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• Operative treatment success relies on a well-planned care strategy.
• Planning should occur stepwise.
• Steps for planning should include: reasons for visit, medical/dental histories, diagnoses, prognosis, plus risk assessment.

Clinical Examination

• A hands-on assessment of oral structures is needed to find abnormalities/diseases and achieve diagnoses.
• This includes: chief complaint, medical history, dental history, and clinical examination.

Chief Concern

• Record the patient's issues that brought them in for the visit verbatim in their dental record before starting any treatments.

Medical History

• The patient fills out a medical history form so the dental professional can spot conditions that might change, complicate, or not allow some dental work.
• The dental professional should ID communicable illnesses requiring special care, procedures, or referrals.
• All allergies/meds that might stop certain drugs from being used should be identified.
• ID systemic illnesses, heart issues, or joint replacements needing preventative antibiotics or other treatment changes.
• Recognize age-related physical changes that could change the way things look clinically and how treatment works.
• Ascertain the necessity for a medical consult or referral before beginning dental work.
• Include all information in patient's permanent record.

Dental History

• Aims at reviewing past dental problems, treatments, and patient responses.
• Aims at finding other problems like food getting stuck, not being able to floss, pain spots, and broken fillings or tooth parts.
• Crucial to understand past experiences to provide better future care, including changing how things are done to avoid problems for patients with bad experiences.
• Record the dates and types of any radiographs so the dental professional knows if more pictures are needed while keeping patient exposure down.

Examination Aids

• Magnification: Loupes make things look bigger for better vision.
• Loupes also help dental personnel keep good posture and less eye strain.
• Photography: Digital images is great for keeping track of things and assessing in an electronic record.
• Photos can record the current look of teeth: color, shape, position.
• Close-up pictures of pits and fissures lets the dental professional track changes that cannot normally be documented for follow-ups.
• Photos of how things look after getting rid of deep caries help with future diagnoses of tooth issues before filling.

Clinical Examination of Caries

• Contemporary caries management relies on enhanced risk assessment and improved lesion detection/classification
• Early detection helps manage enamel lesions likely to reverse/remineralize.
• Early detection helps manage lesions needing operative treatment to conserve tooth structure.

Pit and Fissure Caries

• Grooves and fossae are not susceptible to caries because they do not provide niches for biofilm.
• The rubbing during mastication frequently cleanses grooves and fossae.
• Occlusal fissures and pits are deep, tight crevices/holes in enamel where lobes didn't fully fuse together.

Visual and Radiographical Pit and Fissure Examination

• The dental professional evaluates the teeth in a dry, well-lit field under direct vision/reflected light on tooth's occlusal surface.
• Caries is diagnosed if any of these are identified: chalkiness, apparent softening/cavitation of tooth, brown-gray discoloration radiating outward from fissure/pit.
• The use of the dental explorer can fracture enamel.
• The use of the dental explorer can transfer pathogenic bacteria among various teeth.

Root Caries Examination

• Visual inspection/explorer is valuable to evaluate root surface softness.
• Rapidly progressing lesions are best ID'd using vertical bitewing radiographs.
• Distinguish caries lesion from cervical burnout radiolucency.
• Lesions often found at: cemento-enamel junction (CEJ), or more apically on cementum/exposed dentin in older patients, and/or in patients undergone periodontal surgery.
• Early development: root caries looks like well-defined, discolored area near gingival margin, generally near CEJ.
• Early development: lesions spread laterally around the CEJ.

Proximal Smooth Surface Caries Examination

• It is usually found on bitewing radiograph.
• Visual examination after separating teeth can detect it.
• Fiberoptic transillumination can detect it via the anterior teeth.
• Insert explorer carefully on the proximal surface to detect any cavitation/break on enamel's surface.
• Arriving at a final diagnosis requires the use of all examination methods.
• Caries attacks proximal surface enamel + demineralizes dentin = a white chalky appearance or shadow under the marginal ridge.

Special Conditions: Inactive/Arrested Caries

• Clinical Picture: Hard, brown spots on proximal surface enamel next to contact area, seen in older patients with low caries activity.
• Extrinsic staining during episodes where caries caused demineralization, followed by remineralization, causes incidence.
• Management: Restorative treatment is not indicated.
• Inactive caries sometimes has faint radiographic evidence of remineralized lesion.

Cervical Smooth Surface Caries

• Facial/lingual cervical areas of teeth with high caries activity, less accessible for cleaning, can be affected.
• Early enamel lesion diagnosis: Appears as white spot that disappears by wetting; drying causes reappearance.
• This disappearing/reappearing distinguishes it from white spots from nonhereditary enamel hypo-calcification.
• Surface isn't broken, it's smooth and hard, so either type of white spot can't be felt.
• White spot lesion treatment: nonsurgical remineralization.
• In-office measures: fluoride application.
• At-home measures include MI remineralizing paste (amorphous calcium phosphate remineralizing paste) and fluoridated rinse.
• Advanced smooth-surface caries exhibits discoloration and demineralization, feels soft and explorer can penetrate.
• Discoloration: White to dark depends on how fast the lesion grows; fast-progressing caries = light, slow = darkening over time (extrinsic staining).

Arrested Caries

• Clinically, it is a discolored, hard spot that may be a little rough to probing.
• It occurs as a result of remineralization of decalcified tooth structure, thus hardening the lesion.
• Management: Restoration isn't indicated unless the patient has aesthetic concerns.

ICDAS Visual Caries Assessment

• The ICDAS was developed to serve as a guide for standardized visual caries assessment.
• Visually inspect entire tooth surface-look for localized color, texture, and translucency changes; described by ICDAS codes.
• To prep for inspection: air-dry teeth for sufficient visibility, thoroughly remove biofilm/plaque.

ICDAS Staging

• Consists of code for the status of the tooth plus severity of the caries lesion determined visually on a scale of 0 (sound) to 6 (extensive):
• 0 = Sound tooth structure
• 1 = First visual change in enamel
• 2 = Distinct visual change in enamel
• 3 = Enamel breakdown, no dentin visible
• 4 = Dentinal shadow (not cavitated into dentin)
• 5 = Distinct cavity with visible dentin
• 6 = Extensive distinct cavity with visible dentin

Severity code is paired with a restorative/sealant code from 0 to 8:

• 0 = Sound, surface not restored/sealed.
• 1 = Sealant, partial.
• 2 = Sealant, full.
• 3 = Tooth colored restoration.
• 4 = Amalgam restoration.
• 5 = Stainless steel crown.
• 6 = Porcelain or gold or PFM crown or veneer.
• 7 = Lost or broken restoration.
• 8 = Temporary restoration.