Dr. Yousef Lectures PDF

ORAL DIAGNOSIS ( week 1) Oral diagnosis is the art of using scientific knowledge to identify oral disease processes and to distinguish one disease from another. Oral diseases refer to diseases either localized in the oral cavity or those which appear as oral manifestations of systemic diseases. Typ...

ORAL DIAGNOSIS ( week 1) Oral diagnosis is the art of using scientific knowledge to identify oral disease processes and to distinguish one disease from another. Oral diseases refer to diseases either localized in the oral cavity or those which appear as oral manifestations of systemic diseases. Types of Oral Diagnosis: 1) Comprehensive oral diagnosis: It is done for the patients requiring total dental care. It entails the listing of all dental problems (performing a "problem list") comprising all oral findings that require dental treatment (caries, exposure, edentulous areas, etc...) then a comprehensive dental treatment plan can be designed to achieve optimal oral functions. Any comprehensive diagnostic procedure should include: 1- History taking. 2- Clinical examination. 3- Laboratory investigations (if needed). 2) Emergency diagnosis: The immediate diagnosis of the patient's complaint that requires immediate attention and management by the dentist (acute dental pain, accidental fractures,..). The emergency interferes with obtaining adequate history or full clinical examination (only the area of chief complaint). 3) Spot (snap) diagnosis: In simple cases where rapid diagnosis can be achieved perfectly, based on minimal data e.g. palatal ulcer + history of eating hot pizza = diagnosis of pizza burn. 4) Differential diagnosis: It is the collection and categorization of data to develop a list of two or more different diseases having common primary clinical presentation (though different in etiology). This presentation may be in the form of: -Change in colour: i. White lesions, or white and red lesions ii. Pigmented lesions (red, yellow, brown,…) - Loss of mucosal integrity in the form of ulcers or erosions. - Soft tissue swelling (fibroma, lipoma,….) - Bony lesions. The most likely lesion is put on top of list (presumptive diagnosis, according to clinical impression) then through history, clinical examination and special investigations (if needed), final diagnosis can be reached by "exclusion". 5) Tentative (working or provisional) diagnosis: It is primary, uncertain diagnosis before all diagnostic data are assembled. Final or definitive diagnosis is then reached by confirming the tentative diagnosis or changing it according to: either: response to treatment (+ve or – ve) or : result of diagnostic aid e.g. biopsy. 6) Definitive (final) diagnosis: It is the final diagnosis based on accurate appraisal of all available data (case history, clinical examination and special investigations) that point clearly to a specific disease entity. Some Definitions Used: Technical aid (diagnostic aid) Any technique or special instrument used to help the establishment of a diagnosis such as pulp testing procedures, biopsy, radiographs, blood analysis, urine analysis, … etc. Symptoms and signs: All findings can be grouped as either symptoms (subjective) or signs (objective). Symptoms (subjective): Symptoms are complaints that are described and reported by the patient and cannot be detected by the examiner. For example, pain, sensitivity to hot or cold, altered taste, paraesthesia, nausea and past occurrence of bleeding or swelling. Signs (objective findings): Objective findings are the changes or deviations from normal that can be detected by the examiner. For example, discoloration of teeth or soft tissues, swelling, tenderness to palpation and abnormal consistency of a part. Obviously some overlap between subjective and objective findings is possible. Common conditions such as discoloration, bleeding and mobility of teeth are noticed by both the patient and dentist. Also, a patient may report feeling hot and feverish (symptom) and have a measurable fever (39ºC) detected by the examiner (sign). Prognosis: Prognosis is to guess the final outcome of the disease. It is the prediction of the duration, course and termination of the disease and the likelihood of its response to treatment. Prognosis is usually expressed in general terms as ―excellent, ―good or ―poor. Prognosis must be determined before the treatment is planned. It depends on the patient‘s attitude, his oral hygiene and desire to retain his natural dentition. It also depends on condition of teeth, costs as well as experience and technical skill of the operator. COMMUNICATION SKILLS IN DENTISTRY Communication skills is a term used to describe verbal words and non-verbal actions used in the interaction between two persons. Verbal communication is the ability