1 Diagnosis Body id: C0013067X

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History of Present Dental Problem

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The dialogue between the patient and the clinician should encompass all of the details pertinent to the events that led up to the chief complaint. The conversation should be directed by the clinician in order to produce a clear and concise narrative that chronologically depicts all of the necessary information about the patient's symptoms and the development of these symptoms. In order to help elucidate this information, the patient is first instructed to fill out a dental history form as a part of the patient's office registration. This information will help the clinician decide which approach to use when asking the patient questions. The interview first determines what is going on in an effort to determine why is it going on for the purpose of eventually determining what is necessary for the resolution of the chief complaint.

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Dental History Interview

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After starting the interview and determining the nature of the chief complaint, the clinician continues the conversation by documenting the sequence of events that promulgated the request for an evaluation. The dental history is divided into five basic directions of questioning: localization, commencement, intensity, provocation, and duration.

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Localization: "Can you point to the offending tooth?"

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Often the patient can point or "tap" the offending tooth. This is the most fortunate scenario for the diagnostician because it helps direct the interview toward the events that might have caused any particular pathosis in this tooth. Additionally, localization allows subsequent diagnostic tests to focus more on this particular tooth. When the symptoms are not well localized, the diagnosis is a greater challenge.

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Commencement: "When did the symptoms first occur?"

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A patient who is having symptoms may remember when these symptoms started. Sometimes, the patient will even remember the initiating event: it may be spontaneous in nature, it may have begun after a dental visit for a restoration, trauma may be the etiology, or biting on a hard object may have initially produced the symptoms. However, the clinician should resist the tendency to make a premature diagnosis based on these circumstances. The clinician should not simply assume "guilt by association" but instead should use this information to enhance the overall diagnostic process.

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Intensity: "How intense is the pain?"

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It often helps to quantify how much pain the patient is actually having. The clinician might ask, "On a scale from 1 to 10, with 10 the most severe, how would you rate your symptoms?" Hypothetically, a patient could present with "an uncomfortable sensitivity to cold" or "an annoying pain when chewing" but might rate this "pain" only as a 2 or a 3. These symptoms certainly contrast with the type of symptoms that prevent a patient from sleeping at night. Often the intensity can be subjectively measured by what is necessary for the diminution of pain, e.g., acetaminophen versus a narcotic pain reliever. This intensity level may affect the decision to treat or not to treat with endodontic therapy.

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Provocation and Relief of Pain: "What produces or reduces the symptoms?"

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Mastication and locally applied temperature changes account for the majority of initiating factors that cause dental pain. The patient may relate that drinking something cold causes the pain or possibly that chewing or biting is the only stimulus that "makes it hurt." The patient might say that the pain is only reproduced upon "release from biting." Occasionally, a patient may present to the dental office with a cold drink in hand and state that the symptoms can only be reduced by bathing the tooth in cold water. Some symptoms may be relieved by nonprescription pain relievers, and others may require narcotic medication for the reduction of symptoms (see Chapter 18 for more information). Note that patients who are using narcotic pain relievers may respond differently to questions and diagnostic tests, which may alter the objectivity of the diagnostic results. These provoking and relieving factors may help to determine which diagnostic tests should be performed to establish a more objective diagnosis.

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Duration: "Do the symptoms subside shortly, or do they linger after they are provoked?"

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The difference between a cold sensitivity that subsides in seconds and one that subsides in minutes may determine whether a clinician repairs a defective restoration or provides endodontic treatment. The duration of symptoms after a stimulating event should be recorded as to how long the sensation is felt by the patient, and documented in terms of seconds or minutes.

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With the dental history interview complete, the clinician has a better understanding of the patient's chief complaint and can concentrate on making an objective diagnostic evaluation, although the subjective (and artistic) phase of making a diagnosis is not yet complete and will continue after the more objective testing and scientific phase of the investigatory process.


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Extraoral Examination

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Figure 1-5 A, Canine space swelling of left side of face extending into and involving the left eye. B, Swelling of the upper lip and the loss of definition of the nasolabial fold on the patient's left side, which is indicative of an early canine space infection.

