1. Assessment & investigations of Patients
Dr. Ali Tahir

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

3. Patient Assesment Clinical examination Investigations 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 Breathlessness
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 Conjuctival sacrring (pemphigoid)
Pale, yellow or blue sclera
Exophthalmia
Neck
Lymph nodes
Goitre

8. Clinical Examination Hands Wrists Skin Raynaud’s phenomenon
Koilonychia
Joints
Palmar keratosis
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 mm/h
Red cell count 4-6 × 1012 /l
4-5 × 1012/l
WBC count × 109/l
Platelet × 109/l
Serum B12
µg/l

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

13. Immunological tests Autoantibodies C1 estrase inhibitor
Antinuclear factor
SS-A, SS-B
Epithelial basement membrane
C1 estrase inhibitor
Reduced in hereditory angioedema
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 Intra-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 methylene diphosphonate 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 Ionizing radiations Non-ionizing radiation Plain radiographs
Contrast studies
Radioisotope studies
Computerized tomography (CT)
Non-ionizing radiation
Ultrasound
MRI

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