PART ONE Patient Assessment, Examination, Diagnosis.pptx

PATIENT ASSESSMENT, EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING ◦This phrase represents a fundamental principle: do no harm’. ◦The success of operative treatment depends heavily on an appropriate plan of care, based on: ◦ a comprehensive analysis of the patient’s reasons for seeking care ◦ on a sy...

PATIENT ASSESSMENT, EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING ◦This phrase represents a fundamental principle: do no harm’. ◦The success of operative treatment depends heavily on an appropriate plan of care, based on: ◦ a comprehensive analysis of the patient’s reasons for seeking care ◦ on a systematic assessment of the patient’s current conditions and risk for future problems. Evidence-based Dentistry ◦Research that provides information on treatments that work best in certain situations is expanding the knowledge base of dentistry and has led to an interest in translating the results of that research into practice activities and enhanced care for patients. Patient Assessment Chief Complaint ◦The patient’s chief complaints, or the concerns that initiated the patient’s visit, should be first recorded verbatim. ◦ The patient should be encouraged to discuss all aspects of the current problems, including onset, duration, symptoms, and related factors. Medical History ◦The patient’s medical history helps in identifying conditions that could alter, complicate, or contraindicate proposed dental procedures. ◦The practitioner should identify: ◦I. Communicable diseases that require special precautions, procedures, or referral. ◦II. Allergies or medications, which can contraindicate the use of certain drugs. ◦III. Systemic diseases, cardiac abnormalities, or joint replacements, which require prophylactic antibiotic coverage or other treatment modifications. ◦IV. Physiologic changes associated with aging, which may alter clinical presentation and influence treatment. ◦The practitioner also might identify a need for medical consultation or referral before initiating dental care. Dental History ◦The review of the dental history often reveals information about ◦ Past dental problems, previous dental treatment, and the patient’s responses to the treatments. ◦ Frequency of dental care and perceptions of previous care may be indications of the patient’s future behavior. ◦If a patient has difficulty tolerating certain types of procedures or has encountered problems with previous dental care, an alteration of the treatment or environment might help in avoiding future complications. Examination ◦Examination starts by: ◦Careful observation of extra-oral symmetry of the patient’s physical appearance of the head and neck areas, mandibular movement during speech, ability to articulate ◦ sounds, and tendencies to smile provides vital information relative to overall presence or absence of abnormalities or disease. ◦Utilization of clinical photography to capture full face and profile images is particularly useful in this process. ◦By definition, these early observations are all extra-oral in nature. ◦Any observations will ultimately be followed by the physical examination necessary to assess extra-oral aspects of the muscles of mastication, temporomandibular joints (TMJs), lymph nodes, and other vital structures which will then be followed by intraoral examination. Examination of Esthetic Appearance ◦Examination of esthetic appearance may be described as the evaluation of tooth colour, form, display, and position in relation to the face. ◦Evaluation must include discussion of realistic esthetic expectations when considering treatment options with the patient. Examination of Occlusion ◦A careful examination of the patient’s current occlusal scheme, along with potential impact on the muscles of mastication and TMJs must occur before planning and implementing restorative care. ◦The results of the occlusal examination should be included in the dental record and considered in the restorative treatment plan. Preparation for Clinical Examination ◦The clinical examination is performed systematically in a clean, dry, well-illuminated mouth. ◦ Proper instruments, including a mouth mirror, an explorer, and a periodontal probe, and the ability to air-dry the surfaces of the teeth, are required. ◦ A cotton roll is placed in the vestibular space and another under the tongue to maintain dryness and improve visualization of the teeth and adjacent gingiva. ◦Every accessible surface of each tooth must be inspected for localized changes in colour, texture, and translucency. ◦ A routine for charting should be established, such as starting in the upper right quadrant with the most posterior tooth and progressing around the maxillary and mandibular arches. Clinical Examination for Caries ◦Caries lesions may be detected by: ◦I. Visual changes in tooth surface texture or colour. ◦II. By tactile sensation, when an explorer is used to detect surface roughness by gently stroking across the tooth surface. ◦III. Radiographs, which show changes in tooth density from normal. ◦IV. Adjunctive tests that use various technologies to aid in caries lesion detection and caries activity International Caries Detection and Assessment System ◦The status of the caries severity is determined visually on a scale of 0–6: ◦0 = sound tooth structure ◦ 1 = first visual change in enamel ◦ 2 = distinct visual change in enamel ◦ 3 = enamel breakdown, no dentine visible ◦ 4 = dentinal shadow (not cavitated into dentine) ◦ 5 = distinct cavity with visible dentine ◦ 6 = extensive distinct cavity with visible dentine ◦ This severity code is paired with a restorative/sealant code 0–8: ◦ 0 = not sealed or restored ◦ 2 = sealant, partial ◦ 3 = sealant, full; tooth-coloured restoration ◦ 4 = amalgam restoration ◦ 5 = stainless steel restoration ◦ 6 = ceramic, gold, porcelain-fused-to-metal (PFM) crown or veneer ◦ 7 = lost or broken restoration ◦ 8 = temporary restoration Dental Explorer ◦The recommended instrument for assessment of surface roughness is the Community Periodontal Index of Treatment Needs (CPITN) probe having a 0.5 mm sphere at the tip: ◦The use of the sharp dental explorer for this purpose was found to fracture enamel and serve as a source for transferring pathogenic bacteria among various teeth Radiographs ◦ Radiographic findings must always be clinically verified (if possible) prior to the finalization of a diagnosis and treatment plan. ◦ For diagnosis of proximal surface caries, restoration overhangs, or poorly contoured restorations, posterior bitewing, and anterior periapical radiographs are most helpful. Adjunctive Aids for Examination ◦Magnification in operative dentistry ◦Photography in operative dentistry: for documentation and evaluation. ◦Transillumination ◦Newer caries detection technologies e.g. Laser-induced fluorescence ◦The standard of care for diagnosis of caries remains visual inspection of well-illuminated, clean and dry teeth, with use of radiographs as indicated. Clinical Examination of Proximal Surface Caries ◦Proximal surface caries is mainly identified by radiographic examination, visual inspection (with optional transillumination), or probing with an explorer. ◦Cavitated Proximal surface caries: When the caries lesion has progressed through the proximal surface enamel and has demineralized dentine, a white opaque appearance or a shadow under the marginal ridge may become evident. Clinical Examination of Smooth Surface Caries ◦Smooth-surface caries may occur on the facial and lingual surfaces of the teeth of patients with high caries activity, particularly in the cervical areas that are less accessible for cleaning. Clinical Examination of Root Surface Caries ◦Lesions are often found at the cementoenamel junction (CEJ) or more apically on cementum or exposed dentine in older patients or in patients who have undergone periodontal surgery. ◦Active root caries is detected by the presence of softening and cavitation. Clinical Examination of Amalgam Restorations ◦At least 10 distinct conditions might be encountered ◦when amalgam restorations are evaluated: ◦ (i) amalgam‘blues’, ◦(ii) proximal overhangs, ◦(iii) marginal ditching, ◦(iv)voids, ◦(v) fracture lines,. ◦(vi) improper anatomic contours, ◦ (vii) marginal ridge incompatibility, ◦(viii) improper proximal contacts, ◦(ix)improper occlusal contacts, ◦(x) recurrent caries lesions (i) amalgam‘blues’, ◦Discoloured areas or ‘amalgam blues’ are often seen through the enamel in teeth that have amalgam restorations. ◦This bluish hue results either from the leaching of amalgam corrosion products into the dentinal tubules or from the colour of underlying amalgam seen through the translucent enamel. ◦When other aspects of the restoration are sound, amalgam blues do not indicate caries, do not warrant classifying the restoration as defective, and require no further treatment Proximal Overhangs ◦Proximal overhangs are diagnosed visually, tactilely, and radiographically. ◦The amalgam–tooth junction is evaluated by moving the explorer back and forth across it. ◦Overhangs also may be confirmed by the catching or tearing of unwaxed dental floss. ◦Such an overhang, provides an obstacle to good oral hygiene, and may contribute to chronic inflammation of adjacent soft tissue. ◦ This type of overhang should be corrected, and often indicates the need for restoration replacement. Marginal Ditching ◦Marginal gap formation (or ‘ditching’) is the deterioration of the amalgam–tooth interface as a result of enamel wear and/or restoration edge fracture. ◦It can be diagnosed visually or by the explorer. ◦Shallow ditching less than 0.5 mm deep usually is not a reason for restoration replacement ◦If the ditch is too deep to be cleaned or jeopardizes the integrity of the remaining restoration or tooth structure, the restoration should be replaced. Voids ◦Localized voids, which result from poor condensation of the amalgam, may also occur at the margins of amalgam restorations. ◦ If the void is at least 0.3 mm deep and is located in the gingival third of the tooth crown, the restoration is judged as defective and should be repaired or replaced Fracture Lines ◦A careful clinical examination is able to detect the presence of a fracture line across the occlusal portion of an amalgam restoration. ◦A line that occurs in the isthmus region generally indicates a fractured amalgam, and the defective restoration must be replaced Improper Anatomic Contours ◦Amalgam restorations should duplicate the normal anatomic contours of teeth. ◦Restorations that impinge on soft tissue, have inadequate form or proximal contact, or prevent the use of dental floss should be classified as defective, indicating recontouring or replacement. Marginal Ridge Incompatibility ◦The marginal ridge portion of the amalgam restoration should be compatible with the adjacent marginal ridge. ◦If the marginal ridges are incompatible and are associated with poor tissue health, food impaction, or the inability of the patient to floss, the restoration is defective and should be recontoured or replaced. Improper Proximal Contacts ◦The proximal surface of an amalgam restoration should recreate the normal height of contour such that it comes into contact with the adjacent tooth at the proper occlusogingival and faciolingual area with correct adjacent form. ◦The use of floss is helpful in assessing the intensity of a closed contact. ◦If the contact is open and is associated with poor inter-proximal tissue health, food impaction, or both, the restoration should be classified as defective and should be replaced or repaired. Improper Occlusal Contacts ◦Improper occlusal contacts on an amalgam restoration may cause deleterious occlusal loading (and predisposition to fracture or pain on biting from hyper-occlusion), ◦Premature occlusal contacts may be seen as a ‘shiny’ spot on the surface of the restoration or detected by occlusal marking paper. ◦Such a condition warrants correction by selective occlusal adjustment. Recurrent Caries Lesions ◦Recurrent caries adjacent to the marginal area of the restoration is detected visually, tactilely, or radiographically and is an indication for repair or replacement.