Principles of Diagnosis

● 1-Medical History
● 2-Examination
● 3-Investigations

Medical History
● The first step towards treating any patient is making
a correct diagnosis.
● The diagnostic sequence can be divided into five
levels.
1.History Taking.
2.Clinical examination.
3.Radiological analysis.
4.Laboratory investigations.
5.Interpretation and final diagnosis.

● The aim and objective of this preoperative assessment are to

decide:
-The choice of anaesthesia.
-Whether the patient can withstand general anaesthesia.
-Whether the patient can withstand the surgical procedure.
-Choice of premedication.
-Treatment plan that will suit/benefit the patient.

● The history: is the information gained by a health

care professional with aim of formulating a diagnosis,
providing medical care and identifying medical
problems relevant to health care.
● The history is obtained from either the patient or
people who know the patient and can provide the
necessary information.

● History purpose:
- History taking allow the health care professional to
develop rapport with their patient.
- Formulating a diagnosis.
- Identify relevant physical signs and assess mental
state and attitude towards health care.

● Art of history taking:

-The patient should be encouraged to narrate his
problem in his own words.
-The clinician can help the patient in unfolding his
story by asking a few gentle questions like “is there a
change in the swelling during the course of the
day “ or dose the pain spread to any adjoining
area’’.

● Steps In History Taking:

General or Personal Information:
-Name, age, gender, tribe, occupation, marital status,
residence(address) and tel. NO.
Chief Complaint[C/C]:
-Why the patient is seeking medical attention. This
should be recorded in the patient’s own words(e.g.
‘pain in my face’).

 History Of Present Illness [HPI]:

-The timing of the complaint and its evolution should be
elicited.
-If the patient has pain a useful mnemonic acronym is
‘SOCRATES’ .
S-site, O-onset(gradual or sudden), C-character, R-radiation,
A- association (other symptom), T-timing/duration, E-
exacerbating and aggravating factors, S-severity.
-Also you should asked about the relieving factors and the
treatment already received.

 Past medical history[PMH]:

-A detailed picture of the general medical status of the
patient is obtained.
-This include any past medical and surgical problems,
history of blood transfusion and history of
hospitalization.

 Review of Systems[ROS]:
-General: weight gain or loss, loss of appetite, fever,
chills, fatigue, night sweating.
-Cardiopulmonary: chest pain, shortness of breath,
orthopnea, paroxysmal nocturnal dyspnea, dyspnea on
exertion, claudication, ankle/lower limp edema,
palpitation, cough, sputum(color), hemoptysis,
wheezing .

-haematological: easy bruising, ,joint bleeding,

epistaxis, prolonged bleeding after minor trauma or
extraction, jaundice, family history of bleeding
disorders.
-gastrointestinal: dysphagia, abdominal pain,
nausea, vomiting, flatulence and regurgitations,
hematemesis, diarrhea, constipation, melena(black
tarry stools), hematochezia (bright red blood per
rectum).

-Endocrine: polyuria, polydipsia, skin or hair change,

heat/cold intolerance, pigmentation.
-Musculoskeletal: joint pain or swelling, arthritis,
myalgia, back pain.

● Neuropsychiatric: headache, loss of consciousness,

dizziness and vertigo, weakness, seizures/fits,
paralysis, paraesthesia, visual disturbance /loss,
diplopia, facial numbness, facial weakness, loss of
coordination, deafness, anosmia, taste disturbance,
speech disturbance, memory loss, depression and or
mania, anxiety, delusions.
-Genitourinary: burning micturition, urgency,
anuria, oliguria, hesitancy, hematuria, discharge, ulcer.
-If female: contraception, lactation, pregnancy or
likelihood of pregnancy.
-Vaccination(especially in pediatric patients).

 Drug History:
-Long term medication.
-Current medication.
-Allergy.

Past Dental History[PDH].

Social History:
-Socioeconomic status.
-Health insurance.
-History of recent travelling.
-Domestic animals.
-Habits(smoking, snuff dipping, alcohol, drug abuse).

