Establishing a Differential Diagnosis for Periodontal Manifestations of Systemic Diseases
This chapter aims to provide the reader with a step-by-step guide to history-taking, examination and further investigation of non-plaque-induced lesions that arise withithe periodontal tissues, including the free and/or attached gingiva and associated oral mucosa, to help establish a differential diagnosis.
Having read this chapter the reader should appreciate the need for a forensic and systematic approach to establish differential diagnoses for oral and medical conditions that manifest within the periodontal and associated tissues.
A variety of clinical, procedural and pathological terms and descriptors are used throughout this chapter, and Table 1-1 defines these by category.
|Clinical presentation or procedure||Symptom||Something the patient is experiencing or complaining of as a consequence of their condition.|
|Sign||Something the clinician detects (visual, tactile or olfactory) that may help inform the diagnosis.|
|Biopsy||Acquisition of human cells or tissues to aid diagnosis.|
|Incisional biopsy||A biopsy involving partial removal of the lesion. This may be performed when malignancy is suspected and complete excision of the lesion would result in loss of key surgical landmarks.|
|Excisional biopsy||A biopsy involving complete removal of the lesion.|
|Fine needle biopsy /aspirate||Cells acquired using a fine cutting biopsy needle to obtain diagnostic material from within a lesion whose location or nature is such that surgical management should be delayed until microscopic diagnostic information is available.|
|Broad needle biopsy||Tissue acquired using a broad cutting biopsy needle. The purpose is to acquire diagnostic material from within a lesion whose location or nature is such that surgical management should be delayed until microscopic diagnostic information is available. In addition, it is believed that acquisition of small numbers of cells may be of limited/no benefit to the pathologist.|
|Swab||Use of a soft material (e.g. cotton pellet) to obtain infective material for culture and subsequent identification and testing (e.g. for antibiotic sensitivity) following culture.|
|Smear||Use of a solid/sharp instrument to scrape away cells for microscopic examination.|
|Cytology||Examination of individual cells (human or microbial) by microscopy, with or without special stains.|
|Differential diagnosis||A list of possible diagnoses, ranked in order of the most likely to the least likely.|
|Presumptive (working) diagnosis||A clinical diagnosis made in the absence of confirmatory information from additional clinical investigations and upon which therapy is based.|
|Definitive diagnosis||The working and most likely diagnosis upon which therapeutic strategies are based.|
|Lesions and lesion descriptors||Ulcer||A breach in the epithelium to expose the underlying connective tissue.|
|Erosion||Apartial breach in the continuity of an epithelial surface, which does not expose underlying connective tissue.|
|Fissure||A narrow crack or slit (usually describes an ulcer shape).|
|Vesicle||A small (<0.5cm) fluid filled lesion (not pus)|
|Bulla||A larger (>0.5cm) fluid filled swelling (not pus)|
|Blister||A fluid filled swelling (not pus)|
|Papule||Raised lesion (<1.0cm diameter)|
|Macule||Flat lesion (< 1.0cm diameter)|
|Nodule||Raised lesion (>1.0cm diameter)|
|Pedunculated||Lesion is borne/carried on a stalk/stem|
|Sessile||Lesion is borne on a broad/flat base|
|Sinus||A hole communicating a body cavity with the external environment|
|Sinus tract||An epithelial lined tunnel linking an internal body cavity with the external environment|
|Fistula||A communication between two body cavities|
|Tumour||A neoplasm is an abnormal mass of tissue, the growth of which is uncoordinated with that of normal tissues, and that persists in the same excessive manner after the cessation of the stimulus which evoked the change|
|Granuloma||A well-defined accumulation of modified macrophages (epithelioid cells), surrounded by lymphocytes and often with multinucleated giant cells.|
|Epulis||A benign localised swelling of the gingiva usually affecting the interdental papilla|
|Cyst||A pathological fluid filled (not pus) cavity.|
|Pathological terms or descriptors||Atrophic||Thinning of a tissue.|
|Hyperplasia||An increase in the size of a tissue due to an increase in the number of its constituent cells.|
|Hypertrophy||An increase in the size of a tissue due to an increase in the size of its constituent cells.|
|Overgrowth||An increase in the size of a tissue due to an increase in the size and/or number of constituent cells and/or extracellular matrix components.|
|Dysplasia||Disturbance in the normal maturation of a tissue.|
|Anaplasia||Lack of differentiation of a tissue, characteristic of some tumour cells.|
|Acantholysis||Separation of epithelial cells within the stratum spinosum.|
|Acanthosis||An increase in thickness of the stratum spinosum.|
|Leukoplakia||An adherent white patch or plaque that cannot be characterised clinically or pathologically as any other lesion (WHO).|
|Erythroplakia||A bright red velvety plaque that cannot be characterised clinically or pathologically as any other recognisable condition (WHO).|
|Hyperkeratosis||Excess deposition/formation of keratin within the stratum corneum of epithelium.|
|Oedema||The collection of inflammatory fluid exudate within a tissue or body cavity.|
|Angioedema||A diffuse oedematous swelling that may develop rapidly often involving the facial tissues and frequently, but not universally, results from a hypersensitivity reaction.|
The sub-headings used in the following section are those classically recommended for use in clinical practice and thus are standard procedures.
