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Transcribed by Amit Amin July 07

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, 2014

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[Diagnosis of Oral Diseases] [1] [Introduction to Diagnosis] by [Dr. Vogel]

[No slides]]
[Dr. Vogel] Right now we are just going to show you the clinical aspects of this
patient. This is the right quadrant/ secant (maxillary mandibular). Just look at this.
We are going to continue this for 8 more slides. Mandible. Low right secant. Take a
look. In other words, the information would be what you would do as a clinician. In
others words what you would look up or whatever it might be. Maxillary right. The
insert just shows you the entire extent of the secant. Nothing you want to make a lot
of notes on huh? Maxillary left and mandibular left buccal view. Lingual mandibular
left. Palatal maxillary left. Anterior. You are the clinician. What do you want to do/
find out? Which you will be in about 7-8 months. Mandibular incisors. Again the only
information Im giving is Caucasian female w/ a normal gait. Middle age. When you
look in the mouth this is what you see. Give you 5 minutes to basically determine
what you (do it collectively) you want to know that you dont know already and
what you dont know and why you want to know it. Make a problem list and then a
treatment plan.
Ok. It seems like 5 minutes was too long since I dont see a bunch of people
working on this. So we have asked one of you colleagues to be a scribe. Shes going
to write down what it is you want to know. Dont write down my answers. You can
get the answers. The hard part is coming up w/ the questions. Patients do not come
w/ a question and A, B, C, D, E on their skulls. The answers are easy. You can have
background info that you know. If you dont know the questions you are dead in the
water. You have no idea where you are. This is about the questions not the answer.
Hopefully showing you the answers you will see how important it is to know what
the questions were. What do you want to know about this patient? I can just choose.
Doctor gives me one thing. Their oral health. She brushes 3 times a day. Doctor. Her
Medical history. It is really not significant. She sees OBSGYN on a yearly basis. She
has not gone to a primary physician in 2-3 years. She does see her OBSGYN on a
yearly basis. Not taking any medications. Take a 1-a-day vitamin. Diet. Specifically. I
cant tell you what she ate for dinner for the last two weeks. I definitely eat
carbohydrates. I eat proteins I eat fat. I brush 3 times a day. So I give you some more
information. The patient is relatively short. 53 and looks moderately obese. Shed
definitely be obese by any medical standard but she probably weighs 250-275. Yes.
What brings her in today? Her complaints? 1. Her gums bleed unbelievably when
she brushes. When she eats something they bleed. 2. Shes missing the upper right
bicuspid. It was extracted a year ago. She doesnt like that space. Shes noticed that
over the last couple years that her upper and lower front teeth are moving and the
spaces are getting bigger. She has 3 complaints. Bleeding gums, the space where the
right bicuspid has been extracted and the movement of the maxillary and
mandibular incisors over the last couple of years. Does she floss? No. Does she ever
get dry mouth? No. She drinks coffee and juices but nothing exceptional. Shes a
housewife. She doesnt have a jar of juice or coke on her desk all day. She does not
smoke. As I said she doesnt take any other medications. I cant show you how she
brushes b/c thats therapeutic and not diagnosis. You wouldnt ask that in the first
meeting. But its like this. I dont know when she had a last set of x-rays. It was about
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2-3 years ago when she went to a dentist. Her family history? Her mom is a type II
diabetic. Btw, for our purposes, you can ask me whats the family history/ medical
history. I dont want to give things away. You dont have to do specifics or the big
picture. What do you want to know about? Middle middle class. Husband works for
the city. Shes a housewife. I dont ask how much money they make. Not too hard to
figure out I guess. Does she use recreational drug? She did not admit to using any.
About two years. Are the teeth loose? She has mobility patterns that include 2s and
1s. There are some recurrent caries. Shes not in pain. You would ask a patient that
anyway if they have any discomfort. She appears to have normal salivation. There is
nothing-abnormal period about her saliva. Gums bleed. No particular discomfort
whatsoever. No acid reflux. Do I ask them if bulimic? If you believe they are bulimic
you would ask that question straight up. Why would you be embarrassed? When I
went to dental school oral contraceptives just became very big. I would be
embarrassed if they were on oral contraceptives. You cant be embarrassed. You
have to know the answers to questions. We had a patient complain of a sore palate.
It looked like trauma but if you dont ask the question you cant answer it. Theres
nothing funny about it. Youre trying to find out facts to make an appropriate
diagnosis. Theres nothing embarrassing about being sick or sex. Basically put it off
money wise, life was busy; nothing hurt her, nothing of immediate concern. 30-40%
of adults see dentist on annual basis and the number keeps going down. Children
keep going up though. What are her probing depths? We can show you those. There
we go. So probing depths by themselves is not what you want to know. You want to
know attachment levels. 6mm and no loss. You have to look at gingival margins as
well. Generally 2s and 1s w/ some 0s as well. You dont need to memorize numbers.
