Assessment & investigations of Patients

Dr. Ali Tahir

History◦ Complaint◦ Medical history◦ Drug history◦ Social history

Patient Assesment

Clinical examination◦ Extra-oral◦ Intra-oral

Investigations◦ Blood◦ Biochemical◦ Radiographic◦ Histological

Patient Assesment

Basis of investigation Complaint in patient’s own words Clinician should not try to influence patient’s

response Should not hurry ConfidentialityMedical History

History

History of any previous dental treatment, oral/panoral abnormality, systemic disease, skin disorder, trauma/accident, major surgery

Drug therapy Use of alcohol & tobacco Consult patient’s general practitioner or

go through patient’s file

History

Extra-oral: General appearance

◦ Wasted, mal-nutritioned, anxiety, agitation? Breathlessness

◦ Cardiorespiratory problem? Face

◦ Shape & symmetry◦ Cranio-facial syndromes◦ Cushingoid appearance?◦ Neurological deficits?◦ Cyanosis?

Scalp & face◦ Scant hair

Clinical examination

Eyes◦Conjuctival sacrring (pemphigoid)◦Pale, yellow or blue sclera◦Exophthalmia

Neck◦Lymph nodes◦Goitre

Clinical examination

Hands◦ Raynaud’s phenomenon◦ Koilonychia◦ Joints◦ Palmar keratosis

Wrists◦ Purple papules

Skin◦ Petechiae or ecchymoses, cyanosis. Jaudice,

pigmentation

Clinical Examination

Intra-oral (with adequate light source) Remove all removable appliances Gently retract lips & cheeks Examine the whole oral mucosa Tongue Teeth Hard & soft palate Floor of mouthIn the end, a well taken clinical photograph

Clinical Examination

Blood examinationCan be helpful in diagnosis of Leukopenias Thrombocytopenias Myelomas Anaemias Infectious mononucleosis Polycythemias Leukaemis

Investigations

Normal values Hb 12.5-17.5 (male)

11.5-16 (female) Mean Cell Volume 80-90 ESR 0-15mm/h Red cell count 4-6 × 1012 /l

4-5 × 1012/lWBC count 4-10 × 109/lPlatelet 150-400 × 109/lSerum B12

170-590 µg/l

Blood examination

Glucose Urea Creatinine Electrolytes

◦ Sodium◦ Potassium◦ Calcium◦ Phosphate

Alkaline phosphatase Total protein Liver enzymes

Biochemical Investigations

Autoantibodies◦ RA◦ Antinuclear factor◦ SS-A, SS-B◦ Epithelial basement membrane

C1 estrase inhibitor◦ Reduced in hereditory angioedema

Viral antibodies◦ HIV◦ EBV

C-reactive protein

Immunological tests

A biopsy involves the removal of part or all of a lesion so that it can be examined by histopathological techniques

Done is suspected Neoplasia White patches Swellings (soft or bony) Desquamative lesions

Biopsy

Types

1. Incisional2. Excisional3. FNA

Biopsy

General principles: All sterilization protocols to be followed Patient consent & councelling LA to be given in the adjacent area & not

within the lesion Better taken with a knife than with a cutting

diathermy Specimen should be big enough to allow the

pathologist to make a diagnosis

Biopsy

After excision, put into a fixative (10 formol saline being the standard solution)

Apply stitches to the specimen for orientation

If the specimen is thin, lay it on a piece of card

Label the container with patient’s name & age & site of biopsy

Fill the biopsy form, draw the specimen diagram if necessary

Biopsy

Excisional Biopsy: Done when the lesion is small (usually 2cm

or less)Incisional biopsy: When the lesions is larger than 2cm Should include typical area of lesion & edge

of the lesion with a small margin of normal tissue

Biopsy

Biopsy for immunoflourescence Particularly done for immunobullous

(pemphigus & pemphigoid) or erosive lesions

Clinically normal tissue adjacent to lesion is taken

Fresh unfixed tissue passed on for immediate processing

Biopsy

Fine Needle Aspiration Done in a soft, fluctuant swelling Particularly to collect fluid or pus 20/21 gauge needle is used Ultra-sound can be used to guide the needle Definitive diagnosis is difficult from FNA &

needs vast experience

Biopsy

Direct smear Culture Molecular techniques to avoid culture use

◦ Microbial products Toxins DNA PCR FISH

◦ Antigen/Antibody detection

Microbiological Investigation

Plain film radiography Extra-oral

◦ Panoramic◦ Lateral view◦ Occipitomental◦ PA◦ Submentovertex

Intra-oral◦ Peri-apical◦ Bitewing◦ Occlusal

Digital radiographs

Imaging

Contrast studiesBy enhancing the

radiodensity of patients tissue

Usually used in Salivary glands & TMJ

Imaging

Certain tissues concentrate specific compounds e.g. Thyroid concentrates Iodine

Major salivary glands entrap & release technetium (99mTc)

Bone takes up methylene diphosphonate as carrier of radioisotope

Radioisotope

Machine using ring of X-ray detectors

Uses high doses of radiation

The generated image represents a slice through the area

Used in◦ Soft & hard tissue tumours of

head & neck◦ Facial fractures◦ Osteomyelitis

Metallic objects cause artefacts

Computerized Tomography

Uses high frequency pulsed ultrasound beam

Can be used to detect◦ Vascular disorders◦ Soft-tissue swellings◦ Salivary glands to locate salivary calculi◦ Lymph n nodes◦ Used in conjunction with FNA

Ultrasound

Utilized protons in a magnetic field Produces excellent differentiation between

soft & hard tissues but gives poor hard tissue details

Contraindications Patients having certain surgical clips Heart pacemaker Metallic foreign body (metal silver) in their

eye Severe claustrophobia

MRI

Ionizing radiations◦ Plain radiographs◦ Contrast studies◦ Radioisotope studies◦ Computerized

tomography (CT)

Non-ionizing radiation◦ Ultrasound◦ MRI

Imaging

A careful correlation of the history, clinical examination, radiographic and other investigations can help in reaching the definitive diagnosis.

It should be remembered that careful history taking plays the most important role in reaching the diagnosis

Conclusion

Thank you