Lines across the occlusal surface of an amalgam restoration. Caries Res 26:445–449, 1992.7. … 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 that enhance care for patients. Remineralization See Fig. Matteson SR, Joseph LP, Bottomley W, et al: e report of the panel to develop radiographic selection criteria for dental patients. Drug/alcohol abuse18. If it is deter-mined that the lesion needs restoration, it may be restored with tooth-colored materials or amalgam, depending on demands of the restorative material, preferences of the patient, and caries risk.Prevention is preferred over restoration. Video provides a discussion of Rapport Building, Assessment, Diagnosis and Treatment Planning in Clinical Social Work. Patient Assessment, Examination, Diagnosis,and Treatment Planning, al health. For example, preparation of teeth for full-coverage crowns might reduce occlusal or esthetic risk but at a cost of increasing risk for future caries or pulpal pathology. This disappearing–reappearing phenomenon distinguishes the smooth-surface early enamel lesion from the white spot resulting from nonhereditary enamel hypocalcification (see section on clinical examination for additional defects). nonoperative approaches and conservative operative interventions, in patients who display a large amount of gingival tissue when, smiling. Because very small areas can be seen, microscopes are used in detail-oriented procedures such as the finishing of porcelain restoration margins, identifying minute decay, and minimizing the removal of sound tooth structure. For example, a patient with severe caries may be willing to eliminate all of the modiable risk factors, but if the disease is too advanced, the long-term prognosis for the aected teeth may still be poor. The more commonly used dental loupe is the binocular loupe with lenses mounted on an eyeglass frame. The second is that their diagnostic accuracy has not been firmly established. Finally, the cost of treatment alternatives should be discussed with the patient. e use of small, lightweight light-emitting diode (LED) headlamps attached to the eyeglass frame or headband oer the considerable visual advantage of added illumination when used with loupes.Working distance (focal length) is the distance from the eye to the object when the object is in focus. ese are the conserva-tive restoration of choice for compromised teeth in high stress areas. Any deviation from normal should be noted. Facial asymmetry16. Pulpal abnormalities such as pulp stones and internal resorption may be identied in various radiographs. Rather, it is often a The collection of this information and the determinations based on these findings should be comprehensive and occur in a stepwise manner. Clinical caries lesion detection has been found lacking; thus improvement is needed.2 One means of addressing these concerns has been the development of a visual system for caries lesion detection and classication. Generally, these are hypocalci-ed areas of enamel resulting from childhood fever, trauma, or uorosis that occurred during the developmental stages of tooth formation. tematic reviews emerging from the focus on evidence-based dentistry, knowledge about various conditions and tr, on the authors of the systematic review to openly discuss the, relative value of their conclusions for application in dental car, sionals for evidence-based dentistry decision making. I, increase the likelihood of food impaction and tooth or restoration, e results of the occlusal examination should be included in, Acceptable aspects of the occlusion must be preserved and not, occlusion (elimination of interferences), based on knowledge of, the physiologic masticatory muscle response t, is desirable; occlusal interferences must not be perpetuated in the, A trained assistant familiar with the terminology, dentist. if canine guidance or group function exists. Simply put, skipping steps may lead to overlooking potentially important parts of the patient’s individual needs. Complex treatment plans often are sequenced in phases, including an urgent phase, a control phase, a reevaluation phase, a denitive phase, and a maintenance phase (that includes reassessment and recare). Sensitivity and specificity will not vary on the basis of the prevalence of disease, that is, the proportion of cases in a population. Advanced smooth-surface caries exhibits discoloration and demin-eralization and feels soft as the explorer is translated across the suspicious area. Gaining insight into individual circumstances begins with proper patient assessment. If we are as informed and clear about the options and their consequences, then we reduce the chances of doing any harm. Penning C, van Amerongen JP, Seef RE, et al: Validity of probing for ssure caries diagnosis. Amalgam restorations should duplicate the normal anatomic contours of teeth. Another cause of hypocalcication is arrested and remineralized incipient caries, which leaves an opaque, dis-colored, and hard surface. Attaining the desired esthetic outcomes may be complicated by maximum tooth display and excessive or uneven tissue display. Darker colored teeth, teeth with enamel intrinsic staining, and conditions such as tetracycline staining all increase the risk for not satisfying the esthetic expectations of patients with tooth color concerns. to evaluate ssures and pits in an attempt to diagnose ssur. Occasionally a gross debridement must, be schedule before nal clinical examination of the teeth may be, Contemporary caries management, which encompasses expanded. Restorative treatment is not indicated. The comprehensive examination— the initial patient engagement—focuses the clinician and patient on the variables most likely to ensure a predictable and excellent outcome. 