Oral Diagnosis PDF

HOW TO COLLECT DIAGNOSTIC INFORMATION = METHODS OF COLLECTING INFORMATION = ITEMS OF DIAGNOSTIC DATA BASE: I-patient history II-physical examination III-adjunctive diagnostic procedures PATIENT HISTORY Definition: Is the description of the past events and related information that help to diagno...

HOW TO COLLECT DIAGNOSTIC INFORMATION = METHODS OF COLLECTING INFORMATION = ITEMS OF DIAGNOSTIC DATA BASE: I-patient history II-physical examination III-adjunctive diagnostic procedures PATIENT HISTORY Definition: Is the description of the past events and related information that help to diagnose the condition and assess his health. i-Methods of collecting patient history ii-Components of patient history METHODS FOR OBTAINING A PATIENT'S HISTORY 1- Printed questionnaires. Broad in scope , save time & no need for skills Inflexible, pt. may misinterpret questions & unsuitable for illiterate pt. 2- Patient interview. Flexibility ,careful evaluation of patient's needs & problems. Time consuming &require special skills from the dentist. 3- Combination Methods of presenting questions during the diagnostic interview Types of Questions Open-ended Q. Closed-ended Q. Loading Q. Contradiction Q. Indirect Q. 1-OPEN-ENDED Q. Urge the pt. to be narrative - Can you tell me about your last surgery? Advantage: It is the least stressful method for the patient because the clinician listens while the patient is given the control over the interview and calm anxious patients. Disadvantage: Patients who stray from the topic and are unaware of health issues. 2-CLOSED-ENDED Q -limited &quick answer Do you smoke? When did you last see your physician? Advantage: time saving and more effective with unresponsive patients. Disadvantage: The patient feels that the clinician is cold and remote because he is controlling the interview. 3- LEADING Q Suggests the answer within the question -Do you grind your teeth during sleep?(may the dentist asked when suspected that the pt. has recurring morning headache) Advantage: It promotes the patient confidence because he knows that the clinician understands the problem well. Disadvantage: The patient may agree with the clinician because it is the expected answer and not because it is the actual situation. If the question is based on incorrect postulation, the patient looses confidence.  4- CONTRADICTORY Q Contradictory questions are effective when conflicting information has been given. i.e. patient who is taking Dilantin, but said that he is not epileptic. Example: “Since you said that you do not have epilepsy, is there another reason for taking Dilantin that controls seizures?” 5- INDIRECT Q It is a form of questions that reveals information beyond what is specifically questioned by clinician. Asking about complication is not the aim of the question, but the clinician wants to investigate the patient attitude toward dental care as “Have you had a complication during previous dental treatment?” Advantage: useful in understanding sensitive individuals and exploring patient attitudes. Disadvantage: Can be unproductive and time consuming.  PATIENT’S HISTORY Rules: - Establish a relationship with the patient -Seat comfortably, - Addressed by his name & proper title. - Records in details. - Avoid leading question. - Arrange the facts in inverse chronological order( recent events first). PATIENT’S HISTORY Objectives: Define the physical and mental health of the patient. Identify conditions that may cause an office emergency. Suggest etiologies for existing dental/oral conditions. Enables the monitoring of medical conditions of which the patient may or may not be aware; Determine whether dental treatment might affect the systemic health. Assess possible influence of the patient’s systemic health on the patient dental treatment and oral health. PATIENT HISTORY Components: 1-Patient identification (personal history) 2-Chief complaint 3- History of Chief complaint 4-Dental History 5- Medical History 6-Family History 7-Social History 8-Personal habits I-PATIENT IDENTIFICATION (PERSONAL HISTORY, BIOGRAPHIC DATA) 1- Patient's Name 2-Code number 3- Date of examination 4- Age 5- Sex 6-Birth place 7- Address 8-Phone number 9-Occupation 10-Marital status 11-race  I-PATIENT IDENTIFICATION 1- Name for record keeping & retrieval of the patient's file. Better communication between the dentist &patient. 