Oral Diagnosis and Orofacial Pain Lecture Notes PDF

Course Title: Oral Diagnosis and Orofacial pain Course Code: POM212 Topic of Lecture : Introduction of Oral Diagnosis Lecturer: Dr. Ahmed El Barbary Post : Professor of oral medicine, diagnosis and...

Course Title: Oral Diagnosis and Orofacial pain Course Code: POM212 Topic of Lecture : Introduction of Oral Diagnosis Lecturer: Dr. Ahmed El Barbary Post : Professor of oral medicine, diagnosis and Periodontology FACULTY OF Dentistry The Future Starts Here FALL 2023  Scope of Oral Diagnosis: ▪ The basis for modern therapy is accurate diagnosis. ▪ This requires identification of the disease then proper treatment. Oral diagnosis: It is the art of using scientific knowledge to identify oral disease processes and to distinguish one disease from another. Dia = through Gnostic = having knowledge  Reaching an accurate diagnosis needs collection of data through: ▪ Case history. ▪ Clinical examination. ▪ Special investigations as blood or urine analysis, biopsy or x-ray (diagnostic aids).  Types of oral diagnosis: 1) Comprehensive oral diagnosis: It is the diagnostic assessment of all dental problems for patients requiring total dental care.  It is obtained through: ▪ Full history ▪ Thorough clinical examination ▪ Use of diagnostic aids  It includes the listing of all dental problems and oral findings (caries, exposure, edentulous area, etc….) that require treatment. performing a problem list 2) Emergency diagnosis: It is the immediate diagnosis of the patient’s complaint that requires immediate attention and management by the dentist. e.g. (acute dental pain, accidental fractures…..). ▪ The emergency interferes with obtaining adequate history or full clinical examination (only the area of chief complaint). 3) Spot diagnosis: Immediate and rapid diagnosis (identification of the disease) performed in simple cases and based on minimal data. palatal ulcer + history of eating pizza pizza burn 4) Differential diagnosis: It is the collection and arrangement of data to develop a list of two or more different diseases having similar clinical presentation. ▪ The most likely lesion is put on top of the list. ▪ Final diagnosis can be reached by exclusion after thorough history, clinical examination and special investigations. 5) Tentative diagnosis: (working or provisional) Primary, uncertain diagnosis which is made before collection of all diagnostic data.  Final or definitive diagnosis is then reached by: confirming the tentative diagnosis or changing it according to response to treatment or the results of diagnostic aids (e.g. biopsy). 6) Definitive diagnosis: Final diagnosis based on accurate evaluation of all available data.  Diagnostic terms: Symptoms (subjective findings): Complaints recognized and reported by the patient. e.g. pain, parasthesia, sensitivity to hot or cold, altered taste and past occurrence of bleeding or swelling.  Signs (objective findings): Changes or deviation from normal that are detected by the examiner. e.g. swelling or discoloration of teeth or tissues.  Diagnostic (technical) aids: Any technique or special instrument used to help the establishment of a diagnosis. ▪ such as pulp testing, biopsy, radiographs, blood analysis, urine analysis….. Prognosis: To guess the final outcome of the disease i.e. to predict duration, course, termination and response to treatment. Prognosis is usually expressed 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. Treatment plan: It is a written plan of treatment. It is the end product of data collection and diagnosis. A. Emergency (immediate) treatment plan: It identifies the definitive diagnosis of the chief complaint directly, and must be performed at once. B. Comprehensive (long-range) treatment plan: It deals with all dental problems revealed by thorough examination. It is usually carried out in stages over time. Components of the comprehensive oral diagnosis: I. Case history II. Physical examination III. Adjunctive diagnostic information  Components of the comprehensive oral diagnosis: I. Case history II. Physical examination III. Adjunctive diagnostic aids 1) General physical 1) Patient identification appraisal and 1) Radiographic 2) Chief complaint vital signs examination 3) History of chief complaint 2) Extraoral 2) Laboratory 4) Dental history examination investigations 5) Medical history and review of systems 3) Intraoral 3) Microscopic 6) Family history examination examination 7) Social history (Biopsy) 8) Personal habits 4) Microbiologic studies I. Case history: It is the collection of diagnostic data from the patient related to his condition. It is often called subjective examination of the patient since it contains information that the patient tells to the clinician.  Requirements of ideal case history: 1) It should include all the necessary information. 2) Well organized. 3) Systematic and follows a definite pattern. 4) Brief and concise. Methods for obtaining case history: 1. Printed questionnaire. 2. Patient interview. 3. Combination of both. 1 – Printed questionnaire: Using a printed form to collect information.  Advantages: Disadvantages: 1) Broad in scope. 1) Lack in depth. 2) Time saving. 2) Impersonal. 3) Does not require any 3) Patients may special skill from the misinterpret dentist. questions. 4) A standardized form for 4) Inflexible. obtaining information. 5) Consistent. 2 – Patient interview: It is a verbal interview between the patient and the dentist.  Advantages: Disadvantages: 1) Time consuming. 1) Ability to ask in depth. 2) Personal. 2) Require a special skill from the dentist. 3) Flexibility and the dentist can tailor questions to the individual patient. 3) Not consistent. 