissues:
 Oral mucosa.
 Salivary glands.
 Bone & facial tissues.
2. Oral manifestation of systemic diseases: we know that
many (but not all) of the diseases presented in the oral
cavity are either part of the mucocutaneous diseases
treated by the dermatologist or part of a systemic disease
involving for ex: the endocrine system like diabetes. So
the O.M can't be found as a speciality on its own.
3. Oral & dental treatment of medically compromised
patients.
The O.M specialist might be the first person to indicate
signs of systemic diseases in the oral cavity & can detect
early signs of oral cavity cancer.
What the dr wants from us when examining the pt oral
cavity, is to distinguish the normal from the abnormal
features.

Patient assessment:
1. History taking:
 Chief complaint.
 Dental.
 Medical.
2. Examination:
 Extra oral.
 Intra oral.
3. Investigation: will be delayed to the next lec to talk
about it in details.
The dr refered us to a chapter in the PDF file that has
nice images that will help us
understand these steps & if
anything is unclear, we can ask her
in the clinic about it.

Oral Mucosa: most of the diseases


that we deal with are in the oral
mucosa, it consists of:
1. Oral Epithelium:
 Is a stratified squamous epithelium of
keratinocytes
 It consists of four layers:
1. The keratinised layer
(stratum corneum): 1st arrow.
2. The granular cell layer
(stratum granulosum).
3. The prickle cell layer
(stratum spinosum): 2nd
arrow.
4. The basal layer (or stratum basale): lower
arrow.

 Other cells: Melanocyte & Langerhans cells


It's keratinized on the surface, 2 types:
a. orthokeratosis: without nucleus.
b. parakeratosis: with nucleus.
2. Basement membrane:
 Lamina lucida
 Lamina densa
3. Lamina Propria (corium):
- The connective tissue (C.T) under the epithelium.
- It consists of:
 The papillary layer.
 The reticular layer (deeper).
 Fibroblasts.
 Endothelial cells.
 Nerves.
 Inflammatory cells.
When we take a biopsy for any abnormality, we should take
from the epithelium layer+ the connective tissue (lamina
propria), cz the appearance of the C.T explains what's
going on in the epithelial layer.
Characteristics of oral mucosa:

1. Intact with desmosomes → barrier.


2. Permeability → allow for topical drug use
(Although it's intact).
3. Moist with saliva: Typical characteristic, any decrease
in the saliva will affect the look & the appearance of the
oral mucosa by making it more prone to infections &
trauma.
4. Occupied with normal flora.

Normal changes in oral mucosa caused by age:

1.↓ in epithelium thickness: Increases caries &


periodontal diseases.
2. ↓ in saliva flow.
3. ↓ In collagen flexibility.
4. ↓ in blood supply: Delayed healing.
5. ↓ In permeability.

Abnormal oral mucosa: We will concentrate on it & relate


the clinical appearance with the pathological appearance.
 Abnormalities usually extend to the corium.
 Presentation of the disease in the oral mucosa is
clinically less specific than that presented in the skin;
it's important to notice that some mucocutaneous
diseases on the skin & oral cavity are very much alike
in their oral clinical appearance, so we have to be
specific in the diagnosis.
Abnormal changes in oral mucosa:

1. Hyperkeratosis: Increased keratin layer.


2. Epithelial atrophy: Decreased epithelial layer.
3. Epithelial loss.
4. Separation between epithelial cells.
5. Separation between epithelium & corium.

 Slide 12: Hyperkertinized area.


Hyperkertinized area on the alveolar ridge (white lesion).
Other white conditions in the oral cavity?
1. Leukoplakia: white lesion of unknown cause.
2. Lina alba: hyperkeratosis due to friction.
3. Leukoedema: white lesion due to increase fluids inside
the cells.
 Slide 13: Epithelial atrophy.
From the histo section, the epithelial layer is atrophied
(very much reduced); we find it on the tongue & the
gingivae.
the image with the atrophied gingiva; the red areas are not
blood really, (the C.T is not exposed) but bcz the epithelial
layer is thin, the blood vessels are shown more clearly than
the other parts of the gingiva, & it will be more susceptible
to trauma.

 Slide 14: Epithelial loss.


Total loss of epithelium leaving the C.T exposed, so
clinically it appears as an ulcer.
So not every yellowish or reddish lesion is an ulcer; ulcers
are lesions with total loss of the epithelium & exposed C.T,
appearing yellowish due to the exposed
fibrin.

 Slide 15: Separation between epithelial cells.


From the histo section, we notice a separation between
the epithelial cells, & if u put ur finger on the lesion, u
can feel some sort of sliding; the upper layer will slide
over the lower one & with time, the two epithelial layers
will slough off, which may cause an ulcer.
This separation is caused by the destruction of the
desmosomes connecting the epithelial cells together.

