واالسنان الفم وجراحة لطب التخصصي المركزالمثنى في

اعدادشوكت. عمار د

باشراف االختصاص الدكتور

حسن. محمد د

Principles of diagnosis

introductionThis is series of steps that clinicians take to arrive at a

diagnosis.

Diagnosis is defined as the recognition of the disease, naming

the disease as per agreed criteria.

In other words, diagnosis would mean recognizing the disease

and naming it.

Table 1. Principles of diagnosis

A. A detailed history

B. Clinical examination

Extraoral

Intraoral

C. Special investigations (as appropriate)

Radiography or other imaging techniques

Biobsy for histopathology (including immunofluorescence,

immunocytochemistry, electron microscopy, molecular biological tests)

Specimen for microbial culture

Haematological or biochemical test.

Taking a historyHistory-taking needs to be tailored to suit the individual patient but it is sometimes

difficult to get a clear idea of the complaint. Many patients are nervous, some are

inarticulate, others are confused.

Initial questions should allow patients to speak at some length and to gain

confidence.

It is usually best to start with an 'open' question.

Type of question example

Open Tell me about the pain?

Closed What does the pain feel like?

Leading Does the pain feel like an electric shock?

Open question Advantage

A. Allows patients to use their own words and summarise their view of the problem

B. Allows patients to partly direct the history-taking, gives them confidence and quickly generates rapport

Disadvantage

A. clinicians must listen carefully and avoid interruptions to extract the relevant information Patients

B. tend to decide what information is relevant

Closed question Advantage

A. Elicits specific information quickly.

B. Useful to fill gaps in the information given in response to open questions

C. Prevents vague patients from rambling away from the complaint

Disadvantage

A. Patients may infer that the clinician is not really interested in their problem if only closed questions are asked

B. Important information may be lost if not specifically requested

C. Restricts the patient's opportunities to talk

Summary of taking a history A. Introduce yourself and greet the patient by name

B. Put patients at their ease

C. Start with an open question

D. Mix open and closed questions

E. Avoid leading questions

F. Avoid jargon

G. Explain the need for specific questions

H. Assess the patient's mental state

I. Assess the patient's expectations from treatment

Demographic details

The age, gender, ethnic group and occupation of the patient should

be noted.

History of the present complaint

A. Record the description of the complaint in the patient's own words

B. Elicit the exact meaning of those words

C. Record the duration and the time course of any changes in symptoms or signs

D. Include any relevant facts in the patient's medical history

E. Note any temporal relationship between them and the present complaint

F. Consider any previous treatments and their effectiveness

Taking a pain history

Characteristic Informative feature

Type Ache, tenderness, dull pain, throbbing, stabbing, electric shock.

severity Mild — managed with mild analgesics Moderate

unresponsive to mild nalgesics Severe —disturbs sleep

Duration Time since onset. Duration of pain or attacks.

Nature Continuous, periodic or paroxysmal.

Initiating factors Any potential initiating factors. Association with dental treatment

Exacerbating and relieving factors Record all and note especially

hot and cold sensitivity or pain

on eating which suggest a dental cause.

Localisation The patient should map out the distribution of pain if possible.

Is it well or poorly defined?

Referral try to determine whether the pain could be referred.

The medical history

A medical history is important as it aids the diagnosis of oral manifestations of systemic disease.

It also ensures that medical conditions and medication which affect dental

or surgical treatment are identified.

example of a medical history questionnair

SURNAME………………………………………Address………………………….

Other name…………………………………………………………………………...

Date of birth……………………………………Telephone number……………….

The following questions are asked in the interests of your safety and any particular precautions that may need to be taken as a result of present any previous illnesses or medications.

1. Are you undergoing any medical treatment at present? Yes no

2. Do you have, or have you had any of the following:

a. Heart disease? Yes No

b. Rheumatic fever? Yes No

c. Hepatitis? Yes No

d. Jaundice? Yes No

e. Epilepsy Yes No

f. Diabetes? Yes No

g. Raised blood pressure? Yes No

h. Anaemia ? Yes No

I . Asthma, hay fever or other allergies? Yes No

j. Familial or acquired bleeding tendencies? Yes No

3. Have you suffered allergy or other reactions (rash, itchiness etc) to:

a. Penicillin? Yes No

b. Other medicines or tablets? Yes No

c. Substances or chemicals? Yes No

4. Have you ever had any adverse effects from local anaesthetics? Yes No

5. Have you ever experienced unusually prolonged bleeding after injury or tooth extraction? Yes No

6. Have you ever been given penicillin? Yes No

7. Are you taking any medicines, tablets, injections (etc.) at present? Yes No

If YES can you please indicate the nature of this medication? …………………………..

