Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Diagnosis Procedure: DRG Sri Rezeki, SP - PM

Download as pptx, pdf, or txt
Download as pptx, pdf, or txt
You are on page 1of 94

DIAGNOSIS

PROCEDURE
DRG SRI REZEKI, SP.PM
FACTS THAT MAY HELP DENTIST TO DISPEL THE
SENSE OF ANXIETY & INADEQUACY DEALING
WITH ORAL LESION
• Most lesion category (soft tissue / hard tissue)
• White lesion
• Ulceration
• Vesiculo-bullous
• Tumor (epithel, mesenchym)
• Pigmented lesion

• Most lesion can be diagnosed by histologic (biopsy)


• No sin in being wrong (only individual who never make
errors in diagnoses are those who never see an oral lesion)
COMPONENT OF THE COMPREHENSIVE
DENTAL DIAGNOSTIC DATABASE

I. Patient History I. Patient History


1. Patient identification 5. Family History
2. Chief complaint 6. Social History
3. History of the chief complaint 7. Review of system
4. Medical history 8. Dental history
- Past Medical condition II. Physical Examination
- Infections and immunizations III. Adjunctive Diagnostic
- Prior hospitalization Information
- Known allergies and drug reaction
- Current medical treatment
THE PATIENT HISTORY
“Listen to your patient, he is telling you the
diagnosis!”
1. PATIENT IDENTIFICATION

• Biographic data :
Name
Age
Address
FORM
Job
patient’s physician
2. CHIEF COMPLAINT

• Reason the patient is seeking treatment


• Recorded in the patient own words to accurately reflect the
patient’s perception of the problem
• Restatement of the problem by the dentist, the clarification of
the chief complaint, may be necessary to clearly define the
problem
3. HISTORY OF THE CHIEF COMPLAINT
Describes the patient’s awareness of the problem from the
time it was first notice & include all related symptoms
Determination : location, duration, progress, character of the
disease, relation to function, effect previous treatment
Clarification
of the circumstances surrounding the onset &
development of the problem
Avoid frequent interruptions
Made briefly summary
WHAT SHOULD WE KNOW ABOUT
PAIN HISTORY?
 Type ache, ternderness, dull, throbbing,  Initiating  potential initiating factor?
stabbing, electric  Exacerbating & relieving factor  hot/cold
 Severity  mild (manage analgesic) sensitivity
moderate (unresponsive to  Localisation  well or poorly defined
mild analgesic)  Referral  referred pain?
severe (disturb sleep)
 Duration  time since onset
 Nature  continous, paroxysmal
Taking history  communicate
Dentist must be good communicator

Important  Initial interview


 Self confident

LISTEN  General appearance dentist


 Empathize patient’s complaint
 Concern & interest in patient
Dentist must aware patient’s:

 Intelligence

 Education

 Emotional

 Degree of confident in the examiner


HISTORY
• Patient symptomatic  open/closed question
• Patient asymptomatic  role of clinician
• Type of onset  Acute / chronic
• Duration  healed / worse / not changing
• Clinical course  Systemic (fever, lympadenopathy)
• Distribution  systemic / local
• Exogenous factor (smoking, alcohol, drug, genetic)
QUESTION

Open
Tell me about the pain?
Closed
What does the pain feel like?
Leading
Does the pain feel like an electric shock?
Allows patients to use their own Clinicians must listen carefully & avoid
words and summarise their view of interruptions to extract the relevant
the problem information
Open
Allows patient to partly direct the Patients tend to decide what information is
history taking gives them confident & relevant
quickly generates rapport

Elicits spesific information quickly Patients may infer that the clinician is not
really interested in their problem if only
Useful to fill gaps in the information closed question are asked
given in respone to open question
Closed Important information may be lost if not
Prevents vague patients from spesifically requested
rambling away from the complaint
Restricts the patient’s opportunities to talk
4. MEDICAL HISTORY

