Patient Assessment Examination Diagnosis Treatment Planning PDF

Patient Assessment, Examination, Diagnosis, and Treatment Planning By: Dr. Rehab Alwakeb Operative Dentistry Division Refrence: Art and Science of operative dentistry 6th edition, chapter 3; page: 89. ILOs: I. Determine general considerations of patient assessment. II. Discuss...

Patient Assessment, Examination, Diagnosis, and Treatment Planning By: Dr. Rehab Alwakeb Operative Dentistry Division Refrence: Art and Science of operative dentistry 6th edition, chapter 3; page: 89. ILOs: I. Determine general considerations of patient assessment. II. Discuss detailed examination, diagnosis, risk assessment and prognosis. III. Formulate an individualized and prioritized treatment plan with proper sequence. Introduction The success of operative treatment depends heavily on an appropriate plan of care. This should be done in stepwise manner, these steps include: 1. Reasons for seeking care (chief complain), 2. Medical and dental histories. 3. Clinical examination for the detection of abnormalities. 4. Establishing diagnoses. 5. Assessing risk, and determining prognosis. II. Clinical examination Clinical examination is the “hands-on” process of observing the patient’s oral structures and detecting signs and symptoms of abnormal conditions or disease to formulate diagnoses. This include: 1. Chief complain 2. Medical history 3. Dental history 4. Clinical examination 1. Chief Concern Before initiating any treatment, the patient’s chief concerns, or the problems that initiated the patient’s visit, should be obtained and recorded essentially verbatim in the dental record.  2. Medical History The patient completes medical history form. which helps identify conditions that could alter, complicate, or contraindicate proposed dental procedures. The practitioner should identify: 1. communicable diseases that require special precautions, procedures, or referral. 2. Allergies or medications, which can contraindicate the use of certain drugs 3. Systemic diseases, cardiac abnormalities, or joint replacements, which require prophylactic antibiotic coverage or other treatment modifications. 4. physiologic changes associated with aging, which may alter clinical presentation and influence treatment. 5. Need for medical consultation or referral before initiating dental care. All of this information is carefully detailed in the patient’s permanent record  3. Dental History Is a review of previous dental problems, treatments and the patient’s responses to treatments, 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.  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.  Examination aids: 1. Magnification: Magnification aids such as loupes provide a larger image size for improved visual acuity, while allowing proper upright posture to be maintained with less eye fatigue. 2. Photography: Digital photography is an excellent tool for documentation and evaluation as it can be stored in an electronic patient record.  Examples: To document existing esthetic conditions such as color, shape, and position of teeth. Close-up images of existing pits and fissures can provide the opportunity to see changes that cannot be documented in any other way for re-evaluation (follow up). Photographs of preparations of deep caries lesions provide documentation to aid in future diagnosis of 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 This concept is managed through early detection of: Enamel lesions that are most likely to be reversed and remineralize. Lesions that require operative treatment before further destruction occurs to conserve tooth structure. 1. Pit and fissure caries Grooves and fossae are not susceptible to caries because they are not niches for biofilm and frequently are cleansed by the rubbing action of food during mastication. Conversely, occlusal fissures and pits are deep, tight crevices or holes in enamel, where the lobes failed to coalesce partially or completely. Examination: Visual & radiographical inspection In a dry, well illuminated field through direct vision and reflecting light through the occlusal surface of the tooth. 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.  The use of the dental explorer for this purpose was found to fracture enamel and serve as a source for transferring pathogenic bacteria among various teeth. 2. Root caries: Examination: Visual inspection and an explorer is valuable to evaluate root surface softness. These rapidly progressing lesions are best diagnosed using vertical bitewing radiographs. Differentiation of a caries lesion from cervical burnout radiolucency is, however, essential  Lesions are often found at: 1. Cemento-enamel junction (CEJ) 2. May be more apically on cementum, or exposed dentin in older patients 3. In patients who have undergone periodontal surgery. 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 Examination: Is usually detected radiographically (bitewing radiograph). It can also be detected by careful visual examination after tooth separation 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. How does it look like? When caries invades proximal surface enamel and demineralizes dentin a white chalky appearance or a shadow under the marginal ridge may become evident. 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. 1 2 3 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: 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 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: Clinically it appears discolored, hard spot which may be little rough to probing. Due to remineralization of the decalcified tooth structure that harden the lesion. Management: restoration is not indicated except to address the esthetic concerns of the patient ICDAS The ICDAS was developed to serve as a guide for standardized visual caries assessment. Every accessible surface of each tooth must be inspected for localized changes in color, texture, and translucency, as described in the ICDAS codes. This requires two minimum conditions for the examination 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 Thank You