 Slide 16: Separation between epithelium &


corium; Deep sloughing area forming a deep ulcer.
In this case, the ulcer will start as a bulla filled with
fluids, with time, it will rupture to form a deep ulcer with
an inflamed C.T.
From The histo section, u can see an intact epithelium
layer, but it looks different, & it's aggregating together &
u can move it with ur finger. Also u can see a border
around the normal epithelium layer which also u can feel.
Many immune –mediated disorders are related with these
findings.
There are some diseases that start as recurrent small
ulcers such as recurrent aphthous stomatitis or bahcet's
syndrome, then enlarge to the limit that it will expose the
underlying C.T.

Now we will take briefly about the treatment options, we


will not specify the medication names here, but when
taking each disease, we'll talk about the suitable
medication for it.
Principles of Therapy:

1. Use the safest drug whenever possible: We can use


Iboprufen or Paracetamol, but if the patient is not in sever
pain, we can prescribe Paracetamol cz it's safer on the
stomach.
2. Warn the patient for any drug side effects: For ex:
Metronidazole has a metallic taste & causes change in the
urine color. Also the patient should be warned about any
expected allergic reactions.
3. Avoid medication during pregnancy.
4. Reduce the dose for children & elderly.
5. Check for medical history & concurrent medication; Cz
some medications shouldn't be given together or we might
alter the dose. Also if the patient complains of peptic
ulcer, we shouldn't prescribe prufen & look for
alternatives.
6. Use topical drugs instead of systemic whenever
possible: Best benefit to the region directly & sparing the
body from any side effects.

Rout of administration:

1. Topical Therapy: Most used in O.M.


2. Systemic Therapy:
 Oral.
 Parenteral (IV, IM, SC...).
 Transdermal.
 Inhalational.
Topical medication forms:
1. Mouth wash:
 Chlorhexidine:
 Antibacterial, antifungal & antiplaque.
 Fluoride rinses.
 Steroids (dissolved 5mg prednisolone/
betamethasone tab in 10 ml water): we prepare it or
the patient also can prepare it. We ask the patient to
rinse his mouth with it then spit it unless we want the
systemic effect, so in that case we tell him to swallow
the rinse after washing his mouth with it.
 Antibiotics (dissolved 250mg tetracycline cap in
10 ml water): we use it for the advantage of the
topical application for any bacterial infection
especially for recurrent aphthous stomatitis
particularly for herpetiform ulcers.

2. Paste (orabase): Orabase is composed of gelatin,


pectin and sodium carboxymethylcellulose in
Plastibase; it has the advantage of adhering to the
oral mucosa, so they will stick to the oral lesion.
We have a medication called aloclair. It's used for
aphthous ulcers & it's just made from orobase material.
Other ingredients added to orabase to have more
advantages:
- Covering agent: in case of ulcers, there's an
exposed nerve endings, so when the patient washes
his mouth with this medication, it forms a layer over
the exposed area & offers protection for the nerve
endings.
- Topical analgesics: ( Difflam-C)
 Benzydamine hydrochloride.
 15 ml (about 1 tablespoon) for 20- 30
seconds, every 1.5-3 hours.
 Do not swallow.
 Uninterrupted treatment should not
exceed 7 days.
 Not for children under 6 years.
- Topical steroid: Triamcinolone acetonide 0.1%.

3. Lozenges:A small, medicated candy intended to


be dissolved slowly in the mouth to:
 Lubricate oral tissues (xerostomia).
 Deliver medication:
1. Steroid.
2. Antifungal.
Ex: strepsils.

4. Spray.

5. Creams & ointements:


 Analgesics.
 Antifungal.
 Antiviral: zovirax.
 Antibiotics.
 Topical steroid: Triamcinolone acetonide
0.1%.
Ex:
- Creams: fucidine (fusidic acid).
- Kenacomb: combination of antibacterial &
antifungal.
Creams & ointments are used for Para oral lesions not
intraorally.

Systemic (oral) medication forms:


1. Analgesics.
2. Antibiotics.
3. Antiviral.
4. Antifungal.
5. Steroid.
6. Steroid-sparing immunosuppressant.
7. Antihistamine.
Provided in tablets or capsules.

Systemic (Parenteral) medication forms:


1. IM Analgesics:
1. Diclofinac Na 75- 100 mg.
2. Epinephrine in emergency for anaphylactic
shock.
- Steroidal injections are done by a specialist, not
often used.
- IV antibiotics are mainly given in the hospitals,
so we don't use them in O.M.

The End

Done by: Rawan M. Atallah

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