Documentation of disease/condition in the past


 Past medical condition
Allergy,
adverse reaction to medications,
treatment, prior hospitalization,
Infections, immunizations
 Current medical treatment
PAST MEDICAL CONDITION

Allergy  drug induced hipersensitivity


Disease  diabetic, rhematoid fever, pneumonia
Medication  phenytoin, warfarin, steroid
Hospitalization  reveal condition influencing a diagnosis/treatment
Immunizations
5. FAMILY HISTORY

• Genetic conditions ?
• Communicable infections ?
• A formal medical history evaluates systemic disease affecting at
least three generations of the patient’s family.
FAMILY HISTORY
• Genetic
hemorrhagic, allergic, diabetic, hypertension, tumor
• A good medical history evaluates systemic disease affecting at
least three generations of the patient’s family
6. SOCIAL HISTORY
• Patient’s occupation, hobbies, dialy activities, habits, and emotional adaptation
• Consequence of recurring exposure to toxic materials or conditions  certain
illnesses ?
• Outdoor occupation or hobby sun exposure  UV damage  skin and lip
cancer
• i.v drug habit possibility of hepatitis & HIV infection
• Tobacco, alcohol use ?
SOCIAL HISTORY

 Daily activity  Living enviroment


 expose to toxic material  urban  TBC
 Occupation or hobby  Emotional/habit

 sun exposure (UV)  skin - lip cancer  smoking, alcohol, drug abuse
7.THE REVIEW OF SYSTEM

• General Health • Genitourinary system


• Cardiovascular system • Musculoskeletal system
• Pulmonary system • Integumentary system
• Gastrointestinal system • Special organs of the head and
• Immune system neck
• Endocrine system • Peripheral nervous system
• Blood • Central nervous system
8. DENTAL HISTORY
Past dental care for patients
1. Routine dental care implies regular appointments & timely of
most dental needs
2. Episodic dental care implies less than comprehensive dental care
& an irregular pattern of recall examinations
3. Symptomatic dental care indicates that the patient has generally
consulted a dentist for relief of pain without regular attention to
dental health
8. DENTAL HISTORY

The patient’s attitude toward dental care is usually


revealed by the response to question such as Assesss
the patient’s attitude toward dental care
How often do you usually visit the dentist?
Are your dental appointment usually for checkups
and fillings or toothaches?
CLINICAL EXAMINATION

• NEED adequate light


• ORDERLY examination
Lip  buccal/labial  palate  oropharynx  tongue  gland

• MUST complete head-neck examination


Facial symmetry, lesion, lymphadenopathy, thyroid

• ADDITIONAL examination
If needed, lesion on other area beside head-neck

• DETAILED evaluation oral lesion


ORDERLY EXAMINATION
• Oropharynx : use tongue blade
• Tongue : grasp, pull, palpate
• Salivary gland & duct : palpate, flow, pain, clear saliva
DETAILED evaluation oral lesion
• If possible dry lesion
• Evaluate color, texture, size, consistency, location
• Remember classification oral lesion
• If white lesion  try to scrap it
History

Clinical Examination Definitive Diagnosis


(Radiograph if needed)

Working Diagnosis Biopsy and/or Definitive Diagnosis


Lab test

Treat Empirically Response to Diagnosis


Specific Rx

Resolution with
NO Diagnosis

No resolution Biopsy and/or Definitive Diagnosis


Lab test
WHITE LESION
• Consequence of surface necrosis or hyperkeratosis
• Different by scraping
• General : necrotic more symptomatic than hyperkeratotic
• Necrotic result from trauma or infection
• Keratotic result from chronic irritation, systemic disease,
hereditary condition, carcinoma
• Frequently keratotic : raised plaque  biopsy ?

