University of duhok

College of dentistry

Principles of differential diagnosis in

oral surgery

Prepared by : Tara Maher Abdullatif

Supervised by :Dr.Sargon Eshon Daweed
2023-2024
TABLE OF CONTENTS

Introduction …………………………………………3

The diagnostic process………………………………4

Reference……………………………………………18
Introduction

Diagnosis is defined as utilization of scientific knowledge for

identifying a diseased process and to differentiate it from other
disease process.In other words, literal meaning of diagnosis is
determination and judgment of variations from the normal . The
principles of differential diagnosis involve considering all
possible causes of a patient's symptoms and systematically ruling
them out until a final diagnosis is reached , To provide best
treatment and patient satisfaction, thorough clinical history,
examination and diagnostic aids are required . Since dental
problems are not same in two patients, so thorough examination,
evaluation and diagnosis of an individual patient guides the
effective treatment plan.

The diagnostic process actually consists of four steps:

First step: assemble all the available facts gathered from chief
complaints, medical and dental history, diagnostic test and
investigations.
Second step : analyze and interpret assembled clues each and the
tentative or provisional diagnosis.
Third step :make differential diagnosis of all possible diseases
which are consistent with signs, symptoms and test results
gathered.
Fourth step : select the closest possible choice.
The diagnostic process
Personal data
Patient name :
• Better Communication
• Documentation
Age :
• Related diseases ( Herpetic gingivostomatitis,Bohn nodule
LP, Malignancy)
• Dose of the drugs

Sex :
• Mixed names
• Related diseases

Marital status :
• Sex transmitted disease
• Pregnancy ( G.enlargment, gingivitis)
• Lactation
Occupation :
• Work related hazards ( Gloss blower, Carpenters )
Address :
• Idea about social background
• Endemic disease ( florosis )
• Industrial hazarrds
Presenting complaint
The aim of this part of the history is to establish provisional
differential diagnoses even before examining the patient. The
following is a suggested outline, which would require modifying
according to the circumstances:
Complaining of (C/O) documented in the patient’s own
words :

• Use a general introductory question, e.g. ‘Why did you

come to see us today?’ or ‘What is the problem?’
If symptoms are present :

• Onset and pattern When did the problem start? Was it a

sudden or gradual onset? Is it getting better, worse, or
staying the same?

• Frequency How often and how long does it last? Does it

occur at any par- ticular time of day or night?

• Exacerbating and relieving factors What makes it better?

What makes it worse? What started it?
If pain is the main symptom:

• Origin and radiation Where is the pain and does it spread?

• Character and intensity How would you describe the pain:

sharp, shooting, dull, aching, etc.? This can be difficult, but
patients with specific ‘organic’ pain will often understand
exactly what you mean whereas patients with symptoms
 with a high behavioural overlay will be vague and
prevaricate.
Remember, while ‘severity’ of pain is subjective this may give
an idea of how well a patient is coping.
Associations Is there anything, in your own mind, which you
associate with the problemThe majority of dental problems can
quickly be narrowed down using a simple series of questions
such as these to create a provisional diagnosis and judge the
urgency of the problem.

The dental history

It is important to assess the patient’s dental awareness and the
likelihood of raising it. A dental history may also provide
invaluable clues as to the nature of the presenting complaint and
should not be ignored. This can be achieved by some simple
general questions:
How often do you go to the dentist?
This gives information on motivation, likely attendance patterns,
and may indicate patients who change their general dental
practitioner (gDP) frequently.
When did you last see a dentist and what did they do?
This may give clues as to the diagnosis of the presenting
complaint, e.g. a recent root canal treatment (RCT).
How often do you brush your teeth and how long for? Do you
use mouthwash, floss, or interdental brushes?
This gives information on motivation and likely gingival
condition.
Have you ever had any pain or clicking from your jaw joints?
This may indicate temporomandibular joint (TMJ) pathology.
Are you aware that you grind your teeth or bite your nails?
This may provide information on temporomandibular disorder
(TMD) and personality.
How do you feel about dental treatment?
This helps in ex- plaining any dental anxiety.
What do you think about the appearance of your teeth?
This provides clues about motivation and possible need for
orthodontic Rx.
What types of dental treatment have you had previ- ously?
For example, previous extractions, problems with local anaes-
thesia (lA) or general anaesthesia (gA), orthodontics, and
periodontal Rx.
What are your snacking habits like?
For example, types of foods/drinks and frequency. This can give
indications about hidden sugars, caries rate, and erosion. It is
worth including specific questions as to whether or not they use
tobacco, alcohol, or other recreational drugs.
The medical history
There is much to be said for asking patients to complete a
medical his- tory questionnaire, as this encourages more accurate
responses to sensitive questions. However, it is important to use
this as a starting point and clarify the answers with the patient.
Example of a medical questionnaire :
QUESTION

• Are you seeing a doctor for anything?