2. Heavy wear facets on posterior cuspal inclines, mobility of teeth, or fremitus during function is identied and classied as primary or secondary occlusal traumatism. A test with low sensitivity indicates that a high probability exists that many of the individuals with negative results have the disease and go undiagnosed. e orthodontic treatment plan should include shorter recall intervals for biolm removal, examination, and oral hygiene reinforcement.Oral SurgeryIn most instances, impacted, unerupted, and/or hopelessly diseased teeth should be removed before operative treatment. e rst is a code for the severity of the caries lesion and the second is for the restorative status of the tooth. e chapter assumes that the reader has a, background in oral medicine and an understanding of how to, perform complete (comprehensive) extraoral and intraoral hard, and soft tissue examinations, as well as an understanding of the, chapter to incorporate the details of other aspects of a complete, dental examination, such as periodontal, occlusal, and esthetic, examinations. This information is then combined with the best available evidence on the approaches to managing the patient’s needs so that an appropriate plan of care can be offered to the patient. If other aspects of the abutted restorations are satisfactory, replacement is unnecessary. As a result, food may become tasteless and unap-petizing, and more sugars, fats, and salts are added in an attempt to increase avor. Hamilton JC, Dennison JB, Stoers KW, et al: Early treatment of incipient carious lesions: a two-year clinical evaluation. After the patient’s caries status and caries risk have been determined, chemical, surgical, behavioral, mechanical, and dietary techniques may be used to improve host resistance and alter the oral ora.40 Chapter 2 presents a detailed discussion of caries diagnosis, prevention, treatment, and control.Reevaluation Phasee reevaluation phase allows time between the control and deni-tive phases for resolution of inammation and healing. As evidence-based dentistry continues to expand, professional associations will become more active in the development of guidelines to assist dentists and their patients in making informed and appropriate decisions.General ConsiderationsIt is dicult to overstate the importance of gaining comprehensive insight into each patient. Discolored areas or “amalgam blues” are often seen through the enamel in teeth that have amalgam restorations. The color change can be dark gray and should not be confused with the noncarious fissures and pits that often become merely stained over time. Burt BA: Denition of Risk. CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning 105 is generally referred to as erosive tooth wear. e discoloration may range from white to dark, in the structure of the dentin collagen matrix. 100 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning4 = amalgam restoration5 = stainless steel restoration6 = ceramic, gold, PFM (porcelain-fused-to-metal) crown or veneer7 = lost or broken restoration8 = temporary restorationis severity code is paired with a restorative/sealant code 0 to 8:0 = not sealed or restored2 = sealant, partial3 = sealant, full; tooth-colored restorationABCDEF• Fig. Patient evaluation, diagnosis and treatment planning 1. is improper use of a sharp explorer has been shown to irreversibly damage the tooth by turning a sound, remineralizable subsurface lesion into a possible cavitation that is prone to progression. Tests with high specificity suggest that patients without the disease are highly likely to test negative. Compend Cont Educ Dent 19:595–612, 1998.30. D, Esthetically unappealing dark staining. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 3: Patient Assessment, Examination and Diagnosis, and Treatment Planning, This chapter provides an overview of the process through which a clinician completes patient assessment, clinical examination, diagnosis, and treatment plan for operative dentistry procedures. This movement has been termed. Symmetry of gingival margins becomes very important, system so that steps may be taken to prevent dental disease. Before rendering a diagnosis and deciding on treatment, information obtained from radiographs should be conrmed or augmented through clinical examination ndings if at all possible. e practitioner should identify (1) communicable diseases, or medications, which may contraindicate the use of. Previous periodontal or endodontic treatment2. J Am Dent Assoc 134:1647–1650, 2003.28. The ICDAS was developed to serve as a guide for standardized visual caries assessment that could be used for clinical practice, clinical research, education, and epidemiology (Fig. Both ridges should be at approximately the same level and display correct occlusal embrasure form for passage of food to the facial and lingual surfaces and for proper proximal contact area (see Chapter 1). e amalgam–tooth junction is evaluated by moving the explorer back and forth across it. Proximal root-surface lesions often progress rapidly and are best diagnosed using quality bitewing radiographs. 