Patient Assessment, Diagnosis and Treatment - PDF

Introduction The success of operative treatment depends heavily on an appropriate plan of care. This should...

Introduction The success of operative treatment depends heavily on an appropriate plan of care. This should be done in stepwise manner, these steps Patient Assessment, include: 1. Reasons for seeking care (chief complain), Examination, Diagnosis, 2. Medical and dental histories. and Treatment Planning 3. Clinical examination for the detection of abnormalities. 4. Establishing diagnoses. 5. Assessing risk, and determining prognosis. By: Dr. Rehab Alwakeb Operative Dentistry Division II. Clinical examination Clinical examination is the “hands-on” process of 1. Chief Concern observing the patient’s oral structures and detecting signs and symptoms of abnormal conditions or Before initiating any treatment, the patient’s chief disease to formulate diagnoses. concerns, or the problems that initiated the patient’s This include: visit, should be obtained and recorded essentially verbatim in the dental record. 1. Chief complain 2. Medical history 3. Dental history 4. Clinical examination 2. Medical History The patient completes medical history form. which 4. physiologic changes associated with aging, which helps identify conditions that could alter, complicate, may alter clinical presentation and influence or contraindicate proposed dental procedures. treatment. The practitioner should identify: 5. Need for medical consultation or referral before 1. communicable diseases that require special initiating dental care. precautions, procedures, or referral. All of this information is carefully detailed in the 2. Allergies or medications, which can contraindicate patient’s permanent record the use of certain drugs 3. Systemic diseases, cardiac abnormalities, or joint replacements, which require prophylactic antibiotic coverage or other treatment modifications. Finally, the date and type of available radiographs 3. Dental History should be recorded to ascertain the need for additional Is a review of previous dental problems, treatments and radiographs and to minimize the patient’s exposure to the patient’s responses to treatments, unnecessary ionizing radiation. Identification of other problems such as areas of food impaction, inability to floss, areas of pain, and broken restorations or tooth structure. Aim: It is crucial to understand past experiences to provide optimal care in the future which may include alteration of the treatment or environment to avoid future complications with patients with bad experience.  Examination aids: Examples: 1. Magnification: To document existing esthetic conditions such as color, shape, and position of teeth. Magnification aids such as loupes provide a larger image size for improved visual acuity, while allowing proper Close-up images of existing pits and fissures can upright posture to be maintained with less eye fatigue. provide the opportunity to see changes that cannot be documented in any other way for re-evaluation (follow 2. Photography: up). Digital photography is an excellent tool for Photographs of preparations of deep caries lesions documentation and evaluation as it can be stored in an provide documentation to aid in future diagnosis of electronic patient record. tooth conditions before placement of restoration. 4. Clinical examination Clinical examination of caries Contemporary caries management, which encompasses non-operative approaches and conservative operative interventions, relies on 1. Enhanced risk assessment And 1. Improved lesion detection and classification 1. Pit and fissure caries Grooves and fossae are not susceptible to caries This concept is managed through early detection of: because they are not niches for biofilm and frequently are cleansed by the rubbing action of Enamel lesions that are most likely to be reversed food during mastication. and remineralize. Conversely, occlusal fissures and pits are deep, tight Lesions that require operative treatment before crevices or holes in enamel, where the lobes failed further destruction occurs to conserve tooth to coalesce partially or completely. structure. Examination: Visual & radiographical inspection In a dry, well illuminated field through direct vision The use of the dental explorer for this purpose was and reflecting light through the occlusal surface of found to fracture enamel and serve as a source for the tooth. transferring pathogenic bacteria among various teeth. Caries is diagnosed if chalkiness or apparent softening or cavitation of tooth structure, forming the fissure or pit, is seen or a brown-gray discoloration, radiating peripherally from the fissure or pit, is present.  2. Root caries: Lesions are often found at: Examination: 1. Cemento-enamel junction (CEJ) Visual inspection and an explorer is valuable to evaluate root surface softness. 2. May be more apically on cementum, or exposed These rapidly progressing lesions are best diagnosed dentin in older patients using vertical bitewing radiographs. 