Diagnostic process
It is all the steps that are done to collect informations about the problem.
It contains the following:
I- History.
II-Clinical examination.
III-Investigations.
IV-Analysis of informations.
V-Differential diagnosis.
VI-Definite diagnosis.
VII-Treatment plan.
I- History
-It should be taken from the patient by direct
(face to face in a special room) or indirect
(a special case sheet) interview.
-The reasons for taking history from the patient
are:
a-To have positive professional relationship.
b-To get informations that will aid in diagnosis.
c-To collect medical and dental informations
that may interfere with specific treatment.
Essential principles of history-taking:
1-Introduce yourself and greet the patient by
name.
2-Put patients at their ease.
3-Start with an open question (Tell me about
the pain?).
4-Mix open and closed questions (What does
the pain feel like?).
5-Avoid leading questions (Does the pain feel
like an electric shock?).
6-Avoid jargon.
7- Assess the patient's mental state.
8- Assess the patient's expectations from treatment.
Demographic details
-Name.
-Age.
-Gender.
-Ethnic group.
-Occupation.
-Address.
-Telephone number.
a-The name of the patient is written so that
the given case sheet is registered with the
patient himself.
b-The age of the patient is also important
because:
1-There are certain disease occur
according to the age.
2-Type of treatment differs according
to the age.
3-Type of drug and drug doses are different.
c-The gender of the patient is of an
importance because:
1-There are certain diseases occur
according to gender.
2-Type of treatment differs in both
genders, in some cases.
3-Prescription of druge may be
deferent.
d-Ethnic group: where some diseases are more common in certain ethnic group.
e-The occupation of the patient gives us so many
informations:
1-Some diseases, or anomalies, or lesions may come from profession.
2-certain contagious diseases due to profession.
3-Type of treatment ma be different according
to profession.
f-The address and telephone number are important
because:
1-To contact the patient at any time needed.
2-Also there are some diseases are present
in certain geographic areas.
Types of history:
a-History of the present complaint.
b-The medical history.
c-The dental history.
d-The family history.
e-The social history.
a-History of present complaint:
It could be pain, or swelling, or ulcer, or esthetic.
All informations about the present complaint should be recorded concerning
( starting time, duration, relieving and aggravating factors, progress, and previous treatment.
b- The medical history:
It is an important step of history to the
patients and dentist because:
1-Aid in diagnosis of lesions because there
are certain oral manifestations of
systemic diseases.
2-Interactions of drugs prescribed.
3-Possible hospitalization of the patient.
c-The dental history:
The dentist should ask the patient for past visits and experiences to the dentist.
This will give the examining dentist the following informations:
1-The relation of the present illness
with previous therapy.
2-Difficulties concerning previous treatment.
3-Complications of previous therapy.
4-Response and cooperation of the patient.
5-Type of treatment plan could be done.
d-The family history:
It is also important to the dentist due to:
1-Certain systemic diseases may be found in certain families.
2-Certain anomalies also found in the
same family.
3-Concept of treatment.
4-Difficulties or complications may be
found in the same family.
e-The social history:
It is of importance to the dentist due to:
1-Maternal status.
2-Number of children.
3-Education.
4-Social habits (Qat, smoking…etc).
II-Clinical examination
Types of clinical examination:
1- General examination including body stature,
nutritional status, gait, posture, body
movement and speech.
2-Extraoral examination including skull, the
hair, the eyes, the ears, the nose, the
symmetry of the face, the lymph nodes,
the temporomandibular joint, the neck, and
the cranial nerves which are in relation withoral and dental area.
3-Intraoral examination including mouth opening ,
lips, teeth (number, color, size, attrition, abrasion,
erosion, caries, missing teeth, extracted teeth,
fractured teeth, percussion, and vitality of teeth),
tooth supporting tissues (inflammation of the
gingiva, mobility of the teeth, and resorption of the
alveolar bone), oral mucosa (change in color,
swellings, ulcers, nodules and thickening), saliva
(hypersialorrhea and hyposialorrhea), bones (any
growth , fluctuation, depression, cracking or other
abnormality should be noted on the palate, or
maxilla or mandible), and occlusion.
Techniques of clinical examination:
1-Inspection.
2-Palpation.
3-Probing.
4-Percussion.
5-Auscultation.
6-Diascopy.
7-Aspiration.
8-Vitality tests of the teeth.
9-Other specific examinations.
1-Inspection
- This is done by visual examination using the naked
eyes, this includes general inspection of the patient,
extra-oral and intra-oral inspection.
-To have correct results of inspection:
a-The dentist should know the normal anatomy, tissue, color, size…etc.
b-Inspection is either directly by eyes or by
using adjunctive instruments such as: dental
mirror, special sources of light to
transilluminate the area.
c-Comparing the two sides of the patient.
2-Palpation
-This is done by feeling or pressing the structure,
usually by using the fingers of the hands (digital
examination).
-It gives informations about texture (smooth , rough or
pebbly), consistency (soft, rubbery or hard stony),
size (large or small), temperature (an inflammatory
lesions are hottest than normal tissue), fluctuation
(an inflammatory lesion or other types of lesion),
pulsation (lesions such as hemangioma could be felt
by dorsal surface of the fingers), hardness (firm),
infiltration (detecting of neoplastic tissue in the
neighboring areas), and mobility (mobility of lymph
nodes into deep structure).