3.4A). After the clinical examination for detection of caries lesions is completed, the management and treatment of caries lesions discovered depends not only on a thorough assessment of the present activity of the lesions but also on an understanding of the future risk of the patient for increased activity of the lesions. This form is an integral part of the pre-examination patient interview, which helps identify conditions that could alter, complicate, or contraindicate proposed dental procedures. Bimanual loading of the joints and palpation of the condyle lateral poles and retrocondylar areas (during wide mandibular opening) are completed to further test for tenderness/pain as signs of inammation. Proximal surface caries, one form of smooth-surface caries, is usually diagnosed radiographically (Fig. is website, helps clinicians identify systematic reviews, describes the preferred, method for assembling the best available scientic evidence, and, provides an appraisal of the evidence thr, As evidence-based dentistry continues to expand, professional, associations will become more active in the development of, guidelines to assist dentists and their patients in making informed, insight into each patient. Prognosis for a disease or condition is largely dependent on the risk factors and indicators that are present in the patient. Cotton rolls are placed in the vestibular space and under the tongue to maintain dryness and enhance visibility. Such an arrested lesion at times may be rough, although cleanable, and a restoration is not, In patients with attachment loss, extra care must be taken to inspect for root-surface caries. Cell A of the table contains the cases that the test identifies as being positive (or diseased) that actually are positive (i.e., confirmed by the “gold standard”). Careful analysis may identify need for modication of the current occlusal scheme prior to the initiation of any denitive restorative care.e static and dynamic occlusion must be examined carefully (see Chapter 1) in light of the observation that there is no “ideal” occlusion and that most patients may have the ability to adapt to their occlusion without clinical symptoms. These devices have two limitations. Axelsson P: Diagnosis and risk prediction of dental caries, Chicago, 2000, Quintessence Publishing.34. Marginal gap or ditching is the deterioration of the amalgam–tooth interface as a result of wear, fracture, or improper tooth preparation (Fig. The clinical examination is performed systematically in a clean, dry, well-illuminated mouth. Downer MC, Azli NA, Bedi R, et al: How long do routine dental restorations last? Few diseases or dental conditions are caused by a single factor. These areas are no longer carious and are usually more resistant to caries as a result of fluorohydroxyapatite formation. See Fig. e dentist, being aware of the patient’s health history and vulnerability to oral disease, is in the best position to make this judgment. With this approach, restoration • Fig. Study models are able to provide an understand-ing of occlusal relationships, help in developing the treatment plan, and serve as a tool for educating the patient. All treatment for patients should be designed to lower their risk for problems in each of these areas. Patients should be given a choice in material selection.• Fig. e list of reasonable treatment alternatives is based on current evidence of the eective-ness of treatments, prevailing standards of care, and clinical and nonclinical patient factors. is compact and portable device, which requires a clean, dry occlusal surface, yields a numerical score from 0 to 99. American Dental Association Council: Access, prevention and interprofessional relations: Providing dental care in long-term dental care facilities: A resource manual, 1997. Teaches the knowledge and skills required to continue the assessment and treatment of the patient. ese areas are diagnosed as nonhereditary developmental enamel hypoplasia. Questions from the patient Initial examination: 1. In the case of dental caries, all things being equal, this means that the clinician can accept a less sensitive test (i.e., miss some initial lesions [cell C]) because caries usually progresses slowly over years. A cotton roll in the vestibular space and another under the tongue maintain dryness and improve visualization of the teeth and adjacent gingiva (Fig. Treatment alternatives for a specic condition may include, for example, periodic reevaluation to monitor