The Diagnostic Process/Algorithm

Question 1

Describe the diagnostic process

Answer 1

1. Chief complaint
   History - ask good questions
   Exam - describe findings
2. Analyze and form a Differential Dx
3. Gather more date (i.e. imaging, bloodwork, biopsy, etc)
4. Final Dx
5. Treatment
6. Reevaluation, analyze
   (repeat 2-6 if needed)

Question 2

Gathering Information

Answer 2

Chief complaint, history, physical exam - describe findings and ask questions

Question 3

Analyzing Information

Answer 3

-Description and history will allow you to eliminate or include potential diagnoses
-Create a differential diagnosis (ranked list of possible diagnoses in descending order of probability with your working diagnosis at the top of the list)

Question 4

Final diagnosis and Treat and reevaluate

Answer 4

Final Diagnosis dictates the tx to give

Treat and reevaluate if unresponsive, repeat process!

Question 5

What is the DADD algorithm?

Answer 5

Describe
Ask
Differential (II MIND)
Do

*Each step is critical!
-A correct description and answers to key questions determines the differential diagnosis

Question 6

What does the differential dx determine?

Answer 6

Determines what you should do and how you should communicate with the pt and other providers

Question 7

What is the DADD approach?

Answer 7

-Disease categories (II MIND)
-Questions we could ask to help determine which disease type it could be
-Tx options we have based on the likely disease process
-Then we will come back to description and work the process in order

Question 8

What are the 6 major disease categories?

Answer 8

Keep your I I (eyes) in MIND

1. Injury - (physical, chemical/drug) that heals within 2 weeks when stimulus is removed
2. Infectious - acute/chronic, pain, +/- systemic symptoms, signs of inflammation
3. Metabolic - nutritional, endocrine disturbances
4. Immune-mediated - acute/chronic, often comes/goes or gradual worsening without tx. Redness, ulcers are common
5. Neoplastic - continual growth (benign/malignant)
6. Developmental - congenital or show-up during growth period and don’t change further

Question 9

What are the main features of the Injury category?

Answer 9

Inflammatory reaction that started with physical (mechanical, thermal) or chemical/drug exposure that should heal when stimulus is removed

Question 10

What are the main features of the Infectious Diseases category?

Answer 10

Viral, bacterial or fungal (candidiasis)
-Variety of presentations (acute or chronic)
-Typically painful
-May have systemic symptoms (e.g. fever, LAD, malaise)
-Disease resolves when organism is destroyed through medication (antivirals, antibiotics, antifungals) or immune system self-limits

Question 11

What are the main features of the Metabolic category?

Answer 11

nutritional (vitamin deficiencies), endocrine problems

Question 12

What are the main features of the Immune-mediated category?

Answer 12

-An immune/inflammatory response to something (self antigen, piece of an organize, medication etc)
-Acute or chronic, come/go with flare-ups or show gradual worsening
-Can affect skin and/or mucosal (i.e. oral cavity) sites usually as blisters, erosions, ulcers
-Can’t cure, treat by suppressing the immune response (steroids)

Question 13

What are the main features of the Neoplasms (tumors) category?

Answer 13

Show continued increase in size. Usually painless
-Benign: well-defined, grow slowly (many months to years) can destroy locally but don’t spread (invade/metastasize)
-Malignant (cancer): poorly defined, grow faster (weeks to months), spread (invade and can metastasize). Can cause pain and/or paresthesia

Question 14

What are the main features of the Developmental diseases category?

Answer 14

-Present at birth or show up often during the first 2 decades
-Typically limited growth potential though may grow like a tumor (i.e. some developmental cysts) (exception: cysts do NOT stay stable in size; they tend to grow due to increased pressure)
-Often solitary; if inherited or syndromic - multiple lesions

Question 15

What questions should you ask?

Answer 15

-Isolated finding?
-Duration?
-Pain/paresthesia?
-Change?
-Injury?
-Treatment? (previous tx)

Question 16

How does asking, “Is this an isolated find in the mouth” help?

Answer 16

-Neoplasms and developmental cysts are typically solitary
-Other categories often have >1 lesion
-Immune-mediated diseases can affect the skin and other mucosal surfaces
-Inherited conditions, including syndromes, can effect multiple organ systems

Question 17

List the durations associated with II MIND?

Answer 17

-Injury: however long the injury has been present (usually acute onset though)
-Infectious: days to weeks
-Metabolic: slow and chronic
-Immune-mediated: acute or chronic
-Neoplastic: weeks to years
-Developmental: discovered during youth, cysts-slow growing; others can be discovered abruptly

Question 18

Why is “pain” an important question to ask?

Answer 18

Developmental conditions and most neoplasms (except some cancers) are NOT painful until large. All of the rest can cause pain

Question 19

Why is “change” an important question to ask?

Answer 19

-No change: developmental, trauma (depends)
-Bigger/worse-metabolic, infectious, neoplastic
-Comes/goes- immune-mediated

Question 20

Why is “injury” an important question to ask?

Answer 20

(physical or chemical/drug?)
-Establishes injury as a potential diagnosis

*This could indicate if this is a provider-induced (iatrogenic) or patient-induced (factitial) injury

Question 21

Why is “treatment” an important question to ask?

Answer 21

-What have you or other done to treat this?
-Did it help or make it worse?
(makes sure we aren’t repeating tx that didn’t help)

*This could indicate if this is a provider-induced (iatrogenic) or patient-induced (factitial) injury

Question 22

What are some medical history clues?

Answer 22

-Some immune-mediated diseases are systemic and can affect the mouth
-Immune-mediated reactions (injury) to a new medication or an increase in dose of that medication may occur
-Look for risk factors for malignancy, infection (immunosuppressed, other cancer tx, antibiotic use, diabetes)

Question 23

Describe your tx options

Answer 23

1. Do nothing (have a final dx) - have a final diagnosis that requires no treatment - explanation only
2. Get more information (radiology, lab work, biopsy) to make a final dx
3. No immediate tx, but follow-up to see if additional tx is needed
4. Treat definitively and follow-up (establish appropriate recall strategy)
5. Refer to dental specialist or physician

Question 24

Describe when you would “do nothing”

Answer 24

-Good if have clear final diagnosis and no tx is indicated (good for developmental anomalies)
-Bad for infectious (painful and will spread), immune-mediated (if painful, likely will recur), neoplastic, developmental cyst (will continue to grow), source of trauma

Question 25

Describe when you would “get more information”

Answer 25

(radiology, labwork, incisional biopsy)
-Good for metabolic, neoplastic, developmental cysts and immune-mediated and maybe for infectious. Not needed for traumatic lesions

Question 26

Describe when you would “no immediate tx, but follow-up”

Answer 26

If random injury occurred (eg biting) and not repeated than 2-3 weeks later it should be resolved

Question 27

Describe when you would “treat and follow-up”

Answer 27

(establish appropriate recall strategy)
-Injury: eliminate the source of the injury (crown margin, calculus, biting, etc) and follow-up
-Infectious:
1. bacterial: pulp-related (restore, RCT or extract +/- antibiotic, pain); Perio (debride, antibiotic and/or CHX, pain)
2. viral: give an antiviral medication
3. fungal: give an antifungal medication
-Immune-mediated- steroid therapy, pain control
-Neoplastic or inflammatory mass from trauma: excisional biopsy for final diagnosis

Question 28

Describe when you would “refer”

Answer 28

Refer to PCP only in evaluation for systemic disease is indicated