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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
398
CHAP TER13 The mouth, lips, andteeth
Tongue:ulceration and blistering
Common
• Frictional from sharp teeth/ llings
• Burns or topical irritants
• Primar y herpetic stomatitis
• Aphthous ulceration
• Erosive lichenplanus
• Drug- induced (nicorandil/ chemotherapy).
Uncommon
• Cancer— squamous cell carcinoma
• Behçet’s disease
• Vesiculobullous disorders
• SJS
• Angina bullosa haemorrhagica.
Lips:weakness ofparalysis
(See also E ‘Facial palsy’, pp.340 –2.)
Uncommon
• CVA/ bulbarpalsy
• Hypoglossal nerve lesions
• Iatrogenicinjur y
• Tumour.
Teeth:change inbite
(See also E Chapter 11 and E Chapter 12.)
Common
• Jaw/ dentoalveolar fracture (see E Chapter 11 and E Chapter 12)
• TMJ eusion
• Recent dental treatment.
Uncommon
• Dislocation/ locking TMJ (see E Chapter 12)
• Jaw cysts or odontogenic tumours (see E Chapter 11 and
E Chapter 12)
• Over- erupted wisdomtooth.
Teeth:discolouration/ staining
Common
• Extrinsic stains (coee, wine, cigarettes)
• Trau m a
• Age related.
COMMON PROBLEMS AND THEIRCAUSES
Uncommon
• Excessive uoride exposure during childhood
• Tetracycline
• Dentinogenesis imperfecta.
Teeth:injury
Common
• Crown fractures
• Root fractures
• Dentoalveolar fractures
• Subluxation/ avulsion
• Chipped llings, lost crowns/ caps.
Teeth:toothache
Common
• Pulpitis/ dental or periodontal abscess
• Dentine hypersensitivity
• Recent treatment.
Uncommon
• Referred— sinusitis
• Pain on biting— crackedtooth
• Teething pain— infants.
Teeth:wisdom teeth problems
Common
• Pericoronitis/ dental decay/ pulpitis
• Erupting
• Postoperativepain.
Uncommon
• Infected dentigerouscyst.
399
Gums:bleedinggums
Common
• Poor oral hygiene/ periodontal disease
• Trauma— laceration or fracture
• Ill- tting dentures.
Uncommon
• Pregnancy
• Anticoagulants
• Haematological disorders— leukaemia, haemophilia,
thrombocytopenia
400
CHAP TER13 The mouth, lips, andteeth
• Liver disorders
• Tumours
• Scurv y
• Vitamin K deciency.
Gums:change incolour/ pigmented lesions
Common
• Frictional keratosis
• Oral lichen planus/ lichenoid reaction
• Amalgamtattoo
• Racial pigmentation/ nevi
• Smoking.
Uncommon
• Cancer
• Anaemia
• Heavy metal poisoning (lead, bismuth, and mercury)
• Addison disease
• Albright syndrome
• Bluenevi
• HIV
• Peutz– Jeghers syndrome.
Gums:lumps and swelling
Common
• Dental/ periodontal abscess
• Gingivitis
• Drugs (calcium channel blockers, antiepileptics)
• Pregnancy.
Uncommon
• Pyogenic granuloma
• Uner uptedteeth
• Pregnancy
• Cancer
• Leukaemia
• Malnutrition
• Poorly tting dentures.
Teeth and gums:exposedbone
Common
• Drysocket
• Fracture (see E Chapter 11 and E Chapter 12).
COMMON PROBLEMS AND THEIRCAUSES
Uncommon
• Osteomyelitis/ ORN/ BRONJ
• Cancer
• Denture trauma.
Teeth and gums:bleeding extractionsocket
Common
• Normal/ reactionary haemorrhage— local anaesthetic wearingo
• Iatrogenic— poking the socket/ sucking/ spitting
• Infection
• Anticoagulants.
Uncommon
• Clotting disorders, liver disease, haematological disease.
Teeth and gums:painful extractionsocket
Common
• Normal postoperativepain
• Drysocket
• Abscess.
Uncommon
• Retained root fragment
• Sensitivity from adjacenttooth.
Teeth and gums:looseteeth
Common
• Periodontal disease
• Trau m a .
Uncommon
• Tumours/ jawcysts
• ORN/ BRONJ.
401
Teeth and gums:miscellaneous related problems
Common
• Denture rubbing/ ulceration
• Loose dentures
• Broken dentures/ orthodontic appliance
• Denture candidiasis.
