C, Occlusal caries (c). Describe the symptoms the patient is reporting and the signs you see—or do not see. The first is that they are only indicated for use on unrestored pits and fissures. 118 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planningis available. Bimanual loading of the, joints and palpation of the condyle lateral poles and retrocondylar, areas (during wide mandibular opening) are completed to further, test for tenderness/pain as signs of inammation. expectations when considering treatment options with the patient. e patient should be encouraged to discuss all aspects (symptoms) of the current problem(s), including onset, duration, and related factors they are experiencing. All of this must be accomplished without compromising the short- and long-term dental health of the patient (“do no harm”). If a tooth has a good peri-odontal prognosis, then operative treatment may occur before or after periodontal therapy, as long as the operative treatment is not compromised by the existing tissue condition. In contrast, it is common to observe nondiseased occlusal surfaces with narrow grooves or fossae that exhibit supercial staining, but no visual changes in light reection through the enamel immediately adjacent (see Fig. Both ridges should be at approximately the same level and display correct occlusal embrasure form for passage of food to the facial and lingual surfaces and for proper proximal contact area (see Chapter 1). Root caries is softer than the adjacent tooth structure, and lesions typically spread laterally around the CEJ. For this viewing, the contact must be free of saliva. 3.3A, enamel area adjacent to the central pit/lingual ssure) indicating caries progression in dentin below the translucent enamel. C, Rounded cervical lesions associated with toothbrush abrasion. If it causes problems, an overhang should be corrected, and this often indicates the need for restoration replacement. 100 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning4 = amalgam restoration5 = stainless steel restoration6 = ceramic, gold, PFM (porcelain-fused-to-metal) crown or veneer7 = lost or broken restoration8 = temporary restorationis severity code is paired with a restorative/sealant code 0 to 8:0 = not sealed or restored2 = sealant, partial3 = sealant, full; tooth-colored restorationABCDEF• Fig. us, when it is clear that the patient is unwilling or unable to follow the prescribed remineralization regimen of home care and professional care, it is often appropriate to remove the lesion(s) surgically and restore the defect or to seek to arrest the lesion (see Chapter 2).If conrmed cavitation of the enamel or demineralization penetrating into the dentin on coronal surfaces is present or a break exists in the contour of exposed root and softening of the surface, then operative treatment is usually recommended. All of this must be accomplished without, compromising the short- and long-term dental health of the patient, indirect enamel-supported restorations are mor, long-term risk management than are more aggr, along with potential impact on the muscles of mastication and, TMJs, must occur before planning and implementing restorativ. The largest manufacturers of dental microscopes include Carl Zeiss, Inc. (Dublin, CA); Global Surgical Corporation (St. Louis, MO); and Seiler Precision Microscope Instrument Company (St. Louis, MO). e gingival tissue should be assessed for signs of inammation (redness, edema, tenderness, bleeding on probing). The DIAGNOdent device (KaVo Dental Corporation, Charlotte, NC) uses laser fluorescence technology, with the intention of detecting and measuring bacterial products and changes in the tooth structure in a caries lesion. E, Smooth-surface caries may appear white or dark, depending, area along the marginal ridge when the light is directed thr, the tooth. e appropriateness of the occlusal plane and the positions of malposed teeth should be identied. e earliest clinical evidence of early enamel lesions on these surfaces is a white spot that is visually dierent from the adjacent translucent enamel that appears when the surface is dried. An accurate examination is possible only when teeth are clean and dry. Light of this wavelength supposedly stimulates porphyrins—metabolites unique to cariogenic bacteria—to appear distinctly red, while healthy enamel uoresces to appear green. Another cause of hypocalcication is arrested and remineralized incipient caries, which leaves an opaque, dis-colored, and hard surface. Katz RV: e clinical identication of root caries. A comprehensive review of geriatric dentistry is beyond the scope of this chapter; rather, some issues that are important for treatment planning for older patients are highlighted.46-48Clear and eective communication is crucial. In terms of clinical diagnosis, we will discuss the two main classification systems used around the world – the DSM-5 and ICD-10. 