3. In patients who have undergone periodontal Differentiation of a caries lesion from cervical surgery. burnout radiolucency is, however, essential Early in its development, root caries appears as a well-defined, discolored area adjacent to the gingival margin, typically near the CEJ and lesions spread laterally around the CEJ. 3. Proximal smooth surface caries How does it look like? Examination: When caries invades proximal surface enamel and Is usually detected radiographically (bitewing demineralizes dentin radiograph). It can also be detected by careful visual examination a white chalky appearance or a shadow under the after tooth separation marginal ridge may become evident. Also, through fiberoptic transillumination (in anterior teeth). Careful probing with an explorer on the proximal surface to detect any cavitation, or break in the surface contour of enamel. N.B: The use of all examination methods is helpful in arriving at a final diagnosis. Special conditions: Inactive caries/ arrested caries Clinical picture: Intact, hard brown spots on proximal surface enamel adjacent to and usually gingival to the contact area are often seen in older patients, in whom caries activity is low. Cause of incidence: These discolored areas are a result of extrinsic staining during earlier caries demineralizing episodes, each followed by a remineralization episode. Management: Restorative treatment is not indicated. N.B: These inactive caries lesions sometimes may have faint radiographic evidence of the remineralized lesion. 4. Cervical smooth surface caries can occur on the facial and lingual cervical areas of the teeth of patients with high caries activity, that are less accessible for cleaning. Presentation: 1 2 I. The early enamel lesions Diagnosis: appear as white spot partially or totally disappears with wetting. Drying again causes it to reappear. This disappearing–reappearing phenomenon distinguishes it from the white spot resulting from nonhereditary enamel hypo-calcification Both types of white spots are undetectable tactilely 3 because the surface is intact, smooth, and hard.  Management: For white spot lesions, nonsurgical remineralization therapies should be instituted to promote remineralization. 1. In-office measures: Fluoride application 2. At-home measures: MI remineralizing paste (amorphous calcium phosphate remeniralizing paste). Fluoridated tooth paste/ mouth rinse II. Advanced smooth-surface caries exhibits discoloration and demineralization and feels soft to penetration by the explorer. The discoloration can range from white to dark brown depending on rate of progression of lesion, with rapidly progressing caries usually being light in color while with slowly progressing caries darkening occurs over time because of extrinsic staining. III. Arrested caries: ICDAS Clinically it appears discolored, hard spot which The ICDAS was developed to serve as a guide for may be little rough to probing. standardized visual caries assessment. Due to remineralization of the decalcified tooth Every accessible surface of each tooth must be inspected for localized changes in color, texture, and translucency, as structure that harden the lesion. described in the ICDAS codes. This requires two minimum Management: restoration is not indicated except to conditions for the examination address the esthetic concerns of the patient 1. Teeth must be sufficiently air-dried so that the changes can be seen properly. 2. Biofilm or plaque must be thoroughly removed from teeth prior to the examination. The ICDAS uses a two-stage process, The first is a code for the restorative status of the tooth, and the second is for the severity of the caries lesion determined visually on a scale of 0 to 6: 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 This severity code is paired with a restorative/sealant code from 0 to 8: 0 = Sound, i.e. surface not restored or 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 Patients with one (or more) cavitated lesion(s) are high-risk patients. New technologies in caries detection: Patients with one (or more) cavitated lesion(s) and xerostomia are extreme-risk patients. Sealants are defined as confined to enamel either resin-based These devices may have the potential to or glass ionomer. replace the tactile portion of caries detection. Resin-based sealants should have the most conservatively These devices have two limitations. prepared fissures for proper bonding. Glass ionomer should be considered where the enamel is 1. only indicated for use on unrestored pits and immature, or where fissure preparation is not desired, or fissures. where rubber dam isolation is not possible. 2. their diagnostic accuracy has not been firmly Patients should be given a choice in material selection. established Restoration is defined as in dentin. The technologies currently approved by the U.S. 1. The DIAGNOdent device Food and Drug Administration (FDA) include: Concept: is a portable device that uses laser Laser-induced fluorescence. fluorescence technology, with the intention of Light-induced fluorescence. detecting and measuring bacterial products and AC impedance spectroscopy. changes in the tooth structure in a caries lesion. yields a numerical score from 0 to 99 that represent the presence and extent of a lesion. The device is clearly more sensitive than traditional diagnostic methods.  