2 -Code number Essential for record keeping & retrieval of the patient's file. 3- Date of examination for record keeping & retrieval of the patient's file. May help in certain recurring conditions e.g. allergic seasonal disease. 4- Age As certain diseases occur generally in certain age group & rarely in others. Used to calculate the dose of the drug.  I-PATIENT IDENTIFICATION 5- Sex (gender) Disease-------- prostatic carcinoma in male hemophilia in males SLE mainly in females 6-Birth place....certain endemic diseases are related to specific places bilharziasis in Egypt fluorosis in Saudi Arabi 7- Address home background & recalling the patient 8-Phone number Rapid recalling the patient  I-PATIENT IDENTIFICATION 9-Occupation In some instances, the diagnosis of some diseases will be based on the knowledge of patient's occupation or the nature of his work. Occupational hazard: as workers in lead factories. Actinic cheilitis in farmers.  I-PATIENT IDENTIFICATION 10-Marital status Psychological stress of some married people should be taken into consideration e.g. lichen planus, aphthus ulcer. Infection should considered as T.B. & AIDS, Pregnancy!!! I-PATIENT IDENTIFICATION 11- race the importance of racial impact on the incidence of some diseases is well documented...Burkett's lymphoma in Negros  RACE thalassemia major in Mediterranean Pemphigus vulgaris in Jews TO SUMMARISE Diagnosis... Types of diagnosis..... Methods of collecting diagnostic data base...... pt. history physical examination lab. investigation Patient history....... methods of collecting pt. History components of pt. history PATIENT HISTORY Components: 1-Patient identification (personal history) 2-Chief complaint 3- History of Chief complaint 4-Dental History 5- Medical History 6-Family History 7-Social History 8-Personal habits  2-CHIEF COMPLAINT The chief complaint is the problem for which the patient is seeking help or treatment Is a statement of why the patient consulted the dentist. Recorded in pt. Own words , May be single or multiple Should be listed in order of importance to the patient Example:2 5 female pt. Complaining of excessive gummy smile.  Common Chief Complaints 4. Oral 1. Pain 2. Bleeding 3. Swelling ulceration 5. Burning sensation. 6. Sensitivity. 10. Esthetic problem. 7. T.M.J disorders 8. Bad breath (halitosis). 11. Regular check up. 9. Parathesia and 12. Referred patient. numbness.  CHIEF COMPLAINT(S) Pain: oral and facial pain may be due to: Teeth: pulpal, gingival and periodontal. Mucous membrane diseases. Tongue conditions. Salivary gland inflammations and/or infections. Lymph node inflammations and infections. Lesions of the jaw bones. TMJ diseases & Myofacial pain syndrome. Maxillary sinus disease. Ear diseases or tonsillar diseases. CNS diseases, neuralgia, neuritis, psychoses.  CHIEF COMPLAINT(S) Soreness: usually describes mucosal inflammations or ulcers from any cause Burning sensation: usually felt in the tongue and caused by a thinning or erosions of the surface epithelium. Infections (viral, fungal, bacterial). Xerostomia. Generalized oral mucositis diseases. Anemias. Vitamin deficiency. Neurosis. Psychosis, burning mouth syndrome.  CHIEF COMPLAINT(S) Bleeding: Gingival and periodontal disease. Traumatic incidents, including surgery. Inflammatory hyperplasias. Allergies. Bleeding disorders. Tumors (traumatized tumors or that that are highly vascular).  BLEEDING Periodontitis Hematoma Erythema Leukemia leukemia multiform From: Oral pathology dept KMUH  CHIEF COMPLAINT(S) Loose teeth: may be due to loss of supporting bone or resorption of the roots. Periodontal disease. Trauma. Normal resorption of deciduous teeth. Pulpoperiapical lesions. Malignant tumors. Hypophosphatasia. Papillon lefevre syndrome  CHIEF COMPLAINT(S) Recent occlusal problem: the patient reports that the teeth "don’t bite right, or the teeth are out of line. Periodontal disease. Over-contoured restorations Traumatic injuries (fracture of bone or tooth root). Periapical abscess. Cysts or tumors of tooth-bearing regions in the jaws.  