3.6D). Movement of the mandible from maximum intercuspation to maximum opening is observed and maximum unassisted opening is measured; any “clicking or popping” of the joint disc(s) during mandibular movements is noted and related to any history of trauma, nonworking occlusal interferences, or other possible pathologic changes. In the case of dental caries, all things being equal, this means that the clinician may accept a less sensitive test (i.e., miss some initial lesions [cell C]) because caries usually progresses slowly over years. Most dentists use magnications of 2× to 4×. In the latter, low specificity may not be acceptable if the treatment is invasive and irreversible, but more acceptable if the treatment is non-invasive and temporary. Personal details are necessary for identification and commu-nication with the patient. e International Caries, Detection and Assessment System (ICDAS) was developed to, serve as a guide for standardized visual caries assessment that. Resin-based sealants should have the most conservatively prepared fissures for proper bonding. 3-4). 3-3). 3.6 Restorations may be diagnosed clinically as being defective by observing the following. Brown spots on intact, hard proximal surface enamel adjacent to and usually gingival to the contact area are often seen in older patients, in whom caries activity is low. Frequent high sucrose content in diet9. Generally, the principle of “greatest need” guides the order in which treatment is sequenced. is parameter should be considered carefully before selecting loupes because the desired working distance depends on the dentist’s height, arm length, and seating preferences. tematic reviews emerging from the focus on evidence-based dentistry, knowledge about various conditions and tr, on the authors of the systematic review to openly discuss the, relative value of their conclusions for application in dental car, sionals for evidence-based dentistry decision making. e dynamic functional occlusion in all movements of the mandible, (right, left, forward, and all excursions in between) should be, evaluated. Strassler HE, Syme SE, Serio F, et al: Enhanced visualization during dental practice using magnication systems. The status of the caries severity is determined visually on a scale of 0 to 6: 4 = dentinal shadow (not cavitated into dentin), 6 = extensive distinct cavity with visible dentin. When choosing loupes, several parameters should be considered. Bader JD, Shugars DA, Sturdevant JR: Consequences of posterior cusp fracture. e treatment plan for these patients may start with a plan to denitively address immediate concerns while simultaneously implementing minor changes and reinforcing habits consistent with dental health.Denitive Phasee patient enters the denitive phase of treatment only after the dentist reassesses initial eorts to control disease and, with the patient, determines the need for further care. Gen Dent 52:128–131, 2004.23. Primary occlusal grooves and fossae are smooth “valley or saucer” landmarks indicating the region of complete coalescence of developmental lobes. However, it cannot be over-emphasized that the, Caries lesions are most prevalent in the faulty pits and fissures of the occlusal surfaces where the developmental lobes of posterior teeth failed to coalesce, partially or completely (. These areas may result from numerous factors but do not warrant restorative intervention unless they are esthetically offensive or cavitation is present. The Orthodontic Patient: Examination and Diagnosis Citation: Ramy Ishaq. is theory postulates that rapid dentinal tubule uid movement toward the external surface of the tooth elongates odontoblastic processes (which extend from the pulp through the predentin and into dentin) and associated aerent nerve bers. An in-depth discussion of these anomalies is beyond the scope of this text. History of pain or trauma3. e presence of caries in these self-cleansing areas usually indicates, that the patient is at high risk of developing additional caries (see, Carious pits and ssures also occur on the occlusal two thirds of, the facial or lingual surface of posterior teeth and on the lingual, e clinical interpretation of subtle changes in the appear, ance of tooth structure is aided by simultaneous consideration of, and indicators, may suggest a prediction of current and fu, e ICDAS uses a two-stage process to recor, the caries lesion. from patient assessment for aspects of the patient “, begin during initial conversations with the patient. As a result, food may become tasteless and unap-petizing, and more sugars, fats, and salts are added in an attempt to increase avor. Newbrun E: Problems in caries diagnosis. Current thinking finds that the use of an explorer in this manner might have some relevance for assessing caries activity. If other aspects of the abutted restorations are satisfactory, replacement is unnecessary. Prescription lenses can be fitted in the eyeglass frames for all loupe types. e CarieScan PRO claims to enable clinicians to evaluate demin-eralized tooth structure using ACIST by providing information about tissue being healthy, in the early stages of demineralization, or already signicantly decayed. Community Dent Oral Epidemiol 29:346–353, 2001.22. e clinician must weigh the seriousness of the disease that is left untreated (in cases of low sensitivity) against the invasiveness of the treatment (in cases of low specic-ity). The comprehensive examination— the initial patient engagement—focuses the clinician and patient