Almost a century ago, Dr. Hermann Prinz wrote: "The object of the practice of clinical dentistry…is to institute preventive measures, to relieve suffering, and to cure disease. These purposes are not achieved by the haphazard utilization of a few therapeutic formulas or of certain mechanical procedures, but they are based on a thorough knowledge of clinical pathology."66 But the gathering of scientific data is not enough to formulate an accurate clinical diagnosis. The data must be interpreted and processed in order to determine what information is significant, and what information might be questionable. The facts need to be collected with an active dialogue between the clinician and the patient, with the clinician asking the right questions and carefully interpreting the answers. In essence, the process of determining the existence of dental pathosis is the culmination of the art and science of making an accurate diagnosis.
The purpose of a diagnosis is to determine what problem the patient is having, and why the patient is having that problem. Ultimately, this will directly relate to what treatment, if any, will be necessary. No appropriate treatment recommendation can be made until all of the whys are answered. Therefore a planned, methodical, and systematic approach to this investigatory process is crucial.
The process of making a diagnosis can be divided into five stages:
The patient tells the clinician why the patient is seeking advice.
The clinician questions the patient about the symptoms and history that led to the visit.
The clinician performs objective clinical tests.
The clinician correlates the objective findings with the subjective details and creates a tentative differential diagnosis.
The clinician formulates a definitive diagnosis.
This information is accumulated by means of an organized and systematic approach that requires considerable clinical judgment. The clinician must be able to approach the problem by crafting what questions to ask the patient and how to ask these pertinent questions. Careful listening is paramount to begin painting the picture that details the patient's complaint. The diagnostic tests that are used become the science behind the creation of the diagnosis.
Neither the art nor the science is effective alone. Establishing a differential diagnosis in endodontics requires a unique blend of knowledge, skills, and ability to interpret and interact with a patient in real time. Questioning, listening, testing, interpreting, and finally answering the ultimate question of why will lead to an accurate diagnosis and in turn result in a more successful treatment plan.
Upon arrival for a dental consultation, the patient should complete a thorough registration that includes information pertaining to medical and dental history (Figs. 1-1 and 1-2). This should be signed and dated by the patient, as well as initialed by the clinician as verification that all of the submitted information has been reviewed (see Chapter 11 for more information).
The reasons patients give for consulting with a clinician are often more important than the diagnostic tests performed. These remarks serve as important clues for the clinician that will help in formulating a correct diagnosis. Without these direct and unbiased comments, objective findings may lead to an incorrect diagnosis. The clinician may find dental pathosis, but it may not be the pathologic condition that mediates the patient's chief complaint. Investigating these complaints may indicate that the patient's concerns are secondary to a medical condition or possibly a result of recent dental treatment. Occasionally, the chief complaint is simply that another clinician correctly or incorrectly advised the patient that he or she had a dental problem, with the patient not necessarily having any symptoms. Therefore, the clinician must pay close attention to the actual expressed complaint, determine the chronology of events that led up to this complaint, and question the patient as to any other pertinent issues, including medical and dental history. For future reference and in order to ascertain a correct diagnosis, the patient's chief complaint should be properly documented, using the patient's own words.
The clinician is responsible for taking a proper medical history from every patient who presents for treatment. Numerous examples of medical history forms are available from a variety of sources, or individual practitioners may choose to customize their own forms. After the form is completed by the patient, or by the parent or guardian in the case of a minor, the clinician should review the responses with the patient, parent, or guardian and indicate that this review has been done by initialing the medical history. Any patient "of record" should be questioned at each treatment visit to determine any changes in the patient's medical history or medications. A more thorough and complete update of the patient's medical history should be completed if the patient has not been seen for over a year.32,51
Baseline blood pressure and pulse should be recorded for a patient at each treatment visit. Elevation in blood pressure or a rapid pulse rate may indicate an anxious patient who may require a reduced stress protocol, or it may indicate that the patient has hypertension or other cardiovascular health problems. It is imperative that vital signs be gathered at each treatment visit for any patient with a history of major medical problems. The temperature of patients presenting with subjective fever or any signs or symptoms of a dental infection should be taken.37,51,69
The clinician should evaluate a patient's response to the health questionnaire from two perspectives: (1) those medical conditions and current medications that will necessitate altering the manner in which dental care will be provided and (2) those medical conditions that may have oral manifestations or mimic dental pathosis.
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Figure 1-1 Dental history form that also allows the patient to record pain experience in an organized and descriptive manner.
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Figure 1-2 Succinct, comprehensive medical history form designed to provide insight into systemic conditions that could produce or affect the patient's symptoms, mandate alterations in the modality of treatment, or change the treatment plan.
