Diag N Dia Diff

1
Diagnosis
and
Differential diagnosis
2
di·ag·nos·tic (dī′əg-nŏs′tĭk) (free dictionary)
adj.
1. Of, relating to, or used in a diagnosis.
2. Serving to identify a particular disease; charac
teristic.
n.
1. often diagnostics (used with a sing. verb) --
The art or practice of medical diagnosis.
2. A symptom or a distinguishing feature serving as
supporting evidence in a diagnosis.
3. An instrument or technique used in medical
diagnosis. 3
Diagnostik --- KBBI
• ilmu untuk menentukan jenis penyakit berdasarkan
tanda dan gejala yang ada
• diagnosis/di·ag·no·sis/
1 penentuan jenis penyakit dengan cara meneliti
(memeriksa) tanda dan gejala-gejalanya;
2 Sos -- pemeriksaan terhadap suatu hal;
medis -- penentuan jenis penyakit berdasarkan
tanda dan gejala dengan menggunakan cara dan
alat seperti laboratorium, foto, dan klinik;
pembanding -- diagnosis yang dilakukan dengan
membanding-bandingkan tanda klinis suatu
penyakit dengan tanda klinis penyakit lain;
4
Diagnostic
• As a science, diagnostic must be applied to
maintaining and restoring patient’s health.
• The need for treatment dictated by health
status.
• As an instrument or technique used in medical
diagnosis.
5
Diagnosis
Definition of diagnosis (Merriam Webster)

 plural diagnoses play \-ˌsēz\
1 a : the art or act of identifying a disease from its signs
and symptoms
b : the decision reached by diagnosis the doctor's
diagnosis
2 a : investigation or analysis of the cause or nature of
a condition, situation, or problem diagnosis of
engine trouble
b : a statement or conclusion from such an analysis
 3 biology : a concise technical description of a taxon
6
Diagnosis
• Diagnosis
 is the process of evaluating the patient’s health
resulting opinion formulated by clinician.
• Oral diagnosis
 Is the discipline of dentistry that is specifically
concern with the art and scince of assessment of
patient’s general and dental health status.
 Oral Diagnosis is the art of using scientific

knowledge to identify oral disease processes and to
distinguish one disease from another.
7
 .
• Oral medicine
 The discipline that encompasses all aspects of oral
diagnosis with spesific attention to the management
of patients with compromised general health and the
treatment of non dental diseases that affect the oral
and perioral tissues
 Oral Medicine is defined by the American Academy
of Oral Medicine as the specialty of dentistry
concerned with the oral health care of medically
compromised patients and with the diagnosis non-
surgical management of medically-related disorders
or conditions affecting the oral and maxillofacial
region
8
The Diagnostic Method
• The Application of The scientific method is the
most effective approach to clinical decision.
• The accurate diagnostic decisions rely on
systematic approach to the unique challange
pose by the patient.
• The element of diagnostic method

1. Collection of information
2. Evaluation of information
3. Diagnostic decisions
4. Reassessmnt 9

1. Collection of information
• Ia the initial stage of collection diagnostic
information
• this verbalised by patient, clinician examination,
and the additional laboratorium data.
• premature opinion could be adversely alter
accuracy of the information
10

2. Evaluation of information
• This is the proess to organize information
• Determine the information have a clinical
significant
• Unusual finding is sugestive correlated to identify a
certain disease
• The clinician also assess accuracy of informaion –
it can be repeated or make another additional test.
• The clinician must remain objective or risk bias
intrpretation.
11

3. Diagnostic decisions
• The next step is formulating opinion concerning
the finding.
• Unusual finding must give more attention.
• Each opinion or diagnosis is the explantion for the
patient status that is most consistant with
availabel information
• This is comparable to formulating hypothesis.
• The diagnosis may be somewhat non spesific, but
it should be as spesific as available information
12

4. Reassessment
• Assessment stage is equivalent to hypothesis
testing
• The diagnosis of the abnormality suggest to
additional test or appropriate treatment.
• Clinician can predict the respons of abnormality
following teatment of patient.
13
14
COLLECTING DIAGNOSTIC INFORMATION
• Several sources of diagnostic information available

to contribute patient’s status.
• The collection of diagnostic information referred to
as diagnostic database
• The diagnostic data base consist of :
 patient history, identication, cc, hopi, mh, fh,sh,ROS
 physical examination result and
 the information obtained from adjuntive
diagnostic procedure
15
16

a. patient history, (PtHx):
• description of past event that contributes patient’s health
• Soursce person (their family, guide ... etc)
• Patient history is organized into the following :
o Patient identification
o Chief complaint (CC)
o History of the chief complaint (HOPI)
o Dental history (PDH)
o Medicall history (PMH)
o Family history (FH)
o Social history (SH)
o Review of system (ROS)
17

b. physical examination :
• general patient appraisal : evaluation of general
appearence : posture, speach, vital sign.
• extraoral examination
• Intraoral examinantion
18

