This information is vital to establishing the need for specific diagnostic tests, determining the cause, selecting appropriate treatment options for the concerns, and building a sound relationship with the patient. ese conditions must be considered when planning dental treatment. This analytic approach relies on “2 × 2” contingency tables (. Two mounting systems are currently available for binocular loupes: (1) ip-up and (2) xed or through-the-lens types.Dental microscopes, though limited primarily to endodontic practices in the past, are now being used in some restorative dentistry practices. e ow and buering capacity of the individual patient’s saliva impact the rate of progression of erosive tooth wear. Most dentists use magnications of 2× to 4×. Rewetting results, in partial or total disappearance. Proper instruments, including a mirror, an explorer, and a periodontal probe, and the ability to air-dry the surfaces of the teeth are required. ese defective areas are associated with the binge–purge syndrome in bulimia, or with gastroesophageal reux disease (GERD). The first is a code for the restorative status of the tooth, and the second is for the severity of the caries lesion. If we are informed and clear about options and their consequences, then we reduce the chances of doing any harm.e 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 assessment of the patient’s current conditions and risk for future problems. C, Occlusal caries (c). Br Dent J 187:432–439, 1999.39. Careful probing with an explorer on the proximal surface may detect cavitation, which is defined as a break in the surface contour of enamel. Lines across the occlusal surface of an amalgam restoration. 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). At least 11 distinct conditions might be encountered when amalgam restorations are evaluated: (1) amalgam “blues,” (2) proximal overhangs, (3) marginal ditching, (4) voids, (5) fracture lines, (6) lines indicating the interface between abutted restorations, (7) improper anatomic contours, (8) marginal ridge incompatibility, (9) improper proximal contacts, (10) improper occlusal contacts, and (11) recurrent caries lesions. Although, as a group, older adults enjoy greater nancial resources, many remain on restricted budgets and are faced with tough decisions regarding the spending of limited resources. The chapter assumes that the reader has a background in oral medicine and an understanding of how to perform complete extraoral hard and soft tissue examinations along with intraoral cancer screening, as well as an understanding of the etiology, characteristics, risk assessment, and nonoperative management of dental caries as presented in Chapter 2. Maxillary premolars also frequently fracture, and similar to mandibular teeth, the facial (nonfunctional) cusps fracture more often than the lingual (functional) cusps. Defective enamel organiza-tion and calcication, which results in teeth that are compromised in appearance and strength, is referred to as amelogenesis imperfecta. Simons D, Brailsford SR, Kidd EA, et al: e eect of medicated chewing gums and oral health in frail elderly people: a one-year clinical trial. Rather, these statistics indicate what proportions of existing disease and absence of disease will be correctly identified in any group of individuals. Many multisurface restorations15. American Dental Association Council: Access, prevention and interprofessional relations: Providing dental care in long-term dental care facilities: A resource manual, 1997. 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. Few diseases or dental conditions are caused by a single factor. Caries Res 32:210–218, 1998.31. Close-up images of existing pits and ssures provide the opportunity to image current conditions for the purpose of future reevaluation and detection of changes that may be developing. Partial-coverage bonded indirect tooth-colored restorations may be indicated for the restoration of large defects in low stress areas when esthetics and optimal control of contours is necessary. Defective dentin formation and a compromised dentinoenamel junction (DEJ) resulting in early loss of clinically normal enamel is referred to as dentinogenesis imperfecta. As noted earlier, sharp explorers were used to diagnose fissure caries. Working distance (focal length) is the distance from the eye to the object when the object is in focus. 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. Start studying Dental Theory exam #3, patient record, oral diagnosis, and treatment planning. If it causes problems, an overhang should be corrected, and this often indicates the need for restoration replacement. Such an overhang can provide an obstacle to good oral hygiene and result in inflammation of adjacent soft tissue. CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning 107 For diagnosis of proximal surface caries, restoration overhangs, or poorly contoured restorations, posterior bitewing and anterior periapical radiographs are most helpful. Any deviation from normal should be noted. 