Patients with the following medical conditions may require either a modification in the manner in which the dental care will be delivered or a modification in the dental treatment plan:
Hematologic: Sexually transmitted diseases, HIV and AIDS, diabetes mellitus, adrenal insufficiency, hyperthyroidism and hypothyroidism, pregnancy, bleeding disorders, cancer and leukemia, osteoarthritis and rheumatoid arthritis, systemic lupus erythematosis20,25,48,51,53,58,64,89
Neurologic: Cerebrovascular accident, seizure disorders, anxiety, depression and bipolar disorders, presence or history of drug or alcohol abuse, Alzheimer's disease, schizophrenia, eating disorders, neuralgias, multiple sclerosis, Parkinson's disease21,26
Additionally, the clinician should be aware if the patient has drug allergies or allergies to dental products, an artificial joint prosthesis, or organ transplants or is taking medications that may negatively interact with common local anesthetics, analgesics, and antibiotics.
The previous listing may seem overwhelming, but it emphasizes the importance of attaining a thorough and accurate medical history before any dental treatment is provided. A multitude of textbooks and journal articles are available to keep the dental community current on the appropriate ways to provide dental care for patients with medical problems (e.g., The Merck Manual at http://www.merck.com/mrkshared/mmanual/home.jsp). These sources provide the clinician with details about the various medical conditions and the dental treatment modifications that must be made in order to provide the appropriate care.
Several medical conditions have oral manifestations, which must be carefully considered when attempting to arrive at an accurate dental diagnosis. Many of the oral soft tissue changes that occur are more related to the medications used to treat the medical condition than the medical condition itself. More common examples of medication side effects are stomatitis, xerostomia, petechiae, ecchymoses, lichenoid mucosal lesions, and bleeding of the oral soft tissues.51
In arriving at an accurate dental diagnosis, a clinician must also be aware that some medical conditions can have clinical presentations that mimic oral pathologic lesions.81 Tuberculosis involvement of the cervical and submandibular lymph nodes can lead to a misdiagnosis of lymph node enlargement as a result of an odontogenic infection. Lymphomas can also involve these same lymph nodes.51 Immunocompromised patients and patients with uncontrolled diabetes mellitus respond poorly to dental treatment and may exhibit recurring abscesses in the oral cavity that must be differentiated from abscesses of dental origin.25,48,51,53 Patients with iron deficiency anemia, pernicious anemia, and leukemia frequently exhibit paresthesia of the oral soft tissues. This finding may complicate making a diagnosis when other dental pathosis is also present in the same area of the oral cavity. Sickle cell anemia has the complicating factor of bone pain, which mimics odontogenic pain and loss of trabecular bone pattern on radiographs, which can be confused with radiographic lesions of endodontic origin. Multiple myeloma can result in unexplained mobility of teeth. Radiation therapy to the head and neck region can result in increased sensitivity of the teeth and osteoradionecrosis.51 Trigeminal neuralgia, referred pain from cardiac angina, and multiple sclerosis can also mimic dental pain (see also Chapter 3). Acute maxillary sinusitis is a very common condition that may create diagnostic confusion since it may mimic tooth pain in the maxillary posterior quadrant. In this situation the teeth in the quadrant will be extremely sensitive to cold and percussion, thus mimicking the signs and symptoms of pulpitis. This is certainly not a complete list of all the medical entities that can mimic dental disease, but it should alert the clinician that a medical problem could confuse and complicate the diagnosis of dental pathosis; this will be discussed in more detail in subsequent chapters.
If at the completion of a thorough dental examination, the subjective, objective, clinical testing, and radiographic findings do not result in a diagnosis with an obvious dental etiology, then consideration must be given that an existing medical problem could be the true etiology. In such instances a consultation with the patient's physician is always appropriate. As noted above, there are many current textbooks and journal articles that can serve as reference materials for clinicians who encounter some of these medical problems on an infrequent basis.
The chronology of events that lead up to the chief complaint is recorded as the dental history. This information will help guide the clinician as to which diagnostic tests are to be performed. The history should include any past and present symptoms, as well as any procedures or trauma that might have evoked the chief complaint. Proper documentation is imperative. It may be helpful to use a premade form to record the pertinent information obtained during the dental history interview and diagnostic examination. Often a S.O.A.P. format is used, designating the Subjective Objective Appraisal Plan for the diagnostic workup. There are also built-in features within some practice management software packages that allow digital entries into the patients' electronic file for the diagnostic workup (Figs. 1-3 and 1-4).
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Figure 1-3 When taking a dental history and performing a diagnostic examination, often a premade form can be helpful in facilitating complete and accurate documentation. (Courtesy Dr. Ravi Koka, San Francisco, CA.)
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Figure 1-4 Several practice management software packages have features for charting endodontic diagnosis using mouse-driven inputs, user-defined drop-down menus, and areas for specific notations. Note that for legal purposes, it is desirable that all recorded documentation have the ability to be locked, or if any modifications are made after 24 hours, the transaction should be recorded with an automated time/date stamp. This is necessary so that the data cannot be fraudulently manipulated. (Courtesy PBSendo, Austin, TX.)