principles of diagnosis

what is health?

• The WHO defines it as a state of physical , mental or social state of wellbeing and not merely the absence of disease or infirmity

• health exists on a spectrum - sickness to wellness to then fitness

• the more fit you are the greater buffer to declining into sickness

health - the numbers

out of 544k people who died in the UK in 2023, 21.6%were considered avoidable as they were from preventable conditions

what does health mean to you?

the consultation

Calgary - Cambridge model

name the steps in the Calgary-Cambridge method 5

1. initiation

2. gathering information

3. physical examination

4. explanation and planning

5. closing the session

Initiating the session

1

•Consider this like a first impression - sets the tone

•Introduction - how you/they want to be addressed

•Check the patient identification

•Ascertain the purpose of the consultation

•Explain how you intend to continue the consultation

Gathering information – The History

•Presenting complaint

•The patient’s reason for attending in their own words

•History of presenting complaint

•Further details to elicit signs and symptoms. Further questioning by the clinician

•Medical History

•Details of the patient’s past and ongoing medical problems.

•Dental History

•Details of their dental health problems, ongoing maintenance etc

•Social History

•External factors which impact on oral and systemic health…and vice versa

•Ideas, concerns and expectations

Things to remember

•Patients don’t always know all the details

•The history is not always chronological

•They may only tell you what is important to them and not what you need to know

•The history may not come from the patient, or may be assisted by another party - ask who they are at the start

•Communication difficulties and disabilities - language/cultural barrier

Presenting complaint

”What can I do for you today?”

“I have broken my front second tooth”

“What brings you to see us?”

“I have a swelling under my chin and toothache”

“How are you?”

”Fine!”

History of presenting complaint - SOCRATES

•Site: Where exactly is the pain?

•Onset: When did it start, was it constant/intermittent, gradual/ sudden?

•Character: What is the pain like e.g. sharp, burning, tight?

•Radiation: Does it radiate/move anywhere?

•Associations: Is there anything else associated with the pain, e.g. sweating, vomiting.

•Time course: Does it follow any time pattern, how long did it last?

•Exacerbating / relieving factors: Does anything make it better or worse?

•Severity: How severe is the pain, consider using the 1-10 scale?

Medical History

•Open question

•Systems review - General, CVS, RS, GI, GU, CNS, MSK

•Medications -Names, dosage, indication and duration

•Allergies

•Allergen and type of reaction

•Previously hospitalised?

Dental history

•Current hygiene regimen

•Toothbrushing

•Interproximal cleaning

•Adjuncts - mouthwash

•Topical fluorides

•Mouthwashes

•Toothpastes

•Previous treatment (none, simple, complex)

•Extractions, RCT, crowns, bridges, dentures

•Sedation

Social History

•Smoking

•What and how much? have they ever smoked? how long for?

•Alcohol

•What and how much? (Units / Beer is better than spirits for teeth, wine spirits / Alcohol-free days)

•Recreational drug use

•Occupation -

•Travel

•Hobbies - diving - fillings need to be a specific type

•Support networks and Family

•Pets

ICE

Really helpful for getting back on track, or trying to establish the patient’s agenda

•Ideas

•“What do you think is going on?”

•Concerns

•“You seem worried about this?”

•Expectations

•”What do you hope to get out of today’s consultation?”

Additional parts of the history

•Family History

•Inflammatory bowel diseases, recurrent ulceration, common illness/conditions

symptoms

a physical or mental feature which is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient

signs

a clinical feature whose presence or occurrence indicates the probable presence or occurrence of something else - eg facial swelling

may overlap with symptoms

Examination – “End of bed”

•As the patient walks into the room, what do you see?

•Walking independently - ? Walking aids

•Unstable gait

•Tremors

•Skin tone – pallor / erythema

•Shortness of breath

•Hands – deformity

Examination - General

•Respiratory rate

•Blood pressure

•Pulse

•Temperature

Examination - Extra oral

•Bony symmetry

•Ears

•Nose

•Soft tissues

•Lacerations / Scars / Ecchymosis

•Lips

•Competency (rest together) / Contour / Fissuring

•Lymph nodes

•Submental / Submandibular / Preauricular / Postauricular / Occipital / Cervical / Supraclavicular

•Salivary glands

•Parotid / Submandibular / Sublingual

Examination - Swellings

Site

Size

Shape

Colour

Consistency

Hard/Soft/Fluctuant

Fixed/Mobile

Outline/Border

Surrounding tissues

Broad based/Pedunculated - stalk with stump

Transillumination

Examination – Intra-oral

•Mucous membranes

•Buccal mucosa / Labial mucosa / Palate /

Floor of mouth / Oropharynx /

Retromolar fossa

•Tongue

•colour, texture

•Salivary gland ducts

•Tonsillar tissue

•Periodontal tissues

•Teeth

•Edentulous ridges

•Occlusion

•Dentures

Diagnosis

•Following your history taking and examination must decide on the likely diagnosis

•The provisional diagnosis is your initial or working diagnosis

•A differential diagnosis is a list of possible diagnoses

•Investigations are then required to confirm your diagnosis or exclude a possible diagnosis

Developing a list of differential diagnosis - •Use of surgical sieve

VITAMIN CDEF

VITAMIN CDEF

•V – Vascular

•I – Infective

•T – Trauma

•A – Autoimmune

•M – Metabolic

•I – Iatrogenic

N – Neoplastic

•C - Congenital

•D – Degenerative

•E – Endocrine

•F - Functional

VITAMIN CDEF - example, submandibular swelling , possible diagnosis

Submandibular swelling

•V – Vascular  - Arteriovenous malformations

•I – Infective / Inflammatory – Dental Abscess / Tuberculosis / Sarcoidosis

•T – Trauma – Recent injury / mandibular fracture

•A – Autoimmune – Sjogren’s syndrome / lupus

•M – Metabolic – Diabetes

•I – Iatrogenic – Surgery / dental procedure – extraction

•N – Neoplastic – Squamous cell carcinoma, tumors of the salivary glands

•C – Congenital – Branchial cysts, thyroglossal duct cysts

•D – Degenerative – sialadenitis – see autoimmune

•E – Endocrine – thyroid cysts / goiter

•F – Functional – Blockage, stone

Investigations

•Chairside

•Labs

•Imaging

Chairside

•Vitality testing of teeth - ethyl choloride

•Transillumination

•Cranial nerve examination

•Saliva flow assessment

Labs

• bloods - haematology - full blood count

• biochemistry - renal function

• virology

• immunology

• swabs and saliva samples - microbiology

• virology - swabs

• biopsy - histology - incisionalsample/excisionalwholething , FNA(take a sample from a lump by sticking a needle in it)

imaging - radiation

• dental radiographs

• OPT

• Periapical

• cephalogram - ortho

• CBCT

• CT

non radiating

• ultrasound

• MRI - timely -takes long

definitive diagnosis - is overall based on…..

• History

• Clinical Examination

• Investigations

• Lifestyle factors

management plan

• Explanation and patient factors considered

• Agreed management plan - sign a consent form

• Lifestyle advice

• Short term / Medium term / Long term

• Medical / Surgical treatment

• Referral for specialist opinion / management

treatment

• Treatment is tailored to each patients needs

• Many factors must be considered eg., Patient factors , Prognosis