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• An appropriate care plan is crucial for successful operative treatment
• The plan should be executed step-wise, including the patient's chief complaint, medical and dental histories, clinical examination, diagnosis, risk assessment, and prognosis

Clinical Examination

• "Hands-on" observation of oral structures to detect abnormalities for a diagnosis

Chief Concern

• Patient's primary reason for visit, recorded verbatim

Medical History

• Patient form identifies conditions that alter, complicate, or contraindicate dental procedures
• Identifies communicable diseases requiring special precautions
• Lists allergies or medications
• Notes systemic diseases, cardiac abnormalities, or joint replacements needing prophylactic antibiotics
• Describes physiologic changes associated with aging
• Determines the requirement for medical consultation or referral before care

Dental History

• A review of past dental issues, treatments, and responses
• Identifies problems such as food impaction, pain areas, and broken restorations
• Crucial for optimal future care, avoiding complications

Radiographs

• Ascertains date and type to minimize unnecessary ionizing radiation

Examination Aids

Magnification:

• Loupes enlarge images, improving visual acuity and posture

Digital Photography:

• Documents and evaluates, stored in electronic records

Documentation Examples

• Existing esthetic conditions like color, shape, tooth position
• Changes in pits and fissures for re-evaluation
• Deep caries lesion preparations for future diagnosis

Clinical Examination of Caries

• Contemporary caries management relies on risk assessment and lesion detection

Early Detection

• Enamel lesions are likely reversible and can remineralize
• Lesions require operative treatment to conserve tooth structure

Pit and Fissure Caries:

• Occlusal fissures/pits are tight crevices where lobes incompletely coalesce

Detecting Caries

• Diagnosed visually in a dry, illuminated field
• Look for chalkiness, softening, cavitation in fissures/pits, or gray discoloration
• Explorers can fracture enamel and transfer bacteria

Root Caries Examination

• Visual inspection and explorers determine root surface softness
• Vertical bitewing radiographs diagnose rapidly progressing lesions
• Differentiating caries from cervical burnout is essential

Root Caries Locations

• Cemento-enamel junction (CEJ)
• Apical to CEJ on cementum, or dentin in older patients
• In patients with surgery
• Early development appears as discoloration near the gingival margin/CEJ

Proximal Smooth Surface Caries Examination Techniques

• Radiography (bitewing preferred)
• Visual exam after separation
• Fiberoptic transillumination (anterior teeth)
• Explorer probing to detect cavitation

Special Conditions

Inactive/Arrested Caries

• Hard, brown spots on proximal enamel, common in older patients

Cause

• Extrinsic staining from past demineralization

Management

• Restorative work is not indicated

Cervical Smooth Surface Caries

• Happens on facial/lingual cervical areas of high-caries-activity patients

Early Enamel Lesions Diagnosis

• Spots appear white but disappear when wet, then reappear when dried
• Undetectable by touch as surface is intact, smooth, and hard

White Spot Management

• Nonsurgical remineralization should be started

In-office

• Fluoride application

At-home

• MI remineralizing paste
• Fluoridated toothpaste/mouth rinse

Advanced Smooth-Surface Caries

• Discoloration and demineralization that feels soft upon exploration
• Color ranges from white to dark brown based on lesion progression
• Rapid caries are light, slowly progressing are darker

Arrested Caries

• Appears discolored with a hard spot
• Remineralization hardens the lesion
• No restoration is needed, just address esthetics

ICDAS Purpose

• Standardizes visual caries assessment

How it is implemented

• Inspect each tooth surface for changes based on ICDAS codes

Minimum Conditions

1. Air-dry teeth for visualization
2. Remove plaque/biofilm

ICDAS Codes

• Stage 1 involves restorative status; stage 2 assesses caries lesion severity from 0-6
• 0 = sound
• 1 = first visual change in enamel
• 2 = distinct visual change in enamel
• 3 = enamel breakdown, no dentin visible
• 4 = dentinal shadow, not cavitated
• 5 = distinct cavity with visible dentin
• 6 = extensive distinct cavity with visible dentin

Severity Code

• Paired with a restorative/sealant code from 0-8:
  • 0 = Sound
  • 1 = Sealant, partial
  • 2 = Sealant, full
  • 3 = Tooth-colored restoration
  • 4 = Amalgam restoration
  • 5 = Stainless steel crown
  • 6 = Porcelain/gold/PFM crown or veneer
  • 7 = Lost/broken restoration
  • 8 = Temporary restoration