If you need data ask for it, and Ill show it to you. Ill leave that up for a while.
Anything else you want to know or see? Thats it? Yes sir. Is her drinking water
fluoridated? Where she lived it wasnt. She was in NJ and the area is not fluoridated.
If you would like radiographs Ill show you radiographs. Based on a clinical exam
and history we took a full mouth series. Ill show you 12-15 of them. This is the
upper right posterior. Again upper right. Youre going to make problem list? Make
some notes. Lower right. Maxillary left. Again we didnt put them all here. Just
enough to get a decent idea of whats going on. Mandibular left. Maxillary anterior.
Mandibular anterior. Anything else you want to know? Her fillings? Apple pie filling?
Her restorations. Thats like you dont like gum tissue w/ professionals. She started
to have restorations as a child. Many of them date to her being probably a teenager
or younger. No she does not have any orthodontics. So what would a bigger category
of that be? Dental history, which falls under medical history. So dental history she
has some extractions. Recent one being actually right after we took radiographs and
before clinical pictures. She had an emergency at some point. She went back to a
restorative dentist who took it out and after that we took the photos. She had
restorations and cleanings, etc. The tooth was loose. And it hurt her. Again this is
what the patient says. I didnt attract the tooth. Does she have bone disease? What
kind of disease? No. Again, medical history was normal. If you have low calcium you
have a sick puppy. You wont survive. Your heart starts going into contractions. If
your serum calcium is not 10mg% you have big big problems. If you fall to 9 you
probably wont survive. Yes sir, last one. No her dentist is quote gum problems and
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she needed to brush her teeth better. She hadnt been to a physician. What do you
want to know? Really as a doctor you want to know two things. You want to know if
something is broke or is susceptible to break. Break does it work the way its
supposed to work? It hurts. Patients doesnt like esthetically. Its not stable but its
continuously changing. Its adversely effecting another system. The data collections
got to towards is it broke. The data collection can be asking a patient, looking a
radiograph, whatever it might be. Another thing is susceptibility. Its based on
epidemiology. If a patient manifest this, there is a good chance they will get a certain
condition or disease. If they are not broke or susceptibility game over. You dont do
prevention on someone who isnt susceptibility. No therapy on something that is not
broke. How do I collect the data? Very organized system. Chief complaint, which you
did ask. Someone asked why is the patient here? Nobody asked about a history of
the chief complaint. What does that tell you? Diagnosis. For example, the patient
says they really have significant bleeding gums what might be another question to
help make a diagnosis that it might be a periodontal disease? What do you think? Its
been a couple years. Its continuous. Are they bleeding anywhere else in the body?
Blood in their stool? Blood coming out of their nasal cavities or ears? Dont you want
to rule out if its systemic? Ive seen people treat periodontal disease when its not
perio. If it hurts here, Im going to ask questions about what the possibilities may be
of hurting. What does the pain feel like? Im trying to get an idea of what to examine.
Diagnosis process is not just what is the complaint. Why do you see it? Why is it
there? Remember if something is broke, whats broke? The diagnosis. Why its
broke. Etiology. Based on epidemiology. What happens if we do nothing or A, B, C, D,
or, E. Its not good to just know something is broke? Ok. So chief complaint, history
of chief complaint. We asked about medical history. What we didnt ask about. If Im
a cardiologist, Im going to ask more questions. Dental history is not separate. We
didnt ask for a review of systems. Thats kind of important. Review of systems
basically is where the patient doesnt know they have but based on symptoms you
may say ahaha something is wrong. If I thought the patient was diabetic based on
history I may ask if they are thirsty, get up at night to urinate, sores that dont heal.
