The Diagnostic Process
Diagnosis is the bridge between the study of disease and the treatment of illness. Making a distinction between disease and illness may appear redundant because the words are frequently used interchangeably. However, a holistic approach to patient care makes the distinction significant. In oral pathology, one studies disease; in clinical dentistry, one treats illness. It has been stated that disease as defined by pathologists does not exist, for pathologists deal with abstractions, albeit useful ones. Ulcerative gingivitis may be defined with special emphasis on the bacterial aspects of the disease, or one may speak of an inflammatory reaction featuring “punched-out” erosions of the interdental papillae. However, in terms of illness, ulcerative gingivitis is more complex: it is the totality of signs and symptoms that together characterize an individual patient’s response to infection by spirochetes.
Diseases of the oral cavity and related structures, either local or systemic, may have profound physical and emotional effects on a patient. Furthermore, evidence of systemic disease may well be manifested in the head and neck or other areas of the body readily observed by the astute clinician. It is obvious, then, that oral health-care providers must have a basic understanding of diseases of the body. Such an obligation is tempered only by the extent to which diseases relate to the dental profession’s anatomic field of responsibility, and the extent to which illness requires modification of dental therapy or alters prognosis.
To treat dental disease as an entity in itself is to practice a rigid pseudoscience that is more comforting to the clinician than to the patient. The diagnosis and treatment of advanced carious lesions afford little support to the patient if the clinician overlooks obvious physical findings suggesting that the extensive restorative needs were precipitated by qualitative and quantitative changes in the flow of saliva secondary to polypharmacy, head and neck radiotherapy, or an undiagnosed or uncontrolled systemic problem. The clinician who has a balanced view of dentistry as it relates to illness will recognize that a casual question, “Are you in good health?” can no longer be considered an adequate pretreatment evaluation.
The focus of the diagnostic process is the study of the patient. It requires continuous interplay between the science of inquiry and the art of observation. The first phase in the study of a patient is the process of eliciting a historical profile; performing a physical examination, radiographic evaluation, and laboratory tests; and systematically recording the information obtained. The second phase involves the analysis of all data from and about the patient and the subsequent synthesis of this information into a relevant, timely diagnosis, and the establishment of a prognosis. The final step in this process is to develop a treatment plan and communicate the goals and objectives to the patient to encourage compliance with and participation in the plan.
Proper use and preservation of information in the diagnostic and treatment planning process are ensured by appropriate documentation. The problem-oriented method has proved to be an effective record-keeping system. In a problem-oriented record, the problem list is the central reference point. It provides the clinician with an overview of all the patient’s problems, as well as signaling specific problems requiring consultations and/or referrals. The clinician refers to the problem list and addresses those items pertinent to the therapeutic process.
Data collection is the first step toward initiating therapy. It is the platform upon which the structure of the problem-oriented record depends for stability. The database should include those elements that are effective screening procedures for significant diseases or are likely to be good reference points for future problems. Consequently, the format should focus on eliciting the problems the clinician cannot afford to miss, and should include those diagnostic procedures that are of greatest value in detecting problems.