3.6A). e elongation of the nerve bers results in depolarization and the perception of pain (see Chapter 1). Patient evaluation, diagnosis and treatment planning 1. To make matters even more challenging, none of the treatments we provide is without adverse outcomes and none will likely last for the life of the patient. However, because the sensitivity of radiographs for dentinal lesions on the occlusal surface is rather low (50%), the absence of a radiolucency does not mean that a lesion is not present. Shallow ditching less than 0.5 mm deep usually is not a reason for restoration replacement because such a restoration usually looks worse than it really is.21 The eventual self-sealing property of amalgam allows the restoration to continue serving adequately if it can be satisfactorily cleaned and maintained. e presence of improper contour or inadequate proximal contact, overhanging margin, recurrent caries, or occlusal interfer-ence should be noted and considered for correction. e, specic circumstances of each individual must be considered in, insight into individual circumstances begins with proper patient, assessment. >> Extra- and intraoral examination >> Examination and assessment of teeth and supporting structures Pulpal abnormalities such as pulp stones and internal resorption may be identied in various radiographs. J Am Dent Assoc 126(Special Suppl):1995.35. J Can Dent Assoc 70:251–255, 2004.8. The CarieScan PRO claims to enable clinicians to evaluate demineralized tooth structure using ACIST by providing information about tissue being healthy, in the early stages of demineralization, or already significantly decayed. Growth abnormalities11. The clinical examination for detecting caries lesions is aided by an assessment of the patient’s overall caries risk, along with the patient’s patterns of susceptibility. But given that operative treatment is invasive and irreversible, a highly specic test (i.e., few false positives [cell B]) means that fewer healthy teeth will be incorrectly treated.e dentist should be mindful of the fact that except in cases of relatively large caries lesions, the accuracy of the methods used to detect lesions (visual inspection, radiographs, caries detection devices, etc.) e dentist should recognize the impact of polypharmacy on salivary ow, especially the use of xerostomic medications, and discuss with the physician the potential substitution of medications with fewer xerostomic eects.Oral changes associated with undernourishment, immunosup-pression, dehydration, smoking, alcohol use, disease, medications, and dental problems lead to a depressed sense of taste and smell Nonworking-side excursive contacts are recorded and related to any ndings of masticatory muscle myositis and/or ipsilateral TMJ disc issues. 3.9D). e list of reasonable treatment alternatives is based on current evidence of the eective-ness of treatments, prevailing standards of care, and clinical and nonclinical patient factors. 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. Replacement of the restoration may be considered, however, for elective improvement of esthetics or for areas under heavy functional stress that may require a cusp capping restoration to prevent possible tooth fracture. Awareness of extreme variations in dental anatomy aids in the identication of fracture-prone areas. 3-3, A). 3.3C). Familial history of dental anomalies4. C, White chalky appearance or shadow under marginal ridge (distal #4 and mesial #5). The results of the diagnostic test, positive or negative, are shown across the rows of the table, and the results of a “gold standard” or the “truth” are displayed in the columns. Study of textbooks devoted to this discipline is indicated.40and the patient have a good understanding of the current condition(s), the patient’s risk prole, and all associated prognoses, they will be able to work together as a team to identify treatment options and establish a treatment plan.Treatment PlanningGeneral ConsiderationsPatient assessment, examination, and diagnosis result in a listing of dental problems, an inventory of existing risk factors (or indica-tors), and an accurate prognosis for each tooth and for the patient’s overall oral health. e appropriateness of the occlusal plane and the positions of malposed teeth should be identied. Root-surface restorations are challenging to suc-cessfully perform and are at risk of recurrent decay in the future. Opponents of this hypothesis note that these cervical lesions have been detected in individuals who do not have any apparent evidence of heavy occlusal forces (such as wear facets and/or fremitus). This information is then combined with the best available evidence on the approaches to managing the patient’s needs so that an appropriate plan of care can be offered to the patient. e benet of these restorations is that they cover and reinforce cusps without removal of healthy tooth structure in the middle and cervical areas of the facial and lingual surfaces (see Online Chapter 18). Transportation to and from the dental oce becomes complicated for those who no longer drive. 