Definitions

Sealants

• Limited to enamel, resin-based or glass ionomer
• Prepare fissures conservatively for proper bonding
• Use glass ionomer when enamel is immature, prep is undesired, or rubber dam use is not possible Restore dentin otherwise

Risk Assessment

• Patients with one or more cavitated lesions are high-risk
• Patients with one or more cavitated lesions and xerostomia are extreme-risk
• Select materials based on patient preference

New Caries Detection Technologies

• May replace the tactile portion of caries detection
• Limitations: For unrestored pits/fissures only and lacks firmly established diagnostic accuracy
• FDA-approved technologies: laser-induced fluorescence, light-induced fluorescence, AC impedance spectroscopy

DIAGNOdent Device

• Portable device uses laser fluorescence to measure bacterial products and structural changes
• Scores range from 0-99, which indicates lesion presence and extent, as well as indicating higher sensitivity than traditional methods

Spectra Camera

• LEDs that use high-energy colored light to stimulate porphyrin metabolites from cariogenic bacteria appear red, healthy enamel appears green
• Imaging software analyzes data, highlighting lesions and defining caries activity from 0-5

CarieScan PRO

• Detects/monitors caries via AC (alternating current) impedance
• The device advises management measures, ranging from prevention to intervention

Defective Direct Restoration Clinical Exams

• Requires visual observation and applications of a tactile sense using an explorer, dental floss, and interpretation of radiographs

The following conditions can be encountered in a clinical exams

1. Amalgam blues or tattoo
2. Marginal staining or discoloration in composite restoration
3. Proximal overhangs
4. Marginal ditching
5. Fracture lines
6. Improper anatomic contours
7. Marginal ridge incompatibility
8. Improper proximal contacts
9. Improper occlusal contacts
10. recurrent caries lesions.

Radiography

• An indispensable part of the contemporary dentist's diagnostic armamentarium but cumulative exposure to ionizing radiation potentially can result in adverse effects
• Several technologies, particularly digital radiography, are now available and are designed to enhance diagnostic field and reduce radiation exposure

ADA/FDA Guidelines

• Dictates the required types and frequencies of radiographs based on patient factors

New Patient

1. A full mouth exam is favored if there is clinical evidence of common dental disease.
2. The patient will receive posterior bitewings with a panorama or posterior bitewings and selected periapical images

Recall Patient:

• With clinical caries
• With no clinical caries

Caries

• It can can be dianoised radiographically as translucencies in enamel or dentin.

Implications

1. Cervical Burnout
2. Class V lesion or tooth restoration can be superimposed mimicking a proximal caries lesion
3. Caries lesions clinically may appear radio graphically extensive

Treatment Plan

• A sequenced list designed to remove or control damage and create function
• Consists of a multi phase series of activities

1. Examination problems and assessment with risk identificaiton
2. Recommend intervention
3. Identify treatment alternatives
4. Patrient involvement with treatment

Treatment Plan Sequencing

1. Urgent Phase(preliminary)
2. Control Phase
3. Re-evlauation Phase
4. Definitive phase

Interdisciplinary Considerations in Operative Treatment Planning:

• Endodontics: all the treated patients with large restorations should have a pulpal or periapical evaluation. If it shows no evidence of improvement shall have a re-evaluation by a restoration

Periodontics:

• Should always preceded by operative treatment in order to bring better healthy enviroment with a good prognosis.

Orthodontics:

• Patients should be aware of have had the orthodontic treatment during the caries preventive measures and should follow the necessary steps.

Isolation the operating field:

• Moisture control by the use of the instruments include a rubber dam suction and an absorbent.
• Importance of Isolation:

1. Retraction and Access
2. Harm Prevention

• Advantages of Rubber Dam. 1.Dry, clean operating field.

2. Improved visabilty
3. protection to patient.
4. Opereating efficiency.

Disadvantages: : Time is spent with the appliance of the dam

1- Rubber Dam sheet:

• Dull side placed to the light
• Less deflection

2-Frame:

• U shape borders kept in place 3-Retainer:
• Consists of 4 prongs and 2 jaw _ Active or Passive jaw

4-Foreceps: for placement and removal

5/6-Punch: Precision istrument

7. Napkin :

• Imroves comfort to patients as cusion

Application Steps: Testing contact with the prode . Position over the Retainer / dam over retainer.

Key points:

" Water solubile lubricants do no easily remove. when rubber dam isn't required should apply throat sheild