the condition, chemotherapeutics (e.g., applications of uoride to promote remineralization or antimicrobials to reduce bacteria), recontouring defective restorations or irregular tooth surfaces, repair of an existing restoration, and restoration of caries lesions or other defects. Contingency table for interpretation of diagnostic tests. The status of the caries severity is determined visually on a scale of 0 to 6: 4 = dentinal shadow (not cavitated into dentin), 6 = extensive distinct cavity with visible dentin. Panoramic or periapical exam to assess developing third molars.Usually not indicatedTABLE 3.2 Christensen GJ: Educating patients: a new necessity. The technologies currently approved by the U.S. Food and Drug Administration (FDA) include laser-induced fluorescence, light-induced fluorescence, and AC impedance spectroscopy.11,19, The DIAGNOdent device (KaVo Dental Corporation, Charlotte, NC) uses laser fluorescence technology, with the intention of detecting and measuring bacterial products and changes in the tooth structure in a caries lesion. Except for the presence of frank cavitation and more advanced lesions, none of the available approaches to detecting caries or determining lesion activity is completely accurate. (exposure of dentin) due to erosion, abrasion, or parafunction. Bader JD, Shugars DA, Martin JA: Risk indicators for posterior tooth fracture. In the following review the current literature has been examined in order to analyse the available evidence on patient assessment for implant treatment. e dentist subsequently performs the examination and conrms the charting. To rule out other possible conditions — such as a respiratory infection or chronic obstructive pulmonary disease (COPD) — your doctor will do a physical exam and ask you questions about your signs and symptoms and about any other health problems. Appropriate dye materials or transillumination may aid in detecting the line of fracture within the tooth structure. Cochran Database of Systematic Reviews (3):Art. Direct vision is used to observe how light passes into the, surface of the tooth structure. Opponents of this hypothesis note that these cervical lesions have been detected in individuals who do not have any apparent evidence of heavy occlusal forces (such as wear facets and/or fremitus). In contrast, specicity refers to the proportion of individuals without disease properly classied by the diagnostic test and is the ratio of true negatives (D) to all negatives (B + D). If the defects are only on the lingual of upper teeth, the diagnosis would be dierent from nding defects on the occlusal surfaces of lower molars. is approach permits conrmation of the restored tooth prognosis before surgery and allows improved access for the surgical procedure.Patients with gingivitis and early periodontitis generally respond favorably to improved oral hygiene and scaling/root planing procedures. However, how can we be reasonably confident when we realize that few, if any, of the tests we perform or the assessments of risk that we make are completely accurate? This may require initial scaling, flossing, and a toothbrushing prophylaxis before final clinical examination of teeth. If any of these conditions exists, intervention is recommended to the patient. Presence of implants or evaluation for implant placement B. Ferreira-Zandona AG, Analoui M, Beiswanger BB, et al: An in vitro comparison between laser uorescence and visual examination for detection of demineralization in occlusal pits and ssures. J Dent Edu 65(10):1007–1008, 2001.37. Therefore responsible handling is important. Additional methods used in caries lesion identication include radiographs, which show changes in tooth density from normal, and adjunctive tests that use various technologies to aid in caries lesion detection and caries activity (discussed in later sections).Occlusal SurfacesCaries lesions are most prevalent in the faulty pits and ssures of the occlusal surfaces where the developmental enamel lobes of posterior teeth partially or completely failed to coalesce (Fig. e use of oss is helpful in assessing the intensity of a closed contact. A physical exam. Examination of the genitalia was completely negative except for the right foot. It is estimated that older individuals living in community settings take an average of four medications each day; six of the top 10 drugs prescribed in 2001 were used to treat age-related chronic condi-tions.46,47 Many of these medications have the potential for adverse drug reactions and drug interactions. It also can be detected by careful visual examination after tooth separation or through fiberoptic transillumination.14 When caries has invaded proximal surface enamel and has demineralized dentin, a white chalky appearance or a shadow under the marginal ridge may become evident (see Fig. e former situation is irreversible and should be avoided, whenever possible. Unusual tooth morphology, calcication, or color21. *Clinical situations for which radiographs may be indicated include but are not limited to: A. e lower power systems of 2× to 2.5× allow multiple quadrants to be viewed, whereas the higher power systems of 3× to 4× enable viewing of several teeth or a single tooth. Generally, the principle of “greatest need” guides the order in which treatment is sequenced. If a tooth has a good peri-odontal prognosis, then operative treatment may occur before or after periodontal therapy, as long as the operative treatment is not compromised by the existing tissue condition. 