Dr. Hazem MELAD, DDS , PhDDepartment of Oral and Maxillofacial Surgery

DIAGNOSISDiagnosis: is a fancy name given to the

process of identifying diseases. It means “through knowledge” and entails acquisition of data about the patient and their complaint using the senses :

. Hearing. Observing . Touching.sometimes smelling

The purpose of making a diagnosis is to be able to offer the most :

Effective and safe treatmentAccurate prognostication

Diagnosis is made by the clinical examination, which comprise the :

History physical examinationSupplemented in some cases by

investigations .

HISTORYHistory taking is part of the initial

communication between the dentist and patient. It is important to adopt a professional appearance and manner, and introduce oneself clearly and courteously.

The history is best given in the patient’s own words, through the clinician often needs to guide the patient, and may use protocols to ensure collection of all relevant points.

It is important to cover the following areas:

General information (name, age, gender, ethnic origin, place of residence, occupation)

Presenting “chief” complaintHistory of chief complaintPast medical historyDental historyFamily history Social history.

CHIEF COMPLAINT AND HISTORY OF THE PRESENT ILLNESSThe chief complaint is established by

asking the patient to describe the problem for which he or she is seeking help or treatment.

The chief complaint is recorded in the patient’s own words as much as possible and should not be documented in technical (ie, formal diagnostic) language unless reported in that fashion by the patient.

Direct and specific questions are used to elicit information about chief complaint and should be recorded in the patient record in narrative form, as follows:

1. When did this problem start?2. What did you notice first?3. Did you have any problems or symptoms related to

this?4. What makes the problem worse or better?5. Have the symptoms gotten better or worse at any time?6. Have any tests been performed to diagnose this

complaint?7. Have you consulted other dentists, physicians, or

anyone else related to this problem?8. What have you done to treat these symptoms?

PAST DENTAL HISTORYDental history is one of the most important

components of the patient history.The dental history will give an idea of the: past dental visits; previous restorative, periodontic,

endodontic, or oral surgical treatment; reasons for loss of teeth; untoward complications of dental treatment; fluoride history; attitudes towards previous dental treatment; experience with orthodontic appliances and dental prostheses; and radiation or other therapy for oral or facial lesions.

MEDICAL HISTORYThe medical history comprises a

systematic review of the patient’s chief or primary complaint, a detailed history related to this complaint, information about past and present medical conditions, pertinent social and family histories, and a review of symptoms by organ system.

PAST MEDICAL HISTORYThe past medical history includes

information about any significant or serious illnesses a patient may have had as a child or as an adult. The patient’s present medical problems are also enumerated under this category.

The past medical history is usually organized into the following subdivisions:

(1) serious or significant illnesses,(2) hospitalizations, (3) transfusions, (4) allergies,(5) medications, and (6) pregnancy.

An appropriate interpretation of the information collected through a medical history achieves three important objectives:

It enables the monitoring of medical conditions and the evaluation of underlying systemic conditions of which the patient may or may not be aware.

It provides a basis for determining whether dental treatment might affect the systemic health of the patient

It provides an initial starting point for assessing the possible influence of the patient’s systemic health on the patient’s oral health and/or dental treatment

FAMILY HISTORYSerious medical problems in immediate family

members should be listed.

Disorders known to have a genetic or environmental basis (such as certain forms of cancer, cardiovascular disease including hypertension, allergies, asthma, renal disease, stomach ulcers, diabetes mellitus, bleeding disorders, and sickle cell anemia) should be addressed.

This type of information will alert the clinician to the patient’s predisposition to develop serious medical conditions.

SOCIAL HISTORYDifferent social parameters should be recorded.

These include:

marital status (married, separated, divorced, single, or with a “significant other”)

place of residence (with family, alone, or in an institution)educational levelOccupationReligionTobacco use (past and present use and amount);Alcohol use (past and present use and amount); Recreational drug use (past and present use,

type, and amount).

REVIEW OF SYSTEMSThe review of systems is a comprehensive and

systematic review of subjective symptoms affecting different bodily systems.

Direct questioning of the patient should be aimed at collecting additional data to confirm or rule out those disease processes that have been identified by the clinician as likely explanations for the patient’s symptoms.

This type of questioning may also alert the clinician to underlying systemic conditions that were not fully described in the past medical history.

A complete review of systems includes the following categories1. General2. Head, eyes, ears, nose, and throat 3. Cardiovascular4. Respiratory5. Dermatologic6. Gastrointestinal7. Genitourinary8. Gynecologic9. Endocrine10.Musculoskeletal11. Hematologic-lymphatic12. Neuropsychiatric

EXAMINATION OF THE PATIENTThe examination of the patient represents the

second stage of the diagnostic procedureThe examination is most conveniently carried

out with the patient seated in a dental chair, with the head supported.

Before seating the patient, the clinician should observe the patient’s general appearance and step and should note any physical deformities or handicaps.

A less comprehensive but equally thorough inspection of the face and oral and oropharyngeal mucosa should also be carried out at each dental visit.

The tendency for the dentist to focus on only the tooth or jaw quadrant in question should be strongly resisted.

