Oral Surgery

3rd Year
L3 Diagnosis, history Dr Amera Alkaisi

Diagnosis

The process of identifying or determining the nature and cause of a disease or injury
through evaluation of patient history, examination, and review of laboratory data.
The opinion derived from such an evaluation.

Differential diagnosis
A differential diagnosis means that there are more than one possibility for your
diagnosis. The doctor must differentiate between these to determine the actual
diagnosis and appropriate treatment plan
A provisional diagnosis
A provisional diagnosis means that the doctor is not 100% sure of a diagnosis because
more information is needed. With a provisional diagnosis, the doctor makes an
educated guess about the most likely diagnosis.

Diagnosis is made by
 History this offers the diagnosis in about 80% of cases
 Examination
 Investigations. In some cases are needed
The clinician should use ‘LEAPS
■ Listen ■ Empathize ■ Ask ■ Paraphrase ■ Summarize.

History

Examination
Diagnosis

Invistigation

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Diagnosis in oral surgery
Oral diagnosis is the art of using the scientific knowledge to identify the oral diseases
and also to distinguish one disease from another.
The classical steps of diagnosis
1. History taking
2. Clinical examination.
3. Investigation
4. Provisional diagnosis
5. Definitive diagnosis and treatment plan
Conditions concerning clinician in oral surgery rottenly for diagnosis are
1. Dental and facial pain
2. Swelling, Lump, mass
3. Ulcers
4. Injuries: dental or facial bones
5. Temporomandibular joint problems
7. Medically compromised patients
7. Facial deformity
Case history

The art of taking an accurate case history is probably the most important single step in
the diagnosis of a medical or surgical condition. Sometimes the disorder may be
diagnosed from the history alone. It must be systematic and the dentist should listen to
the patient story and list all important symptoms mentioned by the patient by his own
words.

Case History
Is a planned professional conversation between patient and doctor which enables the
patient to express his symptoms, fear and feelings to the clinician so that the nature of
patient’s real or suspected illness and mental attitude may be determined
Symptoms
Is a subjective problem that the patient describes, ex pain, paresthesia

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Signs
Is objective, abnormal condition observe by clinicians such as ulcer or swelling
Detection of signs and symptoms of the disease can aid in its diagnosis

Case history may be divided in to:

(1) Biographic data Personal information

Patient’s name, age, occupation, address, phone number and address of

his doctor and dental surgeon.

Importance of the personal details

a. Surname
May indicate that the patient is a member of a family known to have a hereditary
disease or in which such anomalies as mandibular prognathism
b. Age
Age related disorders, some diseases are age related. ex At birth – congenital cleft lip
& palate, Old age – Degenerative osteoarthritis of TMJ, cancer
c. Sex
Because patterns of disease vary between both sexes and racial and ethnic group. In
female patients additional questions like pregnancy, nursing, oral contraceptive pills &
menstruation. Males, hemophilia
d. Occupation
If the patient work with substance as lead, mercury, arsenic…etc which cause some
oral conditions.

 In acidic environment: Erosion of teeth.

 Musicians: soft tissue trauma, herpes, dry mouth, TMJ pain.
 Paint industry: mercury poisoning, lead poisoning.
 Mining: silicosis, asbestosis
 Tailors: notching of incisal edges of upper teeth

E. Address
 Give geographical prevalence of dental/oral diseases.
 Gives an idea of the socioeconomic status of the patient

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(2) Patient chief compliant
1. Ask the patient about the major compliant first.
2. The nature and duration of the symptom in the patient own words.
3. It is established by asking the patient to describe the problem for which he or she is
seeking help or treatment pain, swelling, numbness, clicking, bleeding, trismus,
halitosis…etc
4. Make every attempt to quote the patients own words
5. The chief complaint aids in the diagnosis and treatment planning and should be
given the first priority.
6. It is the record of narrative account of patient’s problem from the onset to present
time listing all the symptoms, signs, treatment undergone in a chronological order.

