What are the typical questions you will ask a patient who is suffering

from pain in the oral region? Explain how the information from
each question would help you make a diagnosis

Mohammed D. Ahmed

INTRODUCTION

Diagnosis is the key to understanding and treating disease .The starting point of any

. consultation establishing why the patient has attended to obtain your opinion

A standard framework has been developed for investigating patient's complaint .This

serves as a check list and when summarized , is a form of shorthand for

communication between colleagues . This systematic process of enquiry and

examination intended to uncover the identity and nature of patient's problem leading

to reliable predictions and possible therapy .Special investigations can be done that

.will lead to definitive diagnosis .The diagnosis must relate directly to the compliant

: The diagnosis or identity of a disease is used

. To predict it's behavior or natural history -

. To plan treatment -

. To give the patient support to understand condition -

. To link similar cases for research purpose -

. To enable communication between professionals -

PRESENTING COMPLAINT

Should be written as the patient's own words . If there are multiple complaints should

be dealt with one at a time. The common complaints are of pain, swelling , lump or

ulcer .Allow the patient to tell the story in her or his way and don't ask leading

: questions . Main points to cover

? What is the main trouble today ? What was the first thing that was noticed -

: If symptoms are present

Onset and pattern ; When did the problem start ? Is it getting better ,worse or staying
? the same

Frequency; How often, how long does it last ? Does it occur at any particular time of
. day or night

? Exacerbating and relieving factor Does any thing worsen or improve symptoms

: 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. Does the complaint incapacitate the patient ? such as working, sleeping

Associations Is there anything, in your own mind, which you associate with the
problem?

PAST DENTAL HISTORY

If the patient is new to your practice then you should note details of previous

attendance and treatment . 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 GDP frequently)

When did you last see a dentist and what did he do?
(this may give clues as to the diagnosis of the presenting complaint, e.g. a recent
RCT)

How often do you brush your teeth and how long for?
(motivation and likely gingival condition)

Have you ever had any pain or clicking from your jaw joints?
(TMJ pathology)

Do you grind your teeth or bite your nails?

(TMPDS, personality)

How do you feel about dental treatment?

(dental anxiety)

What do you think about the appearance of your teeth?

(motivation, need for orthodontic treatment)
What is your job?
(socio-economic status, education)

Where do you live?

(fluoride intake, travelling time to surgery)

What types of dental treatment have you had previously?

(previous extractions, problems with LA or GA, orthodontics, periodontal treatment)

What are your favourite drinks/foods?

(caries rate, erosion)

PAST MEDICAL HISTORY

Its essential to assess the fitness of the patient for any potential procedure. The history

will also warn you of any emergencies that could arise and any contribution to the

. diagnosis of presenting complaint

: The medical history should be reviewed systematically . A possible scheme is

. Anaemia . – Gastrointestinal disorders -

. Bleeding disorders . – Hospital admission -

. Cardiorespiratory disorders . – Infections -

. Drug treatment and allergies . – Jaundice or liver disease -

. Endocrine disease . – kidney disease -

. Fits and faints . – Likelihood of pregnancy -

SOCIAL HISTORY

Occupation, home circumstances and traveling arrangement should be reviewed , so

it can help in the treatment plan .Smoking and alcohol consumption also considered in

.this heading

: EXTRAORAL EXAMINATION Look systematically for

Head and facial appearance Look for specific deformities, facial disharmony,
syndromes, traumatic defects, and facial palsy.

Skin lesions of the face should be examined for colour, scaling, bleeding, crusting,
palpated for texture and consistency.
Lips The lips are observed and palpated bilaterally and bimanually, and reflected to
reveal the mucosa.
Eyes Examine conjunctiva for chemosis (swelling), pallor, e.g. anaemia or jaundice.

Lymph nodes ( these should be palpated for enlargement or change in texture ).

TMJ Palpate both joints simultaneously. Have the patient open and close and move

laterally whilst feeling for clicking, locking, and crepitus. Palpate the muscles of

mastication for spasm and tenderness.

INTRAORAL EXAMINATION

Oral hygiene. The presence of plaque, calculus, and stain on teeth can be a critical
finding, because plaque is the primary etiologic agent of both caries and periodontal
disease.

Soft tissues. The entire oral mucosa should be carefully inspected. Any ulcer of >3
weeks' duration requires further investigation . A suggested sequence :

- Buccal and labial sulci ( upper and lower ). - Palate ( Hard and soft ).

- Floor of the mouth . - Oropharynx .

- Tongue ( dorsal and ventral surfaces ) .

Periodontal condition. This can be assessed rapidly, using a periodontal probe.

Pockets >5 mm indicate the need for a more thorough assessment.

Dental examination . Examine each tooth in turn for the following :

1. Caries 11. Palpation

2. Large Restoration 12. Tooth mobility
3. Attrition, Abrasion, and erosion
13. Occlusal interferences
4. Fractures Periodontal infections .14
5. Microfractures
6. Hypersensitive Dentine
7. Swelling and Abscesses
8. Sinus tract
9. Tooth discolorations
10. Sensitivity to percussion

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.

SPECIFIC INVESTIGATIONS
Application of cold This is most practically carried out using ethyl chloride on a
pledget of cotton wool.

Application of heat Vaseline should be applied first to the tooth under test to prevent
the heated GP sticking. No response suggests that the tooth is non-vital, but an
increased response indicates that the pulp is hyperaemic.

Electric pulp tester The tooth to be tested should be dry, and lubricant used as a
conductive medium. Misleading results may occur:

False-positive False-negative
- Multi-rooted tooth with vital - Nerve supply damaged, blood supply
and non-vital pulp intact
- Canal full of pus - Secondary dentine
- Apprehensive patient - Large insulating restoration

Percussion 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.

Mobility of teeth is increased by decreased bony support (e.g. due to peridontal

disease or an apical abscess) and also by fracture of root or supporting bone.

Palpation of the buccal sulcus next to a painful tooth can help to determine if there is
an associated apical abscess.

Biting on to gauze or rubber can be used to try and elicit pain due to a cracked tooth.

Radiographs . ( Intraoral , Bitewing , occlussal and panoramic x-ray ).

DIFFERENTIAL DIAGNOSIS

When many diagnoses might explain the signs and symptoms of the chief complaint,

a differential diagnosis is made .This is a list of possible diagnoses written in order of

probability. Differential diagnosis initially involves the consideration and comparison

of groups of diseases .Then individual diseases can be eliminated because certain

features are unlike those of the patient's illness.

DEFINITIVE DIAGNOSIS AND TREATMENT PLAN

The outcome of history and examination should be a definitive diagnosis and a

treatment plan ,both should be recorded. The diagnosis can be multiple, in which case

the treatment plan should relate to each complaint .

REFERENCES

1. Jonathan Pedlar , John W. Frame : " Oral and Maxillofacial surgery

an objective based textbook " 2001

2. Robert B Morris : " Strategies in Dental Diagnosis and Treatment

planning "
2004 .

3. Mitchell, David A.; Mitchell, Laura : " Oxford Handbook of Clinical

Dentistry " , 4th Edition .

4. Paul Coulthard , Keith Horner , Philip Sloan , Elizabeth D. Theaker

:"
Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine "
2003 .