on the variables most likely to ensure a predictable and excellent outcome. Rather, it is often a This improper use of a sharp explorer has been shown to irreversibly damage the tooth by turning a sound, remineralizable sub-surface lesion into a possible cavitation that is prone to progression. Study models are able to provide an understand-ing of occlusal relationships, help in developing the treatment plan, and serve as a tool for educating the patient. Treatment alternatives for a specic condition may include, for example, periodic reevaluation to monitor the condition, chemotherapeutics (e.g., applications of uoride to promote remineralization or antimicrobials to reduce bacteria), recontouring defective restorations or irregular tooth surfaces, repair of an existing restoration, and restoration of caries lesions or other defects. fractured teeth, and marginal ridge discrepancies should be noted. Gerodontology 5:21–24, 1986.14. Careful selection of restoration design, materials, and nishing is essential if the patient is to be able to perform successful biolm removal and thereby maximize the longevity of restorations. Using this uorescent technology, the data captured by the Spectra system are analyzed by imaging software, which highlights the lesions in dierent color ranges and denes the potential caries activity on a scale of 0 to 5.e CarieScan PRO (CarieScan, LLC, Charlotte, NC) is a device for the detection and monitoring of caries by the application and analysis of ACIST (AC Impedance Spectroscopy Technology). A successful treatment plan carefully sequences and integrates all necessary procedures indicated for the patient. Clinical evidence of periodontal disease2. Therefore responsible handling is important. e second is that their diagnostic accuracy has not been rmly established. Success of the treatment plan is determined by its ability to meet the patient’s initial and long-term needs. examination of patient in pain 240 ii.g. However, images can be distorted, and working lengths can be less than ideal. Unusual tooth morphology, calcication, or color21. Dental treatment in any one of the abovemen-tioned areas may improve risk status in that area but at a cost of increased risk in another area. Restorations can be diagnosed clinically as being defective by observing the following. Because very small areas may be seen, microscopes are used in detail-oriented procedures such as the nishing of porcelain restoration margins, identifying minute caries lesions, and minimizing the removal of sound tooth structure. A and B, Proximal caries tends to occur bilaterally (a) and on adjacent surfaces (b). Develop your skills in evaluation and dental treatment planning for all types of patients! Dierentiation of a caries lesion from a radiolucent artifact created by radiographic cervical burnout is, however, essential.12,13Clinical Examination of Amalgam RestorationsEvaluation of existing restorations should be accomplished systemati-cally in a clean, dry, well-lit eld. Finally, the cost of treatment alternatives should be discussed with the patient. e occlusal surface is diagnosed, as diseased if external chalkiness (enamel caries) or subsurface, opacity (dentin caries) or cavitation of tooth structure, forming, the ssure or pit, is seen. Abutment teeth for xed or removable partial prosthesis17. The first concept is test, A trained assistant familiar with the terminology, notation system, and charting procedure can survey the patient’s teeth and existing restorations and record the information to save chair time for the dentist. Misdiagnosis may occur when cervical burnout (the radiographic picture of the normal structure and contour of the cervical third of the crown) mimics a caries lesion. Restorative exposed dentin, 25% were below the CEJ, and 3% resulted in pulp exposure. Cell C includes the cases identified by the diagnostic test as not being diseased, but actually are diseased, as determined by the “gold standard.” Findings in this cell are termed false negatives. Axelsson P: Diagnosis and risk prediction of dental caries, Chicago, 2000, Quintessence Publishing.34. Discolored areas or “amalgam blues” are often seen through the enamel in teeth that have amalgam restorations. 3-4 for the ICDAS for examples of coding for restorative status and caries severity. Although no clinical criteria are universally accepted for the diagnosis of root caries, it is generally agreed that softened cemental or dental tooth structure compared with the surrounding surface is characteristic.15 Active root caries is detected by the presence of softening and cavitation.16,17 Although root-surface caries may be detected on radiographic examination, a careful, thorough clinical examination is crucial. Clinical caries lesion detection has been found lacking and improvement is needed. Pre-carious or carious pits are occasionally present on cusp tips (see Fig. Root caries is softer than the adjacent tissue, and typically lesions spread laterally around the CEJ. Following is a discussion on sequencing operative care with endodontic, periodontal, orthodontic, surgical, and prosthodontic treatments.EndodonticsAll teeth to be restored with large restorations should have a pulpal and periapical evaluation. Treatment of deep caries lesions often requires caries control (see Chapter 2). 