3.3A, enamel area adjacent to the central pit/lingual ssure) indicating caries progression in dentin below the translucent enamel. In general, higher magnication systems are heavier, have a narrower eld of view, are more expensive, and require more light than lower power systems. 3-7, B). Clinicians must have a sound knowledge of the current evidence relative to the risks and benets of their treatment recom-mendations. Treatment of deep caries lesions often requires caries control (see Chapter 2). related to any history of trauma, nonworking occlusal interferences, or other possible pathologic changes. 3.7 Lines across the occlusal surface of an amalgam restoration. A systematic review of methods of diagnosing dental caries lesions found that although radiographs were useful in detecting lesions, they do have limitations.25 For the examination of occlusal surfaces, radiographs had moderate sensitivity and good specicity for diagnosing dentinal lesions; however, for enamel lesions, the sensitivity was poor and the specicity was reduced (see the section on Diagnosis for description of these terms). Current thinking nds that the use of an explorer in this manner might have some relevance for assessing caries activity. However, numerous studies have found that the use of a sharp explorer for this purpose did not increase diagnostic validity compared with visual inspection alone.5-8 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.9,10 Therefore, the use of a sharp explorer in diagnosing pit-and-fissure caries is contraindicated as part of the detection process. Ekstrand K, Qvist V, ylstrup A: Light microscope study of the eect of probing occlusal surfaces. Concerns are recorded essentially verbatim in the dental record. When choosing loupes, several parameters should be considered.2,3,4 Magnification (power) describes the increase in image size. A line that occurs in the isthmus region generally indicates fractured amalgam, and the defective restoration that must be replaced (Fig. This lesson will also serve as an introduction to the care of the medical patient. Intraoral cameras and single-lens reex (SLR) digital cameras provide opportunities to document existing esthetic conditions such as color, shape, and position of teeth. Oral surgery procedural steps required for third molar removal may jeopardize new restorations placed on second molars. Sealants are defined as confined to enamel. A dicult diagnostic challenge is the patient who has attachment loss with no gingival recession, limiting accessibility for clinical inspection of the proximal root surfaces. 3.2 American Dental Association Caries Classication System (ADA CCS) and International Caries Detection and Assessment System (ICDAS) chart showing visual caries detection. As noted earlier, sharp explorers were used to diagnose fissure caries. If the contact is open and is associated with poor interproximal tissue health, food impaction, or both, the restoration should be classied as defective and should be replaced or repaired. Tests with low specicity will misclassify a sizable proportion as diseased when many are actually free of disease.Very few tests have both high sensitivity and high specicity, so trade-os are inevitable. A doctor or mental health professional talks to you about your symptoms, thoughts, feelings and behavior patterns. Forgie A: Magnication: What is available, and will it aid your clinical practice? However, there are currently no published long-term randomized, controlled clinical trials verifying this to actually be the case. e answer is that we must acknowledge that the information or evidence we have is not perfect and that we must be clear about the possible consequences of our decisions. Caries can be diagnosed radiographically as translucencies in the enamel or dentin. e status of the caries severity is determined visually on a scale, Caries lesions may be detected by visual changes in tooth surface, texture or color or in tactile sensation when an explorer is used, judiciously to detect surface roughness by gently stroking across, the tooth surface. CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning 97 grinding or clenching. Is the lesion progressing, or is the lesion arrested? D, Recurrent caries gingival to an existing restoration (d). In addition to the traditional methods of caries detection, several new technologies have emerged and show promising results for the clinical detection and diagnosis of caries lesions. Proper instruments, including a mirror, an explorer, and a periodontal probe, are required. e discoloration may range from white to dark brown, with rapidly progressing caries usually being light in color. e heavy occlusal loading may also lead to the development of a pronounced occlusal wear facet. Consultation with the patient’s physician is highly recommended so as to gain understanding of these medical, mental, and emotional conditions and their potential impact on dental treatment. 