3-Probing
-This is an important step in dental work since it is
done by any dentist to any patient using a dental
probe (explorer) which is considered as one of the
diagnostic instruments. The dental probe is of
different shapes but all has pointing tip to detect :
a-Dental caries (probing should include all
teeth and all surfaces of the teeth ,since
sometimes a pain coming from a hidden
caries in the distal surface of 3rd molar or
under the gingival margin).
b-Any sensitive dentin by rubbing of the
probe over the cementoenamel area.
c-Periodontal probe is used to measure the
depth of the periodontal sulcus , to examine
the furcation or trifurcation area of the
molars, and to reveal any pocket formation
(false or true pocket).
d-Fistulous tracts can be detected by probes.
e-Blunt probes are used to examine and
catheterize the orifice of the salivary glands,
and also to detect a communication with
the maxillary sinus.
f-Probing is also useful to detect the starting of
anaesthesia by checking the soft tissues of
skin and gingival.
g-It is useful also in detecting the function of
nerves by examiming the espy and
contro-lateral sides of the involved nerves.
h-Using the dental probe in cutting the
periodontal ligament before extraction is
one of the benefits of this instrument.
4-Percussion
- It is a process of frapping or staking the tissues with
fingers or instruments. The resulting sounds are
compared with normal percussion.
-Intra-orally: the using of the handle of the dental
mirror to frap the tooth is the method of percussion.
Putting the ventral surface of the finger of the left
hand over the periapical area and frapping the tooth
with the handle of the mirror will create waves, and
the pulsation of the waves are felt by the finger of the
left hand in case when there is periapical lesion or
destruction of the bone in the area. Lateral and
vertical percussion with this instrument will reveal
any pain to demonstrate periapical or periodontal
disease.
-Tapping the teeth with ankylosis will give sounds
differ from normal teeth.
- In percussion of any tooth, the tooth in cause
(accused tooth) should not be examined at first
because this may give false results since the patient
may have pain from the tooth but it is not tender
to percussion but psychologically may exaggerate the
percussion. So the neighboring teeth should be
tapped left and right, right and left and in between
the accused tooth to mislead the patient and to be
sure that the tooth is tender to percussion.
5-Auscultation
-It is an act of listening for sounds within the body.
-This is by using the ears either directly (direct hearing
of sounds from wheezing of the chest, or clicking of
the temporomandibular joint) , or indirectly by using
the stethoscope.
-The stethoscope is used widely by the physician and
the dentist uses it to check blood pressure or to hear
the sounds of the temporomandibular joint , bruit
over vascular lesions or over fractures.
-The flat type diaphragm of the stethoscope is used to
detect high frequency sounds, while the bell type
collects the low frequency sounds.
6-Diascopy
-It is a specific examination technique whereby the
tissues examined are compressed by a glass slide or
a clear acrylic.
-The technique is by pressing the glass slide or the
clear acrylic down onto the tissue or rocked from side
to side. If the lesion blanches or diascopy, it means
that the lesion is vascular in origin because pressure
or rolling may eliminate blood from area such as
(varices, telangiectasia or haemangiomas).
-No blanching means that the lesion is other than
vascular such as (tattooing by amalgam , ink, nevi or
other pigmented lesions).
7-Aspiration
-It is an act to withdraw a fluid with its contents from
a body cavity by aspirating syringe (differs in length
and diameter).
-The aspirated area may be located in soft tissue or
centrally in the bone.
-Lesions could be injected with saline then aspirated
(lymph nodes and some tumors), or other lesions may contain fluid from the beginning (cysts and
haemangiomic lesions).
-In case of tumor: the result could be negative because
the lesion is hard, or it may contain air as in case of
maxillary sinus, or it may contain fluid with or without
cells which should be examined under microscope.
-The color of the aspirated fluid is of importance where the fluid
of a cyst gives yellow color fluid , while hemorrhagic lesions give red color fluid.
-Local anesthesia is done before giving intramuscular aspiration.
-Fine needle aspiration using needles with different gauges are
used in diagnosis of certain diseases (as primary diagnosis) in
cases of breast cancer and malignant tumors of salivary glands.
-Aspiration is not accurate due to false negative results
because:
a-The aspirated area could touch hard tissue.
b-The needle could injure blood vessels and the
aspirating fluid is blood.
c-The aspirated area is normal , while the neoplastic
changes in other areas.
8-Vitality tests of the teeth
-The tooth should be examined for vitality by
several tests as follows:
a-Cold application.
b-Hot applications.
c-Electric pulp tester.
d-Laser Doppler Flowmetry.
e-Pulp Oximeter.
f-Magnetic Resonance Imaging.
9-Other specific examinations
Some other examinations are done to the patient to aid the diagnosis. For example:
- Milking or massage to the salivary glands
to see their function.
- Movement of certain muscle to see the
function of nerves.
- Putting some dyes for confirming the
diagnosis of certain lesions.
- Blowing of air to confirm communication
of maxillary sinus with oral cavity.
Thank you
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Introduction of oral diagnosis –
28-Jan-2010,11:55 AM 
