Intra Oral Examination

1. The (In)s and (Out)s about oral diagnosis Intra Oral Examination

2. Tell me what You see ??

3. Well its Actually An Oreo

4. Paratrigeminal syndrome of Reader • This syndrome consists of headaches in the upper face associated with eye and skin changes (oculosympathetic palsy) on one side of the face. • The pain is described as intense or throbbing, and there may also be drooping of the eyelid and contraction of the pupil (miosis). • Symptoms are frequent in the morning, and attacks can last between a few days and a few weeks. • Some sufferers experience an unpleasant taste (dysageusia),

5. Sphenopalatine neuralgia • Also known as - Migrainous Neuralgia / Cluster Headache • is characterized by severe pain on one side of the face in the frontal and/or eye (retro-orbital) regions. • These attacks are usually "clustered" over several days to weeks and are followed by remissions lasting weeks to months ( seem to be clustered during this period)

6. Causes • Unknown etiology • Vascular cause have been suggested, possibly mediated by abnormal hypothalamic function

7. Clinical Features • Can occur at any age. • Usually affects persons in 3 - 4 decade. • Strong male predilection( 6:1 ratio) • Pain is always unilateral & Usually involves orbital, supra orbital and temporal areas of face, upper jaw and soft palate.

8. The pain, described as paroxismal stabbing or shooting, lasts from a few minutes to hours, • Occur up to 8 times a day and cluster period usually lasts for weeks with intervening periods of remission that usually last for months to years. • Trigger zones are not present

9. The pain generally begin at the same time in a day ( alarm clock Head ache) with most attacks beginning in the midnight and may awake the sufferer from sleep. • During or following an attack, sufferers may experience tearing, nasal stuffiness or running nose, facial swelling or flushing, and eyelid edema, congestion of conjunctival vessels, all on the affected side.

10. In contrast to true migraine headache where patients feels a need to lie down and rest , a person with cluster head ache feels a need to pace restlessly.

11. Diagnosis • Based on medical history and clinical characteristics. • Care should be taken to avoid improper diagnosis of dental pain which may lead to unnecessary endodontic therapy or extractions

12. Treatment •  In the majority of sufferers medical therapy is the most effective treatment for Cluster Headache. • The mainstay of medical treatments include methysergid, Ergotamine, Verapamil, Flunarizine, Valproic acid, and Lithium carbonate. • Corticosteroids (including Prednisone) can also control cluster headache, and generally take affect within a few days.

13. FREY'S SYNDROME • also known as Auriculotemporal syndrome,or gustatory sweating flushing syndrome • Is a food related syndrome, commonly mistaken for food allergy • The symptoms of Frey's syndrome are redness and sweating on the cheek area adjacent to the ear. • They can appear when the affected person eats, sees, thinks about or talks about certain kinds of food which produce strong salivation. • Observing sweating in the region after eating a lemon wedge may be diagnostic.

14. Usually only one side is involved, although both sides of the face are occasionally affected. • Flushing is normally seen in a line between the edge of the mouth and ears, disappearing within 1-2 minutes. • When flushing occur local temp. may be raised to 1-2 degree

15. To detect sweating Minor’s starchiodine test may be used. -Paint affected area with 1% iodine solution • Allow solution to dry and apply a layer of starch over it • When patient eat something the sweat will mix with iodine which will react with starch and produce blue colour

16. Causes • Arises as a result of injury to auriculotempoal nerve often results as a side effect of parotid gland surgery. • The Auriculotemporal branch of the Mandibular nerve carries sympathetic vasomotor fibers to preauricular skin and secretomotor fibers to the sweat glands of the scalp and parasympathetic fibers to the parotid gland. • As a result of severance and inappropriate regeneration, the fibers may change over courses, resulting in "Gustatory Sweating" or sweating in the anticipation of eating, instead of the normal salivatory response

17. Treatments • This is a harmless condition that usually disappears with time in children and requires no treatment. • Various medications and other treatments (such as surgery to the nerve) have been attempted, with little success and sometimes side-effects.