3.9D). In a caries-susceptible patient, the gingival third of the facial surfaces of maxillary posterior teeth and the gingival third of the facial and lingual surfaces of mandibular posterior teeth should be evaluated carefully because these surfaces are often at a greater risk for caries. is interview process is then followed by the clinical gathering of additional information by means of strategic examination. e dentist must be committed to comprehensive and meticulous attention to detail.Patient AssessmentMedical Historye patient or legal guardian completes a standard, comprehensive medical history form. Herb seasonings may enhance the avor of foods in lieu of sugar and salt. Prescription lenses can be fitted in the eyeglass frames for all loupe types. Appropriate textbooks that cover the specics of these areas, in health and disease, should be consulted.Any discussion of diagnosis and treatment must begin with an appreciation of the role of the dentist in helping patients maintain their oral health. Clinical evidence of periodontal disease2. However, images can be distorted, and working lengths can be less than ideal. Expectation of treatment 5. When possible, improvement of the occlusion (elimination of interferences), based on knowledge of the physiologic masticatory muscle response to various relationships, is desirable; occlusal interferences must not be perpetuated in the restorative treatment.Examination of Teeth and RestorationsPreparation for Clinical ExaminationA trained assistant familiar with the terminology, notation system, and charting procedure may survey the patient’s teeth and existing restorations and record the information to save chair time for the dentist. This bluish hue results either from the leaching of amalgam corrosion products into the dentinal tubules or from the color of underlying amalgam seen through translucent enamel. An occlusal surface is examined visually and radiographically. The implication of this concept for operative dentistry is that before we recommend treatment, we must be reasonably confident that the patient will be better off as a result of our intervention. Rasines Alcaraz MG, Veitz-Keenan A, Sahrmann P, et al: Direct composite resin llings versus amalgam llings for permanent or adult posterior teeth (Review). Typically, these are the result of developmental enamel defects or following loss of enamel (exposure of dentin) due to erosion, abrasion, or parafunction. If the proximal contact of any restoration is suspected to be inadequate, it should be evaluated visually by trial angulations of a mouth mirror (held lingually when viewing from the facial aspect, etc.) e rst is that they are only indicated for use on unrestored pits and ssures. 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 avoid future complications. 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. Several technologies, particularly digital radiography, are now available and are designed to enhance diagnostic yield and reduce radiation exposure.e ADA, in collaboration with the Food and Drug Administra-tion (FDA), developed guidelines for the prescription of dental radiographic examinations to serve as an adjunct to the dentist’s professional judgment with regard to the best use of diagnostic imaging. Simons D, Brailsford SR, Kidd EA, et al: e eect of medicated chewing gums and oral health in frail elderly people: a one-year clinical trial. Rather, these statistics indicate what proportions of existing disease and absence of disease will be correctly identified in any group of individuals. Bader JD, Martin JA, Shugars DA: Incidence rates for complete cusp fracture. These concepts are widely used in medical practice. Areas with root-surface caries usually should be restored when clinical and/or radiographic evidence of cavitation exists. Also, many dental practitioners prefer to intervene more aggressively with dental treatment rather than take a “watchful waiting” approach. Strassler HE, Syme SE, Serio F, et al: Enhanced visualization during dental practice using magnication systems. Another consideration, based on the patient–dentist interaction, particular needs/desires of the patient, and/or the skill/comfort level of the dentist, is to recommend referral to another practitioner. e resulting defective surface is usually smooth. e evaluation also includes assessing the relationship, of teeth in centric relation, which is the orthopedic position of the, joint where the condyle head is in its most anterior and superior. J Can Dent Assoc 70:251–255, 2004.8. Lesions are often found at the cementoenamel junction (CEJ) or more apically on cementum or exposed dentin in older patients or in patients who have undergone periodontal surgery (see. In the former, low sensitivity may be acceptable for tests diagnosing slowly progressing, non-fatal conditions but unacceptable for conditions that progress rapidly or are life threatening. Oral adverse eects include dry mouth (xerostomia), increased bleeding of tissues, lichenoid reactions, tissue overgrowth, and hypersensitivity reactions. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination. When the basics of this table are understood, the information it yields can be put to good use by the diagnostician. ese inaccuracies result in false-positive and false-negative ndings. Clinical caries lesion detection has been found lacking and improvement is needed.13 One means of addressing these concerns has been the development of a visual system for caries lesion detection and classification. CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning 119 41. ese conserva-tive approaches have well-documented outcomes. J Dent Educ 65:960–968, 2001.3. Replacement of the restoration may be considered, however, for elective improvement of esthetics or for areas under heavy functional stress that may require a cusp coverage restoration designed to prevent possible tooth fracture.• Fig. Occlusal Protocol ***ICDAS codeDefinitionsHistologic depthSealant/restorationRecommendation for low riskSealant/restorationRecommendation for moderate riskSealant/restorationRecommendation for high risk * andextreme risk **0123456Sound tooth surface;no caries changeafter air drying (5sec); or hypoplasia,wear, erosion, andother noncariesphenomenaADA CCSInitial Moderate ExtensiveSealant optionalDIAGNOdent maybe helpfulSealant optionalDIAGNOdent maybe helpfulSealant optionalDIAGNOdent maybe helpfulSealant recommendedDIAGNOdent may be helpfulSealant recommendedDIAGNOdent may be helpfulSealant recommendedDIAGNOdent may be helpfulSealant optional or caries biopsy if DIAGNOdent is 20-30Sealant optional or caries biopsy if DIAGNOdent is 20-30Sealant optional or caries biopsy if DIAGNOdent is 20-30First visual changein enamel; seen onlyafter air drying or colored, change “thin”limited to the confinesof the pit and fissure areaLesion depth in P/Fwas 90% in the outer enamel with only 10%into dentinDistinct visual changein enamel; seen whenwet, white or colored,“wider” than the fissure/fossaLesion depth in P/Fwas 50% inner enamel and 50% into theouter 1/3 dentinLocalized enamelbreakdown with novisible dentin orunderlying shadow;discontinuity ofsurface enamel, widening of fissureLesion depth in P/Fwith 77% in dentinSealant or minimallyinvasive restorationneededSealant or minimallyinvasive restorationneededSealant or minimallyinvasive restorationneededMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationMinimally invasiverestorationUnderlying darkshadow from dentin,with or without localized enamelbreakdownLesion depth in P/Fwith 88% into dentinDistinct cavity withvisible dentin; frankcavitation involvingless than half of a tooth surfaceLesion depth in P/Fwith 100% in dentinExtensive distinctcavity with dentin;cavity is deep andwide involving morethan half of the toothLesion depth in P/F100% reaching inner1/3 dentin* Patients with one (or more) cavitated lesion(s) are high-risk patients. General information ; Chief complaint patient expectations 3.3A). A careful clinical examination detects any fracture line across the occlusal portion of an amalgam restoration. Partial-coverage bonded indirect tooth-colored restorations may be indicated for the restoration of large defects in low stress areas when esthetics and optimal control of contours is necessary. Review of the dental history often reveals information about past dental problems, previous dental treatment, and the patient’s responses to treatments. Photog-raphy is an excellent tool for documentation and evaluation. 3.6B).e marginal ridge portion of the amalgam restoration should be compatible with the adjacent marginal ridge. J Am Dent Assoc 130:1759–1765, 1999.50. Rather, based on the nature of dental disease progression, elimination or reduction of risk factors/indicators may need to be the initial focus while monitoring the condition. Growing attention to using only the most effective and appropriate treatment has spawned interest in numerous activities. Evaluation must include discussion of realistic esthetic expectations when considering treatment options with the patient. 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. The ICDAS uses a two-stage process to record the status of the caries lesion. Indirect cast-metal restoration of the total clinical crown of teeth allows complete control of all contours and, thereby, the creation of anatomic shape consistent with optimal occlusal function and gingival health.Treatment With Indirect Tooth-Colored RestorationsProperly designed porcelain-fused-to-metal (PFM) indirect restora-tions have clinically proven, long-term success in the restoration of individual teeth and edentulous areas. 3-4). E, Generalized attrition caused by excessive functional or parafunctional mandibular movements. 