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In the couple of years I have trained, I have come to realize how easy it is for one to overenthusiastically hone in on one particular diagnosis as the patient relates his initial complaint. With that respect, it is necessary to start the patient assessment with open questions to prevent precluding the actual diagnosis or diagnoses. This allows the patient to give a broader scope and formulate the complaint with his words. Open questions include sentences such as: How may I help you? How are you? Once the patient has given their complaint (which is the toothache in the upper left side of the mouth) I would then ask the patient to describe the pain firstly with his own words and then I would go through a detailed pain history. Information that would be useful in the pain history are: Character of the pain Location Is it localised or diffuse? Does it travel anywhere around the face(Radiation) Is there a particular tooth that is the source of the pain? Severity: the use of a pain scale could be useful however it is extremely subjective and relative to the patients tolerance of pain Duration of the pain Frequency of the pain Exacerbating factors e.g. hot, cold, sweet foods Precipitating factors e.g. when biting, on release of biting or spontaneous Relieving factors e.g. use of analgesia, pressure, eating on the other side

As I am taking the history, it is also worth visually inspecting the body language of the patient. If the patient is in severe pain, he may be holding the side of the face that is painful. I would also ask if there are further complaints that needs to be addressed. Other information at the history taking that may prove useful include: Medical history: General patient management, prescribing any medications Dental history: Anxiety, attitudes to dental care Oral hygiene and habits: Assess the patients oral health, parafunctional habits is useful information to the differential diagnoses. Social history: Smoking and alcohol status, occupation

A full oral examination is necessary if I am seeing the patient for the first time. This is necessary to detect early if there is anything sinister the patient has not already mentioned. With the extra-oral examination, I would be checking the head and neck for: Symmetry: obvious swellings Abnormal changes in colour and consistency of the skin e.g. redness if inflammation present Swellings or lumps on palpation Function of the temporomandibular joint: to assess if trismus present or abnormal function

Lip form

Intra-orally, I would examine the soft tissues which includes the gingivae, oral mucosa, tongue, floor of mouth, palate and tonsillar region for any abnormalities. I would then focus on the general state of the dentition: Condition of the natural teeth How much restorative work has been done prior? Condition of the restorative work Is any wear signs present? Physiological or pathological Presence of plaque and calculus Presence of active and arrested caries Periodontal status Occlusion

When examining the suspect tooth (or suspect teeth if the patient is unable to be locate one in particular), assessments I would make are: Any obvious pathology present? E.g. caries, fracture, wear facets into dentine/pulp, Any restorations present? If so, how large and deep are these restorations. Is there any marginal leakage? Periodontal support Mobility Is it in occlusion and if so, is it taking more stress than the other teeth?

With these investigations so far, I am able to filter out my differential diagnoses to the one or few that remain. In order to further support the diagnosis or investigate the treatment options, special investigation tests can prove useful. These are not diagnostic on its own. Special tests used commonly in practice are: Radiographs: bitewings to assess any pathologies at the interproximal areas, a periapical of the tooth or region in question may help to view the extent of pathology, if it involves the periapical or marginal periodontal regions and bucco-palatal fractures, quality of root treatment if present. Vitality tests of the pulp such as the electric pulp test, cold test and hot test. These can be quite variable and one has to consider that they are not entirely conclusive. A heavily restored tooth with a sclerosed pulp chamber may give a negative vitality even though vital pulp tissue may be present in the canals. In contrast, it is possible for a dead pulp to give a positive reading due to fluids in the canal. Percussion and palpation tests is useful to check if the periodontal ligaments are inflamed or in a fracture, painful due to being stretched or broken. Dyes such as methylene blue could be used to detect cracks and non-displaced fractures.

Once special tests have been performed, if necessary, the correct diagnosis can be reached and the appropriate management of the problem and be made. Other necessary special tests can be made if the aetiology may be non-odonogenic in origin. It is possible for a patient complaining of toothache to not actually have a toothache per se. The aetiology of the pain may come from the pulp, periodontal ligament, larger nerves (in the case of neuralgia), referred pain from regional structures e.g. sinus, and psychogenic. Thus my differential diagnoses would be:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Reversible pulpitis Irreversible pulpitis acute/chronic Periapical periodontitis acute/chronic Other periapical pathologies e.g. abcess, cysts Marginal periodontitis - acute/chronic Dentine sensitivity Occlusal trauma Referred pain e.g. in sinusitis, osteomyelitis Malignancy Trigeminal Neuralgia Psychogenic/idiopathic origin