18. Gustatory lacrimtion syndrome / Crocodile tears • This is a condition similar to Frey syndrome and is characterized by profuse lacrimation while eating, especially spicy food. • This follows facial paralysis or injury to facial nerve proximal to geniculate ganglion

19. BELL’S PLASY • Bell palsy is an isolated unilateral, paralysis of the facial nerve resulting in inability to control facial muscles on the affected side that has an abrupt onset and no detectable cause and usually self-limiting . • It is one of the most common neurologic disorders affecting the cranial nerves, and most common cause of facial paralysis worldwide.  • this syndrome was first described in 1821, by the Scottish anatomist and surgeon Sir Charles Bell, • Synonyms: Bell's palsy, Bell palsy, facial nerve paralysis, facial paralysis,

20. Causes • The etiology of Bell's palsy remains unclear, although vascular, infectious, genetic, and immunologic causes have all been proposed. • Patients with other diseases or conditions (eg, brain tumor, stroke, and Lyme disease ) sometimes develop a peripheral facial nerve palsy, but these are not classified as Bell's palsy • Viral infections:. herpes simplex virus type 1 & 2 (HSV-1 &2); human herpesvirus (HHV); varicella-zoster virus (VZV);  influenza B; adenovirus; coxsackievirus; Ebstein-Barr virus; hepatitis A, B, and C viruses; cytomegalovirus (CMV); and rubella virus.

21. Mycoplasma infection: may be a complication of M pneumoniae infection. • Genetics: A family history of Bell's palsy has been reported in approximately 4% of cases. Inheritance in such cases may be autosomal dominant with low penetration.

22. Other causes to be Considered • Herpes zoster Ramsey-Hunt syndromeZoster sine herpetePregnancy (especially third trimester) Polyneuritis Acute otitis Chronic otitis Temporal bone fracture Infectious mononucleosis Parotid tumors Sarcoidosis Cholesteatoma of the middle ear Aneurysm of vertebral, basilar artery, or carotid arteries Carcinomatous meningitis Facial trauma (blunt, penetrating, iatrogenic) Leukemic meningitis Leprosy Melkersson-Rosenthal syndromeMiddle ear surgery Osteomyelitis of the skull base Skull base tumor

23. Pathophysiology • A popular theory proposes that inflammation and swelling of the facial nerve results in compression of the nerve within the temporal bone. • The facial nerve courses through a portion of the temporal bone commonly referred to as the facial canal. • The first portion of the facial canal, is narrowest; has a diameter of only about 0.66 mm. • It seems to be logical that inflammatory, demyelinating, ischemic, or compressive processes may impair neural conduction at this site.

24. Incidence - affects approximately 1 person in 65 in a lifetime. The incidence is 29% higher in persons with diabetes mellitus. • Race - Incidence appears to be slightly higher in persons of Japanese descent. • Sex - No difference exists in sex distribution( slight female predilection) • Age – middle aged are more susceptible. • Least common in persons younger than 10 years and most common in those older than 70 years.

25. History • Develop within few hours or be present when wake up in the morning. • The most common complaint is of weakness on one side of the face. • Postauricular pain: Almost 50% of patients experience pain in the mastoid region or angle of jaw. • Tear flow: Two thirds of patients complain about tear flow. • This is due to the reduced function of the orbicularis oculi in transporting the tears. • Fewer tears arrive at the lacrimal sac and overflow occurs. • The production of tears is not accelerated.

26. Altered taste: While only one third of patients complain about taste disorders, four fifths of patients show a reduced sense of taste. • Patients may fail to note reduced taste because of normal sensation in the uninvolved side of the tongue. • Dry eyes • Hyperacusis: Impaired tolerance to typical levels of noise as a result of paralysis of the stapedius muscle.

27. Signs • Drooping of corner of mouth • Drooling of saliva • Watering of eye • Inability to close or wink the eye which may lead to infection. • On attempting to close the eye, the patient may demonstrate the Bell phenomenon: the eye on the affected side rolls upward and inward. • On smiling paralysis become obvious( corner of mouth and eyebrows do not rise, skin of forehead do not wrinkle)

28. Absence of wrinkling of skin of forehead. • The forehead can therefore still be wrinkled by a patient whose facial palsy is caused by a problem in one of the hemispheres of the brain (central facial palsy). • If the problem resides in the facial nerve itself (peripheral palsy) all nerve signals are lost, including to the forehead.) • Patients have mask like or expression less face • Difficulty in speech and mastication • Lost or altered taste sensation on anterior portion of tongue

29. Diagnosis • Bell's palsy remains a clinical diagnosis • Bell's palsy is a diagnosis of exclusion; by elimination of other reasonable possibilities. Therefore, by definition, no specific cause can be ascertained.