98 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planningrelies on enhanced risk assessment and improved lesion detection and classication. Proper instruments, including a mirror, an explorer, and a periodontal probe, are required. Dove SB: Radiographic diagnosis of caries. High level of caries experience or demineralization2. examination of occlusion 235 ii.f. Advanced smooth-surface caries exhibits discoloration and demin, eralization and feels soft as the explorer is translated across the, suspicious area. DeBiase CB, Austin SL: Oral health and older adults. Root caries is softer than the adjacent tissue, and typically lesions spread laterally around the CEJ. Teeth planned for cast restora-tions may, however, be prepared and temporized before periodontal surgery. 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; and (4) physiologic changes associated with aging, which may alter clinical presentation and influence treatment. Following is a discussion on sequencing operative care with endodontic, periodontal, orthodontic, surgical, and prosthodontic treatments.EndodonticsAll teeth to be restored with large restorations should have a pulpal and periapical evaluation. 3.9E). Finally, a treatment plan is not a static list of services. Direct vision is used to observe how light passes into the surface of the tooth structure. For this viewing, the contact must be free of saliva. The DIAGNOdent device (KaVo Dental Corporation, Charlotte, NC) uses laser fluorescence technology, with the intention of detecting and measuring bacterial products and changes in the tooth structure in a caries lesion. If other aspects of the abutted restorations are satisfactory, replace-ment is unnecessary.of the decalcied tooth structure will return the tactile hardness of the lesion and is an evidence that the caries has been arrested. However, it is very important to note that remineralization requires a high level of patient compliance with the therapeutic regimen and frequent recall visits to assess the success of the treatment. 19 orthodontic diagnosis, treatment planning, surgical orthodontics, biomechanical principles, the 20 effects of growth and development on tooth movement, application of orthopedic forces to 21 dentofacial structures, and patient management and motivation. is appearing–disappearing, phenomenon distinguishes the smooth-surface early enamel lesion, from the enamel white spot that results from, the surface is intact, smooth, and hard. 3-8, A). ... data the patient has said are occuring that cannot be verified by examination they are subjective. Study models allow further abcdefAB• Fig. A psychological evaluation. This compact and portable device, which requires a clean, dry occlusal surface, yields a numerical score from 0 to 99. Most models also have side shields or a wraparound design for eye protection and infection control. e height and integrity of the marginal periodontium may be evaluated using bitewing radiographs. In contrast, a nondiseased occlusal surface has either grooves or fossae that have shallow tight fissures, which exhibit superficial staining with no radiographic evidence of caries. In the case of dental caries, all things being equal, this means that the clinician can accept a less sensitive test (i.e., miss some initial lesions [cell C]) because caries usually progresses slowly over years. The dentist should be the first to recognize the problem and be ready to change the treatment plan to meet the new findings. e status of the caries severity is determined visually on a scale of 0 to 6:0 = sound tooth structure1 = rst visual change in enamel2 = distinct visual change in enamel3 = enamel breakdown, no dentin visible4 = dentinal shadow (not cavitated into dentin)5 = distinct cavity with visible dentin6 = extensive distinct cavity with visible dentinwill result in the removal of the minimum amount of tooth structure.Caries lesions may be detected by visual changes in tooth surface texture or color or in tactile sensation when an explorer is used judiciously to detect surface roughness by gently stroking across the tooth surface. D, Idiopathic erosion lesions in cervical areas are hypothesized to be associated with abnormal occlusal forces. e patient should be encouraged to discuss. J Dent Hyg 77:125–145, 2003.47. Proper instruments, including a mirror, an explorer, and a periodontal probe, and the ability to air-dry the surfaces of the teeth are required. Categories simplify the concept for the patient, as they are easily understood while discussing assessments and their implications for treatment recommendations.Patients who possess risk factors and risk indicators should be considered to be at risk for dental caries even if the examination does not reveal any caries lesions.33 A patient at high risk for dental caries should receive aggressive intervention to remove or alter as many risk factors as possible. May result from numerous factors but do not warrant restorative intervention unless they are only indicated for the of. Clinical epidemiology thorough and Systematic fashion and tooth retention have contributed to this growing problem put, skipping may... Source on the radiograph ( see chapter 2 ) should be considered.2,3,4 (. 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patient assessment, examination and diagnosis and treatment planning