It basically is organ system by organ system trying to find reasons. We did do family
history. Mom had diabetes, which was the only big part. We got a little bit into social
history. I like to think about the big picture first. We asked about drugs, smoking but
not alcohol. If you think about the big topic, I know the general concepts (social,
family, medical history, review of systems) I can feel that in. Its looking at the big
questions and knowing through them what it is you want to find out. After that you
have the physical evaluation. I heard nothing. You didnt want to know anything
about her. No bop. pulse, respiration. I told you she had a normal gait. Lesions on the
skin. You didnt see the skin or ask me about it. Youre going to look at the mouth but
not the patient. Let me see the teeth. Youre not going to wipe anyone off this earth if
you miss caries. You will, if you miss other things. Thats just a fact. It happens all the
time. So we didnt ask about that. Even in the physical in your area, all I heard about
was from teeth and gums. How about head and neck exam? Lumps, bumps, nodes,
thyroid enlarged, oral mucosal lesions? You didnt ask about that. Teeth? Sure caries
we heard. There were some caries. What else about teeth? Having to do w/
susceptibility. What did you notice on the clinical photos? Any real large
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restorations that undermine cusp tips? Make them more susceptible to fracture. You
ask for probing but you want to know for loss of attachment. All that by itself lets
you know how large it will be to clean that area. Based off that I will charge how
much I will charge to clean it. I will charge more for more mms. Past 5-6mms, my
chance of fully cleaning the area just by physical manipulation is decreased
significantly. Might need to clean it chemically as well. What does attachment loss
tell me as well? Susceptibility. Theres a lot of information that we probably should
have know. What were some of the other questions? Why do you care how much
they brush their teeth? Do you really care? Or do you care how effective they are? If
they brush 9 times a day but when they open their mouth it looks terrible? It doesnt
really matter how much they brush, its more about how effective they do oral
hygiene. I floss twice a day and you go interproximal you have 5lbs of plaque. They
are doing ineffectively. You still have to show them oral hygiene. How they brush is
a good thing but you dont do that diagnostically. The patient needs to do better
home care. Then you have them demonstrate and redemonstrate and correct. Its a
whole cyclomotor skill. You cant teach them how to hold a scalpel. Its much more
complicated. What else did we talk about? Dry mouth would be a part of what? A
review of systems. Do you have any problems chewing your food? Here you are
dentist and this is your organ system. Im trying to show you that for 20 some odd
years youve been asked for the answers. As a professionals the answers are easy.
You have to know to ask the questions. Btw did anybody ask if you have any
problems w/ your smile? Part of the chief complaint was part of that. What did she
complain about esthetically? I didnt tell you. You didnt ask. No she complained
about spaces. You didnt ask what she cared about. You got to know what was
important to her. It was the esthetics. Otherwise you dont know how to fix it. One
fix might fix one thing and another might fix another. Lets go over what I thought
we found about the patient in an orderly way. Chief complaint, medical complaint.
So she was about 42. I said she was middle aged and she was 42. Chief complaint
spacing of lower incisors. All of those were esthetics. Quote bleeding gums in her
words. History. Teeth moving over past few years. Why is that important? What is
that going to lead you to do differently then if she said the spaces occurred 5 years
ago and they have been the same the last 5 years? What are you going to do
differently as a clinician? You have to know why they are moving? One reason why
anything moves is b/c of forces. You have to see where the forces are. The forces are
on a diminished periodontal. They may not be tolerable since they have lost
resistant. If I didnt know these teeth are still moving I wouldnt know the cause or
how to fix it. I could fix it orthodontically but if I dont know the cause then they will
break again. These are real life things you have to know. Based upon asking the
questions. Medical history, we told you that. Saw a primary physician 3 years ago.
Extraction 2 years ago extractions/ cleaning. Review of systems that based upon
extensive bleeding gums. Were there any systemic magnifications? There wasnt
any. You have to ask the question though. Family history, housewife, her mother had
type II diabetes. Very sedentary. She almost waddled b/c of her weight. Shes a
housewife. Physical exam, I didnt do it. She was 52 165lbs. Normal gait. B.P.
slightly elevated. Head/ Neck WNL. Occlusion, history of migration. Mobility- 1,2,
Teeth shaking on several teeth in intercuspal position and excursion. She went into
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protrusive or lateroprotrusive and they were moving quite a bit. You saw forces that
you could guestimate that they could continue to move and get looser. She had some
caries and some larger restorations. One or two recurring caries. What Im trying to
show you. Its really not difficult. Its not memorizing facts. Its the idea of
memorizing a broad process. Its an understanding of what I want to know and how
do I find it out. And youve been doing that all your life. Thats what an infant does.
They basically do it. Its not the answers, its the questions. What is the break, how
much, why, and how do I find out its broken? Whats the orderly process for doing
it. The history of the chief complaint. Its not just how long its been there. The idea
of medical history. Review of histories, systemic symptoms, good head and neck to
try to understand whats going on. So really its what the most important part of
why they call you doctor. I can teach you how to make wonderful fillings 2 years
after high school. Its been proven to be able to be done. If you want to differentiate
yourself you need to say I need to do the doctor part. Youre homework is what are
the patients problems? If you cant identify the problems you can fix. Im not
interested tooth by tooth. Caries. Im not interested for our discussion what tooth
has caries. They do have a problem of an infectious disease called caries. Whats
their problem list? You can start thinking about what you want to do first.