The examination procedure in dental office settingsincludes the following:1. Registration of vital signs (respiratory rate,

temperature, pulse, and blood pressure).2. Examination of the head, neck, and oral

cavity, including salivary glands, temporomandibular joints, and lymph nodes.

3. Examination of cranial nerve function.4. Special examination of other organ systems.5. Requisition of laboratory studies.

Vital SignsPULSE RATE AND RHYTHMRESPIRATORY RATEBLOOD PRESSURE TEMPERATURE

PULSE RATE AND RHYTHM

Cardiac rate, rhythm, and strength are assessed by taking the radial or carotid artery pulse.

For the carotid pulse, the first two fingers are placed just anterior to the sternomastoid muscle, posterior to the larynx, and below the angle of the mandible in the region of the carotid bulb.

Only light pressure is applied until pulsations are readily detectable.

The radial pulse is accomplished by placing the first two fingers in the slight trough produced by a tissue depression between the radius and the flexor tendons located on the ventral wrist just proximal to the thumb’s thenar eminence

Only light pressure is exerted until pulsations are perceived.

The cardiac rate is determined by counting the number of beats during 15 seconds and multiplying by 4.

Normal heart rate is 60 to 80 beats per minute.

RESPIRATORY RATE

Respiration rate is determined by sitting next to or standing behind the patient seated in the dental chair and looking down at the patient’s chest.

Count the number of times the chest rises and falls for 30 seconds and then multiply by 2.

A normal respiratory rate is 12 to 15 respirations per minute.

BLOOD PRESSURE Measuring blood pressure assesses pressure within

the arteries during cardiac contraction (systole) and pressure during cardiac pause (diastole).

To obtain these values, one must generate an external pressure that exceeds that within the artery then slowly lower that pressure until the intra-arterial pressure exceeds the externally applied pressure, thereby opening the arteries and being able to detect the pulse as blood is again pumped through. The pressure at which the first evidence of a pulse can be detected is the upper, or systolic pressure, which normally is about 110 to 130 mm Hg.

After detecting the systolic pressure, the externally applied pressure continues to be decreased until pulsations are no longer detected. This level of pressure, the diastolic, varies normally from 70 to 90 mm Hg.

TEMPERATURE

Temperature is recorded using a thermometer or temperature sensitive disposable oral strips. Either of these recording devices should be inserted orally, with the tip placed under the tongue, and left in place for 1.5 to 2.0 minutes. Recall that normal body temperature is 37°C (98.6°F).

Head, Neck, and Oral Cavity

The examination routine encompasses the following eight steps:1. Note the general appearance of the individual and

evaluate emotional reactions and the general nutritional state. Record the character of the skin and the presence of petechiae or eruptions, as well as the texture, distribution, and quality of the hair. Examine the conjunctivae and skin for petechiae, and examine the sclerae and skin for evidence of jaundice or pallor. Determine the reaction of the pupils to light and accommodation, especially when neurologic disorders are being investigated.

2. Palpate for adenopathy. Palpate any swellings, nodules, or suspected anatomic abnormalities.

3. Examine in sequence the inner surfaces of the lips, the mucosa of the checks, the maxillary and mandibular mucobuccal folds, the palate, the tongue, the sublingual space, the gingivae, and then the teeth and their supporting structures. Last, examine the tonsillar and the pharyngeal areas and any lesion, particularly if the lesion is painful.

4. Completely visualize the smooth mucosal surfaces of the lips, cheeks, tongue, and sublingual space by using two tongue depressors or mirrors. Perform a more detailed examination of the teeth and supporting tissues with the mouth mirror, the explorer, and the periodontal probe.

5. Have the patient extend the tongue for examination of the dorsum; then have the patient raise the tongue to the palate to permit good visualization of the sublingual space. The patient should extend the tongue forcibly out to the right and left sides of the mouth to permit good visualization of the sublingual space and to permit careful examination of the left and right margins. A piece of gauze wrapped lightly around the tip of the tongue helps when manually moving the patient’s tongue. Examine the tonsillar fossae and the oropharynx.

6. Use bimanual or bi-digital palpation for examination of the tongue, cheeks, floor of the mouth, and salivary glands. Palpation is also useful for determining the degree of tooth movement. Two resistant instruments, such as mirror handles or tongue depressors, placed on the buccal and lingual surfaces of the tooth furnish more accurate information than when fingers alone are directly employed.

7. Examine the teeth for dental caries, occlusal relations, possible prematurities, inadequate contact areas or restorations, evidence of food impaction, gingivitis, periodontal disease, and fistulae.

8. After the general examination of the oral cavity has been completed, make a detailed study of the lesion or the area involved in the chief complaint.

FACIAL STRUCTURESObserve the patient’s skin for color,

blemishes, moles, and other pigmentation abnormalities; vascular abnormalities such as angiomas, telangiectasias, nevi, and tortuous superficial vessels; and asymmetry, ulcers, pustules, nodules, and swellings. Note the color of the conjunctivae. Palpate the jaws and superficial masticatory muscles for tenderness or deformity. Note any scars formation.