to present one‘s ideas in clear words to different persons. Non-verbal communication is the ability to express one‘s ideas through the use of body language, voice tone, facial expressions, clothing, and also the use of pictures, posters, symbols, … etc. Effective communication is important to achieve good dentist-patient, dentist- coworkers, and patient-coworkers relationships. This is crucial for a successful dental clinic. Active listening involves trying to understand what the speaker is trying to transmit. It includes not only the speaker‘s own words, but also the tone spoken with, the facial expression, and the body language. Dealing with difficult patients Types of difficult patients: The talkative patient The silent patient The angry patient The depressed, sad patient The anxious patient The dramatic patient The long suffering patient The restless patient The main rules to handle difficult patient or co-worker: Keep cool & calm Don‘t try to change him (her) Set firm boundaries Acknowledge his (her) feelings Use fewer words Use the word ―we‖ or ―the clinic‖ instead of ―I‖  Write the patient‘s comments down To allow proper dentist-patient communication, there are main five points that should be carefully managed during the dental visit. 1- Patient first contact & history taking: Since first impression lasts long, focusing on some points is necessary: Receive the patient while standing and introduce yourself with a friendly smile. Introduce your staff. Explain what will happen during the visit Sit at the patient‘s eye level & keep eye contact. Listen to the patient‘s complaint & watch his (her) body language. Listen to his (her) concern & try to have an idea about the expectations from treatment. Don‘t use scientific or technical words (dental jargon). Ask the permission for adjusting chair position & starting examination. 2- The dental examination: Careful dental examination is one of the most important steps during the visit. 3- Discussing treatment options: In order to help the patient to take the decision that meets his (her) expectations, detailed discussion of treatment plan options is of great importance. First explain the findings after your examination Explain in details every treatment option including steps, the overall duration, the longevity, etc… Use simple words Use pictures, models, or posters to simplify your words Summarize what you said to check out that you have been understood INFORMED CONSENT - This is “permission obtained as a result of information sharing in the dialogue between the dentist and patient”. No treatment should be performed without the consent of the patient. - Consent must be obtained in advance of treatment – not in the middle and not after. Remember to document consent decisions in the patient’s chart. 4- Discussing fees: Discussing fees is rarely comfortable. Many patients are embarrassed to ask about the fees, so you have to take the lead. Never let the subject be told by co-workers Hold the discussion while the patient is sitting in upright position The patient needs to know that fees are determined on many factors, most of them can‘t be changed like materials, lab work, … etc Don‘t conclude the conversation while the patient is walking away Use your patient‘s name at least at the beginning and at the end of the conversation 5- Concluding the visit Paraphrase and summarize the treatment plan options and the one chosen by the patient End the visit by asking the patient ―Do you have any other questions or concerns? According to the American Dental Association, the top 10 skills for success in dental communication can be summarized as follows: 1. Build rapport with patients Verbal skills: conversation starters (about work, school,study…), compliment plus question, free information. Non- verbal skills: -greeting patient with their name - Introduce yourself to the patient - Smiling - Firm confident hand shake - Eye to eye contact 2. Listen carefully Why? For diagnostic accuracy, patient satisfaction, and patient persuasion You need: Attention Patience Time Emotional control Examples: Turn away from the computer Put the chart down or the history taking sheet Eye to eye contact Move closer to the patient Nod and smile Interrupt with more focused questions to save time Use less open end questions and more leading questions 3. Speak with confidence and assertiveness 4. Explain dental conditions Communication Support for the Oral Examination Tell the patient what is about to happen Explain the head and neck examination Explain the oral examination Involve the patient 5. Convince patient to accept the treatment Begin with outline Appeal to patient values and priorities Don‘t refer to teeth by numbers Avoid medical jargon Don‘t tell them what you like to do Use more patiepractical examples Use appropriate humor List advantages and disadvantages of treatment 6. Overcome patient objection to treatment 7. Respond to difficult patients 8. Manage financial discussion at a later stage 9. Get patient to take actions 10. Effective team communication PATIENT’S HISTORY ( week 2) A History Serves the Following: 1- To discover complaints about oral structures. 