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). A cotton roll in the vestibular space and another under the tongue maintain dryness and improve visualization of the teeth and adjacent gingiva (Fig. Areas with root-surface caries usually should be restored when clinical and/or radiographic evidence of cavitation exists. Primary occlusal grooves and fossae are smooth “valley or saucer” landmarks indicating the region of complete coalescence of developmental lobes. For this viewing, the contact must be free of saliva. J Dent Edu 65(10):1007–1008, 2001.37. It is hypothesized that the exural force produces tension stress in the aected wedge-shaped region on the tooth side away from the tooth-bending direction, resulting in loss of the surface tooth structure by microfractures, which is termed abfracture.19 Proponents of this hypothesis add that microfractures may increase the rate of tooth structure loss during abrasion from tooth brushing and/or from acids in the diet or biolm. 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. Oral surgery procedural steps required for third molar removal may jeopardize new restorations placed on second molars. The first is that they are only indicated for use on unrestored pits and fissures. The decision of surgical intervention or nonintervention carries some risk for the patient in either direction, but studies would conclude that all diagnostic doubts should benefit the tooth by choosing non-operative options over irreversible operative dentistry options. J Am Dent Assoc 129:1471–1473, 1998.52. A difficult diagnostic challenge is a patient who has attachment loss with no gingival recession, limiting accessibility for clinical inspection. However, how can we be reasonably confident when we realize that few, if any, of the tests we perform or the assessments of risk that we make are completely accurate? A two-surface restoration is defined as apreparation that has one part of the preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to be in dentin). Proximal surface caries in anterior teeth can be identified by radiographic examination, visual inspection (with optional transillumination), or probing with an explorer. Appropriate textbooks that co. these areas, in health and disease, should be consulted. Fissures and pits are detected visually. Diagnosis and Treatment Planning in Dentistry, 3rd Edition provides a full-color guide to creating treatment plans based on a comprehensive patient assessment. An open contact typically is annoying to the patients, so correcting the problem usually is an appreciated service. 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. 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. The ICDAS uses a two-stage process to record the status of the caries lesion. ese areas are diagnosed as nonhereditary developmental enamel hypoplasia. The marginal ridge portion of the amalgam restoration should be compatible with the adjacent marginal ridge. Responses to the. Caries Res 21:368–374, 1987.9. It also can be detected by careful visual examination after tooth separation or through fiberoptic transillumination.14 When caries has invaded proximal surface enamel and has demineralized dentin, a white chalky appearance or a shadow under the marginal ridge may become evident (see Fig. Study models allow further abcdefAB• Fig. Hintze H, Wenzel A, Danielsen B, et al: Reliability of visual examina-tion, ber-optic transillumination, and bite-wing radiography, and reproducibility of direct visual examination following tooth separation for the identication of cavitated carious lesions in contacting approximal surfaces. When possible, improvement of the occlusion (elimination of interferences), based on knowledge of the physiologic masticatory muscle response to various relationships, is desirable; occlusal interferences must not be perpetuated in the restorative treatment.Examination of Teeth and RestorationsPreparation for Clinical ExaminationA trained assistant familiar with the terminology, notation system, and charting procedure may survey the patient’s teeth and existing restorations and record the information to save chair time for the dentist. Available on www.ada.org. Poor family dental health10. e practitioner also might identify a need for medical consultation or referral before initiating dental care. e diagnostic yield or potential benet that might be gained from a radiograph must be weighed against the nancial costs and the potential adverse eects of exposure to radiation. Irregular dental careFrom American Dental Association, US Food and Drug Administration: The selection of patients for dental radiograph examinations. : The American Dental Association Caries Classication System for Clinical Practice, A report of the American Dental Association Council on Scientic Affairs, J Am Dent Assoc 146(2):79–86, 2015. Drying again causes it to reappear. Clinically suspected sinus pathology10. , information by means of strategic examination. If the defects are only