 Family History:
-Disease run in family.
-History of similar condition in family.
-Common cause of death in family.
-No of siblings (sisters, brothers).
-No of offspring( daughters, sons).

 Family History:
-Disease run in family.
-History of similar condition in family.
-Common cause of death in family.
-No of siblings (sisters, brothers).
-No of offspring( daughters, sons).

Examination
● The clinical examination of the patient begins as he/
she enters the clinic.
● The history and clinical examination are designed to
put the clinician in a position to make provisional
diagnosis, or a differential diagnosis.
● Special test or investigation may be required to
confirm this diagnosis.

● Physical disabilities, such as those affecting gait, and

learning disabilities, are often immediately evident as
the patient first seen.
● The patient should be carefully observed and listened
to during history taking and examination; speech and
language can offer a great deal of information about
the medical and mental state.
● Always remember the patient has the right to refuse
all or part of examination, investigations or
treatment.

 General examination:
● when examining the patient , the clinician should be
well-versed with the four aspect of examination:
- inspection.
- Palpation.
- Percussion.
- Auscultation.

● General examination may sometimes include the

recording of body weight and the ‘vital
signs’( conscious state, temperature, pulse, blood
pressure and respiration rate).
● Vital signs:
- The conscious state: causes ranging from drug use
to head injury.

- The temperature: measured by Thermometer, the normal

body temperature are: oral 36.6 c, rectal or ear 37.4 c, and
axillary 36.5 c.
- The pulse : can be measured manually or automatically.
The pulse can be recorded from any artery , but in particular
from the following sites:
a. the radial artery, on the thumb side of the flexor surface of
the rest.
b. The carotid artery , just anterior to the mid third of the
sternomastoid muscle.
c. The superficial temporal artery, just in front of the ear.

● Pulse rates at rest in health are approximately as follows:

- infant, 140 beat/min.
- Adults, 60-80 beats/min.
● Pulse rate is increased in:
- exercise.
- Anxiety or fear.
- Fever.
- Some cardiac disorder.
- Hyperthyroidism and other disease.
● The rhythm should be regular. The character and volume
vary in certain disease and may require a physician’s advice.

- The blood pressure: measured with a

sphygmomanometer. Seat the patient , place the
sphygmomanometer cuff on the right upper arm , with about
3 cm of skin visible at the antecubital fossa , palpate the radial
pulse . Inflate the cuff to about 200-250mmHg or until the
radial pulse is no longer palpable, deflate the cuff slowly while
listening with the stethoscope over the brachial artery on the
skin of the inside arm below the cuff, record the systolic
pressure as the pressure when the first tapping sound appear,
deflate the cuff further until the tapping sound become
muffled( diastolic pressure). Normal values about 120/80
mmHg, but these increase with age.
- respiration: normal range in adult is 12-20
breaths/min.
● Other signs:
- Weight loss or gain.
- Hands: conditions such as arthritis and Raynaud
phenomenon. Disability , such as in cerebral palsy.
- Skin: lesions(rashes, blisters) and pigmentation.
- Skin appendage: nail change, hair changes
(alopecia) and finger clubbing. Nail beds may reveal
the anxious nature of the nail-biting person.

● Extraoral head and neck examination:

- The following structures are examined:
1. face.
2. Skin and soft tissue.
3. Skull.
4. Bony skeleton of the face.
5. Temporomandibular joints.
6. Lymphatic system.
7. Salivary gland.
8. Eye..

● Inspection:
- Face: should be examined for asymmetry, swelling ,
erythema, rash and pallor.
- Skin and soft tissue: for color and texture.
- Skull: for any abnormalities in the size and shape of
the cranium is indicative of a probable congenital
abnormality. Special care for trauma should be taken(
swelling, depression, laceration).

- Eyes: should be assess for Visual acuity, Corneal

arcus, Exophthalmos, Jaundice, Redness, Scaring.
- Nose : depression of nasal bridge, deviation of nasal
septum, obliteration of the nose, nasal discharge,
epistaxis and loss of smell should be recorded.
- Malar and Paranasal sinus.
- Ears : for bleeding, pus discharge, tinnitus or
hearing impairment should be recorded. The external
ear may be missing that seen in Goldenhar syndrome.