Uncommon
• Flabby ridge, denture hyperplasia, denture broma.
402
CHAP TER13 The mouth, lips, andteeth
Useful questions and what
tolookfor
Bleeding (non- extraction)
Askabout
• Histor y of tr auma or dent al treatment
• Duration
• Generalized or discrete
• Swelling or other symptoms (pain/ ulceration/ blisters)
• Bleeding from othersites
• PMH/ drug history
• Family history of bleeding disorders.
Lookfor
• Conrm site anddegree
• Oral hygiene
• Associated structures, e.g. loose/ painfulteeth
• Bruising/ petechiae, hepatosplenomegaly
• Signs of injury/ infection/ malignancy at site of bleeding.
Bleeding following dental extraction
Askabout
• How long af ter the extraction did the bleedingstart
• History of bleeding disorders
• Anticoagulant medication.
Lookfor
• Signs of active bleeding from soft tissue andbone
• OP T to exclude retained root fragments
• Signs of local or systemic infection— inamed gums, swelling,
abscess, lymphadenopathy
• Signs of underlying bleeding disorder.
Change incolour
Askabout
• How has colour changed
• Smoking/ sun exposure/ diet/ known precipitant
• Associated changes in lesion (growth, itching, bleeding, pain,etc.)
• Discrete or widespread
• Other sites onbody.
Lookfor
• Single/ multiple lesions
• Blanching or bleeding
• Possible melanoma.
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Depapillation (loss ofsurface roughness)
Askabout
• Howlong
• Painful/ painless
• Diet and nutritionalstatus
• Histor y of tr auma, friction, andburns.
Lookfor
• Conrm depapillation
• Blood tests — haematinic screen:iron, folate, vitamin B12,
magnesium, and zinc to rule out micronutrient deciency
• Adjacent sharp or rough teeth causing trauma.
Diculty swallowing (dysphagia)
(See also E Chapter 8.)
Askabout
• Duration
• Progressively worsening
• Smoking/ alcohol histor y
• Is it causing issues with aspiration or nutrition?
• Signs of chest infection
• Signs of reux or vomiting indicating oesophageal obstruction
• PMH of diabetes, stroke,cancer
• Any paroxysmal nocturnal dyspnoea.
Lookfor
• Oral hygiene or signs of odontogenic infection, such as swelling,
trismus, elevated tongue, and oor ofmouth.
• Any ulcer ations in the oral cavity, tongue, oor of mouth, or throat
suggestive of atumour
• Hoarsevoice
• Signs of facial nerve or hypoglossal ner vepalsy
• Signs of chest infection
• Wasting, cachexia, signs of nutritional deciency.
403
Discolouredteeth
Askabout
• Single tooth or multiple teeth aected
• Histor y of tr auma toteeth
• History of foods causing staining— wine, soy sauce, tea/ coee, or
smoking
• History of tetracycline antibiotics in childhood.
Lookfor
• Conrm whether single or multiple teeth aected
• Colour— black/ grey, brown/ yellow.
404
CHAP TER13 The mouth, lips, andteeth
Exposedbone
Askabout
• Histor y of recent extraction or trauma from denture
• Histor y of radiation therapy tojaws
• History of bisphosphonate medication
• History of immunocompromise, diabetes, steroids, smoking
• Oral hygiene
• Severity of pain, or problems with malnutrition.
Lookfor
• Site,extent
• Signs of pathological frac ture— checkonOP T
• Signs of necrosis or infected bone— pus, swelling, or stula
• Signs of oral cancer with induration, ulceration and
lymphadenopathy.
Halitosis
Askabout
• Howlong
• Painful/ painless
• Symptoms of chest/ throat/ sinus/ dental infection
• Any gastric/ oesophageal symptoms
• Tongue scrubbing and oral hygiene regimen.
Lookfor
• Conrm halitosis objectively
• Anaemia, signs of diabetic ketoacidosis, liver failure, lung abscess,
or bowel obstruction
• Poor oral hygiene
• Dental infection
• Tonsillitis, sinusitis.
Injuries (dental— fractured, avulsed,loose)
Askabout
• Trauma history
• If avulsed tooth, time out ofmouth
• Gradually loosening tooth/ teeth
• Does the bite feel normal?
Lookfor
• Ensure all broken teeth are accounted for. Consider imaging.
• Single tooth aected, or segment of loose teeth suggesting alveolar
bone fracture
• Signs of tooth root and jaw fracture on OPT and PA mandible
• Changes in bite (occlusion).
