Assessment & investigations of Patients

1. Assessment & investigations of Patients Dr. Ali Tahir

2. Patient Assesment • History • Complaint • Medical history • Drug history • Social history

3. Patient Assesment • Clinical examination • Extra-oral • Intra-oral • Investigations • Blood • Biochemical • Radiographic • Histological

4. History • Basis of investigation • Complaint in patient’s own words • Clinician should not try to influence patient’s response • Should not hurry • Confidentiality Medical History

5. 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

6. Clinical examination 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

7. Clinical examination • Eyes • Conjuctivalsacrring (pemphigoid) • Pale, yellow or blue sclera • Exophthalmia • Neck • Lymph nodes • Goitre

8. Clinical Examination • Hands • Raynaud’s phenomenon • Koilonychia • Joints • Palmarkeratosis • Wrists • Purple papules • Skin • Petechiae or ecchymoses, cyanosis. Jaudice, pigmentation

9. 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 mouth In the end, a well taken clinical photograph

10. Investigations Blood examination Can be helpful in diagnosis of • Leukopenias • Thrombocytopenias • Myelomas • Anaemias • Infectious mononucleosis • Polycythemias • Leukaemis

11. Blood examination 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/l WBC count 4-10 × 109/l Platelet 150-400 × 109/l Serum B12 170-590 µg/l

12. Biochemical Investigations • Glucose • Urea • Creatinine • Electrolytes • Sodium • Potassium • Calcium • Phosphate • Alkaline phosphatase • Total protein • Liver enzymes

13. Immunological tests • Autoantibodies • RA • Antinuclear factor • SS-A, SS-B • Epithelial basement membrane • C1 estrase inhibitor • Reduced in hereditoryangioedema • Viral antibodies • HIV • EBV • C-reactive protein

14. Biopsy 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

15. Biopsy Types • Incisional • Excisional • FNA

16. 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

17. 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

19. 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

20. 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

21. 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

22. Microbiological Investigation • Direct smear • Culture • Molecular techniques to avoid culture use • Microbial products • Toxins • DNA • PCR • FISH • Antigen/Antibody detection

23. Imaging Plain film radiography • Extra-oral • Panoramic • Lateral view • Occipitomental • PA • Submentovertex • Intra-oral • Peri-apical • Bitewing • Occlusal • Digital radiographs

24. Imaging • Contrast studies By enhancing the radiodensity of patients tissue Usually used in Salivary glands & TMJ

25. Radioisotope • Certain tissues concentrate specific compounds e.g. Thyroid concentrates Iodine • Major salivary glands entrap & release technetium (99mTc) • Bone takes up methylenediphosphonate as carrier of radioisotope

26. Computerized Tomography • 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

27. Ultrasound • 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

28. MRI • 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

29. Imaging • Non-ionizing radiation • Ultrasound • MRI • Ionizing radiations • Plain radiographs • Contrast studies • Radioisotope studies • Computerized tomography (CT)

30. Conclusion 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

31. Thank you