3-8, A). J Am Dent Assoc 124:86–87, 1993.53. It is crucial to understand past experiences to provide optimal care in the future. is improper use of a sharp, remineralizable subsurface lesion into a possible cavitation that is, also theoretically risks cross-contamination from one pr, is valuable for detecting root surface softness. Cell C includes the cases identied by the diagnostic test as not being diseased, but actually are diseased, as determined by Gold StandardDiagnosticTestResultsCell A true positivesCell B false positivesCell C false negativesCell D true negativesACBD• Fig. Your doctor will try to rule out physical problems that could cause your symptoms. Inadequate uoride exposure7. An accurate examination is possible only when teeth are clean and dry. Malposed or clinically impacted teeth5. F, diagnostic quality of available radiographs should be recor, as to ascertain the need for additional radiographs and to minimize, and clearly understood. The manufacturer has recommended threshold scores that represent the presence and extent of a lesion. is form is an integral part of the preex-amination patient interview, which helps identify conditions that could alter, complicate, or contraindicate proposed dental proce-dures. B, Tooth with an existing restoration (g) that encroaches on the biologic width requires crown-lengthening procedures before placement of a new restoration. If a patient has difficulty tolerating certain types of procedures or has encountered problems with previous dental care, an alteration of the treatment or environment might help avoid future complications. This compact and portable device, which requires a clean, dry occlusal surface, yields a numerical score from 0 to 99. related to any history of trauma, nonworking occlusal interferences, or other possible pathologic changes. Oral involvement in known or suspected systemic disease12. Module 3 covers the issues of clinical assessment, diagnosis, and treatment. These discolored areas are a result of extrinsic staining during earlier caries demineralizing episodes, each followed by a remineralization episode. … Corrective procedures include recontouring, polishing, repairing, or replacement of the restoration.One of the main concerns with anterior teeth is esthetics. J Dent Hyg 77:125–145, 2003.47. Postoperative evaluation of healing5. ese loupes are inexpensive and lightweight and may provide magnication of up to 2.5×. is is sometimes expressed by using color-coded categories: red for high risk, yellow for medium risk, and green for low risk. Therefore, this cell denotes false positives. Tooth color evaluation becomes a factor if teeth are more visible when smiling or at the resting position of lips. Date of Exam: 4/24/2015 Time of Exam: 11:59:56 AM Patient Name: Jones, January Patient Number: 1000010659260 PRE -ADMISSION ASSESSMENT Presenting Problem: Psychosis The following information was received from: Jan Family Psychotic symptoms are described or reported. Most fractures were treated with direct or indirect restorations or recontouring and polish-ing; 3% of the fractured teeth were extracted, and 4% received endodontic treatment.22 Risk factors for nontraumatic fracture of posterior teeth were found to be the presence of a stained fracture in enamel and an increase in the proportion of the volume of the natural tooth crown occupied by a restoration.23,24 e examination process should notate the presence and activity of all fracture areas.e dental examination also may reveal dental anomalies that include variations in size, shape, structure, or number of teeth—such as dens in dente, macrodontia, microdontia, gemination, concres-cence, dilaceration, amelogenesis imperfecta, and dentinogenesis imperfecta. If the proximal contact of any restoration is suspected to be inadequate, it should be evaluated with dental floss or visually by trial angulations of a mouth mirror (held lingually when viewing from the facial aspect) to reflect light and see if a space at the contact (“open” contact) is present. is role is summarized by the Latin phrase “primum non nocere,” which means “do no harm.” is phrase represents a fundamental principle continually embraced by those in the healing arts over many centuries.e implication of this concept for operative dentistry is that, before we recommend treatment, we must be reasonably condent that the patient will be better o as a result of our intervention. In addition to transillumination, tactile exploration of anterior teeth is appropriate to detect cavitation because the proximal surfaces generally are more visible and accessible than in the posterior regions.Another form of smooth-surface caries may occur on the facial and lingual surfaces of the teeth of patients with high caries activity, particularly in the cervical areas that are less accessible for cleaning. Description: Develop your skills in evaluation and dental treatment planning for all types of patients Diagnosis and Treatment Planning in Dentistry, 3rd Edition provides a full-color guide to creating treatment plans based on a comprehensive patient assessment. During