Patient Evaluation, Diagnosis, and Treatment Planning PDF

▪ To provide best treatment and patient satisfaction , thorough clinical history , examination and diagnostic aids are required. ▪ Diagnosis is defined as utilization of scientific knowledge for identifying a disease process and to differentiate from other disease proces...

▪ To provide best treatment and patient satisfaction , thorough clinical history , examination and diagnostic aids are required. ▪ Diagnosis is defined as utilization of scientific knowledge for identifying a disease process and to differentiate from other disease process.  The diagnostic process actually consists of four steps;  First step ; assemble all the available facts gathered from chief complaints, medical and dental history, diagnostic test and investigations.  Second step ; analyze and interpret assembled clues and the tentative or provisional diagnosis.  Third step ; make differential diagnosis of all possible disease.  Fourth step ; select the closest possible choice.  Case history is defined as; planned, professional conversation between the patient and the clinician in which the patient reveals his/her symptoms fears, or feelings to the clinician so that the nature of the real or suspected illness and mental attitude to it may be determined.  The purpose of recording patients history and conducting a clinical examination is to arrive at a logical diagnosis to the patients chief compliant and to institute a suitable treatment plan.  It is the description of the problems for which the patient seeks treatment.  It should be recorded in patients own words and should not be recorded in medical terminology.  It is the detailed description of chief complaint.  Examples for the type of questions asked by clinician include 1. How long you had the pain? 2. Do you know which tooth it is? 3. What initiate pain? 4. How would you describe pain? 5. When was the problem first noticed? 6. Mode of onset 7. Associated symptoms etc..  The most common toothache may arise either from pulp or from PDL.  Mild to moderate type of pain can be of pulpal or periodontal origin.  If pain from PDL ,teeth will be sensitive to percussion.  Pulpal pain will be sharp and depends on the pulpal fibres involved. ‫لجملة تعني أن ألم اللب السني (وهو األلم الذي يحدث داخل السن) يكون حادًا (مفاجئًا وقويًا) ويعتمد على‬ :‫ هناك نوعان من األلياف العصبية‬.‫األلياف العصبية في لب السن التي تتأثر‬.‫تسبب أل ًما حادًا وسريعًا‬A-delta: ‫ألياف‬.‫ومستمرا‬ ً ‫تسبب أل ًما بطيئًا‬C: ‫ألياف‬.‫ شدة وطبيعة األلم تختلف حسب األلياف المتضررة‬،‫إذن‬   This helps to know any previous dental experience, and past restorations. dental history is a review of previous dental experiences and current dental problems. Review of the dental history often reveals information about past dental problems, previous dental treatment, and the patient’s responses to treatments. Frequency of dental care and perceptions of previous care may be indications of the patient’s future behavior. If a patient has difficulty tolerating certain types of procedures or has encountered problems with previous dental care, an alteration of the treatment or environment might help avoid future complications. It is crucial to understand past experiences in order to provide optimal care in the future. Also, this discussion might lead to identification of specific problems such as areas of food impaction, inability to loss, areas of pain, and broken restorations or tooth structure. Finally, the date, type, and diagnostic quality of available radiographs should be recorded so as to ascertain the need for additional radiographs and to minimize the patient’s exposure to ionizing radiation.  For a proper medical history, importance should be given to the following; 1. Allergies and medications(allergic to local anaesthetics) 2. Communicable diseases(HIV , hepatitis) 3. Systemic diseases( valvular heart diseases, oral lesions , immunocompromised patients) 4. Psychological problem associated with aging.(gingival recession,staining,decreased salivary flow) CHECKLIST FOR MEDICAL HISTORY BLEEDING DISORDER CARDIORESPRIRATORY DISEASES ENDOCRINE DISEASES GASROINTESTINAL DISTURBANCES INFECTIONS JAUNDICE KIDNEY DISEASES PREGNANCY DRUG TREATMENT AND ALLERGIES 1. Diet. 2. Oral habits like smoking and alcohol. 3. Bowel and bladder. 4. Apatite. 5. Oral hygiene methods.  Patient is asked about the health of other members of his/her family.  Genetic and hereditary diseases are ruled out. 1. Diabetes 2. Hypertension 3. Bleeding disorder 4. Flurosis etc.. Clinical examination- extra oral and intraoral examination. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Exploration  Intraoral examination include; 1. Hard tissue examination 2. Soft tissue examination Extra oral examination(head & neck)  Face (gross abnormality)  Skin(pallor , pigmentation and cyanosis)  Hair(alopecia ,hirrusitism)  Nails(clubbing)  Eyes( anaemia and jaundice)  Nose(nasal deviations)  T M J (deviation of mandible , any mass over TMJ , tenderness on palpation, clicking sounds)  Lymph nodes of head and neck (site , size, number, consistency , tenderness ,fixity)  Salivary gland( enlargement of major glands, dryness of mouth, quantity and character of secretion) Extra-Oral Examination Explained: 1. Face (Gross Abnormality): Definition: Checking for visible deformities, asymmetry, or abnormal growths in the facial structure. 2. Skin: Pallor: Pale skin, which might indicate anemia or poor blood flow. Pigmentation: Dark spots or abnormal coloring that could suggest conditions like Addison's disease. Cyanosis: Bluish skin, often caused by a lack of oxygen in the blood. 3. Hair: Alopecia: Hair loss, which could indicate systemic diseases or hormonal imbalance. Hirsutism: Excess hair growth, which may suggest hormonal disorders like polycystic ovary syndrome (PCOS). 4. Nails: Clubbing: Rounded and thickened nails, often linked to chronic lung or heart diseases. 5. Eyes: Anemia: Pale conjunctiva, indicating low red blood cell count. Jaundice: Yellowing of the eyes, suggesting liver or biliary system issues. 6. Nose: Nasal Deviations: Structural abnormalities that may cause breathing issues or be a sign of trauma. 7. Temporomandibular Joint (TMJ): Deviation of Mandible: Misalignment of the jaw during opening/closing. Mass Over TMJ: Any swelling or abnormal growth near the joint. Tenderness on Palpation: Pain felt when the joint is pressed. Clicking Sounds: Audible clicks during jaw movement, which could indicate TMJ dysfunction. 8. Lymph Nodes of Head and Neck: Site: Location of the lymph nodes (e.g., submandibular, cervical). Size: Enlarged nodes may indicate infection or malignancy. Number: Number of nodes affected. Consistency: Hardness or softness of the nodes. Tenderness: Pain when touching the nodes, suggesting infection. Fixity: Whether the nodes are mobile or fixed to underlying tissues (fixed nodes could suggest malignancy). 9. Salivary Glands: Enlargement: Swelling of major salivary glands (parotid, submandibular). Dryness of Mouth: Reduced saliva production, possibly linked to conditions like Sjögren's syndrome. Quantity and Character of Secretion: Assessing the volume and consistency of saliva to detect abnormalities