Oral Diagnosis PDF

Dr. Baher Al-Tayar II – Chief complaint (cc) The chief complaint (cc) is a statement of why the patient consulted the dentist. It is usually recorded in the patient’s words to accurately reflect the patient’s perception of the problem and to provide an idea about his level of knowledge...

Dr. Baher Al-Tayar II – Chief complaint (cc) The chief complaint (cc) is a statement of why the patient consulted the dentist. It is usually recorded in the patient’s words to accurately reflect the patient’s perception of the problem and to provide an idea about his level of knowledge about dentistry.  Common chief complaints Usually the patient comes to the dental clinic complaining of one or more of the following common complaints: 1 – Pain Which may be:- - somatic, - neurogenous - or psychogenic. 2 – Burning sensation As a manifestation of:- - viral and fungus infection, - geographic and fissured tongue, - atrophy of tongue coating, - anemia and vitamin deficiency. PAIN 3 – Paraesthesia and numbness Caused by vitamin deficiency, pressure on the mandibular nerve such as :- - neurofibromatosis, - injury to the trigeminal nerve, - trauma from anaethetic needles - and following surgical procedures. Also, it may be caused by:- - diabetes, - pernicious anemia, - syphilis - and prolonged use of some medications such as:- - streptomycin, - sedatives, - tranquilizers 4 - Sensitivity Sensitivity to hot, cold and sweats may result from decayed teeth, pulpitis or exposed roots. 5 – Bleeding Bleeding or hemorrhage may occur accidentally or following surgery including extraction. It may result from different causes such as :- - trauma, - post-operative infection - or even uncontrolled blood disorders. Gingival bleeding may be the early manifestation of periodontal problems. The patient may complaint of bleeding gums spontaneously or on slight provocation such as tooth brushing or eating hard food. 6 – Swelling - Soft tissue swelling such as:- - facial cellulitis - and glandular swelling - hard tissue swelling such as:- - Paget’s disease - ameloblastoma. 7 – Oral ulceration Ulceration of the oral mucous membrane are multiple and caused by different etiologic factors. The most common oral ulcerations in dental practice are:- - recurrent aphthous ulceration - and traumatic ulcers. 8 – T.M.J. disorders Patients with T.M.J. disorders may complaint of:- - clicking in jaw joint - and unilateral pain felt in the ear and radiates to the angle of the mandible with or without limitation of jaw function.  9 – Functional disorders The patient complaint may result from functional disorders such as:- - dysphagia - xerostomia, which is a clinical manifestation of salivary gland dysfunction not representing a disease entity.  10 – Bad breath (halitosis) It results from either extra-oral or more commonly oral causes especially poor oral hygiene. Dental infection In some instances the cause may be psychogenic. 11- Esthetic problem Orthodontic treatment or malposed teeth may be the only complaint of certain age group of patients. Also, discolored or hypoplastic teeth may result in psychological esthetic problem for many individuals. It should be noted that in many cases of gum recession and exposure of the roots especially of the anterior teeth, the main complaint of the patient is bad esthetic.  Chief complaint chart Chief complaint C/c …………………………………………….………………………………… …………………………………… History of chief complaint ………………………………. 1 – Onset: ……………… Date: …………………Character: …….. 2 – Duration ……………………………………………………… 3 – Character and severity of the complaint ……………………... 4 – Course ……………………………………………………… 5 – Location and site ……………………………………………. 6 – Distribution …………………………………………………. 7- Precipitating factors ………………………………………… ……………………………………………………………... 8 – Associated phenomenon ……………………………………. 9- Relieving factors ………………………………………………. 10- Previous medications ………………………………………...  Onset a - Character b - Date Sudden (abrupt) a) Character of onset: gradual (1) Acute inflammatory Sudden onset = conditions e.g. Acute dentoalveolar abscess, Erythema multiforme or (2) Allergic conditions  Gradual onset = (1) Chronic inflammatory conditions (2) Neoplastic lesions. (b) Date of onset: Should be recorded in:- day, month and year.  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 - 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 - paroxysmal trigeminal neuralgia.. (3) Interference with sleep and work: Acute dental pain e.g. acute pulpitis.  Location and site: * Location : - The anatomical area : tongue, cheek, gingiva, etc.. * Site: - The specific area in an anatomical location e.g. lateral aspect of the tongue N.B. Sometimes pain may be r eferred from its origin to a remote area.  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 Recurrent Intermittent Remission/Exacerbati on One lesion heals and a It is the same lesion, Lesion is present all similar one appears in the with signs and the time, signs are same site or another site symptoms disappearing present and the then reappearing. change is in the.* Patient is completely * Patient is completely severity of symptoms. free from signs and free from signs and symptoms between symptoms between attacks attacks. * During remission no * Frequency well Frequency of attacks is or less severe separated within very short period symptoms, (weeks, months, years)* of time e.g. within the reappearing with same day. exacerbation e.g. E.g. salivary gland * Frequency well RAU, separated e.g. stone, accompanied by erythema multiforme- intermittent gland seasonal swelling, at meal times Paroxismal trigeminal neuralgia attacks..e.g. lichen planus  History of recurrence: The history of previous occurrence of the lesion may be of importance in diagnosis, e.g. RAU, eryhthema multiform. 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 ii) Bilateral lesions - which are either :- - symmetrically distributed : e.g. lichen planus - assymetrical distributed : e.g. erythema multiforme.  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 ppt 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  Relieving factors: Factors which relieve chief complaint e.g.:- - Rest, - Medications as simple analgesics, - Vasodilators - Morphine should be noted.  Associated phenomena: These are manifestations associated with the complaint: Fever ( acute abscess). Foetid odour + pain + bleeding gingiva + mild fever + lymphadenopathy (ANUG.) Others: e.g. nausea, vomiting trismus, numbness,...etc. all have value in diagnosis of cases.  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