Diagnosis is a determination and judgement of variations from the normal

Diagnosis means ‘through knowledge’ and entails collection of data about the patient and their complaint .

Following history taking and examination, investigation may be required to help confirm the diagnosis or to include some diagnosis

Diagnosis , investigations and treatment planning

Why important? Diagnosis made at an early stage

can be life changing event for a patient .

Wrong diagnosis will lead to wrong treatment which is not desirable for both the clinician and the patient.

Right approach Appropriate diagnosis can be

made with the help of signs,symptoms and investigations

Different types of diagnosisProvisional diagnosis

Laboratory diagnosis

Radiographic diagnosis

Differential diagnosis

Pathological diagnosis

Serological diagnosis

Direct diagnosis

Hematological diagnosis

Therapeutic diagnosis

Emergency diagnosis

Diagnosis by exclusion

Remote diagnosis

Final diagnosis

Provisional diagnosis Diagnosis made on the basis of

medical signs and patient reported symptoms

Patients chief complaint should be given priority

Actual or definitive diagnosis is uncertain and can be only given after necessary investigations

Laboratory diagnosis A diagnosis significantly based on

laboratory report or test results.

A laboratory test interpreted in conjugation with informations from history and physical examination will confirm a diagnostic impression

Radiographic diagnosis Diagnosis established after

taking appropriate radiograph is called radiographic diagnosis

It can be intraoral periapical radiograph or highly informative like CT and MRI

Differential diagnosis Developing differential diagnosis

involves rearranging the list of possible diagnosis

Order them according by rank according to several criteria

A common criteria used in listing a differential diagnosis is frequency of occurrence, with most probable diagnosis at the top and least at the bottom

Age ,sex ,race and other associated factors are concerned

Defintive diagnosis is confirmed after necessary investigation

Pathological diagnosis These types of diagnosis are made from

pathology results

Mostly histopathological diagnosis will be the final diagnosis

Serological diagnosis

Diagnosis confirmed with the help of serological test

Eg. investigations for HIV and hepatitis

Remote diagnosis

A type of telemedicine that diagnose a patient without being physically in same room as physician

Direct diagnosis

Made by observing pathognomonic features

Eg abnormally translucent brownish teeth are characteristic for dentinogenesis imperfecta.

Hematological diagnosis

Diagnosis established by haematological tests

Eg .sickle cell anemia.

THERAPEUTIC DIAGNOSIS Diagnosis arrived after benefial

effects of therapy

EMERGENCY DIAGNOSIS

Diagnosis made on situations such as accidents, injuries is called emergency diagnosis

Diagnosis is made without waiting for detailed examination

Diagnosis by exclusion

Identification of disease by excluding all possible causes

Final diagnosis

Final diagnosis is made after critical evaluation of information obtained from patient history,physical examination, radiologic and laboratory investigation.

TREATMENT PLANNING

Developing treatment plan After determining significant

findings a list of diagnosis and problem is listed

Treatment objective has to be created with patient assistance

Good treatment objective articulate clear goal from both dentist and patient perspective

Patient goals and desire Before creating any treatment plan

dentist must determine patients own desire

The most important goal is to resolve the chief complaint

Determining patient goals begin during initial interview

Avoid leading questions about treatment expectation

Patient modifier Treatment goals frequently influenced by

the patients attributes are referred as patient modifiers

Positive modifiers

Interest in oral health Ability to afford

treatment H/o regular dental care

Negative modifiers Time and financial

constraints Fear of dental

treatment Poor oral and

general health Destructive oral

habits

Dentist modifiers Knowledge

Technical skill

dentist level of knowledge and experience can influence the selection of goals and objective

in addition to knowledge the dentist must have technical ability to provide treatment

Establishing the nature and scope of treatment

Visioning

Identifying the key tooth

Phasing procedure

Visioning Experienced practioner will develop

a vision of what patient mouth look like when treatment is complete

Experienced practioner construct and deconstruct various plans mentally

Key tooth First step in treatment planning is

identifying the key tooth that can be salvaged

Retaining the key tooth improves and loss of key tooth can limit the treatment options available