LIPSNote lip color, texture, and any

surface abnormalities as well as angular or vertical fissures, lip pits, cold sores, ulcers, scabs, nodules, keratotic plaques, and scars. Palpate upper lip and lower lip for any thickening (induration) or swelling. Note orifices of minor salivary glands and the presence of Fordyce’s granules.

CHEEKSNote any changes in pigmentation and

movability of the mucosa, a pronounced linea alba, leukoedema, hyperkeratotic patches, intraoral swellings, ulcers, nodules, scars, other red or white patches, and Fordyce’s granules. Observe openings of Stensen’s ducts and establish their patency by first drying the mucosa with gauze and then observing the character and extent of salivary flow from duct openings, with and without milking of the gland. Palpate muscles of mastication.

MAXILLARY AND MANDIBULAR MUCOBUCCAL FOLDS

Observe color, texture, any swellings, and any fistulae. Palpate for swellings and tenderness over the roots of the teeth and for tenderness of the buccinator insertion by pressing laterally with a finger inserted over the roots of the upper molar teeth.

HARD PALATE AND SOFT PALATE

Illuminate the palate and inspect for discoloration, swellings, fistulae, papillary hyperplasia, tori, ulcers, recent burns, leukoplakia, and asymmetry of structure or function. Examine the orifices of minor salivary glands. Palpate the palate for swellings and tenderness.

THE TONGUEInspect the dorsum of the tongue (while it is at rest) for any

swelling, ulcers, coating, or variation in size, color, and texture. Observe the margins of the tongue and note the distribution of filiform and fungiform papillae, crenations and fasciculations, depapillated areas, fissures, ulcers, and keratotic areas. Note the frenal attachment and any deviations as the patient pushes out the tongue and attempts to move it to the right and left.

Wrap a piece of gauze around the tip of the protruding tongue to steady it, and lightly press a warm mirror against the uvula to observe the base of the tongue and vallate papillae; note any ulcers or significant swellings. Holding the tongue with the gauze, gently guide the tongue to the right and retract the left cheek to observe the foliate papillae and the entire lateral border of the tongue for ulcers, keratotic areas, and red patches.

Repeat for the opposite side, and then have the patient touch the tip of the tongue to the palate to display the ventral surface of the tongue and floor of the mouth; note any varicosities, tight frenal attachments, stones in Wharton’s ducts, ulcers, swellings, and red or white patches.

Gently palpate the muscles of the tongue for nodules and tumors, extending the finger onto the base of the tongue and pressing forward if this has been poorly visualized or if any ulcers or masses are suspected. Note tongue thrust on swallowing.

FLOOR OF THE MOUTH

With the tongue still elevated, observe the openings of Wharton's ducts, the salivary pool, the character and extent of right and left secretions, and any swellings, ulcers, or red or white patches. Gently explore and display the extent of the lateral sublingual space, again noting ulcers and red or white patches.

GINGIVAE

Observe color, texture, contour, and frenal attachments. Note any ulcers, marginal inflammation, resorption, festooning, Stillman’s clefts, hyperplasia, nodules, swellings, and fistulae.

TEETH AND PERIODONTIUM

Note missing or supernumerary teeth, mobile or painful teeth, caries, defective restorations, dental arch irregularities, orthodontic anomalies, abnormal jaw relationships, occlusal interferences, the extent of plaque and calculus deposits, dental hypoplasia, and discolored teeth.

TONSILS AND OROPHARYNX

Note the color, size, and any surface abnormalities of tonsils and ulcers, tonsilloliths, and inspissated secretion in tonsillar crypts. Palpate the tonsils for discharge or tenderness, and note restriction of the oropharyngeal airway. Examine the faucial pillars for bilateral symmetry, nodules, red and white patches, lymphoid aggregates, and deformities. Examine the postpharyngeal wall for swellings, nodular lymphoid hyperplasia, hyperplastic adenoids, postnasal discharge, and heavy mucous secretions.

MaculeA macule is a change in surface color, without elevation or depression and, therefore, nonpalpable, well or ill-defined, variously sized, but generally considered less than either 5 or 10mm in diameter at the widest point.

PatchA patch is a large macule equal to or greater than either 5 or 10mm, depending on one's definition of a macule. Patches may have some subtle surface change, such as a fine scale or wrinkling, but although the consistency of the surface is changed, the lesion itself is not palpable

PapuleA papule is a circumscribed, solid elevation of skin with no visible fluid, varying in size from a pinhead to either less than 5 or 10mm in diameter at the widest point.

NoduleA nodule is morphologically similar to a papule, but is greater than either 5 or 10 mm in both width and depth, and most frequently centered in the dermis or subcutaneous fat. The depth of involvement is what differentiates a nodule from a papule.

VesicleA vesicle is a circumscribed, fluid-containing, epidermal elevation generally considered less than either 5 or 10 mm in diameter at the widest point.

BullaA bulla is a large vesicle described as a rounded or irregularly shaped blister containing serous or seropurulent fluid, equal to or greater than either 5 or 10 mm, depending on one's definition of a vesicle.