Ulceration
• Result from trauma, local/systemic disorder, carcinoma
• Induration border, base of lesion, surround mucosa
• Biopsy to any lesion fail to heal in 14 days
Vesiculobulosa

• Result from deposition fluid beneath epithelial surface


• Blister : <5 mm  vesicle, >5 mm  bullae
• Usually vesicle/bullae rupture  ulceration
• Frequently viral infection (cytologic smear, serologic test)
• Autoimmune & drug eruption (biopsy, immunofluorescence,
cytologic smear)
Pigmented lesion

• Endogenous or exogenous pigment


• Different color, lesion not raised
• Often the first sign of systemic disease (addison disease)
• May need biopsy & laboratory test
Tumor
• Benign or malignant (>>benign)
• Endophitic / exophitic
• Indurated / rolled border
• Biopsy is mandatory
DIAGNOSIS &
DIFFERENTIAL DIAGNOSIS
INITIAL CATEGORIZATION OF
SUSPECTED ABNORMALITIES
Two decisions must be made early in dd/ of Suspected
nondental abnormality of the oral cavity :
(1) Variation of normal tissue or evidence of disease ?
(2) Disease  Category?
FEATURE OF NORMAL TISSUE VARIATIONS
COMPARED WITH EVIDENCE OF ABNORMALITY
Bilateral symmetry
Predictable location
Asymptomatic
Independent finding
Static
Increased prominence with age
Remain unchanged following empiric treatment
CATEGORIZATION OF SUSPECTED
NONDENTAL ABNORMALITIES OF THE
ORAL CAVITY BY PRIMARY MANIFESTATION
UNUSUAL FINDING (S)
Bilateral symmetry
Predictable location Variation
Asymptomatic of Healthy
Independent finding Tissues
ABNORMALITY
Remains unchanged
Older patient

By Location & Tissues


Affected

Ulcers, vesicles, or bullae Radiographic abnormality


Abnormal white color of
Pain Enlargement or mucosal
the mucosa
changes may be present,
No enlargement
No enlargement but are secondary
No radiographic
No loss of surface
integrity
No Radiographic findings Multiple dissimilar
Tissue enlargement abnormalities
No radiographic findings
Abnormal dark color of
Mucosal changes may be
the mucosa
present but are secondary
No enlargement
No loss of surface
integrity
No radiographic findings
DD/ OF WHITE MUCOSAL LESION
WHITE MUCOSAL LESION
WITHOUT ENLARGEMENT

•Symptomatic •Asymptomatic
•Asymtomatic
•Opaque •Translucent
•Opaque
•Rough •Smooth
•Rough
•Soft •Does not rub off
•Does not rub off
•Rubs off leaving •Static or progress
•Persist or progress
a raw surface •A cause may be present
•May be a cause or
cofactor (s) •Regresses (heals)
•A cause may be present

EPITHELIAL SURFACE SUBEPITHELIAL


THICKENING MATERIAL CHANGE
DD OF DARK MUCOSAL LESION
DD/ OF ORAL ULCERS
ORAL ULCER –
HISTORY TAKING
ULCER
• Irregularly shaped
excavation of the
epithelium that extends
below the basal cell
layer
• May heal with scar

RAU / SAR
DEFINITION
• Ulcer :
• In the mouth, ulcer are usually painful, except most
importantly malignat tumours, which be initially painless

• Biopsy  essential establish the diagnosis of any ulcer that


does not respond to treatment or persist for more 2-3
weeks
(Birnmaum W, Dunne SM. Oral Diagnosis : the Clinician’s Guide. 1st Ed. Oxford: Wright,
2000.)
PRIMARY LESIONS OF THE SKIN & ORAL
MUCOSA

Vesicle
• Circumscribed elevated
intraepithelial or subepithelial
lesion
• Size < 1 cm
Vesicle
• Contains : serous fluid
PRIMARY LESIONS OF THE SKIN
& ORAL MUCOSA

Bulla
• Circumscribed elevated
intraepithelial or
subepithelial lesion
• Size > 1 cm
• Contains : serous fluid
Bulla in a patient with
Pemphigus vulgaris
HISTORY
• “ Listen to your patient, he is telling you the diagnosis ”

