The systematic approach to get the final diagnosis

A series of relevant events and situations to get differential

diagnosis then the final diagnosis

Prepared by:

رمضان السالم عبد سميةالفيتوري

 INTRODUCTION In routine dental practice patients seek oral care for various reasons. Some of these reasons are

..pain, swelling and ulcers ,etc …

Accurate diagnosis is the only true cornerstone on which rational treatment can be built.

(1) C Noyek

General look

Taking history

Careful examination

Define your investigationsWhich should

be Sensitive and

specific

To get correct diagnosis

First step :

Clues of general look

Importance of general look

Give you hints about patient’s :•Chief complain •Mentality •General health •Altitude and education •May help in discovering undiagnosed diseases•Planning of treatment

Don’t depend on general look only

Hypo/hyper-thyrodism

Second step:

Taking history

Taking history

History of present illness

Dental history

Medical history / systemic review

Social history / habit

Family history

Chief complain

Drug history / allergy

Common symptoms of oral and maxillofacial disease processes include the following:Discomfort: Pain, ache, numbness, itching (pruritus), burning, tenderness, and clicking/popping of temporoman-dibular joint (TMJ) .Also may the patient complain of :Sores , gingival /intraoral bleeding , burning mouth/ tongue , loosing of teeth , delay tooth/teeth eruption , sudden change in occlusion , halitosis .. Etc

Causes of pain felt in the oral tissues (2)

• Disease of teeth and/or supporting tissues• Oral mucosal diseases• Diseases of the jaw• Pain in the edentulous patient• Postoperative pain• Pain triggered by mastication• Referred pain• Neurological diseases• Psychogenic (atypical) facial pain

Painful jaw diseasesFractures

OsteomyelitisInfected cysts

Malignant neoplasmsSickle cell infarcts

(3 )Pain from extra-oral disease

• Diseases of the maxillary antrum: Acute sinusitis , Carcinoma, particularly when it involves the antral floor

• Diseases of salivary glands : Acute parotitis , Salivary calculi , Sjogren's syndrome

• Malignant neoplasms• Diseases of the ears : Otitis media , Neoplasms in this

region• Myocardial infarction• Painful intracranial and psychological disorders

Third step :

Clinical examination

Clinical examination

Extra- oral Intra-oral

teeth/ soft tissues /hard tissues

• Inspection • Palpation • Percussion • Auscultation

• General examination • Vital signs • lymph nodes • Cranial nerves

You should know the normal variations

Common signs of oral and maxillofacial disease processes include the following:

• Soft-tissue changes .• Hard-tissue changes (Clinical/radioghraphical). • Neuromuscular functional changes.

Sebaceous glands lying superficially in Usually labial mucosa and buccal mucosa.

Fordyce spots

A milky white translucent whitening of the oral mucosa which disappears or fades on stretching. Commoner in black races

Leukoedema

Exostoses Tori

horizontal streak on the inner surface of the cheek, level with the biting plane

Linae alba

The keratinized mucosa, in particular the gingiva, is most commonly affected

Physiologic Pigmentation

Gingival GraftsLingual Tonsil

Must know the

landmarks and

anatomical variations

oral mucosal lesions : •surface lesions - epithelial thickening, surface debris, and sub-epithelial change•Pigmented lesions : 1. Generalized pigmented surface lesions2. Localized pigmented surface lesions - intravascular blood,

extravascular blood, melanin pigment, and tattoo• Vesicular-ulcerated-erythematous surface lesions - hereditary, autoimmune, viral, mycotic, and idiopathic• Reactive soft tissue enlargements of oral mucosa• Benign tumors of oral mucosa - epithelial, mesenchymal, and salivary gland• Malignant neoplasms of oral mucosa • Cysts of oral mucosa

Sub mucosal swelling( by region)

• Gingival • Tongue • Lips and buccal mucosa• Floor of the mouth • Palate • Neck

Jaw lesions

• Cyst of jaw• Odontogenic tumors• Inflammatory disease • Non odontogenic tumors• Malignancy of jaw • Metabolic and genatic diseases

Upon the finding , choose your investigation

Fifth step :

Investigation

Most used investigations /tests in

clinical examination

Vitality tests of Pulp

Electrical pulp test

Thermal test

Unfortunately it may not be apparent that a pulp test result smisleading. Care must always be

taken to avoid causes of false positive or false negative results.)

Other tests to determine the offending tooth:

By air syringe

By using local anesthesia

Percussion horizontal/ vertical

Bleeding provoked / spontaneous

Frimatus test

Imaging investigation

Intra_oral Extra_oral

Peri-apical rxBitewing rx Occlusal rx

Panorama and other extra oral rx techinqueUltrasound Cbct MRI

Milking test for parotid gland

Chief complain analysis Clinical examination Radiological examination

List of possible lesions with

similar features

Classify the lesion

Development of differential diagnosis

Make differential diagnosis

** Depend on : •Age•Gender •Race •Country of origin •Anatomical location •Onset and course•Habits

Rate the lesion/ condition/pain from most common to least

common , according a relative frequency of occurrence .

Development of final diagnosis

Development of final diagnosis needs further investigations to find the correct diagnosis and exclude other possible diseases .

BIOPSY

*BRUSH BIOPSY

*SMEAR BIOPSY

*FINE NEEDLE ASPIRATIRATION

*INCISIONAL BIOPSY *EXICISIONAL BIOPSY

UNDER LIGHT MICROSCOPE

FLOUROCENCE• DIRECT • INDIRECT

biopsy specimen for histopathological examination

Exfolaitive cytology

Content of lesion

TOLUIDINE BLUE stain

Haematology, clinical chemistry and serology

Types of blood test useful in oral diagnosis • Cbc • Peripheral blood film• ESR • Serum iron and total iron binding capacity / Serum ferritin• Autoantibodies • Viral antibody titres • Paul-Bunnell or monospottest• Syphilis serology• Complement tests• Serum calcium, phosphate, and parathormone levels• HIV test• Skeletal serum alkaline phosphatase

Examples of other tests

patch test relies on the principle of a  type IV hypersensitivity reaction

Nikolsky sign

Diascopy test

Urine analysis

Hb electrophersis

Bacteriological diagnosis

pathergy test

Color atlas of common oral disease

Formulating final diagnosis

History

Examination

Special investigation

Final /Definitive diagnosis

+/ -therapeutic trials may be in order ; example: traumatic bone

cyst , stafne bone cyst .

Formulating a Treatment Plan

the following management strategies are considered:

( 1 )no treatment ,(2 )surgical removal ,

(3) pharmacologic agents,( 4 )palliative treatment ,

(5 )behavioral or functional treatment (6 )psychiatric therapy.

(7 )Referral to a medical or dental specialist

may be requiredfollow-up

Conclusion So , diagnosis is systematic process started from patient’s entry with complain to the

patient discharge with treatment .

Reference (1) http://pocketdentistry.com/3-diagnosis-investigation

s/ (1)

(2) Clinical outline of oral pathology : DIAGNOSIS AND TREATMENT FOURTH EDITION, Lewis R. Eversole 2011 .

(3) CAWSON'S ESSENTIALS OF ORAL PATHOLOGY AND ORAL MEDICINE SEVENTH EDITION , R. A. CAWSON , E. W. ODELL , S. PORTER 2002 (2),(3) .

(4) Wood & Goaz differential diagnosis of oral maxillofacial lesions .