In periodontal medicine, the ‘history’ has a unique temporal relationship with the other diagnostic stages, because it should continue throughout the consultation process, i.e. never hesitate to return to and refine the history in the light of each new piece of information gathered.
The complaint is information that must be provided by and recorded in the patient’s own words. It is important when the complaint involves a symptom such as ‘pain’ or ‘soreness’ to clarify the exact details of that complaint, e.g.:
Associated signs or symptoms?
Similar lesions elsewhere on the body?
The history of the complaint often holds the key to its diagnosis. For example, the appearance of the lesion or symptoms may be subsequent to the patient commencing new medication, implying a potential aetiological role for that medication. For an abscess that is of pulpal origin, any swelling may present after an episode of dental pain, whereas with an abscess of periodontal origin the swelling often precedes the development of pain; temporal issues are important. Other key issues to explore include:
Current status (i.e. improving or becoming worse?)
Often by careful and detailed history taking it is possible to form a provisional diagnosis before even examining the subject, (but be wary of this approach to ensure you do not become biased). Some patients are good historians and others poor. It is important to record historical findings in a logical and succinct manner, which may be a challenge in the latter type of patient. It is good practice to return to a more focussed history after the clinical examination has provided pointers towards further questions which may help clarify the diagnosis.
A thorough medical history is essential and the process should be a staged one. Some of the issues highlighted below impact upon patient management and others are important in establishing a diagnosis. Key systems to explore would be:
Cardiovascular system – including cardiac murmurs, a history of rheumatic fever or infective endocarditis, blood pressure, cardiac surgery.
The respiratory system – including evidence of atopic disease e.g. metal allergies, allergies to drugs, asthma, chronic obstructive airway disease or granulomatous conditions such as sarcoidosis, T.B.
The central and peripheral nervous systems – a history of epilepsy, fitting, blackouts, neurological or neuropathology.
The musculoskeletal system – diseases or disorders of bone or muscle, connective tissue diseases.
The vascular system – evidence of haemorrhagic disease (e.g. idiopathic thrombocytopenic purpura – ITP), bruising, clotting disorders or disorders of the lympho-reticular system.
Endocrine problems – diabetes, thyroid or sex hormone/androgen disorders, including adrenal function. If diabetic, how well controlled is the diabetes? How often does the patient check their glucose levels? Do they know their last HBA1C level? A well-informed and health-conscious diabetic should know their most recent HbA1C level (see Book 1 of this series, Chapple and Gilbert).
Renal or urinary tract problems may be relevant to diagnosis or management. For example, patients who have been or are currently suffering from chronic renal failure may present issues surrounding:
Calcification of cardiac valvular tissue secondary to chronic hypercalcaemia (need for antibiotic prophylaxis).
Metabolism of drugs that may be considered for their oral disease.
Hypertension (e.g. use of calcium channel blocking drugs, which may be associated with drug-induced-gingival-overgrowth).
Hepato-biliary system disorders or diseases may impact on the diagnosis or management of oral lesions. Normally the question asked relates to a history of jaundice or hepatitis. Other issues may include:
Platelet levels and the risk of haemorrhage.
Associated systemic diseases e.g. primary biliary cirrhosis (PBC) is associated with secondary Sjögren’s syndrome.
Drug metabolism may also be affected (the cytochrome P450 enzyme system).
Gastro-intestinal tract disease such as Crohn’s, ulcerative colitis or coeliac disease may frequently present with oral manifestations. Malabsorption syndromes may lead to anaemia manifesting as oral ulceration or atrophic glossitis.
Skin/dermatological disease commonly presents with gingival manifestations, including erosive lichen planus, mucous membrane pemphigoid, pemphigus, Papillon Lèfevre Syndrome (PLS).
Connective tissue diseases, such as systemic sclerosis (scleroderma) or systemic lupus erythematosis (SLE) may have oral manifestations or require special precautions (e.g. 26% prevalence of cardiac valve damage is reported in SLE patients).
Medications must be comprehensively recorded, as many cause oral mucosal as well as periodontal lesions, such as lichenoid drug reactions, oral pigmentation, xerostomia, gingival overgrowth or ulcerative conditions.