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How to improve our diagnostic acumen: Teach it to our residents — Part II

Dennis J. Tartakow, DMD, MEd, EdD, PhD, is Editor in Chief of Ortho Tribune U.S. Edition. (DTI/Photo Dennis J. Tartakow)
Dennis J. Tartakow, USA

Dennis J. Tartakow, USA

Mon. 21 April 2014


To continue the discussion regarding what our residents are missing in his or her orthodontic training, nothing is a better teacher than personal experience(s) regarding what we do and how we do it in our practices. Expert training is a reflection on the educators and mentors in postgraduate residency programs.

The following considerations are important subjects in the diagnostic process and examination; they are especially valuable and significant for the orthodontic resident to recognize.

Clinical photography often demonstrates dermatological diseases, tumors and other pathology of the head and neck. We can diagnose important health issues by taking the time to look. Diagnosing diseases of the skin in our patients, e.g. squamous cell carcinoma, basal cell carcinoma, melanoma, etc., is an astute part of our responsibility and demonstrates good judgment as a doctor. Because orthodontists take so many clinical photographs, very little time is required to scan for such pathology prior to examining facial structures and the dentition. Accuracy and precision are extremely important; for example, in the intraoral photo (Fig.1), is this documentation of an aberrant occlusal plane cant or just sloppy photography?

Clinical photography can identify many diseases of facial expression or appearance. Facial diseases are often related to development or physiology and can affect facial structure, facial behavior or both. Through clinical photography, we can teach the resident how to recognize various signs in the face that indicate particular diseases. Signs of facial diseases include (a) changes in appearance, (b) alterations of muscular movement, and (c) behavioral expression. Facial signs are often used to diagnose the presence of certain diseases that can be diagnosed via clinical photography.

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The most obvious relationships between facial signs and disease are for the genetic and congenital diseases. Specific genetic abnormalities cause such diseases as Lesch-Nyhan, Down syndrome and Cornelia DeLange syndrome, producing specific patterns of facial abnormality. Certain congenital diseases such as fetal alcohol syndrome, cretinism and hydrocephaly also produce specific facial signs and symptoms. Many infectious diseases can be diagnosed from facial signs, including Lyme disease, Fifth disease, shingles and HIV infections.

Articulated Models are not as popular as hand-held models and most orthodontists never consider using an articulator except for surgical cases. However, they may be extremely helpful in diagnosis, treatment planning and for medical-legal protection. When documenting patients with asymmetry, such as when the cant of the occlusal plane is not level, hand-held models are often prepared inaccurately without demonstrating the exact degree of incongruity or anomaly (Fig. 2). Articulated models provide excellent representation of the patient’s condition and are extremely accurate.

There is much to reveal as we appraise the past and contemplate the future. Learning can be defined as useful changes in behavior resulting from reflection and experience. How can we teach our students to become better practitioners and sharper diagnosticians? Will they learn to focus on the dental problems in the context of, and in concert with, a patient’s general health issues?

As orthodontists, we are still responsible for diagnosing pathology in the head and neck, and treating or referring the patient to someone who can provide proper care. By example, we must demonstrate how to be the best orthodontist possible and the consummate expert in our field.

Note: This article was published in Ortho Tribune U.S. Edition, Vol. 9, No. 2, AAO Edition 2014. A reference is available from the publisher.

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