2. Spectra Camera (Air Techniques, Melville, NY) Special LEDs project high-energy violet or blue light onto the tooth surface stimulates porphyrins metabolites unique to cariogenic bacteria to appear distinctly red, while healthy enamel fluoresces to appear green. 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. 3. The CarieScan PRO (CarieScan, LLC, Charlotte, NC) is a device for the detection and monitoring of caries by the application and analysis of AC (alternating current) impedance spectroscopy (ACIST). 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. Clinical examination of defective direct restorations Clinical evaluation of previous restorations requires: 1. Visual observation. 2. Application of tactile sense with the explorer. 3. Use of dental floss. 4. Interpretation of radiographs The following conditions can be encountered: 1. amalgam “blues "or tattoo 2. Marginal staining or discoloration of 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. A: amalgam blues B: Significant marginal ditching a. Improper contour. b. Recurrent caries. a. Marginal discoloration in composite restoration. a. Extensively restored teeth with weakened and fractured cusps. b. Fracture line indicates replacement Proximal overhang can be diagnosed radiographically (bitewing radiograph). It can be evaluated by moving the explorer across it. Overhangs also can be confirmed by the catching or Occlusal high spot tearing of dental floss The ADA/FDA guidelines Radiographical examination directs the type and frequency of radiographs needed Radiographs are an indispensable part of the according to patient condition and risk factors contemporary dentist’s diagnostic armamentarium For New patient: but cumulative exposure to ionizing radiation A full mouth intraoral radiographic examiation is potentially can result in adverse effects. preferred when the patient has clinical evidence of Several technologies, particularly digital generalized dental disease or a history of extensive radiography, are now available and are designed to dental treatment. enhance diagnostic field and reduce radiation In the form of Individualized radiographic examination exposure. consisting of posterior bitewings with panorama or posterior bitewings and selected periapical images.  Caries (or recurrent caries) can be diagnosed Recall patient: radiographically as translucencies in the enamel or with clinical caries or at increased risk for caries. dentin. In 36-month patients before third molar eruption: Posterior bitewing exam at 6–12 months intervals if proximal surfaces cannot be examined visually or with a probe.(6-18 M in adult dentate or partially edentulous patients) with no clinical caries and not at increased risk for caries Posterior bitewing exam at 18–36 months intervals (24-36 month in adult patients dentate or partially edentulous) Dental radiographs should always be interpreted cautiously to avoid limitations. Implications: 1. The image is a two-dimensional representation of a 1. Cervical Burnout three-dimensional mass. The radiographic picture of the normal structure and 2. False-positive and false-negative diagnoses. contour of the cervical third of the crown mimics a To guard against these limitations, clinical and caries lesion. radiographic findings should be correlated continually, and the implications of their limitations should be understood when formulating a diagnosis and deciding on treatment. Implications: 2. Class V lesion or tooth colored restoration Treatment plan May be radiographically superimposed on the proximal area, mimicking a proximal caries lesion. A treatment plan is a carefully sequenced series of services designed to 3. Caries lesion extent Eliminate or control etiologic factors, May be more extensive clinically than it appears radiographically Repair existing damage, Create a functional, maintainable environment. Treatment plan is not a static list of services. Rather, it is often a multi-phase and dynamic series of Treatment plan sequencing: activities. Urgent phase: (pre-limenary) It consists of four steps It typically refers to the initial stage where immediate (1) Examination, problem identification, and risk intervention is done to stabilize the patient‘s assessment condition and manage acute concerns before moving (2) Decision to recommend intervention to longer treatment goals. (3) Identification of treatment alternatives e.g: patient presenting with swelling, pain, bleeding, (4)Selection of treatment with the patient’s or infection should have these problems managed as involvement soon as possible, before initiation of subsequent phases.  