• Have you ever been admitted to hospital?
• If yes, please give brief details.
Have you ever had an operation?
• If so, were there any problems?
• Have you ever had any heart trouble or high blood pressure?
Have you ever had any chest trouble?
• Have you ever had any problems with bleeding? Do you
bruise easily?
• Have you ever had asthma, eczema, or hayfever? Do you
have fits, faints, or headaches?
• Do you have any known allergies such as penicillin, latex,
or Elastoplast?
• Are you allergic to any other drug or substance?
• Are you pregnant or breastfeeding?
• Are you taking any drugs, medications, or pills?
• If yes, please give details .
• If a patient cannot recall their regular medications, ask
them to bring their prescription to their next appointment or
contact their general Medical Practitioner (gMP).
 Do you have or ever had:
• Arthritis?
• Diabetes?
• Epilepsy?
• Tuberculosis?
• Jaundice?
• Hepatitis especially B or C?
• Other infectious disease, HIV in particular?

The social history

The patient’s social history can give a lot of information about
their lifestyle and risk factors for diseases such as periodontal
disease and oral cancer. It is important not to be judgemental at
this stage; however, these questions can be helpful in getting to
know patients and in Rx planning.
Smoking
What do they smoke? How long have they smoked for? If they
have stopped smoking, when did they stop?
Alcohol
The Chief Medical Officer’s guidelines now advise no more than
14 units of alcohol per week for both men and women to keep
health risks from alcohol to a low level.
Occupation
Certain occupations may affect both routine and diet so should be
considered when delivering oral health advice and motivating
patients.
Diet
General information can be gathered regarding a patient’s diet;
how- ever, a more formal approach is to use a diet sheet. Ideally,
this should be completed across a mixture of both working days
and non-working days to get an idea what the patient’s frequency
of sugar intake is. They should include drink as well as food and
record if sugar is added to these. It is tempting for patients to
change their diet once they know it is being ana- lysed, or to
avoid recording things they feel they shouldn’t have eaten. It is
important to educate patients about hidden sugars and the impact
of diet on their dental health regardless of what is recorded, in
case there have been any omissions on their completed diet
sheets
Other substances
It is useful to know whether patients are using other substances
such as gutka, betel nut, or paan (with or without to- bacco) as
these can lead to staining of teeth and gingival tissues as well as
an i risk of oral cancer.

Medical examination
For the vast majority of dental patients attending as out-patients
to a prac- tice, community centre, or hospital, simply recording a
medical history should suffice to screen for any potential
problems. The exceptions are pa- tients who are to undergo gA
and anyone with a positive medical history undergoing extensive
Rx under lA or sedation. The aim in these cases is to detect any
gross abnormality so that it can be dealt with (by investigation,
by getting a more experienced or specialist opinion, or by simple
Rx if you are completely familiar with the problem).
 • CVS (Chest pain, difficulty in breathing, palpitation,
clubbing finger)
• Respiratory (Cough, wheeze, difficulty in breathing)
• GIT (Diarreha, constipation, difficulty in swallowing,
vomiting, jaundice, bleeding)
• Endocrine system (Polyurea, thirst, polyphagia, weight loss,
hair loss, heat intolerance)
• Genitourinary system (Burring on urination, blood with
urination)
• Hematopietic system (Fatique, brittle nail, eccyhmosis,
bruising, gingival enlargment, )
• Central nervous system (Seizure, numbness, confused,
disoriented)

Extra-oral examination

Head and facial appearance

look for specific deformities Cleft lip and palate, facial
disharmony , traumatic defects .
Skin
Skin lesions of the face should be examined for colour, scaling,
bleeding, and crusting, and palpated for texture and consistency
and whether or not they are fixed to, or arising from, surrounding
tissues. Those with facial hair who have had radiotherapy may
have hairless patches indicating the area which was irradiated.
Eyes
Note obvious abnormalities such as proptosis and lid retraction
(e.g. hyperthyroidism) and ptosis (drooping eyelid). Examine
conjunctiva for chemosis (swelling) and pallor (e.g. anaemia or
jaundice). look at the iris and pupil. Ophthalmoscopy is the
examination of the disc and retina via the pupil. It is a specialized
skill requiring an adequate ophthalmoscope and is acquired by
watching and practising with a skilled supervisor. However,
direct and consensual (contralateral eye) light responses of the
pupils are straightforward and should always be assessed in
suspected head injury .
Ears
gross abnormalities of the external ear are usually obvious.
Further examination requires an auroscope. The secret is to have
a good auroscope and straighten the external auditory meatus by
pulling upwards, backwards, and outwards using the largest
applicable speculum. look for the pearly grey tympanic
membrane; a plug of wax often intervenes.
Neck
The neck Inspect from in front and palpate from behind. look for
skin changes, scars, swellings, and arterial and venous
pulsations. Palpate the neck systematically, starting at a fixed
standard point, e.g. beneath the chin, working back to the angle
of the mandible and then down the cervical chain, remembering
the scalene and supraclavicular nodes. Swellings of the thy- roid
move with swallowing. Auscultation may reveal bruits over the
carotids (usually due to atheroma).
Temporomandibular joint
Palpate both joints simultaneously. Have the patient open and
close and move joint laterally while feeling for clicking, locking,
and crepitus. Palpate the muscles of mastication for spasm and
tenderness. Auscultation is not usually used. Clicking can be
physiological rather than pathological and in these cases simple
reassurance may be re- quired. Examine for diversion of the
mandible.