8. Have you been treated with any of the following in the past 5 years:

a. Cortisone (hydrocortisone, prednisone etc)? Yes No

b. Blood-thinning medication? Yes No

c. Antidepressants? Yes No

9. Have you ever received radiotherapy? Yes No

10. Do you smoke? Yes No

If YES how much on average per day?.....................................

11. For female patients — are you pregnant? Yes No

PLEASE ADD ANY OTHER INFORMATION OR COMMENTS ON YOUR MEDICAL

HISTORY, BELOW

.....................................................................................................

Signature ……………………………………date………………….

Address (if not the patient)…………………………………………

The dental history

A dental history and examination are obviously essential

for the diagnosis

The family and social history

Whenever a symptom or sign suggests an inherited disorder, such as haemophilia, the family history should be elicited.

social history which can be effect , for example, psychosomatic factors

Consentt is imperative to obtain patients' consent for any procedure. At the very least, the procedure to be used should be explained to the patient and verbal consent obtained.

A Consent Form should therefore be used and should state1.The type of operation or investigation.

2. Possible risks and complications

3. A signed and dated statement by the clinician that he or she has

explained these matters and any options that may be available in terms

understandable to the patient, parent or guardian.

4. A section for the patient, parent or guardian to confirm;

a. that the information was understandable.

b. that the person signing the form has a legal right to do so, i.e. is the

patient, parent or guardian

c. that the procedure has been explained and agreed

d. that there are certain additional procedures that would be completely

unacceptable and should not be carried out.

Extra-oral examination

Learning objectives

• know how to palpate lymph node

• be able to identify and assess swellings, sensory disturbance and motor disturbances

• understand what to look for based on the history

Visual areas would cover• general patient condition

• symmetry

• swellings

• lips/perioral tissues.

Palpation would cover:

• lymph nodes

• temporomandibular joint (TMJ)

• salivary glands

• problem-specific examination.

Lymph node examination

The major lymph nodes of the maxillofacial region and neck are submental ,

submandibular and the internal jugular nodes ( jugulo-digastric and jugulo-omohyoid

node being the largest) are of particular importance because these receive lymph

drainage from the oral cavity. Examination of the nodes should be systematic, although

the order of examination is not critically important.

To palpate the nodes, the examiner should stand

behind the patient while he/she is seated in an

upright position. Use both hands. A common sequence would

be to start in the submental region, working back to the

submandibular nodes then back to the jugulodigastric

node. Then continue by palpation of

the parotid region downwards to the retromandibular

area and down the cervical chain of nodes.

a. Submental

b. Submandibular

c. pre auricular

d. Post auricular

e. Occipital

f. juculo. digastric

g. Juculo omohyoid

h. Mid jucular

i. Mid posteriar cervical

j. Lower jucular

k. Lower posterior cervical

Temporomandibular joint

Temporomandibular joint Joint examination

Movement.

Face the patient and ask him/her to open slowly to maximum. Normal range (inter-

incisal) is 35 to 40 mm. If opening is thought to be reduced, ask whether the limiting

factor is pain or an obstruction. Note the path of opening and any lateral deviation.

Pain on palpation.

Palpate in front of the ear and within the external auditory meatus.

Auscultation.

This needs a stethoscope to be done properly. However, clicks may well be audible

without a stethoscope.

Salivary glands

Salivary glandsAs always, symptoms are often indicative of the abnormality present. These can include:

• slowly developing swelling or mass, suggesting a tumour

• swelling (at the site of a major gland) associated with sight/taste/smell of food, slowly

subsiding subsequently, suggesting obstruction by calculus

• pain and swelling (of a major gland) perhaps with a bad taste, suggesting infection

• dry mouth, suggesting a wide range of causes, including Sjogren's syndrome.

