This document outlines the process for conducting a thorough medical examination and workup. It discusses obtaining a detailed patient history, performing extra-oral and intra-oral clinical examinations, ordering relevant blood tests, radiographs and biopsies, and correlating all findings to reach an accurate diagnosis. A complete workup involves gathering information from the patient's history, conducting physical examinations both inside and outside the mouth, ordering diagnostic tests and imaging, and considering all factors together to understand the patient's condition.

1. Dr. Ali Tahir

2.  History
◦ Complaint
◦ Medical history
◦ Drug history
◦ Social history

3.  Clinical examination
◦ Extra-oral
◦ Intra-oral
 Investigations
◦ Blood
◦ Biochemical
◦ Radiographic
◦ Histological

4.  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 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. Extra-oral:
 General appearance
◦ Wasted, mal-nutritioned, anxiety, agitation?
 Breathlessness
◦ Cardiorespiratory problem?
 Face
◦ Shape & symmetry
◦ Cranio-facial syndromes
◦ Cushingoid appearance?
◦ Neurological deficits?
◦ Cyanosis?
 Scalp & face
◦ Scant hair

7.  Eyes
◦ Conjuctival sacrring (pemphigoid)
◦ Pale, yellow or blue sclera
◦ Exophthalmia
 Neck
◦ Lymph nodes
◦ Goitre

8.  Hands
◦ Raynaud’s phenomenon
◦ Koilonychia
◦ Joints
◦ Palmar keratosis
 Wrists
◦ Purple papules
 Skin
◦ Petechiae or ecchymoses, cyanosis. Jaudice,
pigmentation

9. 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. Blood examination
Can be helpful in diagnosis of
 Leukopenias
 Thrombocytopenias
 Myelomas
 Anaemias
 Infectious mononucleosis
 Polycythemias
 Leukaemis

11. Normal values
 Hb 12.5-17.5 (male)
11.5-16 (female)
 Mean Cell Volume 80-90
 ESR 0-15mm/h
 Red cell count 4-6 × 1012 /l
4-5 × 1012/l
WBC count 4-10 × 109/l
Platelet 150-400 × 109/l
Serum B12
170-590 µg/l

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

13.  Autoantibodies
◦ RA
◦ Antinuclear factor
◦ SS-A, SS-B
◦ Epithelial basement membrane
 C1 estrase inhibitor
◦ Reduced in hereditory angioedema
 Viral antibodies
◦ HIV
◦ EBV
 C-reactive protein

14. 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. Types
1. Incisional
2. Excisional
3. FNA

16. 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.  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. 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 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. 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.  Direct smear
 Culture
 Molecular techniques to avoid culture use
◦ Microbial products
 Toxins
 DNA
 PCR
 FISH
◦ Antigen/Antibody detection

23. Plain film radiography
 Extra-oral
◦ Panoramic
◦ Lateral view
◦ Occipitomental
◦ PA
◦ Submentovertex
 Intra-oral
◦ Peri-apical
◦ Bitewing
◦ Occlusal
 Digital radiographs

24. Contrast studies
By enhancing the
radiodensity of
patients tissue
Usually used in
Salivary glands &
TMJ

25.  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.  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.  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.  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.  Ionizing radiations  Non-ionizing
◦ Plain radiographs radiation
◦ Contrast studies ◦ Ultrasound
◦ Radioisotope studies ◦ MRI
◦ Computerized
tomography (CT)

30. 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