c. adjunctive diagnostic procedures:
• It is rely on distant source of information;
• radiographyc, laboratory, other clinician
...etc is an sample of routine adjunctive
diagnostic information.
• referral and consultation that provide
diagnostic data and opinion from other
clinician are consider as adjunctive sources
of diagnostic information.
19
EVALUATION OF DIAGNOSTIC INFORMATION
• Organizing Diagnostic Information
 Clinician search for associations and patern

among the data from the health history, physical
examination and adjunctive diagnostic
 Comparing normal finding, normal variation and
diseased tissue or organ
 Comparison may reveal that certain finding are
inaccurate or inconsistent ---- preliminary opinion
is incorrect --- certain element of history should
be reevaluated or additional diagnostic
procedure are needed to clarify.
 Some general finding or spesific feature may be
20
related to several problem.
 Clinician must reorganized informaton by whether
it conribute to the evaluation of medical problems,
dental condition or non dental abnormlities.
o Physical assesssment.
 Related to the medical status is arrange by the
physiologic system
 Finding related to a sepesific system are group by
relationship to past conditions, currently diagnosed
illnesses or undiagnosed disease.
 Weight loss or fever are indicative of general
problems or spesific system disoders. 21
 Related to the medical status is arrange by the
physiologic system. An example of medically status is
related to systemic diseases
Example of physical examination and it’s significant
related to
1. Respiratory system
2. Gastrointestinal system
3. Temperature
4. Endocrine system
5. Carbohydrate metabolism
22
Example of physical examination and it’s significant related
to 1.Respiratory system
Upper Respiratory Infection:

 inflamed mucous
membranes of the throat
◦ Caused by Group A -
hemolytic streptococci
(Streptococcus pyoge nes)
◦ Virulence factors: resistance
to phagocytosis
 Streptokinases: lyse fibrin
clots
 Streptolysins: cytotoxic to
tissue cells, RBCs, and
protective leukocytes
23
related to 1.Respiratory system
Sinus disease :
1. Acute sinusitis
2. Chronic sinusitis
3. Tumours : Polip, Papiloma. Hemangioma, Osteoma
Lower respiratory tract disorders
Asthma
24
related to 2 Gastrointestinal system
Eating disorders :
a.Anorexia nervosa : extreme loss of appetite
o It may cause by underlying systemic condition :
gastrointestinal disease, alcoholism, drugs and
neoplasia.
b.Bulimia : ‘ox hunger’ abnormal hunger
o both are the behavioral eating disorders
o the etiology is not understood but the psychologic
and cultural factors play important etiologic role
25
Eating disorders :
a.Anorexia nervosa : extreme loss of appetite
b.Bulimia :
Oral manifestation and consideration:
o A diagnosis clue is the change in the appearance of the
enamel teeth
o The erosion teeth on palatal aspect  perimylolysis
o Posterior pharyngeal wall may appear erythematous.
o The parotid glands may enlarge  full and round
o More sensitive teeth should desensitized
o Antacids as mouth rinse after vomiting  to neutralize
26
1)Eating disorders :
c.Xerostomia :
o A complex symptom of less than normal amount of
saliva, dry mouth
o Etiology : advancing age, Sjögren’s syndrome
o Radiation therapy, HIV
• Clinical finding:
o Diminution in taste, inability to masticate and
swallow food and loss of salivary electrolytes and
immunoproteins  infections
27
28
Xerostomia
Clinical finding:
o Diminution in
taste, inability to
masticate and
swallow food and
loss of salivary
electrolytes and
immunoproteins
 infections
29
Lower gastro intestinal disease, include :
Liver Disease
Hepatitis
o Is defined as inflammation of the liver.
o Characterized by ballooning degeneration of
hepatocytes, scattered areas of round cell
infiltration and necrosis and varying amounts of
cholestasis, jaundice and bowel retention.
o The clinical sign and symptom is vary
o There are HAV, HBV, Non-A, Non-B hepatitis,
HCV, HDV
30
Hepatitis
Oral manifestation and consideration
• All type of hepatitis produce similar oral manifestation

• The most common feature is deposition of bile
pigments on the oral mucosa.
• The discoloration is best visualized in the posterior
palate and the floor of the mouth along the lingual
frenum
• Severe liver disease may also induce intraoral
bleeding, petechiae or ecchymosis
• No spesific treatment for this condition
31
Lower gastro intestinal disease,

Liver Disease
Dental evaluation of viral hepatitis
Clinical approach
all patients with histories of hepatitis or clinical
findings of jaundice of sclera, icterus, should be
laboratory test.
Laboratory test
SGPT, SGOT, LDH, HBsAg. Prothrombine time
Physician consultation
32
related to 3 Temperature
• The mouth is the site of entry for many

pathogenic micro-organism into the human
body.
• Some pathogens proliferate locally in the
oropharynx  with or without tissue damage 
gain entry into the blood stream directly or via
lymphatics  development of systemic disease.
• The systemic disease will show the sign and
symptom. oropharynx or perioral area  fever
33
Fever
• Fever is a common medical symptom (also known

as pyrexia or controlled hyperthermia)
• Characterized by an elevation of temperature above
the normal range of 36.5–37.5 °C (98–100 °F) due
to an increase in the body temperature regulatory
set-point.
34
Fever
• This increase in set-point triggers increased muscle
tone and shivering.
• As a person's temperature increases, there is, in
general, a feeling of cold despite body temperature
is increase
• Once the new temperature is reached, there is a
feeling of warmth.
• A fever is one of the body's immune responses that
attempts to neutralize a bacterial or viral infection.
35
Oral Manifestation of fever