(3) History of present illness HPI History of the chief complaint

The patient should describe his symptoms in his own words.
If the patient is child or mentally retarded the accompanied person should be asked.
Symptoms: are what the patient feel or complain,
Patient may complain either from pain or a lump or an ulcer.
Ask the patient the following questions
1. The onset the disease: date and manner of onset
2. Duration: record the length of complaint.
3. Precipitating, predisposing factors: such as cold or hot or sweet
4. Characteristics
a. Nature, continuous, intermittent
b. Severity, mild, sever and very sever
c. Location
d. Radiation
e. Temperature feature
f. Aggravating and relieving factors
g. Associated signs and symptoms
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5. Course of progress
6. Therapy,
a. Type, dose and provider
b. Effect of therapy
c. Date of therapy
Pain
Pain is a subjective symptom can be described by the patient and the dentist must
listen carefully to patient words and the clinician will direct his examination
accordingly. un like lump or ulcer which can be examined and assessed.
Pain history (questions which must asked about any pain)
1. The site of pain
Ask the patient to point by any one finger to the place where the pain is felt. (localized
,diffuse ,referred, radiating).
2. The onset and duration of the pain
If the pain is recent or present for years. (spontaneous, on stimulation, intermittent)
3. The character of pain
Pain may be described as dull, sharp, throbbing, burning, constant…etc.
4. The severity
 Patients differ by their pain threshold. Sever pain felt by one patient may be
mild by other.
 Relief of the pain by a mild analgesic drug such as aspirin help to indicate the
degree of severity that is sever.
 If powerful analgesic such as pethidine are required to relieve pain it means
sever pain.
 Interference with sleep indicate it’s severity.
5. Is the pain continuous or have there been remission
 Pain seldom absolutely continuous short remission should exist.
 Intermittent pain ask about the number of episodes, it is length and frequency
and duration.
 Patient psychosomatic pain as continuous.
6. Course and progress: Is it increasing or decreasing severity
If increase in severity it must be designed by further examination and investigation.

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7. The timing of the pain
Some pain worsen at particular time, ex Pulpal pain episode aid diagnosis oftenly awake
the patient at night. Acute periodontitis, the pain worse at meal time.

8. Where is the point of maximum intensity?

Patient must point of maximum intensity of pain.
9. Area to which pain spread
Pain usually spread from the point of maximum intensity to involve surrounding area
10. Area to which the pain radiate
 Referred pain: Pain that may be felt in a site other than that of the causative
lesion is described as.
 Pain is never referred across the midline.
For example
 The pain of the coronary thrombosis is sub sternal but the pain radiate to
the left arm.
 Pain in the mouth may be referred from one jaw to other or the same side
some time the patient point to the site of referred pain.
 Pain of pericoronitis radiate to the ear.
11. Any factors which precipitate the pain
Exacerbating and alleviating factors
 Exacerbate by: Cold, heat, palpation, percussion
 Relieved by: Cold, heat, any medication ,sleep
 pulpal pain exacerbated by thermal and osmotic stimuli ,hot, cold and sweet.
 Periodontal Pain often precipitated by biting and chewing
Acute pulpitis: Pain is sharp and sever
Pulpal pain is often precipitated by the thermal (cold and hot) and osmotic stimuli.
Periodental pain is often precipitated by biting and chewing
Trigeminal neuroglia may be triggered off by a light touch on the face.
Pain of maxillary sinus, acute sinusitis is frequently exacerbated by biting, binding,
lifting and straining.
12. The presence of other symptoms
Local, such as

 Intra or extra-oral swelling , discharge, bad taste,

 Clicking and timing of movement. Which indicate tempromandibular joint
problems.
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13. The patient may be asked about relevant past medical history which may assist in
diagnosis such as:

A. Facial pain of vascular origin like migraine

B. Psychosomatic origin

Lump
1. How long the swelling has been present
2. Whether it is getting larger or smaller or fluctuated in size
3. Whether there in any possible cause for swelling ex. Trauma, injuries or systemic
disease
4. What are the symptoms?
A. Is it painful?
B. Is associated with Paresthesia or numbness? Ex lower lip
D. How the patient discover it? By chance, felling pain or someone notice it
Ulcer
1. Ask whether there is any known factor such as trauma … etc.
2. Ask about the duration of the ulcer.
(4) Past medical history
 Review of patients past and present diseases.
 Any history of systemic disease, ask the patient by leading questions, ask him
 If any hospitalization. indicates Previous disease and how it was treate
 If he had major operation or illnesses,
 What drugs he is taking now
 Any injuries to the head and neck
 Whether he has allergy
 If he has difficulty in climbing steps
 Do you ever have chest pain or tightness?
 Have you palpitations?
 Did you suffer from fleeting joint pains, sore throat or fever?
 Do you have any breathlessness on exertion?
The importance of taking past and present medical history
1. The information may aids in diagnosis of conditions occurring or it has oral
manifestation related to specific systemic disease such as leukemia and aids

2. Several disease need modification of treatment plan

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3. Some drugs used for certain disease may affect the mouth or need to be modified
before dental or surgical Procedures such as anticoagulant and chemotherapy.
Ask the patient about
1. Heart problems
Heart failure, valvar heart disease, myocardial infarction, angina pectoris,
congenital heart disease, rheumatic fever, heart murmer and cardiac arrhythmias.
Stroke (cerebrovascular accident) Elective dental care should be avoided in the
immediate post stroke period because of increased risk for subsequent strokes.
Vasoconstrictors should be used cautiously. Anticoagulant medications and
antiplatelet medications can result in prolonged bleeding. Stress and anxiety reduction
measures may be necessary