CHIEF COMPLAINT(S) Delayed tooth eruption: Malposed or impacted tooth. Cysts. Odontomas. Tumors. Mal-development. If generalized → anodontia, hypothyroidism.  CHIEF COMPLAINT(S) Dry mouth: Inflammation, infection and fibrosis of the major salivary glands. Dehydration states. Drugs: Tranquilizers, Diuretics, Antihistamines, Anticolinergics Autoimmune diseases (Sjogren syndrome). Chemotherapy, post radiation changes. Psychosis. Alcoholism. Too much saliva: New denture insertion. Increased or decreased vertical dimensions. Psychosomatic problems (physical diseases worse by mental factors such as anxiety and stress).  CHIEF COMPLAINT(S) Swelling: Inflammations and infections. Inflammatory hyperplasia. Cysts. Retention phenomena. Benign and or malignant tumours.  BAD TASTE Heavy smoking Diabetes Poor oral hygiene Hypertension Dental caries Periodontal disease Medication Dry mouth Uremia Intraoral malignancies Neurogenic disorder Psychosis  CHIEF COMPLAINT(S) Halitosis: Poor oral hygiene. Periodontal disease. Pericoronitis. Decayed teeth. Oral cancer. Tobacco use. Pharyngeal, nasal and sinus infections. Gastric problems.  CHIEF COMPLAINT(S) Paresthesia and anesthesia: Injury to regional nerves (anesthesia needles, jaw bone fracture, surgical procedures) Malignancies. Medications (sedatives, hypnotics…) D.M. Pernicious anemia. Multiple sclerosis. Psychosis. Acute infection of the jaw bone (unusual). III-HISTORY OF THE CHIEF COMPLAINS Additional information usually needs to be elicited by the examiner. The patient’s responses to these questions constitute the history of the present illness (HPI). The HPI is the course of the patient’s chief complaint: III-HISTORY OF THE CHIEF COMPLAINS 1-Onset 2-Duration 3- Character & severity of the complaint 4- Course 5- History of recurrence 6- Distribution 7- Associated phenomenon 8- Previous medications 9- location & site III-HISTORY OF THE CHIEF COMPLAINS (1) Onset Sudden: Acute inflammatory condition and allergic condition Gradual: Chronic inflammatory condition, neoplasm, salivary (2)Duration Short: hrs, days→ acute inflammation Long: months, years → chronic inflammation & benign neoplasms (3)Character & severity of the complaint Sharp, Lancinating, Dull, Throbbing, Itching  III-HISTORY OF THE CHIEF COMPLAINS (4)Course Progressive: Acute inflammatory & neoplasms Regressive: Self-drained abscess Intermittent: S. gland stone (repeated swelling with meals & relief in between meal times) Exacerbation and remission: Chronic periapical abscess (5)History of recurrence May imply chronicity. e.g., Acute exacerbations of chronic periapical abscess  III-HISTORY OF THE CHIEF COMPLAINS (6)Distribution Unilateral: acute dento-alveolar abscess. Bilateral: Mumps, allergy. (7)Associated phenomena Fever = acute inflammation. Pain = +ve with acute inflammation, -ve with neoplastic lesions. Salty taste: cyst. (8) Previous medication Drugs to which the patient is allergic. Antibiotics: if good response, thus swelling is caused by bacterial infection. (9)Location and site periapical, periodontal and gingival abscesses III-HISTORY OF THE CHIEF COMPLAINS 1. When did this problem start (ONSET)? 2. What did you notice first? 3. Did you have any problems or symptoms related to this? 4. What makes the problem worse or better? 5. Have the symptoms gotten better or worse at any time (COURSE)? 6. Have any tests been performed to diagnose this complaint? 7. Have you consulted other dentists, physicians, or anyone else related to this problem? 8. What have you done to treat these symptoms? IF PAIN IS THE MAIN SYMPTOM: ASK ABOUT Origin and radiation: Where is the pain and does it spread? Character and intensity: How would you describe the pain: sharp, shooting, dull, aching, etc Severity of pain, mild, moderate, sever Site of pain Duration of pain HISTORY OF SWELLING Onset.....since birth or early in life Vs recent Duration.....acute or chronic Character...painful or painless Progress Numbness Discharge thank you