- Lips : cyanosis, cleft lip, herpes infections, angular

chelitis, any swelling or ulcerative lesions.
- In addition, the clinician must evaluate any facial
asymmetry, facial swelling, extraoral draining sinus,
scars, color, and texture of skin and any sign of
ecchymosis, hemorrhage, laceration and abrasion.
- All patients with facial asymmetry/ swelling have to
be inspected from either below or from above and
behind.

● Palpation:
- must be done gently, without causing much distress
to the patient.
- A quick and thorough palpation helps the clinician to
establish his / her primary diagnosis
- Palpation of the facial skeleton is begun from the
frontal bone and proceeds downwards, and carried
out simultaneously, bilaterally.

- TMJ palpated by placing the index fingers of both the

hands just anteroinferior to the tragus of the ear.
- The joint are examined for any:
1. tenderness.
2. clicking, crepitus on opening or closing of the
mouth.
3. The range of opening.
4. Left and right lateral excursions.
5. The muscle of mastication are palpated for
tenderness.

- A facial swelling that is infective in nature will be soft,

fluctuant and tender.
- A facial swelling that is neoplastic or cystic in origin
is usually firm to bony hard and may or may not be
tender.
- Palpation for salivary gland disorder (examined pre-
auricular, inferior auricular and post-auricular), the
parotid and submandibular gland9 bimanual
palpation) are palpated extraorally.

- The per-auricular, sub-mandibular, sub-mental, and

cervical lymph nodes are palpated for : enlargement,
tenderness, mobility and consistency.
- The neck is best examined by observation the patient
from the front , noting any obvious asymmetry or
swelling, then standing behind the seated patient to
palpate the lymph nodes.

● Auscultation:
- mainly used in 2 conditions:
1. Vascular lesion to hear bruit.
2. Temporomandibular joint disease or to hear the
joint movement.

● Examination of cranial nerve:

- Facial movement should be tested and facial
sensation determined.
- Examination of the upper face(around the eye and
forehead) is carried out in the following way:
a. Ask the patient to close the eyes.
b. Ask the patient to wrinkle the forehead.

- The lower face (around the mouth) is best examined

by asking the patient to:
a. smile.
b. Blow out the cheeks or whistle.

● Once the extraoral examination is complete, the oral

opening should be measured prior to intraoral
examination. oral opening or maximal incisal
opening is a distance measured between the incisal
edges of the maxillary and mandibular central
incisors.
● Intraoral examination:
- Many systemic disease cause oral signs or symptoms that
may constitute the main complaint, for example in some
patients with HIV, leukopenia or leukemia.
- The examination, therefore, should be conducted in a
systemic fashion to ensure that all areas are included.
- Complete visualization with a good source of light is
essential.
- All mucosal surfaces should be examined, starting away
from the location of any known lesion or the focus of
complaint.

- The structures to be examined during intraoral

examination are as follows:
1. buccal, labial, and alveolar mucosa.
2. Hard and soft palate.
3. Floor of the mouth and tongue.
4. Retromolar area.
5. lateral and Posterior pharyngeal wall and uvula .
6. Salivary gland and their orifices.
7. Dentition and occlusion.

● Inspection:
- When the patient opens his mouth, the first thing the
clinician sees is oral hygiene.
- The mucosa is inspected for color, texture, and
presence of ulceration, growth or draining sinuses.
- The salivary gland orifice are examined for any signs
of inflammation or bus discharge.

- The dentition is then examined, and a mention of

missing, carious, mobile, restored and malposed
teeth is made. The occlusion is checked and any
deviation from the normal canine and molar relation,
posterior gagging, anterior open bite, deep bite,
reverse overjet.
- The periodontal tissues are examined for the color
and texture of the gingiva. Any signs of recession,
hyperplasia, infection is noted.

● Edentulous ridges should be thoroughly examined .