• A detailed history  an essential component of the diagnosis

• Age
• Viral infections, reccurent aphthae  more common in
children & adolescent
• Erosive LP, MMP, SCC affect middle age to elderly
HISTORY
• Ask your patient :
• How long have you had the ulcer(s) ?
• A painless ulcer which has been present in an elderly patient for several
weeks  suggest carcinoma
• How many are there?
• Multiple  suggest viral
• If multiple & reccurent  aphtous ulcer
• Where is the ulcer located?
• ANUG affects the interdental papillae at first
• Aphtous ulcer rarely affect the gingival margins
HISTORY
• Ask your patient :
• Is it Painful ?
• Most ulcers are painful
• However early stage of oral carcinoma are often painless
• Do you know of anything that may have caused the ulcer
• e.g trauma, eating hot or heavily spiced food?
• Have you ever had any ulcer before ?
• Reccurent vesicles/ulcers on the lips and other mucocutaneous junctions
likely to be herpes simplex. Reccurent intraoral ulcer  aphthae
HISTORY
• Ask your patient :
• If yes, when? How many? How often? How long do they last?
• Are there any associated problems?
• e.g. pain, bleeding, halitosis
• Is it getting bigger, smaller, or staying at the same size?
• Smaller  suggest healing
• Becoming larger and painful  indicate a more serious aetiology
HISTORY
• Ask your patient :
• Do you get tingling or itching before the ulcer appear?
• Indicates possible viral aetiology, eg. Herpes simplex/zoster, or
aphtae
• Do the ulcers start as blisters?
• Pemphigus, Mucous membrane pemphigoid
• Do you get ulcers at other body sites, e.g skin, eyes, genital region?
• Behçet’s syndrome, erythema multiforme
HISTORY
• Ask your patient :
• Do you smoke ? If so, how many cigarettes per day and for how
long?
• Increased risk of oral cancer in heavy smokers and alcohol
drinkers.
• Do you drink alkohol? If yes, how many units per week?
• A glass of wine/measure of spirits/half pint of beer ≈ 1 unit
• > 21 units for ♂ & 14 for ♀  exceeds the government’s
recommended safe level of consumption alcohol.
HISTORY
• Ask your patient :
• Do you chew tobacco? If so, how much and how often ?
• Increased risk of OSCC
• Do you chew betel quid? If so, how often?
• Leads to submucous fibrosis (A premalignant condition)
• A comprehensive past medical history is also required (include
medications and serious skin, gastrointestinal and
haematological illness)
DD/ OF ORAL SOFT TISSUE
ENLARGEMENTS
TUGAS KELOMPOK

• Deskripsikan Lesi
CASE 1
CASE 2
CASE 3
CASE 4
CASE 5
CASE 6
CASE 7
LESION IDENTIFICATION

• Review

1.a RIH 1.b Aphthous ulcers


LESION IDENTIFICATION

• Review

1.C Aphtous ulcers 1.d RIH


CASE REVIEW
CASE REVIEW
CASE REVIEW
CASE REVIEW
CASE REVIEW
HOMOGENOUS LEUKOPLAKIA
NON-HOMOGENOUS LEUKOPLAKIA
Clinical characteristic of oral cancer

Epithelial
keratosis

Erythema

Contact pain
CLINICAL CHARACTERISTIC OF POTENTIALLY
MALIGNANT LESION

Erythema
Epithelial keratosis

No contact pain
EARLY STAGE OF ORAL CANCER

Asymptomatic and no dysfunction


ADVANCED STAGE
Dysfunction, sore, bleeding,
necrotic and smell
BENIGN
LESIONS
Less thickened patch, Soreness, no induration
indistinct boundaries

Frictional lesion Decubital ulcer


CASE REVIEW
BENIGN LESIONS
Chronic hyperplasitic
Whitish changes with the accessory salivary pseudomembranous candidosis
gland duct orifices presenting as small red which can not be rubbed off
dots

Smoker’s palate
Oral candidosis
CASE REVIEW
CASE REVIEW
Thank You

You might also like