2- Recognition of underlying medical problems which is important in : a. Prophylactic measures may be necessary for the safety of patient and clinician. b. Unusual reaction to drugs can be discovered c. Referral to a physician may be necessary. 3- To detect any complications associated with previous dental treatment. 4- To detect any diseases running in the family that may be of dental significance or may be a potential threat to the patient during dental treatment. 5- To provide information about oral hygiene methods of the patient, patient‘s diet, and any habits such as smoking. Methods for Obtaining a Patient's History 1. Printed questionnaires. 2. Patient interview. 3. Combination of both. It is obvious that a combination of the direct interview and the printed questionnaire would make use of the advantages of each and tend to minimize their disadvantages. Methods of Presenting Questions During the Diagnostic Interview: 1. Open-ended questions Open-ended questions urge the patient to be a narrative. The patient should be allowed to respond fully to the question with few interruptions from the dentist. For example ―Can you tell me about your surgery that was performed last year?‖. The question will direct the patient to describe the entire topic. 2. Closed-ended questions Simple and specific answers are expected for closed-ended questions. After the answer is given the clinician quickly proceed to the next question. The patient answer is limited to a small single sentence or even Yes or No For example: - Do you smoke? 3. Leading questions Leading is a technique, which suggests the answer within the question. For example; the dentist may suspect that recurring morning headache described by the patient is caused by bruxism. The dentist asks: ―Do you grind your teeth during sleep? 4. Indirect questions Indirect question is a way of revealing information beyond what is requested by the question. An example of indirect questions is to give information about the manifestation of a systemic disease e.g. ―have you had chest pain especially following exertion. If the answer is ―Yes, it may reveal heart problem. 5. Loaded questions: A loaded question is considered a variant of the indirect approach in which an emotional element is inserted into the phrasing to get the patient‘s attention. For example ―With the problems you have, do you think it might be best to extract all of your teeth? Non-verbal responses such as nervous shifting of position or negative facial expressions may reveal the response of the patient to this type of indirect questions. 6. Contradiction questions: The contradiction question states inconsistent information and allows the patient to resolve the contradiction. For example; ―Since you said that you do not have epilepsy, is there another reason for you to be taking a medicine that is usually prescribed to control seizures? Items of History: a. Identification data b. Chief complaint c. History of chief complaint d. Health history e. Past dental history A- Identification Data ( the administrative chart) Recording of routine data of the patient such as code number, name, age, sex, marital status , occupation , address , etc ….. Significance of components of the administrative chart 1 – Code number Code number is essential for record keeping and retrieval of the patient‘s file. 2 – Name Patient‘s full name and how he or she prefers to be addressed should be recorded. Patient‘s name is important for: Record keeping and retrieval of the file. Better communication between the dentist and the patient. 3 – Date of birth (patient’s age) Age is important as certain diseases occur generally in certain age groups and rarely in others. For example : Primary acute herpetic gingivostomatitis, moniliasis, measles and mumps occur commonly in childhood. Squamous cell carcinoma, atrophic and degenerative changes are common in old age. 4 – Sex (gender) Recording the sex of the patient is important particularly in those who carry names that could be taken for both sexes e.g. Esmat. Also, some diseases are common in males e.g. leukoplakia and carcinoma of the lip, while females more frequently suffer from the manifestations of iron deficiency anemia and carcinoma of the breast. 5 – Birth place Birthplace is important to detect diseases acquired in childhood (endemic diseases) such as Dental fluorosis occurs in areas drinking water from wells.  