If the patient wears any removable prostheses , these
should be removed in the first instance.
● Palpation:
- For consistency and extension of lesions, tenderness,
mobility of the teeth, step deformity, milking of salivary
gland to assess the normal salivary flow and quantity of
saliva.

● Once the clinical examination is complete, the

clinician has a general idea regarding the location,
extent, and clinical nature of the lesions. A
tentative( provisional) diagnosis is established in the
clinician mind. Radiological studies and other
biochemical investigations, then support this
provisional diagnosis.
Investigations
 URINALYSIS

● glycosuria: which may suggest diabetes mellitus

● ketonuria: which may be a sign of diabetic ketoacidosis or
starvation
● bilirubin or urobilinogen: which may indicate hepatobiliary
disorders
● proteinuria: which may be due to menstruation, or indicate
renal, urinary tract or cardiac disease
● haematuria: which may be due to menstruation, or indicate
renal or urinary tract disease

 BLOOD TESTING

-CBC
-Liver Function Test
-Renal Function Test
-Co agulation Profile
-Viral Screening
-…….Others

 SKIN TESTING

● Patch tests
● Intradermal injections
● Prick test
● Modified prick test
● Scratch test

 BIOPSY

● Biopsy is the removal of a small piece of tissue from

the living body for the purpose of diagnosis by
microscopic examination.
● It is often indicated in order to confirm or make a
precise diagnosis, especially in the case of mucosal
lesions, when a specimen for immunostaining is often
also called for.
● Indications for biopsy include

● lesions that have neoplastic or premalignant features

or are enlarging
● persistent lesions that are of uncertain aetiology
● persistent lesions that are failing to respond to
treatment
● confirmation of the clinical diagnosis
● lesions that are causing the patient extreme concern

● Biopsy precautions
● Ensure that comprehensive medical history is completed
and
if patient is on:
● anticoagulants: warfarin requires up-to-date INR within
36 h of biopsy
● corticosteroids: if 10 mg or above for >3 months, requires
100 mg hydrocortisone i.v. 30 min before procedure
● immunocompromised: if neutropenic (neutrophils <1.5)
requires antibiotic prophylaxis

● Biopsy technique
● Tissue may be obtained by two main methods: techniques
not requiring anaesthesia (e.g. exfoliative cytology and
brush biopsy) and techniques requiring local anaesthesia
(analgesia).
● Those requiring local anaesthesia are largely employed,
and include:
● scalpel or tissue punch – incisional biopsy
● scalpel, diathermy or laser cutting – excisional biopsy

● curettage
● needle biopsy, these include:
● cutting biopsy using a 14 G Tru-Cut needle, which is wide
bore
● cutting biopsy using a 16 G Vim Silverman needle
● fine-needle cutting biopsy (FNCB) using an 18 G TSK
Surecut needle
● fine-needle aspiration biopsy (FNA or FNAB) or cytology
(FNAC) using a 22 G or 25 G standard disposable
needle, sometimes as ultrasound-guided fine-needle
aspiration cytology (US-FNAC).

● Usually a single biopsy is taken, but multiple biopsies

may be indicated where:
● ■ additional investigations, such as immunostaining,
are required
● ■ malignant disease is suspected
● ■ there are widespread leukoplakic or erythroplakic
field changes (such biopsies may be termed
‘geographic’ biopsies).

 Remember

● The biopsy should include lesional and normal tissue

and should be large enough to handle, and to provide
adequate information about the lesion
● Immunostaining and immunofluorescence
● Oral smears for cytology
● Lymph node biopsy
● Labial salivary gland biopsy
● Frozen sections for rapid diagnosis

 Radiography

● Plain radiography
● Chest radiography
● Abdominal radiography
● Intra-oral radiography
● Dental panoramic tomography (DPT)
● Sialography
● Arthrography
● Angiography
● CT scan
● ………others

● References:
1. Oral and Maxillofacial medicine, the basis of
diagnosis and treatment, third Edition.
2. Neelima, Oral and Maxillofacial Surgery, Second
Edition.