2. Blood diseases
Anemia, polycythemia, hemophilia, Christmas disease , vanwillebrands disease ,
purpara and leukemia .
.
3. Hypertension
In mild and moderate hypertension we can do our surgical procedure with
vasoconstrictor.
4. Diabetes
 Type of diabetes must be diagnosed and control measures taken.
 Type1 diabetes have a greater number of complications and are of greater
concern regarding management than are those with type 2 diabetes.
 Patients with diabetes typically do not handle infection very well and may have
exaggerated periodontal disease.
 Patients who take insulin are potentially prone to episodes of hypoglycemia in
the dental office if meals are skipped.

5. Allergy
 Patients may be allergic to some drugs or materials used in dentistry. Common drug
allergens include antibiotics and analgesics.
Latex allergy also is common. For these patients, alternative materials such as vinyl
or powderless gloves can be used to prevent an adverse reaction.
 Any unusual reaction to dental anesthetics?
Symptoms consistent with allergy include itching, urticaria (hives), rash, swelling,
wheezing, angioedema, runny nose, and tearing eyes.
6. Kidney diseases
Genitourinary Tract disease Patients with end-stage kidney failure or a kidney
transplant must be identified
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7. Epilepsy
Some medications used to control seizures may affect dental treatment because of drug
actions or adverse effects. For example, gingival hyperplasia is a well-known adverse
effect of diphenylhydantoin
8. Pregnancy
Women who are or may be pregnant may need special consideration in the taking of
radiographs, administration of drugs, or timing of dental treatment
9. Thyroid disease
Patients with uncontrolled hyperthyroidism are potentially hypersensitive to stress
and sympathomimetics, the use of vasoconstrictors is generally contraindicated. In
rare cases, infection or surgery can initiate a thyroid crisis a serious medical emergency
10. Any drugs the patient takes
 Drug use may cause orofacial lesions – hemorrhagic diathesis caused by decreased
prothrombin level (mineral oil used as a laxative interferes with vit-k absorption)
 Drug allergies?? (urticaria, skin rash, angioedema, respiratory symptoms)
 Drug abuse (behavioral problems, cross infection)
Corticosteroids:
Adrenocortical depression - patients don’t respond to stress, trauma, operation or
infection - stress causes adrenal crisis and collapse
11. Liver diseases.
 Patients also may have chronic hepatitis (B or C), they may be asymptomatic
carriers of the disease and can transmit it to dental personnel or other patients.
As well as cirrhosis, both impair liver function.
 This may result in prolonged bleeding and an impaired ability to efficiently
metabolize certain drugs, including local anesthetics and analgesics
12. Gastrointestinal Diseases
 Drugs that are directly irritating to the gastrointestinal tract, such as aspirin or
nonsteroidal antiinflammatory drugs.
 Patients with colitis or a history of colitis may not be able to take certain
antibiotics.
 Some drugs used to treat ulcers may cause dry mouth
13. Aids immune deficiency syndrome
14. Rheumatic fever or disease
15. Neoplasm and methods of treatment, surgical or cytotoxic drugs especially if the
tumor in head and neck area and if the patient received radiotherapy. Chemotherapy
can produce many undesirable adverse effects, most commonly a severe mucositis
(5) Past dental history
 Past experience during and after local anesthesia and general anesthesia.
 Past experience during and after extraction
 Fainting
 Previous dental treatment, any difficulties with previous dental extraction
 Any history of post-extraction hemorrhage
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(6) Family history
Medical history of all near relatives of the patient is of interest to dental surgeon. If
there is any infections disease such as tuberculosis. Family history is of interest to oral
surgeon such as haemophilia and congenital anomalies. Hereditary problems, such as
amelogenesis imperfecta, hemophilia or hereditary angioedema, Thalassemia, Familial
conditions, such as recurrent aphthous stomatitis or diabetes

(7) Personal history

If the patient take sleeping tables or he take alcohol or he is a heavy smoker and if he
expose to radiation.

Importance of taking history

1. Assessment Of Systemic Compliance Some systemic disease has oral

manifestation which may be the early signs and symptoms of the disease which can be
diagnosed easily
2. Some time the disease may be such that dental treatment may need to be modified
for the patient safety
3. Drugs used in treatment of systemic disease, sometimes affect the mouth or need
some modification in dental treatment
4. Prevention of any Possible Medical EMERGENCIES with known medical History
5. Give good basic knowledge of oral diseases to establish diagnosis
6. Good case history aids correct diagnosis & effective treatment Planning

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