The_Principles_Of_Diagnoses_&_Laboratory_Investigations_In_Dentistry-1.pdf

The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan Definition of Oral Medicine: A...

The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan Definition of Oral Medicine: A branch of dentistry dealing with diseases of the oral and paroral structures and the oral management of systemic diseases. An effective approach to the patient who requires dental care entails the following steps: (1) personal information. (2) Learning the chief complaint. (3) Recording the history of the present illness. (4) Taking and recording the medical and dental history. (5) Clinical examination. 1- personal information:- This step provides a gentle introduction in to the meeting of patient and clinician, in a format that can be individualized to suit a particular culture. That Includes 1- name 2-age 3-sex 4- address 6- occupation 7-educational status 8-relationship status 9- contact details 2- Chief complaint:- Is the reason for which the patient has come to the dentist or the reason for seeking the treatment and it should be recorded in the patient’s own words and first attention should be given to it. 3- History of the present illness:- Collecting information (history commences) from the beginning of the first symptom and extends to the time of examination. And should include the information related to mode of onset (sudden or gradual), cause of onset, duration, relapse and remission, intensity, nature and previous treatment It should be collected by asking the following questions: -when did the problem start? -what did you notice first? -did you have any problems or symptoms related to this? -did the symptoms get better or worse at any time? -what have you done to treat these symptoms? -have you consulted anyone else for this problem? 4- Medical and dental history Medical history (past and present):- An evaluation of the patient’s general health before treatment is necessary to identify any systemic condition which may influence the treatment and allow the dentist to evaluate risks Page 1 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan and reduce possibilities of complications , e.g (history of allergy to the drug, previous hospitalizations and operations, history of immunization, take any types of medications ) The final aspect of the medical history is a Review of systems. Questions must be posed so as to reveal any diagnosed as well as undetected systemic diseases. It is important, as health care providers, that dentists be familiar with signs and symptoms of systemic diseases so that timely referral to a physician can occur or that precautions may be taken for patient protection. Pertinent questions are posed for each of the major organ system (Cardiovascular, Renal, Pulmonary, Endocrine, Nervous, Musculoskeletal, Gastrointestinal, Hepatobiliary, Hematopoietic, Immune (include allergies) Dental history (past) It is important to assess the patient’s dental awareness and the likelihood of raising it and to know the nature of the presenting complaint Social history It includes the information about the lifestyle habits (alcohol, tobacco, betel and recreational drugs), socioeconomic status, hobbies, and marital status Family history Take the information about genetic conditions. The main things that we usually ask about are diabetes, hypertension, ischemic heart disease, and cancer 5- clinical examination:- Principles of Examination: Inspection: It is a routine clinical practice this can usually be limited to a visual evaluation such as swelling, asymmetry, ulcer, colour, finger clubbing and any abnormality or deformities can be seen. Palpation To feels the texture, size, shape, consistent, fixity of any mass by bimanual palpation and tenderness of TMJ Percussion By gently tapping with the end of the dental diagnostic instrument to know the tenderness. Auscultation The sound are usually recorded and observed by stethoscope auscultation e.g. TMJ and during the evaluation of blood pressure Page 2 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan First, the clinician (dentist) should pay attention to the patient’s general appearance, behaviour, gait and should note any physical deformities or handicaps. And must be evaluate the patient’s vital signs, which include respiratory rate (12-18 breaths/ min), heart rate (adult 60-80 beats/ min; child is higher (up to 140 beats/min in infants), blood pressure (120-140/ 60-90 mmHg), and body temperature (35.5 – 37.5 C or 95.9 -99.5 F), Note) - Before any investigation are initiated, the patient's consent must be obtained by explicit written consent A) Extra oral examination In addition to the patient’s general appearance and behaviour the eyes, neck, hands, scalp and the skin of the face and arms should usually be examined because each of these visually accessible areas can demonstrate signs that alert the dentist to possible underlying systemic disease. Observation Information(examples of associated conditions) General appearance and Wasted, undernourished (e.g. malnutrition, underlying malignancy); behaviour low mood, anxiety (e.g. depression) Breathlessness Cardiorespiratory problems Face Shape and symmetry (masseteric hypertrophy, craniofacial syndromes);cushingoid appearance (e.g. corticosteroid therapy); neurological deficits (e.g. Bell’s palsy); cyanosis (e.g.cardiorespiratory disease); pallor (e.g. anxious, anaemic) Scalp and facial hair Alopecia (e.g. lichen planus ,after radiation) Eyes Pale sclera(anaemia); yellow sclera(jaundice); exophthalmia (hyperthyroidism) Neck Enlarged lymph nodes (oral infection, neoplasms); goitre Hands Finger clubbing (chronic cardiorespiratory problems, including infective endocarditis Skin Petechiae or ecchymoses (e.g. blood dyscrasia) B) Intra oral examination The most important points that must be noted before starting of the intraoral examination are:- 1- The whole of the oral mucosa must be carefully examined. 2- All removable appliances should be taken out. *** The lips and cheeks must be gently retracted to display the full extent of the sulci. The tongue gently held by using a piece of gauze, and extended forward and to each side to see all surfaces of the tongue(dorsum, lateral and ventral) , floor of the mouth and undersurface of the tongue. The posterior part of the tongue, tonsillar fauces, uvula and soft palate are exposed by Page 3 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan gentle pressure on the tongue and helped by phonation of ‘ah’ by the patient and this examination must be combined with a careful assessment of the other dental structures by using diagnostic instruments. There are many important points and special features (characteristics) to do the examination for the most dental complaints:- 1) Oral ulceration 1- Mode of onset: traumatic, secondary changes on a Swelling 2- Frequency of ulceration 3- Duration of ulceration 4- Number of ulcers 5- Site of ulceration: in which areas of the oral cavity 6- Size. 7- Shape of ulcers: oval, round, irregular 8- Edge of ulcer: undermined (tuberculosis), punched out(gammatous ulcer), Raised / Beaded (Basal cell carcinoma), Rolled out / Everted(Squamous cell carcinoma) 9- Base of ulcer 10- Surrounding tissue: if the surrounding area of an ulcer is glossy, red and edematous the ulcer is acutely inflamed. 11- Floor(exposed surface ): red granulation tissue (healthy and healing)black mass at the floor(malignant melanoma) 2) Pain 1- Location. 2- Onset: when did the pain start? 3- Duration: by time (seconds, one day….) 4- Nature: the general quality of pain complaint should be classified as how it makes the patient feel (burning, throbbing, dull, aching, cutting, shooting, stabbing, squeezing). 5- Radiation: referred pain and shifting or migration of pain. 6- Severity: mild, moderate or severe. 7- Provoking factors: talking, brushing of teeth, shaving, washing the face... Page 4 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan 8- Periodicity 9- Relieving factors. 10- Associated factors or symptoms. 3) swelling (mass or lump) 1- Duration: how many days the swelling is present to determined if its acute or chronic nature. 2- Mode of onset: slow growth, moderately or rapidly growing. 3- Symptoms: 4- Progress of swelling: gradually or rapidly increase in size. 5- Impairment of function: 6- Shape: ovoid, pear, spherical or irregular. 7- Size. In diameters. 8- Surface: smooth, corrugated, papillomatous. 9- Edges: clearly defined or indistinct, sessile or pedunculated. 10- Number: multiple (neurofibromatosis) or solitary (lipoma). 11- Tenderness: inflammatory swelling is mostly tender whereas neoplastic swelling is non tender. 12- Consistency or degree of firmness: soft (lipoma, mucocele), rubbery (lymphoma), firm (fibroma), bony hard (osteoma, exostosis). Laboratory investigations:- There are special Laboratory investigations must be noted such as (Haematological tests, biopsy, radiological investigations, biochemical investigations.....) to be combined with the patient’s history and clinical examinations to provide a definitive diagnosis according to the results. These tests may be done either as screening tests to help in the diagnosis of unidentified condition or by the specific tests to confirm a diagnosis. Page 5 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan Haematological tests Test name Normal range Level increase Level decrease Red cell count male 4.2- 6.1* 1012 /L Polycythemia Anemia (RBC) Female 4.2- 5.4* 1012/L Hemoglobin male 13.0- 18.0 g/dL Polycythemia; Anemia (Hb) Female 11.5- 16.5 g/dL erythrocytosis; fluid loss due to dehydration, diuretics, diarrhea. Hematocrit male 40-54% Polycythemia; Anemia (packed cell Female 37- 47% dehydration volume [PCV] Mean cell volume 78- 99 fl (femtoliter) Vitamin B12 Iron deficiency (MCV) and folate anemia ; deficiency thalassemia Mean cell 27- 31 pg/cell Pernicious Iron deficiency; hemoglobin (picograms/cell) anemia thalassaemia (MCH) White cell count 4-10 * 109 /L Infection; Early leukemia; (WCC; total) leukemia; drugs:- stress; (corticosteroids, pregnancy chemotherapy) Erythrocyte 