on the lingual of upper teeth, the diagnosis would be dierent from nding defects on the occlusal surfaces of lower molars. D, Esthetically unappealing dark staining. If any of these conditions exists, intervention is recommended to the patient. e status of the caries severity is determined visually on a scale of 0 to 6:0 = sound tooth structure1 = rst visual change in enamel2 = distinct visual change in enamel3 = enamel breakdown, no dentin visible4 = dentinal shadow (not cavitated into dentin)5 = distinct cavity with visible dentin6 = extensive distinct cavity with visible dentinwill result in the removal of the minimum amount of tooth structure.Caries lesions may be detected by visual changes in tooth surface texture or color or in tactile sensation when an explorer is used judiciously to detect surface roughness by gently stroking across the tooth surface. Unexplained bleedingGuidelines for Prescribing Dental Radiographs—cont’dTABLE 3.218. Cell A of the table contains the cases that the test identifies as being positive (or diseased) that actually are positive (i.e., confirmed by the “gold standard”). 2. Senna P, Del Bel Cury A, Rösing C: Non-carious cervical lesions and occlusion: a systematic review of clinical studies. Because very small areas can be seen, microscopes are used in detail-oriented procedures such as the finishing of porcelain restoration margins, identifying minute decay, and minimizing the removal of sound tooth structure. One exception to this general guideline is the lesion that is deemed arrested.Treatment Plan Sequencing/PhasingProper sequencing is a crucial component of a successful treatment plan. and serve as a source for transferring pathogenic bacteria among, pit-and-ssure caries is contraindicated as part of the detection, An occlusal surface is examined visually and radiographically, e visual examination is conducted in a dry, eld. Areas of signicant occlusal attrition that have exposed dentin, are sensitive, or annoying should be considered for restoration or at least protection from additional loss of tooth structure. This severity code is paired with a restorative/sealant code 0 to 8: 3 = sealant, full; tooth-colored restoration, 6 = ceramic, gold, PFM (porcelain-fused-to-metal) crown or veneer. is analytic approach relies on “2 × 2” contingency tables (Fig. J Endod 14: 455–458, 1998.42. Full analysis of the occlusion may require articulated diagnostic models. 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. A prognosis may be described as excellent, good, fair, poor, or even hopeless. But given that operative treatment is invasive and irreversible, a highly specific test (i.e., few false positives [cell B]) means that fewer healthy teeth will be treated. Generally, microscopes include ve or six levels of magnication that typically range from 2.5× to 20×. Clinical evaluation of amalgam restorations requires visual observation, application of tactile sense with the explorer, use of dental floss, interpretation of radiographs, and knowledge of the probabilities that a given condition is sound or at risk for further breakdown. 3.7 Lines across the occlusal surface of an amalgam restoration. Clinicians must have a sound knowledge of the current evidence relative to the risks and benets of their treatment recom-mendations. Restorative treatment is not indicated. 3.2). 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, e discovery of additional risk factors/indicators may occur during, the examination. If indicated, teeth should have endodontic treatment before restoration is completed. Reliablity, validity, specicity, and sensitivity of diagnostic procedures. should be instituted to promote remineralization. e process of treatment planning requires that the dentist develop an ever-increasing, comprehensive knowledge of dental disease manage-ment in the context of individualized patient care. Lesson 3-5 Detailed Physical Exam. In vivo study. Current thinking nds that the use of an explorer in this manner might have some relevance for assessing caries activity. If abnormal attrition is present, the patient’s functional movements should be evaluated and inquiry made with regard to potential parafunctional habits such as tooth grinding or clenching/grinding (bruxism). Remineralization, and training to use the system with an online tutorial, are available. Clinical caries lesion detection has been found lacking; thus improvement is needed.2 One means of addressing these concerns has been the development of a visual system for caries lesion detection and classication. This same recurrent caries (d) also is shown in B. This role is summarized by the Latin phrase “primum non nocere,” which means “do no harm.” This phrase represents a fundamental principle of the healing arts over many centuries. If a tooth-colored restoration has dark marginal staining or is discolored to the extent that it is esthetically unappealing to the patient, the restoration should be judged as defective (see Fig.
patient assessment, examination and diagnosis and treatment planning