• Periodic fever syndrome is composed of a group of
disorders that present with recurrent predictable
episodes of fever, which may be accompanied by:
o (1) lymphadenopathy; (2) malaise; (3)

gastrointestinal disturbances; (4) arthralgia; (5)
stomatitis; and (6) skin lesions.
o These signs and symptoms occur in distinct
intervals every 4 to 6 weeks and resolve without
any residual effect, and the patient remains healthy
between attacks. 36
• The evaluation must exclude: (1) infections; (2)

neoplasms; and (3) autoimmune conditions.
• (1) joint pain; (2) skin lesions; (3) rhinitis; (4) vomiting;
(5) diarrhea; and (6) an unusual asymptomatic,
marked, fiery red glossitis with features evolving to
resemble geographic tongue and then resolving
completely between episodes.
• This may represent the first known reported case in the
literature of a periodic fever syndrome presenting with
such unusual recurring oral findings.
37
• Dengue viral infection is a
cause of considerable morbidity
and mortality and may be
associated with a variety of
mucocutaneous manifestations
that may provide important
early clues to the diagnosis of
this condition.
Petechiae present on
lower limbs
Small blood-filled vesicles at
the junction of the hard and
soft palate
38
Presence of hemorrhagic
ulcerative erosion in relation to
gingivoalveolar mucosa
• Cutaneous and mucosal findings:

o erythema, morbilliform
eruptions, and hemorrhagic
lesions may figure prominently
in the clinical features of
dengue.
o The differential diagnoses
include a large number of
bacterial and viral exanthems as
well as drug rash.
Mucosal lesion on the
gingival area
39
• Dengue virus is a single-stranded RNA virus
transmitted mainly by the mosquito Aedes aegypti.
Various hypotheses regarding the etiology are as
follows:
a. Viral replication, which occurs primarily in
macrophages, although dendritic cells
(Langerhans cells) in skin may be the early
targets of infection.
b. Direct infection of the skin by dengue virus.
c. Immunologic and chemically mediated
mechanisms induced by interaction of the virus
with the host.
40
Tongue Lesions
Scarlet fever - strawberry tongue (lingua scarlatinosa) with and without

remnants of white fur
Coated tongue: white fur of the tongue peels from the tip in the shape of a
41
turned letter V, lichen ruber pemphigoides
• Scarlet fever (also called scarlatina in older
literature) is an infectious disease which most
commonly affects 4–8-year-old children.
• Symptoms include sore throat, fever and a
characteristic red rash.
• Scarlet fever is usually spread by inhalation.
There is no vaccine, but the disease is effectively
treated with antibiotics.
• Most of the clinical features are caused by
erythrogenic toxin, a substance produced by the
bacterium Streptococcus pyogenes (group A
strep.) when it is infected by a certain
bacteriophage.
42
related to 4 Endocrine system
Introduction
• The gland located at the postero superior pole of the
kidneys.
a. Function :
• adrenal cortex produces glucocorticoids,
mineralocorticoids and sex hormon
• adrenal medulla produces epinephrine and
norepinephrine
• the steroid hormon are synthesizied from the same
precursor : cholesterol
• inner medulla secretes catecholamines : regulate
metabolism, maintaining blood pressure, stimulating
43
the sympathetic nervous system.

44
Introduction
Control :
• Adrenal cortical function is controlled by ACTH from
anterior pituitary which in turn is controlled by
corticotropic releasing factor (CRF) from hipothalamus
• The balance is maintained by feedback inhibition by
circulating cortisol upon the pituitary and hypothalamus
• Adrenal medullary function is dependent upon the renin-
angiotensin system, serum potassium status and plasma
volume
-
45
Aldosterone → secreted by zona glomerulosa, regulate salt

and water balance by stimulating sodium reabsorbtion and
potassium excretion from the distal renal tubules
• Aldosterone secretion regulate by → ACTH, renin-
angiotensin, potassium plasma concentration
EXAMPLE :
• Blood pressures fall  renin is release  convert
angiotensinogen to angiotensin  ( 1. vasoconstrictor and
2. enhances sodium and water)  blood pressure 
result balances feedback loop aldosterone  back to
normal aldosterone function
46
Feedback
loops
involving
the
adrenal
gland
47
• Cortisol  glucocorticoid regulation carbohydrate, fat and