0- 15 mm/h Infections; ------------- sedimentation anemia; rate (ESR) connective tissue disease; tumors; pregnancy platelets 150-400*109 /L Thrombocytosis Thrombocytopenia in bleeding related to leukemia; HIV ****(You must check Normal values with your laboratory Notes: - MCV = PCV / RBC, MCH = Hb / RBC Page 6 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Dr.Ahmad Fliah Hassan Oral Medicine lecture Biochemical investigations biochemistry Level increase Level decrease Glucose Diabetes mellitus; Addison disease; severe hyperthyroidism; Cushing's liver disease syndrome Ferritin liver disease; leukemia; Iron deficiency lymphoma; thalassemia Folic acid Folic acid therapy Alcoholism; dietary deficiency; hemolytic anemia; pregnancy; oral contraceptive Steroids Cushing's syndrome Addison disease (corticosteroids) Vitamin B12 Leukemia; polycythemia; Pernicious anemia Thyroxin (T4) Hyperthyroidism; oral Hypothyroidism; phenytoin contraceptive Calcium Primary hyperparathyroidism, Hypoparathyroidism, renal sarcoidosis, malignancy in failure, lack of vitamin D bone cholesterol Hypercholesterolemia, Malnutrition, hypothyroidism hyperthyroidism Page 7 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan Biopsy Removal of tissue from the living body, performed to establish precise diagnosis that examined by histopathologist and the decision to take each techniques (incisional, excisional and fine needle aspiration) will depend upon the nature, size, number and location of the lesion. There are special considerations for the taking specimen biopsy:- 1- The specimen must including a small area of normal tissue. 2- By using a scalpel better than the cutting diathermy because it may cause considerable distortion of the tissues. 3- The specimen should be big enough to allow the pathologist to make a diagnosis because if it is small a biopsy is difficult to handle and to orientate for sectioning. 4- The local anaesthesia injection should be far from the biopsy site to obtaining a correct laboratory result to prevent the distortion of the histological picture. 5- The biopsy specimen should be placed with the minimum of delay into a fixative, 10 per cent formal saline. 6- The biopsy site should be sutured 7- Full clinical details should always be given documentary to the pathologist by the report. The indications of the biopsy techniques:- 1- Incisional biopsy Removal of a selected portion of a lesion depends on a clinically typical area and the edge of the lesion. 2- Excisional biopsy It’s particularly useful for the diagnosis and possible to combine primary treatment in the cases of single small ulcers (lesion) and small, localized, soft swellings. 3- Fine needle aspiration (FNA) biopsy It’s useful to collect a soft-tissue lesions and fluid contents of a lesion (pus or cystic fluid), sometimes it is not possible to obtain a definitive diagnosis often there is enough information to differentiate between malignant and benign. A 20/21 gauge needle is employed for sampling tissue and ultrasound can be used to guide the needle position in the centre of the lesion. Page 8 of 9 The Principles Of Diagnoses & Laboratory Investigations In Dentistry Mustansiriyah University, College of Dentistry, Department of Oral Medicine. Oral Medicine lecture Dr.Ahmad Fliah Hassan Imaging 1- Plain film radiography:- Is the most common imaging technique used in dental practice because it is particularly helpful diagnostically, inexpensive, rapidly achieved and widely available. And there are intraoral views (e.g. periapical, bitewing and occlusal) and extraoral views (e.g. panoramic, occipitomental and lateral). 2- Computerized tomography:- Provides good anatomical representation of the soft-and hard tissue tumours of the head and neck, facial fractures, intracranial lesions and osteomylitis.The contraindications include pregnancy. 3- Cone beam CT (CBCT) This is CT in which the X-rays are divergent, forming a cone. It is useful in implantology, endodontics and orthodontics, for accurate visualization of the jaws, teeth and roots (erupted and non-erupted) and of anomalous structures that conventional 2D radiography cannot capture. 4- Magnetic resonance imaging (MRI) This technique is valuable in assessing intracranial lesions, lesions of the salivary glands, sinuses, pharynx, TMJ and produces excellent differentiation between soft tissues, hard tissues and normal and abnormal tissues but gives poor hard tissues detail. The contraindications include the presence of a cardiac pacemaker, defibrillator or monitor, vascular or surgical clips, any types of orthopaedic prosthesis, rods or pins and dentures or appliances must be removed before the scan. 5- Ultrasound (Ultrasonography) Is a safe and useful for evaluating vascular disorders and soft tissue swelling of the neck and face, including salivary glands and lymph nodes. It is ideal for differentiating between solid and cystic masses and it can be used with fine needle aspiration to ensure correct positioning of the biopsy needle and to locate salivary calculi. Page 9 of 9