Problem-specific examination

The examination will be made in the light of the symptoms

reported by the patient

But the examiner may detect swelling, sensory or motor

disturbance that the patient has not noticed.

Swelling/lump.anatomical site

.shape and size

.colour

.single or multiple

.surface texture/warmth

. tenderness

. fluctuation

.sensation/pulsation

To assess fluctuation, place two fingers on the swelling and press down with one finger.

If fluid is present the other finger will record an upward pressure. Pulsation in a swelling

will indicate direct (i.e. it is a vascular lesion) or indirect involvement (i.e. in immediate

contact) of an artery.

Paraesthesia / anaesthesia It is important to identify the extent of the affected area and the degree of alteration in

sensation It is best to use a fairly fine, but blunt-ended, instrument for this at first, for

example the handle of a dental mirror. First, run the instrument gently over what is

assumed to be a normal area of skin . Then repeat this over the symptomatic area,

asking the patient to say whether they can feel anything. Record the area of altered

sensation in the notes using a drawing.

Paralysis/motor disturbance

While paralysis or motor disturbance may be reported as a symptom by the patient, it

may initially be identified during an examination. In the maxillofacial region, the motor

nerves that are likely to be under consideration are the facial nerve, the hypoglossal

nerve and the nerves controlling the muscles that move the eyes.

The latter is seen in a large number of conditions but, for the dentist, important

causes include Bell's palsy , parotid tumours, a misplaced inferior dental local

anaesthetic and trauma.

Trigeminal nerve

V1 ophthalmic division

V2 maxillary division

V3 mandibular division

Cervial nerve

C2 _c4 branches

Sjogrens syndrome

Sjogren's syndromeSjogren's syndrome is an autoimmune chronic inflammatory disease involving the salivary and lacrimal glands.

Diagnosis

/. Ocular symptoms

three selected questions

1. Have you had daily, persistent, trouble some dry eyes for more than 3 months?

2. Do you have a recurrent sensation of sand or gravel in the eyes?

3. Do you use tear substitutes more than three times a day?

//. Oral symptoms

three selected questions

1.Have you had a daily feeling of dry mouth for more than 3 months?

2. Have you had recurrently or persistently swollen salivary glands as an adult?

3. Do you frequently drink liquids to aid swallowing dry food?

///. Ocular signs

two tests:

1.Schirmer's test

2. Rose Bengal score

IV. Histopathology

A focus score >1 in a minor salivary gland biopsy.

V. Salivary gland involvement

three diagnostic tests:

1.Salivary scintigraphy

2. Parotid sialography

3. Unstimulated salivary flow (<1.5 ml in 15 minutes)*

VI. Autoantibodies

Presence in the serum of the following antibodies:

1. Antibodies to Ro (SS-A) or La (SS-B) antigens, or both

Oral examinationExamination of the oral cavity can only be performed adequately with good

light, mirrors and compressed air or other means of drying the teeth.

Soft tissuesThe soft tissues of the mouth should usually be inspected first.

Examination should be systematic to include all areas of the mouth.

ensure complete examination of the lateral tongue and posterior floor of mouth the

tongue must be held in gauze and gently extended from side to side.

After examination of the oral mucosa try to visualise the oropharynx and tonsils.

TeethAs a minimum, the standing teeth with a summary of their periodontal health,

caries and restorative state, should be recorded.

When dental pain is a possibility, full charting, assessment of mobility and

percussion of teeth are necessary .

Some anatomical variants and normal structures often misdiagnosed as lesions

Fordyce spots

Description

Sebaceous glands lying superficially in the mucosa are visible as white or cream coloured spots up to 0.5 mm across. Usually labial mucosa and buccal mucosa. Occasionally prominent and very numerous .

Lingual tonsils

Enlarge with viral infection and occasionally noted by patients. Sometimes

large or ectopic and then mistaken for disease.

Circumvallate papillae

Readily identifiable but sometimes prominent and misinterpreted by

patients or health care workers.

Retrocuspid papilla

Firm pink nodule 0.5-4 mm diameter on the attached gingiva lingual to the

lower canine and lateral incisor, usually bilaterally but sometimes unilateral.

Prominent in children but regress with age.

Dorsal tongue furFurring of the dorsal tongue mucosa is very variable and is heavier when the diet is

soft. Even light furring is regarded as pathological by many patients. When pigmented

black by bacteria the condition is called black hairy tongue.