30. Treatment • The primary treatment of patients with Bell's palsy in the ED is pharmacologic management. • The remainder of care focuses on reassurance, eye care instructions, and appropriate follow-up care.

31. Complications • Most patients with Bell's palsy recover without any cosmetically obvious deformities; however, approximately 5% are left with an unacceptably high degree of sequelae. • Incomplete motor regeneration • Incomplete sensory regeneration • Aberrant reinnervation of the facial nerve

32. Lab Studies • No specific laboratory tests exist to confirm the diagnosis of Bell's palsy. : • Complete blood count • Erythrocyte sedimentation rate • Thyroid function studies • Lyme titer • Serum glucose level • Rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test • Human immunodeficiency virus (HIV) antibodies • Cerebral spinal fluid analysis • Immunoglobulin M (IgM), immunoglobulin G (IgG), and immunoglobulin A (IgA) titers for CMV; rubella; HSV; hepatitis A virus; hepatitis B virus; hepatitis C virus; VZV; M pneumoniae; and Borrelia burgdorferi

33. Imaging Studies • Facial CT scan or plain radiographs: Perform to rule out fractures or bony metastasis. • CT scan: Perform when the differential diagnosis includes stroke or CNS involvement from acquired immunodeficiency syndrome (AIDS). • MRI: Perform in patients with a suspected neoplasm of the temporal bone, brain, parotid gland, or other structure, or to evaluate for multiple sclerosis. MRI can visualize the course of the facial nerve through the intratemporal and extratemporal regions from the brain to the facial muscles and glands. MRI also may be considered in lieu of CT scan.

34. Prognosis • The natural course of Bell's palsy varies from early complete recovery to substantial nerve injury with permanent sequelae. • Prognostically, patients fall into 3 groups: • Group 1 - Complete recovery of facial motor function without sequelae • Group 2 - Incomplete recovery of facial motor function, but no cosmetic defects are apparent to the untrained eye • Group 3 - Permanent neurologic sequelae that are cosmetically and clinically apparent • Of patients with Bell's palsy, 85% achieve complete recovery, 10% have some persistent asymmetry of facial muscles, and 5% experience severe sequelae.

35. CAUSALGIA • Is a term used to describe severe pain which arise after injury to or sectioning of a peripheral sensory nerve. • Reports of causalgia are there after extraction of teeth

36. Jaw winking syndrome • Congenital unilateral ptosis (Drooping of the upper eyelid caused by muscle paralysis and weakness), with rapid elevation of ptotic eyelid occuring on the movement of mandible to the contralateral side

37. Atypical Facial Pain •  Atypical facial pain (or idiopathic facial pain) is characterized by deep, achy, constant, pulling or crushing pain that involves diffuse areas of the face and head. • The pain fluctuates in intensity and severity. • Trigger points on the face cannot be found, the pain is often worse at night, and may be aggravated by activity.

38. Difference from trigeminal neuralgia • Continuous nature • Lack of paroxism • Poor response to carbamazepine • Lack of trigger points • Nonanatomic distribution

39. Myasthenia gravis • Autoimmune disease that affect the acetylcholine receptors of muscle fibers and results in abnormal and progressive fatiguability of skeletal muscles. • 90% of patients have circulating AChR antibodies

40. Progressive muscle weakness involve the head and neck region leading to - inability to focus eyes - drooping eyelids - double vision( diplopia) -difficulty in chewing & swallowing - slurring of speech

41. Dysgeusia/ Phantom taste • Persistent aberrant taste • Patients may describe the taste as metallic foul or rancid • Altered taste require a stimulus such as certain food or liquid • If no stimulus is required dysguesia is termed as Phantom taste.