protein
• Cortisol is anti insulin that promote gluconeogenesis
• Cortisol exhibit anti inflamation by
a. Reducing migration of inflamatory cells and the
formation of bradykinin
b. Stabilizing cell membranes and thereby preventing the
release of lysosomal enzymes
c. Reducing capillary permeability.
d. Reduce movement of water into cells and maintain ECF
volume (extra cellular fluid) 48
Hyperfunction of the adrenal cortex (hyperadrenocorticism)
Cushing’s syndrome :
o Hypersecretion of cortisol as a result of :
• diseases affecting the hypothalamus >>> CRH
• affecting the anterior pituitary >>>ACTH
• affecting the adrenal gland itself >>> Cortisol
o Clinical presentation
Moon face, truncal obesity, muscle wasting, hirsutism
(unusual growth hair) , easy bruisability, poor wound
healing, osteoporosis, susceptibility to infection ,
hyperglycemia
49
Hypofunction of the adrenal cortex
(hypoadrenocorticism)
Addison’s disease
o Hyposecretion glucocorticoid as a result of :
• Autoimmune destruction of the adrenal cortex,
anemia pernicious, hypoparathyroidism
• Therapeutic bilateral adrenalectomy
o Clinical presentation
Weakness, weight loss, orthostatic hypotension,
nausea, vomiting, hyperpigmentation, hy
perkalemia, hypeglycemia
50
Hyposecretion
Cortisol  ACTH
fail to control 
ACTH →
intervention to
MSH  MSH  
melanin deposition
Hyperpigmentation
(dorsum linguae)
51
Black hairy tongue
Elongated of the
papilla related to
smoking
Drugs induce
52
Pregnancy
General guidelines
• Take a history of the trimester and note complications
and blood pressure
• T1 trimester I
• Fetus susceptible to teratogenic influence and
abortion
• T2 trimester 2 :optimal trimester for dental care
• T3 trimester 3 : syncope and hypertension risk are
greatest secondary to fetal position 53
Pregnancy causes hormonal changes that increase
your risk for developing oral health problems like
gingivitis (inflammation of the gums) and
periodontitis (gum disease, pregnancy gingivitis).
54
Pregnancy
Specific guidelines
• Preventive dental prophylaxis should be under taken at the
beginning of the second trimester and the third trimester
• All elective dental care should be deferred
• Non deferrable treatment should be completed at T2
• Radiographs are contra indicated in all emergency
situations ; when taken lead shielding is mandatory.
55
Pregnancy
Specific guidelines
• There should medical clearance for all drugs included
local anesthetics, analgesics and antibiotics
• Lidocaine, penicilline.erythromycin, and
acetaminopen are geebkrakkg approved
• Aspirin and vasoconstrtors in local anesthesia and all
drugs causing respiratory deprexsion are relatively
contraindicted
• Diacepam , nirroyus oxide and tetracycline are
absolutley contra indicted 56
related to 5 Carbohydrate metabolism
1. Diabetes mellitus (DM)
The classical symptoms :

• polyuria (frequent urination),
• polydipsia (increased thirst) and
• polyphagia (increased hunger)
57
INADEQUATE INSULIN ACTIVITY
HYPERGLYCEMIA
GLYCOSURIA
OSMOTIC DIURESIS
POLYURIA AND NOCTURIA

GLYCOSURIA
POLYDIPSIA
LACK OF METABOLISM OF URINARY LOSS OF

INGESTED NUTRIENTS INGESTED CALORY
HUNGER, MALNUTRITION, WEIGH LOSS
POLYPHAGIA 58
Complication :
• Clinical course is variable  rapid to
ketoacidosis
o Is a multifactorial disorders :
- genetic predisposition
- destruction of islets of Langerhans
- endocrine abnormality
- iatrogenic factors
- infectious agent
- insulitis
59
Complication :
• Kussmaul respiration
o deep gasping respiration associated
with ketoacidosis in diabetes mellitus.
• Acetone breath :
o abnormal and accelerated amino acid
metabolism and fat result in the
production of keton bodies and
ketoacidosis
60
Complication :
• Sensorium depression, cardiovascular
insufficiency, coma and death
o combination of hyperosmolarity and
metabolic acidosis lead to
progressive dehydration, acetone
breath, exaggerated breathing
(Kusmaul respiration)
61
Complication :
• Vascular manifestation  end organ disease
• Atherosclerosis (arteria coronary disease)
• Retinopathy
• Renal failure
• Susceptibility to infection
62
Complication :
• Neuropathy
• Gangrene
• Xanthomata
• Xanthelesma
63

• Inflammatory condition and infection
because of abnormal neutrophyl function
• Macro and Microangiopathy
• Altered microflora
• Dry mouth and burning tongue
• Persistent gingivitis
• Multiple carious lesion
64

