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
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