Bilharziasis is of common occurrence in Egyptian villages. 6 – Race A race is a genetically determined population group having the same criteria regarding skin colour, hair characters and shape and form of the body and head as well as facial features. Race is important, as certain diseases are dominant in certain races. For example: Blond race is more liable for skin carcinoma, which is rare in Africans and dark skinned individuals. Negroes are more susceptible to Burkitt‘s lymphoma. Jews are more liable to develop pemphigus vulgaris. 7 – Address Address may help in throwing light about the patient‘s social and home background. Patients living near factories are liable for pulmonary diseases. Also, in absence of a phone number, the address may be useful for recalling the patient. Address may also throw light on the socio-economic level of the patient. 8 – Phone number The telephone number of home, office and mobile is important for recalling the patient. Also, rapid recalling of the patient is of special importance during taking oral biopsy when malignancy is suspected. 9- Occupation In some instances, the diagnosis of some diseases will be based on the knowledge of the patient‘s occupation or the nature of his work. Occupational diseases are generally defined as those characteristic of a certain field of human activity and resulting from the effect of the harmful factors of the working environment. For example: Industrial use and manufacture of acids may produce tooth erosion, discoloration and decalcification of the enamel as well as inflammation of the mucosa. Lead intoxication may occur in workers in battery factories, while mercury intoxication may occur in workers in fluorescent lamp manufactures. These heavy metals may form dark metallic line on the patient‘s gingiva. Cancer of the mouth and tongue may occur in industrial workers with tar and arsenicals. Cancer lip may appear following contact with tar and after prolonged exposure to solar rays. Cervicofacial actinomycosis is likely to occur in individuals concerned with cattle. 10- Marital status Psychological stress of some married people should be taken into consideration. It may exacerbate or predispose to certain oral diseases such as lichen planus and aphthous ulceration. Also, the marital status may be a source of infection in certain diseases such as T. B., AIDS, and other viral infections. 11- Parent or guardian name and address A parent or guardian, such as a grandparent or a relative, must provide the patient history for a child or legally disabled adult. It is critical to ascertain who can give consent for treatment, and who will be responsible for payment of fees. 12- Physician name and address In some instances, the only dependable source of information may be the patient‘s physician. Medical consultation may be unavoidable to obtain an adequate patient history. B- Chief Complaint The underlying cause for the patient‘s visit to the dentist is known as the chief complaint. It is recorded in the patient‘s own words and in chronological order if the patient has more than one complaint. Common oral chief complaints include: 1- Pain. 2- Sores (ulcers). 3- Swelling. 4- Burning sensation. 5- Paraesthesia and numbness 6- Bleeding. 7- Hypersensitivity with thermal changes. 8- Loose teeth. 9- Occlusal problem. 10- Delayed tooth eruption. 11- Xerostomia (dry mouth). 12- Ptyalism (too much saliva). 13- Bad taste. 14- Halitosis (bad odor). 15- TMJ problems. 16- Esthetic problems. N.B. Patients may come to the dental clinic having no chief complaint:. Regular check-up (notation – no chief complaint) Some patients are accustomed for regular recall appointments usually for routine dental care and treatment of all dental needs. Referred patient The most common type of referred patients is the referral from a general practitioner to a specialist for a specialty level care such as the referrals to an oral surgeon, periodontist, endodontist, orthodontist...etc. In these cases, the complaint of the patient was previously diagnosed by the former dentist and the specialist should concentrate his effort to treat only the complaint for which the patient is referred. C- History of Chief Complaint: Learning more about the chief complaint is the "History of the Present Illness." Once it is known why a patient seeks care, it is important to learn as much as possible about the condition that brought her/him to the dentist. How long has the condition been present? Is there pain? What events initiated the condition? These are but a few questions that may be asked to obtain a history of the condition (history of present illness). Onset a) Character of onset: - Sudden (abrupt) - Gradual - Insidious (1) Acute inflammatory conditions Sudden onset = e.g. Acute dento-alveolar abscess, erythema multiforme