• Periodontal disease
• Candida infection
• Mouth odor
• Debris and calculus
• Diabetic sialadenitis
• Greenspan’s syndrome ( dm, hypertention, erosive
lichen planus)
• Increase salivary viscosity
65
Diabetes mellitus T II
periodontal/gingival
manifestation
Clinical finding:
• These patient
produce insulin
endogenously.
Most of these
patient are obese
and do not
require insulin.
• Leads to
peripheral
vascular disease,
kidney failure and
poor wound
healing.
66
Diabetes mellitus T II
Palatal Candidiasis
Clinical finding:
• These patient
produce insulin
endogenously.
Most of these
patient are obese
and do not
require insulin.
• Leads to
peripheral
vascular disease,
kidney failure and
poor wound
healing.
67

o Dental conditions,
Abnormal dental finding from the chief
complain, dental history, oral examinaion and
radiographic examination are arrange as
primarily affecting either the teeth or
supporting tissue
o Nondental conditions.
Abnormalities of the oral cavity and perioral
stucture that are unrelated to the teeth are
caegorized as mucusal alteration,
enlargement, bone abnormality or
manifestation of cclinical syndrom. 68
 Example dental examination
69
 Example non dental examination
70
• Preliminary Decisions Concerning Diagnostc

Information
1. Relationship of finding
2. Reliability
3. Consistency
4. Clinical significance
71
• Prliminary Decisions Concerning Diagnostc

Information
1. Relationship of finding
 Abnormal feature from the history and the
physical examination that are related to a
spesific physiologic system are group on the
initial assumption that they relate to a single
abnormality.
 In some cases a group of feature may be
cause by more than one disease --- chronic
asthma and pulmonary disease.
72

Information
2. Reliability
 The reliability reflects the diagnostician’s
opinion of its accuracy
 Patient consistence gives the information in
describing their history although patient ask
in different question.
 Reliability may also be affected by the source
of information
 Clinical sign are generally more reliable than
symptom say by patient
73
Information
3. Consistency
 This is refers to the agreement among the
available diagnostic data from different
sources that relate to specific case.
 Patient taking antihypetensive medication,
blood pressure measure within normal range
is the consistence feature.
 Conistency of finding support definitive
diagnostic dicisions.
 If it is contrary suggest the need to revaluate
74
Information
 Clinical examination may showes unusual
finding that considered as either normal
variation or evidence of disease.
 Most disease produce both alteration of
tissue morphology called lesions and
changes of color as evidence of inflamation.
 All dental abnormalities and non dental
conditions of the mouth are clinically
significant to the dentist.
75
Information
 In contrast , chronic skin diseases and
arthritis of the lower limbs are examples of
diseases with little significance direct bearing
on dental care.
 Diseases or disorders as an examples can
generally be excluded from additional
diagnostic considerations as clinically
insignificant
76
DIAGNOSIS
• The clinician must be able to determine and utilize

diagnostic information to decide patient’s problem.
• Diagnosis is the basic for treatment
• The compleet diagnostic information and its evaluation
are directed to achieve the patient diagnosis.
• The diagnostic approach for spesific problem depend on
whether any systemic disease, a dental problem or non
dental abnormalities oral and their structure.
77
DIAGNOSIS
Dental Disease
• The dental disease or disorders include dental caries,

gingivitis, peridontitis, periapical lesion secondary to pulp
necrosis, developmental dental condition and
abnormality of dental eruption
• These features show special characteristics so that a

confident diagnosis can be quick determined
78
79
80
Mild Periodontitis Advance Periodontitis
81
DIAGNOSIS
Systemic Disease
• The definiive diagnosis of systemic disese is beyon the

scope of dental practice.
• Nevertheless dentist should prepare by training or

experience to perform and interpret physical examination
procedure, such as the assessment of heart sound that
are essential to the diagnosis of systemic dseases.
82
Moon-face
• Moon facies, or moon

face, is a medical sign in
which the face develops a
rounded appearance due
to fat deposits on the
sides of the face.
• It is often associated with
Cushing's syndrome or
steroid treatment
(especially
corticosteroids), which
has led to it being known
as Cushingoid facies
("Cushing's-like face"). 83
DIAGNOSIS
Systemic Disease
• If there any problem on

systemic disease, as says on
patient anamnesis, it must be
accomplished by medical
consultation.
• Definitive diagnosis of sytemic

disease should not be
confused with physical
assessment.
84
DIAGNOSIS
Nondental Condition of
The Oral Cavity And
Adjacent Structures
• Dentist is also responsible for

the definitive diagnosis and
treatment of nondental
condition of the oral cavity
and adjacent structure.
• This abnormality generally

present more chalenging
diagnostic problem than do
dental disease. What reason.
85
DIAGNOSIS
Nondental Condition of The Oral Cavity And