Key tooth must be periodontlly stable

Canine - anterior tooth Molar - posterior tooth Key tooth are usually favorably

positioned in the arch Key teeth that are decayed or

broken should be restorable

Phasing While treating patient with complex

needs its advantageous to braek treatment plans into phases or segments

Systemic phase Acute phase Disease control phase Definitive treatment phase Maintenance care phase

Systemic phase Through evaluation of health

Procedures necessary to manage patient patients general and psychological health before dental treatment

Consultation with physician

Antibiotic prophylaxis

Avoidance of certain medication and product

Acute phase To resolve any symptomatic

problem that patient present withAcute phase treatment Extraction Endodontic therapy Initial periodontal therapy Placement of provisional

/permanent restorations Repair of prosthesis Medication to control pain and

infection

Disease control phase To control active oral disease and

infection

Stop occlusal and esthetic detiortaion

Manage any risk factor

Oral hygiene instruction

Scaling and root planning

Caries risk assesment and prevention

Endodontic therapy

Extraction of hopeless tooth

Operative treatment to eradicate dental pain

Disease control phase is valuable if the dentist is uncertain about-

Disease severity

Patient commitment to treatment

Treatment option

Success or failure of disease control phase is evaluated with post treatment assessment examination before proceeding to definitive treatment

Definitive treatment phase To rehabilitate the patient oral

condition and includes procedure that improves appearance and function

Additional periodontal treatment

Orthodontic treatment and occlusal therapy

Oral surgery (elective extraction , preprosthetic surgery and orthognathic surgery)

Elective endodontic procedure

Single tooth restoration

Replacement of missing tooth with fixed or removable prosthesis including implant

Cosmetic and esthetic procedure

Maintenance care phase Constitute of highly personalised

plan that strives to maintain the patient in optimum health.

Periodic examinations Periodontal maintenance treatment Application of fluoride Oral hygiene instructions

Informed consent After the formulation of the

treatment plan patient has to sign the case record

This is the informed consent that patient is willing for the treatment

Informed consent is very important for medicolegal purposes

Prognosis “Prognosis is a prediction of the

probable course,duration and outcome of a disease based on a general knowledge of the pathogenesis of the disease and presence of risk factor”

Prognosis can be –

Excellent Very good Good Fair Poor

When the prognosis is one step below fair and one step above poor it is called guarded prognosis

DETERMINATION FOR PROGNOSIS The patients desires and capabilities

Systemic health

The status of the supporting structures

Condition of teeth

Matching treatment plan with patient desire

Conclusion Gathering information about the

patient often requires more time than any other aspect of treatment planning .To prevent missing important findings the dentist should gather data in an organized systematic manner

Each practitioner must develop a consistent and standardized mechanism for gathering historical information about the patient ,obtaining radiographs and performing clinical examination .

It is essential that any data gathered be both complete and accurate. If differences occur in either completeness or accuracy the validity of the final treatment may be suspected.

References Oral medicine diagnosis and treatment planning

burket,s-9th and 11th edition Oral diagnosis, Oral medicine and Treatment

planning –Steven L Bricker,Robert P Langlais,Craig S Millar 2nd edition

Diagnosis and treatment planning –Stefnac and Nesbit

Textbook of oral medicine –SR prabhu Clinical manual for oral medicine and radiology –

Ravikiran ongole 1st edition Oral and maxillofacial medicine – Crispan scully

1st edition Practical medicine for students and practitioners –

P.J Mehta Oral Diagnosis the clinician’s guide – Warren

birnbaum , Stephen M Dunne 1st edition Color atlas of common oral diseases – Robert P.

Langlais,Craig S. Miller 2nd edition Handbook of Local Anesthesia 5th Edition Stanley

F. Malamed