or (2) Allergic conditions Gradual onset = (1) Chronic inflammatory conditions (2) Neoplastic lesions Insidious onset: The patient discovers the lesion by chance, and can‘t give a precise answer regarding its onset, such lesions include: (1) Congenital malformations (2) Developmental anomalies (3) Physiologic conditions e.g. racial pigmentation. (b) Date of onset: Should be recorded in day, month and year. When compared to date of presentation, the duration can be deduced. Duration: Recorded is hours, days, weeks, months, years, including periods of remissions and exacerbations. Short duration (hours – days): characteristic for acute conditions. Weeks–months: characteristic for chronic conditions and neoplastic lesions ( if with large size malignancy is suspected) Years: characteristic for chronic conditions and benign neoplasms Character and severity : Severity: (Mainly of pain) : This will be affected by pain threshold of patient and may be described as : mild, moderate or severe. Character (of pain ) : may be: (1) Throbbing pain means fluid accumulation e.g.: pus accumulation in acute dento-alveolar abscess (2) Lancinating, stabbing, shooting or electric shock like pain: pain of nerve origin e.g. herpes zoster, post herpetic neuralgia and paroxysmal trigeminal neuralgia.. (3) Interference with sleep and work: Acute dental pain e.g. acute pulpitis. Location and site: Location: is the anatomical area : tongue, cheek, gingiva, etc.. Site: is the specific area in an anatomical location e.g. lateral aspect of the tongue N.B. Sometimes pain may be referred from its origin to a remote area. Precipitating factors and relation to other activities: Pain may increase by eating, swallowing, sleeping, cold or hot drinks: which are then called "precipitating factors" (ppt). According to precipitating factors diagnosis could be guessed: e.g. Any exposed dentin will lead to sensitivity with thermal changes specially cold, e.g. carious lesions, exposed root dentin Differentiation should then be done between pain which stops as the stimulus disappears and pain that persists. On the other hand, pain with mastication is related to disease in the supporting structures e.g. periodontal disease, periapical abscess. Relation to other activities: Sometimes pain may accompany activities not related to the oral cavity: Pain on exertion referred particularly to left mandibular region indicates cardiac condition. Pain in upper teeth increasing with leaning downwards indicates maxillary sinusitis. Pain with sleeping may indicate accumulation of edema fluid leading to pressure on nerve endings. Relieving factors: Factors which relieve chief complaint e.g. rest, medications as simple analgesics, vasodilators or morphine should be noted. Also, dental pain relieved by cold water or conversely by hot fomentation. Course: Could be recorded as: Progressive: (increasing in severity) e.g. tumours, acute inflammatory lesions. Regressive (decreasing in severity) e.g. self-drained abscess. Recurrent, intermittent, remission and exacerbation.  History of recurrence: The history of previous occurrence of the lesion may be of importance in diagnosis, e.g. RAU, erythema multiforme. Distribution: (A) The lesion may be (1) Solitary e.g. traumatic ulcer or (2) Multiple: Multiple lesions are either: i) Unilateral e.g. Herpes Zoster or ii) Bilateral lesions which are either symmetrically distributed e.g. lichen planus or in asymmetrical (random) fashion e.g. erythema multiforme. (B) Lesions may be restricted to one region of the oral cavity e.g. anterior part as 1ry herpetic gingivostomatitis or posterior part as herpangina. (C) The lesions may be restricted to the oral cavity or distributed both extra and intra orally. Intra oral only e.g. traumatic ulcer, RAU Extra + intra-oral e.g. dermatologic diseases with oral manifestations as lichen planus, lupus erythematosus. Associated phenomena: These are manifestations associated with the complaint: Eg: Fever (hyperpyrexia with acute abscess). Prodrome of fever, malaise, lymphadenopathy 1ry herpetic gingiva-stomatitis Foetid odour + pain + bleeding gingiva + mild fever + lymphadenopathy ANUG Previous medication: Mouth washes, analgesics, antibiotics, previously used by the patient, and their effect on c/c., as well as duration of treatment should be noted. e.g. Mouth wash: patient may use anti-inflammatory mouth wash as benzydamine hydrochloride, if pain is relieved, therefore pain is of gingival origin, if not, therefore it is of dental origin. Antibiotics: if c/c. is relieved or better, therefore it is due to bacterial infection. Mild analgesic: if pain is relieved, therefore the condition is not severe Also: sometimes previous medication is the cause of c/c: e.g. Long term antibiotics or cortisone oral candidiasis.