Adjacent Structures
• Reason 1. this condition are less common than dental
disease – less opportunity to accumulate and experience
in diagnosis and treatment.
• Reason 2. the diagnosis of non dental oral condition
based solely on the appearence of lesion or sign of
dysfunction is less likely to be correct as with the dental
disease, because similar manifestation may be produce
by many different disease,
86
DIAGNOSIS
Adjacent Structures
• Therefore the nondental problem requiries the

comparison of its features with several disease that
capable of producing abnormality.
• This comparative diagnostic technique is called

differential diagnosis.
87
DIAGNOSIS
Adjacent Structures
• The clinician list the diseases that could explain the

general feature of lesion or dysfunction.
• Specific dignostic finding that are contradictory with

typical characteristics of these diseases can be use to
exclude them from dignostic concideration.
88
DIAGNOSIS
Adjacent Structures
• After eliminating as many disease from concideration, the

remaining possibility are rank in the order of diagnostic
probability.
• This diagnosis is referred to as working diagnosis,

presumptive diagnosis or the clinical impression.
• .
89
DIAGNOSIS
Adjacent Structures
• Working diagnosis and the other less likely possibility

determine the need for additional test and preliminary
treatment.
• Additional procedures, such microscopic tissue

examination limit the list to a single disease. It is called
definitive diagnosis or final diagnosis or just the diagnosis.
90
REASSESSMENT
• Reassessment of the abnormality following appropriate

management is the final element of the diagnostic
method. It is consist of :
 Reevaluating patient symptom
 Reexamining the affected region after treatment
 This stage is the hypothesis test If diagnosis is
correct, the treatment is competently perform and
the response of the condition can be predicted.
91
TYPES OF CLINICAL EXAMINATION
• Diagnostic method can be modified to the most

effectively suitable need of the patient
• The modification will alter the amount of
diagnostic information collected initially or the
scope of diagnostic decision made by the
clinician
.
92
Comprehenshive Dental Diagnosis

• Is the most extensive diagnostic assessment and it is
appropriate for patient who request total dental care and
has not been evaluated previously.
• Requires the collection of all diagnostic information and
diagnostic decisions that are within the scope of dental
practice
• The information include detailed patient history, intra and
extra oral exmination, typical adjunctive procedure
93
Comprehenshive Dental Diagnosis

• This examination extend beyond planning total dental
care
• This database protect the clinician by documenting
patient’s initial status if any problem of substandart
treatment.
• This examination requiry concideration time but it reliably
provide foundation for comprehensive dental care.
94
Recall Diagnosis
• This examination is the appropriate approach for a patient
requests total dental care when the result of prior
comprehensive dental diagnois are available.
• The assumption is the part a prior data is still accurate but
the next patient’s medical and dental status have
changed.
95
Recall Diagnosis
• The goal of recall diagnosis is to identify the condition that
have changed, so it reflects current patient’s status.
• The update data refamiliarizes the dentis with the patient
original conditions and provide the new finding for
comparison.
96
Diagnosis Of A Specific Problem (SOAP)

• Dentist frequently asked to provide opinion concerning a
specific problem for recently evaluated patient
• For this purpose SOAP format is suitable applied. The
reason for evlation is briefly stated The format is as
follows :
S : subjective information or symptom of the patient.
O : objective or physical finding by the clinician
A: assessment or analysis or clinical impression
P : plan or recomended management for the problem; it may
specific treatment, referall or other.
97
Emergency Diagnosis
• Is design to expeditiously manage chief complain such as
bleeding, pain, acute infection that requiry immediate
attention.
• This is depends on the emergency complain and clinical
situation.
• Comprehensive diagnosis is sacrified to provide an urgent
problem.
98
Screening Diagnosis
• The evaluation is limited to obtaining the information
needed to answer the question without any treatment
responsibility
• An example is screening examination of oral cancer is
conducted in health awarness.
• It is focused on whether or not evident of lesions is
present without specific attention to routin dental
condition or physical assessment.
99
Various Diagnosis
• Multiple/dual diagnoses
 Preliminary diagnosis • Preclinical diagnosis
 Working diagnosis • Incidental finding
 Differential diagnosis • Over-diagnosis
 Syndrome diagnosis • Diagnosis complication
 Etiologic diagnosis • Billing diagnosis
 Possible diagnosis • Telephone diagnosis
 Problem on Problem List • Postmortem diagnosis
 Self limited diagnosis • Prenatal diagnosis
 Ruled-out diagnosis • Rare diagnosis
 Computer diagnosis (EKG read) • Difficult/challenging
 Deferred diagnosis diagnosis
• Undiagnosed disease 100
Various Diagnosis
 Contested diagnosis
 Novel diagnosis
 Refractory (to Rx) diagnosis
 Futile diagnosis (e.g., hospice pt)
 Delayed diagnosis
101
Staging in learning oral diagnosis
1. Learning the fundandamental of oral diagnosis and the

techniques and collecting diagnostic information
• Description of diagnostic procedure
• Anamnesis, taking history, physical examination ..etc
2. Evaluation and assessment of diagnostic information
• Structure alteration
• Color surface changes
3. Formulate diff diag of non dental disease of the oral cavity
and associated structure
102
Concepts of Differential Diagnosis
• The clinical manifestation of routine dental disease such

as dental caries and periodontitis can be recognized
their characteristic appearence because no other
diseases produce these lesion.
• Dentist often develope unrealistic expectation that
mucosal and other lesions of the oral cavity should easily
diagnosed by the same appearance recognition
approach. This diagnostic approach has been describe
as appearence recognition method
• .
103
• The diagnostic approach for non dental condition must