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Injuries(oral)
Askabout
• When it occurred— date and specictime
• Mechanism of injury— high/ low impact, likely cervical spineinjury
• Loss of consciousness
• Progression of symptoms since time ofinjury
• Diculty swallowing or stridor
• Numbness or weakness
• Change inbite
• Other injuries
• Clean or dirt y injury and tetanus vaccination status.
Lookfor
• Other injuries— face andspine
• Lacerations— check intra- and ex traorally. Document size, depth,
and involvement of key structures, such as ver million border. Note
any gross tissueloss
• Mobility of jaw or teeth suggesting fracture
• Account for any missing or chipped teeth— CXR to exclude
aspiration
• Floor of mouth swelling or sublingual haematoma suggesting
potential for airway compromise.
Lumps
Askabout
• History trauma or dental treatment
• Cheek- bitinghabits
• Duration
• Generalized or discrete
• Painful/ painless
• Is it growing?
Lookfor
• Conrm site andsize
• Mobile orxed
• Associated structures, e.g. loose/ painfulteeth
• Bony or sof ttissue
• Lumps elsewhere
• Blanching or pulsation
• Are the lumps bilateral and part of normal anatomy?
405
Pain and numbness
Askabout
• Histor y of facial tr auma, surgery, or dental treatment
• Episodic or progressive
• Rapid onset or gr adual
• Any improvement
406
CHAP TER13 The mouth, lips, andteeth
• Exact site (perioral/ dermatome)
• Associated masses or swelling
• Other neurological symptoms, e.g. dysarthria, limb weak ness,
hemiplegia,tetany
• Past histor y of surgery to head and neck with nerve damage or
sacrice
• Recent stress or viral infection.
Lookfor
• Conrm site and degree (unilateral vs bilateral, dermatomal or
nerve distribution)
• Test cranial nerves (especially facial and trigeminal). Forehead
sparing
• Associated structures, e.g. loose/ painfulteeth
• Parotidmass.
Painful extractionsocket
Askabout
• Nature of extraction— simple or surgical
• Onset ofpain
• Associated symptoms of dry socket— inammation, badtaste
• Risk factors for dry socket— smoking, poor oral hygiene,
contraceptive pill, past history of drysocket
• Symptoms of infection— fever, swelling, pus, lymphadenopathy
• Symptoms of nerve damage— numbness, tingling, sharp shooting or
electric shockpain.
Lookfor
• Is the clot present or absent?
• Is the socket inamed or pus present?
• Signs of food packing and poor or al hygiene
• OP T to exclude retained root fragments.
Swellings
Askabout
• Onset— acute or gradual/ duration
• Localized or generalized
• Episodic or persistent
• Obvious triggers/ allergies
• Trauma or lip biting history.
Lookfor
• Is the swelling soft tissue orbony?
• Painful, hot, or uctuant
• Associated bleeding or ulceration
• Any lymphadenopathy
• Systemic features— hypotension, ushed,r ash
• Dental pain or infection.
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Toothache, dental pain, wisdomteeth
Askabout
• Pain duration, intensity, location, character, exacerbating and
relieving features
• Symptoms of systemic infection
• Analgesia taken (can overdose with severe toothache)
• Histor y of tr auma toteeth.
Lookfor
• Conrm aected tooth/ teeth with OPT and clinical examination
• Tongue mobility— able to swallow secretions
• Tris m u s
• Fever
• Swelling, lymphadenopathy andpus.
Ulceration and blistering
Ask about
• Duration
• Progressive or episodic
• Painful or painless—ability to maintain oral intake
• Solitar y or multiple
• Risk fac tors (heav y smoker, sun exposure)
• Widespread mucocutaneous involvement
• Weight loss/fatigue
• Any new medications.
Look for
• Signs of malignancy—persistent ulcer with round rolled margins,
induration
• Lymphadenopathy
• Iron/B12/folate deciency
• Ill-t ting dentures or sharp teeth causing trauma.
407
Miscellaneous:denture/ orthodontic appliance
(braces)- related problems
Askabout
• Age of dentures
• Loose and rubbing
• Tight dentures
• Any pain, mobility, or problems with adjacent teeth and soft
tissues.
Lookfor
• Signs of traumatic ulceration
• Signs of reactive hyperplasia of supporting soft tissues under
denture base orange
• If patient complains of tight dentures, check for signs of acromegaly
and Paget’s disease.