LeukoedemaA milky white translucent whitening of the oral mucosa which disappears or

fades on stretching. Commoner in black races.

Exostoses in the midline of the palate or in the lingual alveolus in the

premolar region are termed tori.

Medical examinationThe dentist should be capable of performing simple medical examinations of the head

and skin of the face, hair, scalp and neck may reveal unexpected foci of infection to

account for cervical lymphadenopathy or even malignant neoplasms.

The eye can readily be inspected for conjunctivitis or signs of mucous membrane

pemphigoid, anaemia or jaundice. Examination of the hands may also reveal relevant

information .

Useful diagnostic information from examination of the hands

Flexor surface of wristsigns

Rash (or history of rash) consisting of purplish of papules suggests lichen planus,

especially if itchy.

Finger morphology

signs

Clubbing may be associated with some chronic respiratory and cardiac conditions

(including infective endocarditis) and sometimes remote malignancy.

Abnormal nails

signs

Koilonychia suggests long-standing anaemia Hypoplastic nails may be associated with

several inherited epithelial disorders of oral significance including ectodermal dysplasia

and dyskeratosis congenita

Skin of fingers

Signs

May be thin, shiny and white in Raynaud's phenomenon (periodic ischaemia resulting

from exposure to cold — often associated with autoimmune conditions particularly

systemic sclerosis or Sjogren's syndrome)

Palmar-plantar keratosis

signsAssociated with several syndromes including Papillon-Lefevre syndrome

(includes juvenile periodontitis).

Imaging

The most informative imaging techniques in the head and neck are radiography and

computerised tomography (CT), magnetic resonance imaging (MRI) and ultrasound.

Requirements for useful radiographic information

A. Always take bitewings when dental pain is suspected.

B. When imaging bony swellings always take two views at right angles

C. Panoramic tomograms cannot provide high definition of bony lesions. Only a cross-

section of the lesion is in the focal trough . For more information, oblique lateral views of

the mandible or oblique occlusal films should be taken

D. Radiography of soft tissues is occasionally useful, for instance to detect a foreign

body or calcification in lymph nodes.

HistopathologyValue and limitations

Removal of a biopsy specimen for histopathological examination is the mainstay of

diagnosis for diseases of the mucosa, soft tissues and bone.

BiopsyBiopsy is the removal and examination of a part or the whole of a lesion

Types of biopsy

• Surgical biopsy (incisional or excisional)

Fixed specimen for paraffin blocks

Frozen sections

• Fine needle aspiration biopsy

• Thick needle/core biopsy

Essential biopsy principles

A. Choose most suspicious area

B. Avoid sloughs or necrotic areas

C. Give regional or local anaesthetic — not into the lesion

D. Include normal tissue margin

E. Specimen should preferably be at least 1 x 0.6 cm by 2 mm deep

F. Specimen edges should be vertical not beveled

G. Pass a suture through the specimen to control it and prevent it being swallowed or aspirated by the suction

H. For large lesions, several areas may need to be sampled

I. Include every fragment for histological examination

J. Label specimen bottle with patient's name and clinical details

K. Suture and control any bleeding

I.

L. Warn patient of possible soreness afterwards. Give an analgesic

M. Check the findings are consistent with the clinical diagnosis and investigations

N. Discuss with pathologist or repeat biopsy if diagnosis is unclear or not understood

Surgical biopsyIncisional biopsy (removal of part of a lesion) is used to determine the

diagnosis before treatment. Excisional biopsy (removal of the whole lesion

such as a mucocele) is used to confirm a clinical diagnosis.

Frozen sectionsFrozen section technique allows a stained slide to be examined within 10 minutes of

taking the specimen. The tissue is sent fresh to the laboratory to be quickly frozen,

preferably to about -70°C .

Fine needle (FNA) aspiration biopsy

Even if not completely conclusive, the information from fine needle aspiration (FNA) is

often sufficient to distinguish benign from malignant neoplasms.

Exfoliative cytology

Exfoliative cytology is examination of cells scraped from the surface of a lesion or occasionally of material in aspirates of a cyst

Brush biopsy

This technique uses a round stiff bristle brush to collect cells from the surface and subsurface layers of a lesion by vigorous abrasion