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Definitions

• Clinical diagnoses are informed by patient history and examination findings.
• Pathological diagnoses stem from pathology results.
• Direct diagnoses occur through observation of pathognomonic signs.
• Provisional (working) diagnoses are the most common type.
• An intial diagnosis allows for further investigations and planning.
• Deductive diagnoses are made after careful evaluation of historical data, examinations, and investigations.
• Differential diagnoses involve discerning a diagnosis via analysis of similarities and differences between conditions.
• Diagnosis by exclusion involves identifying a disease by ruling out other possibilities.
• Diagnosis ex-juvantibus is reached via observing treatment response results.
• Example: atypical trigeminal neuralgia’s pain is confirmed only by confirming carbamazepine's positive response.
• Provocative diagnosis involves inducing a condition to establish a diagnosis.

Types of examination

• Complete examination refers to the physical examination of head to toe for signs or symptoms of underlying medical condition.
• Screening examination involves quick assessment of large number of people to identify those who may have a disease or condition.
• Emergency/limited examination is the examination done in case of emergency or acute condition to determine the immediate treatment.

Statistics

• Patient registration provides useful information for for records, billing, and legal purposes.
• Date assists in recording of admission time, referencing future visits, and record keeping.

Pertinent Questions for Patient

• Important to ask about the patient's name for communication, establish rapport, and for record keeping.
• Age is important for diagnosis, treatment planning, and behavioral management.
• Focus on diseases common at birth, in children/young adults, and in adults.
• Diseases common at birth include micrognathia, cleft lip/palate, ankyloglossia, predeciduous dentition, and teratoma
• Diseases common in children/young adults include benign migratory glossitis, juvenile periodontitis, pemphigus, recurrent apthous stomatitis, hemophilia, dental caries, Dentigerous cyst, Diptheria, Trigeminal neuralgia
• Diseases more common in adults/older patients include Attrition, Abrasion, Gingival recession, Periodontitis, Lichen planus, Ameloblastoma, Fibroma, Verrucous carcinoma, Iron deficiency anemia, Diabetes, and Hypertension

Diseases More Common by Sex

• Diseases more common in females include iron deficiency anemia, sickle cell anemia, adenoameloblastoma, myasthenia gravis, thyroid diseases, malignant melanoma, recurrent apthous stomatitis, central giant cell granuloma, peripheral ossifying fibroma, peripheral cemental dysplasia, peripheral giant cell granuloma
• Diseases more common in males include pernicious anemia, caries in deciduous teeth, attrition, liposarcoma, herpes simplex, Ewing's sarcoma, adenolymphoma, multiple myeloma, carcinoma- in- situ, basal cell carcinoma, benign osteoblastoma, carcinoma of the buccal mucosa.

Visual Examination: The Key to Inspection

• Inspection is a passive visualization of lesions.
• It is performed with the naked eye or with tools like mouth mirrors for indirect vision.
• Transillumination is used for maxillary sinus exams.

Palpation: The Sense of Touch

• Palpation involves touching to gather further information.
• Evaluation parameters for the soft tissues include evaluation of tenderness, consistency, scrapability, and fixity.

Percussion

• Percussion means striking a body part, evaluating underlying structures through sound or echo analysis.

Auscultation

• It involves hearing to the body’s functional sounds; for example, TMJ clicking.
• Crepitus is a crackling sensation, felt or heard, from bone fractures or joint issues.
• Thrills are palpable vibrations arising from blood flow via narrowed orifices.

Normal Pulse Statistics

• Normal pulse rate is 60-80 beats/min; average is 72 beats/min.
• Physiological increases occur in infants or after exertion.
• Pathological increases indicate fever and cardiopulmonary distress.
• Pulses are an important index for illness severity or heart/vascular abnormalities.
• Pulse rhythm can be regular or irregular.

Pallor

• Pallor is the paleness of skin/mucous membranes due to decreased circulating red blood cells or blood supply.
• This can be caused by anemia, iron/folic acid, or vitamin deficiency, pregnancy, or malignancy.
• Pallor can be assessed in the lower palpebral conjunctiva, tongue, soft palate, palms, and nails.

Cyanosis

• Indicative of >5mg% reduced hemoglobin in capillary blood, causing bluish nail discoloration.
• Types, central, peripheral, or from abnormal pigments; mixed.
• Sites include the palate, tongue, inner lip sides, or conjunctiva.

Clubbing

• Bulbous enlargement of the terminal phalanges occurs with transverse and longitudinal nail curving.
• Swelling occurs from both interstitial edema and the dilation of arterioles/capillaries.

Schamroth’s Sign

• A space present when fingers are held together vanishes with clubbing.

Palpation

• Palpate the pre-tragus area by having the patient gently open and close the mouth while palpating with index finger.

Intra-Auricular Palpation

• Little finger is inserted into ear canal, pressed anteriorly determining condyle movement symmetry as well as clicking/crepitus.

Masseter Muscle

• Originates at zygomatic arch's lower portion; insertion is at the mandible's angle and coronoid process.
• Palpate the masseter body with thumb and index finger, jaws forcibly closed.

Pterygoid Muscles

• The internal pterygoid origin is at the medial pterygoid plate lateral surface and the the maxilla tuberosity; unable to palpate.
• Palpate the anterior insertion of the external pterygoid by placing your index finger at a 45-degree angle inside of tongue. Palpate the body by extraorally rotating index finger upwards origin on tuberosity.

Lymph Node

• Located in front of the near
• Palpate by rolling finger in front of ear, against the maxilla.
• Enlargement indicates external auditory canal infection.
• Postauricular is located behind the ear near the sternomastoid insertion
• Enlargement is due to scalp and temporal/frontal area infection
• Occipital area is at the junction of head and neck which drains the scalp and head, enlarges with respective infections.
• Submental area is below the chin draining the lower lip through roll of fingers below/lingual to the chin against the mylohyoid muscle.
• Submandibular area is medial to mandible's inferior head tilted towards inspection-side, for infections of head, neck, sinuses, and more.

Inspection

• White indicates leukoplakia/oral candidiasis.
• Black indicates black hairy tongue, from hyperkeratosis in smokers.
• Red indicates erythroplakia.
• Coated tongue (from epithelium, debris, fungi, bacteria)
• Transverse fissures are congenital; longitudinal fissures are syphilitic.

Laboratory Investigations in Dentistry

• Types of biopsy are incisional and excisional

Biopsy Types

• Incisional biopsies sample a margin/perilesional area using a scalpel for lesions like carcinomas and ulcers
• Excisional biopsies remove small lesions completely.
• Incisional is for larger lesions where total removal isn't feasible with local anesthesia.
• Punch biopsies use surgical instruments with little need for suturing.
• Intraosseous biopsies are less frequent.

Aspiration Biopsy

• Used to assess fluid nature in deep-seated lesions/cysts.
• May be used alone or prior to another procedure.

Cytology

• Cytology examines cells exfoliated/scraped from lesions, adjunct to biopsy and not substitute.
• Indicated when biopsy is not possible or patient refuses and interpretation doubts warrant biopsy usage.
• Fine Needle Aspiration Cytology examines a lesion aspirate; safe rapid diagnosis.