Control phase of treatment includes: Treatment plan sequencing: 1. Extractions 2. Occlusal adjustment Control phase: (phase I & II) 3. Periodontal debridement and scaling The goals of this phase are to remove etiologic factors 4. Caries removal; replacement or repair of defective and stabilize the patient’s dental health. restorations such as those with gingival overhangs These goals are accomplished by 5. Caries control measures. (1) Eliminating active disease such as caries and (as chemical, surgical, behavioral, mechanical, and inflammation, dietary techniques can be used to improve host (2) Removing conditions preventing maintenance, resistance and alter the oral flora) (3) Eliminating potential causes of disease (control 5. Endodontics risk factors), (4) Beginning preventive activities. Re-evaluation Phase: Recare and Re-assessment Phase: (Maintenance) This phase allows time between the control and The re-assessment phase includes regular re-evaluation definitive phases for resolution of inflammation and examinations to: healing. 1. Reveal the need for adjustments to prevent future Home care habits are reinforced, motivation for further treatment is assessed, and initial treatment and breakdown pulpal responses are re-evaluated before definitive 2. Provide an opportunity to reinforce home care. care is begun. The frequency depends on the patient’s risk for dental Definitive Phase: (phase III) disease. After the dentist reassesses initial treatment and determines the need for further care, the patient enters A patient at low risk of dental caries and periodontal the corrective or definitive phase of treatment. This problems, may have longer intervals (e.g., 9–12 months) phase may include fixed or removable prosthodontic between recall visits. treatment. In contrast, patients at high risk should be examined much more frequently (e.g., 3–4 months). Interdisciplinary Considerations in Periodontics Operative Treatment Planning Generally, periodontal treatment should precede operative treatment to create a more desirable Endodontics environment. All teeth to be restored with large restorations A tooth with a questionable periodontal prognosis should have a pulpal or periapical evaluation. If should not receive an extensive restoration until indicated, teeth should have endodontic treatment periodontal treatment provides a more favorable before restoration is completed. prognosis. Endodontically treated tooth that shows no The correction of gross restorative defects in evidence of healing or has an inadequate filling restoration contours (e.g., open contacts, gingival should be evaluated for re-treatment before overhangs, and poor embrasure form) is considered restorative therapy is initiated a part of initial periodontal therapy, and such corrections enhance a favorable tissue response. Orthodontics: Orthodontic therapy may include extrusion or Fixed, Removable, and Implant Prosthodontics: realignment of teeth to provide favorable interdental Preferably, operative direct restorations should be spacing, stress distribution, function, and esthetics. completed before placing indirect restorations. All teeth should be caries-free before orthodontic The design of the operative restoration and the banding. selection of appropriate restorative materials must Patients with orthodontic treatment should receive be compatible with the design of the contemplated more intense caries prevention measures. removable prosthesis This includes allowance for Oral Surgery: rests, guide planes, and clasps. Impacted, unerupted, and hopelessly involved teeth should be removed before operative treatment. In addition, soft-tissue lesions, and improperly contoured ridge areas should be eliminated or corrected before final restorative care.  Introduction Operative dentistry cannot be executed properly unless the moisture in the mouth is controlled. Isolation of the Moisture control refers to excluding sulcular fluids, saliva, and gingival bleeding from the operating field. operating field It also involves preventing the spray from the handpiece and restorative debris from Dr.Doaa Alhelais being swallowed or aspirated by the patient. The rubber dam, suction devices, and absorbents are variously effective in moisture control. Introduction Raskin et al. and Fusayama have reported, however, that achieving effective isolation is more important Why to isolate? than the specific technique used. Why to isolate? 1-Retraction and Access Retraction and access provides maximal exposure of the operating site and usually involves having the patient maintain an open mouth and depressing or retracting the gingival tissue, tongue, lips, and cheek. Isolation techniques 2-Harm Prevention Excessive saliva and handpiece spray can alarm the patient ,Small instruments and restorative debris can be aspirated or swallowed Soft tissue can be damaged accidentally. All of this can be prevented by isolation Isolation techniques: Dry, clean operating field. 1- Rubber Dam: Improved access and visibility The rubber dam is used to define the operating field by isolating one or more teeth from the oral environment. Advantages Potentially improved properties of dental materials Protection of the patient and the operator Operating efficiency.  