Intra-oral examination

Oral hygiene
A validated plaque score is advised, preferably using scores
where a higher number is better, to motivate the patient with an
objective measurement.
Soft tissues.
The entire oral mucosa should be carefully inspected.
Any ulcer of >3 weeks’ duration requires further investigation .
Examination should include the tongue, floor of mouth, lips,
oropharynx, tonsillar crypt and tonsils, and hard palate. It is
important to recognize normal anatomy.
Periodontal condition
This can be assessed rapidly, using a periodontal probe .
Chart the teeth present

Examine each tooth in turn for caries and examine the integrity
of any restorations present.
Occlusion
This should involve not only getting the patient to close together
and examining the relationship between the arches, but also
looking at the path of closure for any obvious prematurities and
displacements .Check for evidence of tooth wear

For those patients complaining of pain, a more thorough

examination of the area related to their symptoms should then be
carried out, followed by any special investigations.
Vital signs
Temperature
(35.5–37.5°C or 95.9–99.5°F)
Increase physiologically post-operatively for 24h, otherwise may
indicate infection or a transfusion reaction.
Decrease in hypothermia or shock.
Pulse rate
Adult (60–80 beats/min)
child is higher (up to 140 beats/min in infants).Should be regular.
Blood pressure
(120–140/60–90mmHg). Increase with age. Falling BP may
indicate a faint, hypovolaemia, or other form of shock. High BP
may place the patient at risk from a gA.
Respiratory rate
(12–18 breaths/min). i in chest infections, pulmonary
oedema, shock, anxiety, panic attacks, and asthma attacks.
Investigations—specific
Sensibility testing
It must be borne in mind when vitality testing that it is the
integrity of the nerve supply that is being investigated. However,
it is the blood supply which is of more relevance to the continued
vitality of a pulp. Test the suspect tooth and its neighbours for
comparison.
Application of cold
This is most practically carried out using Endo- Frost or ethyl
chloride on a pledget of cotton wool, held against a dry tooth.
Application of heat
Petroleum jelly should be applied first to the tooth being tested to
prevent the heated gutta-percha (gP) sticking. No response
suggests that the tooth is non-vital, but an increase response
indicates that the pulp is hyperaemic.
Electric pulp tester
The tooth to be tested should be dry, and prophy paste or a
proprietary lubricant used as a conductive medium. Most ma-
chines ascribe numbers to the patient’s reaction, but these should
be in- terpreted with caution as the response can also vary with
battery strength or the position of the electrode on the tooth.
Test cavity Drilling into dentine without lA
is an accurate diagnostic test, but as tooth tissue is destroyed it
should only be used as a last resort. Can be helpful for crowned
teeth but should be used with caution.
Percussion
This is carried out by gently tapping adjacent and suspect teeth
with the end of a mirror handle. A positive response indicates
that a tooth is extruded due to exudate in apical or lateral
periodontal tissues.
Tooth mobility
Tooth mobility is increase by decrease in the bony support (e.g.
due to periodontal disease or an apical abscess) and also by a
fracture (#) of the root or supporting bone.
Palpation
Palpation of the buccal sulcus next to a painful tooth can help to
determine if there is an associated apical abscess.
Biting on to a Tooth Slooth, gauze, or rubber This can be used to
try and elicit pain due to a cracked tooth.
Local anaesthesia lA can help localize organic pain.
Radiographs
Differential diagnosis and treatment plan
Arriving at this stage is the whole point of taking a history and
performing an examination, because by narrowing down your
patient’s symptoms into possible diagnoses. and it is not always
possible to follow this approach from beginning to end. The
principles, however, remain valid and this general approach,
even if much abbreviated, will help you deal with every new
patient safely and sensibly.

Reference