CONCEPTS OF DIFFERENTIAL DIAGNOSIS David E. Wojtowicz, DDS, MBA

IntroductionIntroduction l Differential Diagnosis –List of Diseases With Similar Manifestations –Rule Out (R/O) on the Basis of Contradictions –Example: Oral Ulcer l Differential Diagnosis –List of Diseases With Similar Manifestations –Rule Out (R/O) on the Basis of Contradictions –Example: Oral Ulcer

Oral Ulceration l This is a Manifestation, NOT a Disease l The Differential Diagnosis Might Include –Zinc Deficiency –Trauma –Herpes –Aphthous l The Appearance Alone is Rarely Sufficient l This is a Manifestation, NOT a Disease l The Differential Diagnosis Might Include –Zinc Deficiency –Trauma –Herpes –Aphthous l The Appearance Alone is Rarely Sufficient

Multiple Etiologies l Local or Systemic Monomorphic Presentation –White –Red –Ulceration (and more...see below) l The Appearance Alone is Rarely Sufficient l Local or Systemic Monomorphic Presentation –White –Red –Ulceration (and more...see below) l The Appearance Alone is Rarely Sufficient

Clinical Appearance l For Caries / Periodontal Disease –Clinical Appearance is Sufficient l For Non-dental Lesions One Relies On –Signs –Symptoms –History (What does this include?) l For Caries / Periodontal Disease –Clinical Appearance is Sufficient l For Non-dental Lesions One Relies On –Signs –Symptoms –History (What does this include?)

HistoryHistory l HPI l PMH l ROS l MEDS –Crucial: We, the dentists do not want to overlook anything serious, such as CANCER. l HPI l PMH l ROS l MEDS –Crucial: We, the dentists do not want to overlook anything serious, such as CANCER.

PharyngitisPharyngitis l The Differential Might Include –Strep Throat –Mononucleosis –VD –Viral Common Cold l Signs, Symptoms, History, Throat Culture l The Differential Might Include –Strep Throat –Mononucleosis –VD –Viral Common Cold l Signs, Symptoms, History, Throat Culture

6 Stages of Differential Diagnosis ¶ Classify the abnormality into one of 7 Primary Clinical Manifestations-- –Normal Variation –White –Red, Pigmented or Dark –Ulceration –Exophytic –Radiographic –Syndrome ¶ Classify the abnormality into one of 7 Primary Clinical Manifestations-- –Normal Variation –White –Red, Pigmented or Dark –Ulceration –Exophytic –Radiographic –Syndrome

6 Stages of Differential Diagnosis6 Stages of Differential Diagnosis · List the Secondary Clinical Features –Visual –Palpation –Probing –Patient Awareness · List the Secondary Clinical Features –Visual –Palpation –Probing –Patient Awareness

6 Stages of Differential Diagnosis Prognosis ¸ List Conditions Capable of Causing the Primary Lesion ¹ Eliminate Improbable Conditions (Look for Inconsistencies in Secondary Features) º Rank Possible Causes » Working Diagnosis (Probability/Tests/Safety) ¸ List Conditions Capable of Causing the Primary Lesion ¹ Eliminate Improbable Conditions (Look for Inconsistencies in Secondary Features) º Rank Possible Causes » Working Diagnosis (Probability/Tests/Safety)

Visual Features l Location l Shape & Contours l Size l Solitary/Multiple l Borders l Homogenous/Heterogeneous l Surface Color/Texture l Displacement (of Teeth?) l Location l Shape & Contours l Size l Solitary/Multiple l Borders l Homogenous/Heterogeneous l Surface Color/Texture l Displacement (of Teeth?)

PalpationPalpation l Induration l Mobility l Compressible l Tender l Color Change (Blanching) Probing l Exudate l Induration l Mobility l Compressible l Tender l Color Change (Blanching) Probing l Exudate

Patient Awareness l Pain or Altered Function l Duration –Acute –Recurrent –Chronic l Progressive Course or Remission l Response to Stress/ Foods l Pain or Altered Function l Duration –Acute –Recurrent –Chronic l Progressive Course or Remission l Response to Stress/ Foods

Risk Factors l Demographic (Age, Gender, Race) –These the patient cannot change. l Social (Alcohol, Tobacco, Oral Habits): SCC l Recent History (Trauma,Infection,Surgery) l Medical History (Chronic Disease, Acute Illness, Medications,Treatments) –HTN, Diabetes, Nicotine, Cholesterol: Heart Disease l Demographic (Age, Gender, Race) –These the patient cannot change. l Social (Alcohol, Tobacco, Oral Habits): SCC l Recent History (Trauma,Infection,Surgery) l Medical History (Chronic Disease, Acute Illness, Medications,Treatments) –HTN, Diabetes, Nicotine, Cholesterol: Heart Disease

Clues to Normal l Bilateral Symmetry l Predictable Locations l Asymptomatic l Independent Finding (no Secondary Features such as redness, swelling) l Increase with Age l Remains Unchanged w/ Treatment l Bilateral Symmetry l Predictable Locations l Asymptomatic l Independent Finding (no Secondary Features such as redness, swelling) l Increase with Age l Remains Unchanged w/ Treatment