4) 3- Combination: 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 ► The diagnostic interview is usually the first and often the most important step in effective diagnosis and treatment planning. ► Depending on the patient’s complaint and his personality, different types of questions can be used during the diagnostic interview. Types of questions: 1. Open -ended question: This type of question allows the patient to talk freely and answer the question fully 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: - Problem that required surgery. - Nature of the operation. - Possible complications. - Duration of hospitalization. - Response to surgical stress. - Effectiveness of surgery.  Advantages: Less stressful to the patient. Effective method of covering a complicated topic. It calms patients by allowing them to talk in their way. Disadvantages: Time consuming. Patient may deviate from the topic. 2. Closed-ended question: Simple and specific answers are expected for closed-ended questions. The patient answer is limited to a small single sentence or even “Yes” or “No”. After the answer is given the dentist goes quickly to the next question.  For example: - Do you smoke? How many cigarettes do you smoke each day? For how long have you been smoking?  Advantages: Time saving. Answers are simple and specific. Effective with unresponsive or unaware patients. ▪ Disadvantages: Patients answer directly without clarifying information. Patients may misinterpret questions. Less effective for responsive and aware patients. 3 – Leading question: 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 the patient: “Do you grind your teeth during sleep?”  Advantages: A positive answer confirms the dentist’s doubts. A positive answer increases the patient’s confidence in his dentist. Useful in getting information from unresponsive patients. Disadvantages: Some patients will answer “yes” because it is the expected answer rather than the actual situation. Dentist’s error in asking a leading question may cause the patient to lose confidence. 4 – Option question: In the option questions the patient is provided with two or more options. For example:- «Do you think that recurring morning headache is caused by bruxism or by stress at your job ?».  Advantages: Effective for sensitive topics. Effective with forgetful patients. Disadvantages: The dentist may receive an incorrect answer if the actual answer is not provided as an option. The answer of uncertain patients may be variable. 5 – Contradiction question: This type of question clarifies the contradiction in information given by the patient during the diagnostic interview. For example:- “ You said that you don’t have epilepsy, is there another reason for you to take a medicine that is usually prescribed to control seizures?”  Advantages: Effective when contradictory information has been given Effective in obtaining hidden information. Disadvantages: Suspicious and worried patients refuse the contradiction approach because they feel trapped.  6 – Indirect question: a) It is used to get information beyond what is requested by the question. For example:- “Have you had any complications during or after previous dental treatment?” This question will clarify complications as well as the patient’s general attitude toward dental care.  b) Itis used to get information about the systemic condition of the patient. For example:- “Have you had chest pain especially following exertion?” If the answer is “Yes” it may reveal heart problem.  Advantages: Useful in understanding sensitive individuals. Useful in discovering patient’s way of behaving. Useful in discovering undiagnosed systemic conditions. Disadvantages: Time consuming. Indirect approach can be unsuccessful with some individuals. 7 – Loaded question: A loaded question is considered a type of the indirect approach in which an emotional factor is inserted into the question to get the patient’s attention. For example;- “With the problems you’ve had in the past, do you think it might be best to extract all of your teeth?”. Nervous shifting of position or negative facial expressions may reveal the response of the patient to this type of indirect question.  Aspects for effective and successful interview: 1. Setting: Receive the patient in an office or consultation area. Conceal dental instruments when talking before treatment. 2. Opening: Introduce yourself to the patient. Do not address adult patients by their first name.  The initial conversation is limited to topics unrelated to dentistry such as hobbies, job and activities to help anxious patients to relax. Begin the diagnostic interview by asking about the chief complaint. 3. Choice of questioning method: The initial question concerning the chief complaint should be open-ended. Closed-ended questions can be used: -to obtain missed details. -redirect conversational deviations.  4. Choice of words: The conversation should be in common language. Words chosen should be clear, correct, understandable and familiar to the patient. Words should not frighten the patient. 5. Listening: It is the key for facilitating information flow from the patient. It gives the dentist the chance to understand both spoken and unspoken messages. 6. Feed back: To determine if the patient has understood what you have said, let him repeat it back in his or her own words. 7. Avoid wasting time: Discussing every medical topic with every patient wastes time. For example:- asking a young patient about diseases that are rare before the age of 50. asking about the details of appendicectomy performed 20 years ago.  8. Confrontation: Patients may refuse to discuss sensitive topics thinking that: the dentist does not need to know such information. A calm explanation of how apparently unrelated problems can affect dental care may be necessary. 9. Communication aids: Pamphlets, posters, albums or video presentations may be highly beneficial for the patient.  10. Summarize information and request agreement: This is done at the end of the interview. For example: - “As I understand it, except for your allergy to penicillin and history of sinusitis, you are in a perfect health, is that right?  This moves the interview to the end. It requests the patient to agree with the dentist’s conclusions. It helps the patient to clear up any misinterpretations or omitted details.