Disadvantages Materials and Instruments: Time consumption and patient objection are the most frequently quoted disadvantages of the rubber dam. However, the rubber dam usually can be placed in less than 5 minutes. The advantages previously mentioned certainly outweigh the time spent with placement. 1- Rubber Dam sheet 1- Rubber Dam sheet The rubber dam material has a shiny side and a dull side. The rubber dam material has a shiny side and a dull side. Because the dull side is less light reflective, it is generally placed facing The rubber dam material has a shiny side and a dull side. Because the dull side is less light reflective, it is generally placed facing the occlusal side of the isolated teeth. the occlusal side of the isolated teeth. The dull side is less light reflective, The rubber dam material it is generally placed facing the occlusal side has a shiny side and a of the isolated teeth. dull side. The dull side is less light reflective, it is generally placed facing the occlusal side 5x5 Inch. 6x6 Inch of the isolated teeth. 2- Frame Light the contacts easier, Rubber which dam helpful when contacts are tight. is particularly Dark Rubber dam easier, the contacts U-shaped which is metal frame particularly helpfulwith when small contactsmetal are tight.projections for securing the borders Advantages: Maximum retraction, Excellent of the rubber dam. Advantage: of passing through the contacts easier, which is particularly contrast, More resistance for tearing. It maintains the borders of the rubber dam in position. helpful when contacts are tight. Disadvantages: Tear easily Disadvantages: Perforations need to be precised, Difficult to stretch 3- Retainer The rubber dam retainer consists of four prongs and two jaws connected by a bow the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. properly selected retainer should contact the tooth in its four line angles prevents rocking or tilting of the retainer. 3- Retainer the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. No 8 W8 The wings designed : Provide extra retraction of the rubber dam from the operating field Allow attachment of the dam to the retainer before applying the clamp 3- Retainer Materials and Instruments: 3- Retainer the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. Active Clamp: The prongs of some retainers are gingivally directed (inverted) Helpful when the anchor tooth is partially erupted or when additional soft tissue retraction is indicated 3- Retainer the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. Retentive clamp : The retainer is used to anchor the dam to the most posterior tooth to be isolated. Retraction clamp: Retainers are used to retract gingival tissue the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight.  3- Retainer the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. The bow of the retainer (except the No. 212, which is applied after the rubber dam is in place) should be tied with dental floss approximately 12 inches (30 cm) in length before the retainer is placed in the mouth. The floss allows retrieval of the retainer or its broken parts if they are accidentally swallowed or aspirated. Materials and Instruments: 4- Forceps the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. The rubber dam retainer forceps is used for placement and removal of the retainer from the tooth Materials and Instruments: Materials and Instruments: 5- Puncher 5- Puncher Precision instrument having a rotating metal table (disk) with holes of varying sizes and a tapered, sharp-pointed plunger the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. Materials and Instruments: Materials and Instruments: 5- Puncher 5- Puncher When the distance between holes is excessive, the dam material is excessive and wrinkles between teeth. Too little distance between holes the dam to stretch, resulting in space around the teeth and leakage the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. When a thinner rubber dam is used, smaller holes must be punched to achieve an adequate seal around the teeth because the thin dam has greater elasticity. Materials and Instruments: Materials and Instruments: 6- Napkin 7- lubricant the contacts easier, which is particularly helpful when contacts are tight. the contacts easier, which is particularly helpful when contacts are tight. A water-soluble lubricant applied in the area of the punched holes facilitates the passing of the dam septa through the proximal contacts. The rubber dam napkin, placed between the rubber dam and the patient’s skin, has the following benefits: A rubber dam lubricant is commercially available, but other lubricants such as shaving cream also are satisfactory. 1. It improves patient comfort by reducing direct contact of the rubber material with the skin. Cocoa butter or petroleum jelly may be applied at the corners of the patient’s mouth to prevent irritation. These two materials are not satisfactory rubber dam lubricants, because both are oil-based and not easily rinsed from 2. It absorbs any saliva seeping at the corners of the mouth. the dam when the dam is placed. 3. It acts as a cushion.