accommodate the possibility that the lesion could be
caused by any of several diseases and that a diagnosis
on he basis of appearance alone is to be incorrect.
• Most oral ulcers,for example, have more appearance
features in common despite many of the possible causes
• More generally,a differential diagnostic procedure is a
systematic diagnostic method used to identify the
possibility the presence of multiple disease
104
105
• A differential diagnosis is the distinguishing of a

particular disease or condition from others by using
evidence such as symptoms, patient history, medical
knowledge.
• A differential diagnosis is the determination of which of
two or more diseases with similar sign and symptom is
the one from which the patient is suffering.
• This method is essentially a process of elimination or at
least a process of obtaining information that shrinks the
"probabilities" of negligible levels,
106
• Physiologic pigmentation is
simmetry and persistent and
does not altered normal
structure.
• Found in any location but the
gingiva is the most commonly
affected intraoral tissue.
• Abnormal pigmentation has

been linked to cigarette
smoking and has been
designated as smoker’s
melanosis
• The component of tobacco
smoke stimulates melanocyte. 107
DIFFERENTIAL DIAGNOSIS
• Differential diagnosis is considered conceptually and

procedurally in several distinct stage.
• These stage are the categorisation of the abnormality by
primary manifestation, the listing of additional clinical
feature, listing of condition that can cause the primary
manifestation, elimination of unlikely cause and ranking
of possible causes by probability
108
109
St 1 Categorization of the abnormality by primary
manifestation
• Nearly all intra orally abnormalities are characterized
by a prominent feature that demonstrates the general
nature of the lesion.
• The primary manirestations of intra oral lesion serve
as a basis for categorization before differential
diagnosis.
• Nearly all intra oral abnormalities can be concired as
predominantlhy an alteration of mucosal color, a loss
of mucosal integrity, enlargement , or combination.
110
St 2 Listing of secondary clinical features
• The suspected abnormality base on primary
manifestations should be followed by an objective
determination of the secondary features of the lesion.
• The inexperience clinician would concidered specific
diagnosis, but it tendency to misinterpreted the
secondary features because of diagnostic bias.
• Careful visual examination after removal of saliva and
food debris allows observation of the lesion size, shape,
and location.
• These secondary features of the lesion along with
contributory information: age, gender, and medical
history provide the basis for differential diagnostic
decisions. 112
St 3 Listing of conditions known to cause the
primary manifestation
• Most non dental abnormality usually requires
consideration of many possible causes.
• The tendency is to consider a few common conditions
and interpret the clinical finding to ‘fit’ one of the disease.
• This can be an efficient method of mis diagnosis.
113
St 4 Elimination of unlikely causes.
• After the diagnostic features of the lesion and the
possible causes of the primary manifestation have been
listed, secondary finding and additional clinical
information can be compare to eliminate unlikely causes
• The goal is to eliminate as many causes from
consifderation as possible, which simplifies the
consideration of more likely causes.
114
St 5 Ranking of possible causes by probability
• After elimination of impossible conditions as potential
diagnoses, the next stage of differential diagnosis is to
rank the diseases that could explain the abnormality by
probabiiiity. This is relativly subjective.
• Nevertheles comparing the features of a patient’s lesion
with the thpical features of a possible diagnosis usuallu
yeilds an impression that the diagnosis is likely possibel
but not as probable, or unlikedly but possible.
115
Ranking of possible causes by probability
• The condition considered the most likely cause of the
lesion is referred to as the working tentative or
preliminary diagnosis or the clinical implmpression
• The working diagnosis and the less likely diagnostic
possibilities provide the basis for additionil diagnosis
procedure, sach as a biopsy or clinical laboratory test,
and for the initial clinical management of the condition.
• If all but one disease are eliminated from the differential
diagnosis then that is the definitive diagnosis or final
diagnosis.
116
Ranking of possible causes by probability
• Definitive treatment can be instituted once a diagnosis
has been made assuming that a definitive treatment is
available for that condition and that the problem has no
resolved..
• The final aspect of differential diagnosis are reevaluatiion
and recall.
• Of the definitifve diagnosis is incorrect, then an
unexpected clinical cours of the abnormality often reveal
diagnostic error.
• For that reason reevaluation and recall are essential
elements of the differential diagnosis process
117
INITIAL CATEGORIZATION OF SUSPECTED
ABNORMALITIES
• Two decisions must be made early in the differential
diagnosis of a suspected non dental abnormality of the
oral
1. Could the suspected abnormality be a variation of
normal tissues or is it actually evidence of disease.
2. If the abnormality is evidence of disease which lesion
category would provide the most appropriate
differential diagnosis of the condition. Look at table.
118
Features Of Normal Tissue Variations Compare With
Evidence Of Abnormality
1. Bilateral symmetry
o Symmetry both in location and the degree of extent of the
unusual apppearance is thipycal.
2. Predictable location
o Example of foramen mentale of mandible commonly
encountered mis intefpretation with periapical lesion.
3.Asymptomatic
4. Independent finding:
o intra oral lesion often present secondary changes such as
erythema of altered tissue consistency along with the primary
manifestation
119
Features Of Normal Tissue Variations Compare With
Evidence Of Abnormality
5. Static normal variation remain unchanged
6. Increased prominence with age,:
o variation of health itissues beme mor common or
more prominent with increase age of the patient
7. Remain unchanged followig empiric treatment,
120
Categorization Of Abnomalities By Tissues Affected And
Primary Manifestation
• By primary manifestation simplifies the diffrential
diagnosis by allowing the clinician to focus on conditions
capable of producing the abnormaoity.
• Disease that cause different primary manifestations can
be exclude from consideration early in the differential
diagnosis.
• For an abnormality to be considered in the mcosal lesion
category the primary manifestion of tne abnormality is
altered apearance of the superficial oral mucosa.
• Additional fiinding imply that the condition should be
considered within another differential diagnosis category.
121
Categorization Of Abnomalities By Tissues Affected And
Primary Manifestation
• White mucosal lesion :it is essestial for differential
diagnosis. The texture are smooth or rough provides an
indication af the nature of the lesion. Some white lesion
rub off with lateral pressure using a cotton gauze, which
indicaes that the white lesion appearence is cause by
eign maat al materal .
• Dark mucosal lesion.: the lesion represent abnormal of
blood pigmentation or excessive melanin pigment or dark
foreign accumulation.
• Soft tissue enlargment : soft tissue enlargement is an
indication of the composition of the abnormality :clinical
examination is known by palpation
122
123
TERMINOLOGY USED TO DESCRIBE
MUCOSAL ABNORMANITIES
• The primary and secondary features is particularly used
during yhe differential diagnosis when making
comparisons.
• Most of the terms standarized by dermatologist in the
differential diagnosis of skin lesions can be directly
applied to mucosal lesions.
• Descriptive term applicable to lesion of mucosal
discoloration
• Descriptive term applicable to loss of mucosal integrity
124
Summary
• In summary the differential diagnostic sequence consists
of
1. Categorization of the abnormality by manifestations
2. Listing the secondary clinical manifestations and
finding
3. Listing the conditions that are known to cause the
primary manifestation’
4. Elimination of unlikely cause
5. Ranking of possibile cause by probability’
6. Determination of a working diagnosis and a plan to
arrive at a definitive diagnosis 125
Lorum ipsum
126