Basic diagnostic protocol suggests that a practitioner observe patients as they enter the operatory. Signs of physical limitations may be present, as well as signs of facial asymmetry that result from facial swelling. Visual and palpation examinations of the face and neck are warranted to determine if swelling is present. Many times a facial swelling can be determined only by palpation when a unilateral "lump or bump" is present. The presence of bilateral swellings may be indicative of a normal finding for any given patient; however, it may also be a sign of a systemic disease. Palpation allows the practitioner to determine if the swelling is localized or diffuse, firm or fluctuant. These latter findings will play a significant role in determining the appropriate treatment.

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Palpation of the cervical and submandibular lymph nodes is an integral part of the examination protocol. If the nodes are found to be firm and tender along with facial swelling and an elevated temperature, there is a high probability that an infection is present. The disease process has moved from a localized area immediately adjacent to the offending tooth to a more widespread systemic involvement.

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Extraoral facial swelling of odontogenic origin typically is the result of endodontic etiology because diffuse facial swelling resulting from a periodontal abscess is rare. Swellings of nonodontogenic origin must always be considered in the differential diagnosis especially if an obvious dental etiology is not found.49 This will be discussed in subsequent chapters.

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A subtle visual change such as loss of definition of the nasolabial fold on one side of the nose (Fig. 1-5) may be the earliest sign of a canine space infection.50,84 Pulpal necrosis and periradicular disease associated with a maxillary canine should be suspected as the source of the problem. Extremely long maxillary central incisors may also be associated with a canine space infection, but most extraoral swellings associated with the maxillary centrals express themselves as a swelling of the upper lip and base of the nose. Further discussions of space infections may be found in Chapter 15.

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Figure 1-6 Buccal space swelling associated with an acute periradicular abscess from the mandibular left second molar.

If the buccal space becomes involved, the swelling will be extraoral in the area of the posterior cheek (Fig. 1-6). These swellings are generally associated with infections originating from the buccal root apices of the maxillary premolar and molar teeth and the mandibular premolar (Fig. 1-7) and first molar teeth. The mandibular second and third molars may also be involved, but infections associated with these two teeth have as much likelihood to exit to the lingual where other spaces would be involved. For infections associated with these teeth, the root apices of the maxillary teeth must lie superior to the attachment of the buccinator muscle to the maxilla, and the apices of the mandibular teeth must be inferior to the buccinator muscle attachment to the mandible.50,84

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Figure 1-7 A, Buccal space swelling of the left side of the patient's face. Note the asymmetry of the left side of the face. B, Swelling in this case is also present in the left posterior mucobuccal fold. C, This buccal space infection was associated with periradicular disease from the mandibular left second premolar. Note on the radiograph the periradicular radiolucency and large restoration associated with this tooth.

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Figure 1-8 Swelling of the submental space associated with periradicular disease from the mandibular incisors.

Extraoral swelling associated with mandibular incisors will generally exhibit itself in the submental (Fig. 1-8) or submandibular space. Infections associated with any mandibular teeth, which exit the alveolar bone on the lingual and are inferior to the mylohyoid muscle attachment, will be noted as swelling in the submandibular space.50,84 There is a complete review of facial space infections in Chapter 15.

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Sinus tracts of odontogenic origin may also open through the skin of the face (Figs. 1-9 and 1-10). These openings in the skin will generally close once the offending tooth is treated and healing occurs. A scar is more likely to be visible on the skin surface in the area of the sinus tract stoma than on the oral mucosal tissues (Figs. 1-9 and Fig. 1-11). Many patients with extraoral sinus tracts will give a history of being treated by general physicians and dermatologists with systemic or topical antibiotics and/or surgical procedures in attempts to heal the extraoral stoma. In these particular cases, only after multiple treatment failures are the patients finally referred to a dental practitioner to determine if there is a dental etiology.41

Intraoral Examination

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The extraoral examination may give the clinician insight as to which intraoral areas may need a more focused evaluation. Extraoral swelling, localized lymphadenopathy, or an extraoral sinus tract should provoke a more detailed assessment of relating and proximal intraoral structures.

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Figure 1-9 A, Note parulis on the right anterior side of the face. The extraoral drainage was found to be associated with periradicular disease from the mandibular right canine. B, Note the initial scar associated with the extraoral drainage incision after parulis was drained and root canal therapy was performed on the canine. C, The healed incision area three months after drainage was achieved. Note the slight inversion of the scar area.

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