the clinical examination, the dentist must be keenly sensitive to subtle symptoms (that the patient reports), signs (that the dentist detects), and variations from normal to detect pathologic conditions and determine etiologic factors. Xerostomia13. Diagnosis in complete denture is a continuing process and is not accomplished in a short time. e patient’s medical history, dental history, oral hygiene, diet, and age, among other caries risk factors and indicators, may suggest a prediction of current and future caries activity. C, White chalky appearance or shadow under marginal ridge (distal #4 and mesial #5). Using evidence-based research this book shows how risk assessment prognosis and expected treatment outcomes factor into the planning process. Typically, the lower the magnication, the greater is the depth of focus.Patient with other circumstances including, but not limited to, proposed or existing implants, pathology, restorative/endodontic needs, treated periodontal disease, and caries remineralizationClinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these circumstances. The device provides a color scale and a numerical scale to determine the severity of the caries lesion and is accompanied by management recommendations that range from therapeutic prevention to operative intervention appropriate for the extent of the demineralization. is principle suggests that what the patient needs most is performed rst—with pain, bleeding, and swelling at the beginning of the treatment plan and elective esthetic procedures at the end. See Fig. 25.19. In addition, soft tissue lesions, complicating exostoses, and improperly contoured ridge areas should be eliminated or corrected before nal restorative care.Fixed, Removable, and Implant ProsthodonticsDirect restorations should be completed, if possible, before placing indirect restorations. This may require initial scaling, flossing, and a toothbrushing prophylaxis before final clinical examination of teeth. Review of the dental history often reveals information about past dental problems, previous dental treatment, and the patient’s responses to treatments. The success of operative treatment depends heavily on an appropriate plan of care, which, in turn, is based on a comprehensive analysis of the patient’s reasons for seeking care and on a systematic assesssment of the patient’s current conditions and risk for future problems. Br Dent J 187:432–439, 1999.39. e use of diagnostic ionizing radiation is, however, not without risks. Small early enamel lesions may be detectable only on the radiograph. Finally, the date and type of available radiographs should be recorded to ascertain the need for additional radiographs and to minimize the patient’s exposure to unnecessary ionizing radiation. The earliest clinical evidence of early enamel lesions on these surfaces is a white spot that is visually different from the adjacent translucent enamel and partially or totally disappears with wetting. ese devices may have the potential to replace the tactile portion of caries detection, where explorers are used to try to estimate the depth of the caries lesions into the pits and ssures. Using this fluorescent technology, the data captured by the Spectra system are analyzed by imaging software, which highlights the lesions in different color ranges and defines the potential caries activity on a scale of 0 to 5. Grippo JO, Simring M, Coleman TA: Abfraction, abrasion, biocor-rosion, and the enigma of noncarious cervical lesions: A 20-year perspective. Current thinking nds that the use of an explor, in this manner might have some relevance for assessing caries, from a ssure or pit). However, the dentist must weigh the benets of taking dental radiographs against the risk of exposing a patient to ionizing radiation, the eects of which accumulate from multiple sources over time. From the time an intake appointment is scheduled, the Intake Clinician is the point person for the client until they are matched with a TRC Clinician. e nal cell, cell D, includes true negatives, where the diagnostic test accurately identies nondiseased cases that are truly negative as conrmed by the “gold standard.” A perfect diagnostic test would result in all cases being assigned to cells A or D with no false positives (cell B) or false negatives (cell C).When the basics of this table are understood, the information it yields may be put to good use by the diagnostician. In a radiograph, a proximal caries lesion usually appears as a dark area or a radiolucency in the enamel slightly apical to the contact (see Fig. Marginal • Fig. Early in its development, root caries appears as a well-defined, discolored area adjacent to the gingival margin, typically near the CEJ. Complex treatment plans often are sequenced in phases, including an urgent phase, a control phase, a reevaluation phase, a denitive phase, and a maintenance phase (that includes reassessment and recare). In many of these situations, conservative direct or, ). Caries can be diagnosed clinically by careful inspection. Treatment plans identify what the professional counselor and client are going to work on together and what strategies will be used to achieve these goals Assessment