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1

Definition of diagnosis (Merriam Webster)

 Oral Diagnosis is the art of using scientific

• The element of diagnostic method

• The element of diagnostic method

• The element of diagnostic method

• The element of diagnostic method

• The element of diagnostic method

• Several sources of diagnostic information available

• The diagnostic data base consist of :

• The diagnostic data base consist of :

• The diagnostic data base consist of :

 Clinician search for associations and patern

Upper Respiratory Infection:

• All type of hepatitis produce similar oral manifestation

Lower gastro intestinal disease,

• The mouth is the site of entry for many

• Fever is a common medical symptom (also known

Oral Manifestation of fever

o (1) lymphadenopathy; (2) malaise; (3)

• The evaluation must exclude: (1) infections; (2)

• Cutaneous and mucosal findings:

Scarlet fever - strawberry tongue (lingua scarlatinosa) with and without

the sympathetic nervous system.

Aldosterone → secreted by zona glomerulosa, regulate salt

• Cortisol  glucocorticoid regulation carbohydrate, fat and

1. Diabetes mellitus (DM)

The classical symptoms :

POLYURIA AND NOCTURIA

LACK OF METABOLISM OF URINARY LOSS OF

HUNGER, MALNUTRITION, WEIGH LOSS

Oral manifestation and consideration

Oral manifestation and consideration

• Organizing Diagnostic Information

• Preliminary Decisions Concerning Diagnostc

• Prliminary Decisions Concerning Diagnostc

• Prliminary Decisions Concerning Diagnostc

• The clinician must be able to determine and utilize

• The dental disease or disorders include dental caries,

• These features show special characteristics so that a

• The definiive diagnosis of systemic disese is beyon the

• Nevertheless dentist should prepare by training or

• Moon facies, or moon

• If there any problem on

• Definitive diagnosis of sytemic

• Dentist is also responsible for

• This abnormality generally

Nondental Condition of The Oral Cavity And

• Therefore the nondental problem requiries the

• This comparative diagnostic technique is called

• The clinician list the diseases that could explain the

• Specific dignostic finding that are contradictory with

• After eliminating as many disease from concideration, the

• This diagnosis is referred to as working diagnosis,

• Working diagnosis and the other less likely possibility

• Additional procedures, such microscopic tissue

• Reassessment of the abnormality following appropriate

• Diagnostic method can be modified to the most

Comprehenshive Dental Diagnosis

Comprehenshive Dental Diagnosis

Diagnosis Of A Specific Problem (SOAP)

1. Learning the fundandamental of oral diagnosis and the

• The clinical manifestation of routine dental disease such