Patient Assessment, Examination,

Diagnosis and Treatment Planning

Presented by
Dr / Belal
 Objective of the chapter

(1) Recording chief complaint of the patient.

(2) Identification medical and dental history
from patient.
(3) Examination and diagnosis of the existing
dental problem.
(4) Design the suitable and proper treatment
plane for the diagnosed dental problem.
 Charting and Records

The dental record should include the following:

1- Patient personal information.

2 Medical history.
3 Dental history.
4 Clinical examination, diagnosis, ttt planning.
5- Documentation of informed consent.
Examination:
The process of observing
both normal and abnormal
conditions.

Diagnosis :
The determination and judgment of variations
from normal.
 Patient Assessment
1- Infection control

Gloves Plastic barrier Mask &

eye glasses
- Use of disinfectants and instruments sterilization
2- Chief complaint

It should be in the patient’s own wards

Related
Onset factors

Duration Symptoms
 3- Medical review
The practitioner may identify:

1 Communicable disease that require special precautions

or procedures.

2 Allergies or medications that may contraindicate the

use of certain drugs.

3 Systemic diseases and cardiac abnormalities that

demand less stressful procedures or prophylactic
antibiotic coverage.

4 Physiologic changes associated with aging that may

alter clinical presentation and influence treatment.
4- Dental history

Past • Frequency of dental care

Dental • Difficulty to certain types
of procedures
History

Present • Chief complaint

Dental • Dates and types of radi-
ographs should be recorded
History
Clinical examination

1. Oro-facial soft tissue

2. Caries lesions
3. Non caries lesions
4. Existing restorations
5. Periodontium
6. Occlusion
7. Examination of patient
in pain
 Examination of orofacial soft tissue

It involves examination and palpation of :

1 Submandibular glands and cervical nodes for

abnormalities in size, texture, mobility and sensitivity
to palpation.
2 Masticatory muscles for pain or tenderness.
3 Checks, vestibules, mucosa, lips, lingual and facial
alveolar mucosa, palate, tonsillar areas, tongue and
floor of the mouth.
 Diagnosis of dental caries

1 Caries risk assessment

The probability that a specific number of
new lesions will develop and/or specific
number of an already existing lesions will
progress over a specified period of time.
 Diagnosis of dental caries
2 Identification of caries
Traditional means of caries diagnosis:

I Visual changes in the tooth surface texture

or color.
II Tactile sensation by using mirror and probe.
III Radiographs:
Traditional periapical and bite wing radiographs
are still mandatory. It is used for detecting
caries interproximally.
 Diagnosis of dental caries

Periapical radiograph Bitewing radiograph

 Diagnosis of dental caries
IV Magnification

A Dental loupes B Dental microscopes

 Diagnosis of dental caries
Advanced tools for caries diagnosis:

1. The intraoral camera

 Diagnosis of dental caries

2. Direct digital radiography:

There are two types:

a. Charge-coupled device (CCD): It is composed of a sensor
connected directly to the computer through a cable.

b. Storage-phosphor-based:
The reusable image plate is
exposed to radiation to create
a latent image. The plate is
exposed to a laser scanner to
obtain the stored information.
 Diagnosis of dental caries

The advantages of digital radiography over

conventional radiography:
(1) Ease of manipulation of contrast and density.
(2) Lower exposure of radiation.
(3) Absence of dark room and processing solutions.
(4) It takes less time for imaging.
(5) Image storage and communication is easier.
 Diagnosis of dental caries

3. Laser based device (Diagnodent)

-It is a quantitative method of caries
diagnosis based on the fluorescing
nature of bacterial products.

- Numeric data between 5 and

25 initial enamel lesions
- Greater values dentinal
lesions.
 Diagnosis of dental caries

4. Quantitative fiberoptic transillumination (FOTI)

 Diagnosis of dental caries

5. Electrical caries monitor ECM

- It is based on the electrical
conductivity differences between
sound dentinal tissues and caries
dental tissues.

6. Ultrasonic caries detection

- Ultrasound waves have been used to image the
tooth and to find caries lesion
 Diagnosis of dental caries

Diagnosis of occlusal surface

Chalkiness or softing/cavitation
of tooth structure or brown
gray discoloration radiating
peripherally from pit/fissure.

Radiograph of the carious

surface will have radiolucency
beneath the occlusal enamel
surface originate from the DEJ.
 Diagnosis of dental caries
Diagnosis of proximal surface
a Visually the carious proximal surface will
appear with a chalky appearance or a shadow
under the marginal ridge

b Probing by an explorer to detect

cavitation.

c Fiberoptic transillumination.

d- Radiograph (bitewing radiograph).

 Diagnosis of dental caries

Diagnosis of facial & lingual surfaces

Incipient white spot which disappear by wetting
and appear again by drying the surface. This is called
disappearance-reappearance phenomenon which used to
differentiate between incipient caries and hypocalcification.
 Diagnosis of dental caries

Diagnosis of root caries

- It appears well- defined discolored area adjacent to
the gingival margin , softer than the adjacent tissue
and spread laterally around the CEJ.
- It is diagnosed either visually or by bitewings.
 Examination of non carious lesions

1 Tooth wear

Erosion Attrition Abrasion

2 Developmental enamel hypocalcification

3 Fracture or craze line

 Examination of non carious lesions

Attrition
Physical wear of one tooth against another. Affects
the incisal edges and occlusal surfaces of opposing
teeth. May be accelerated by erosion or may be
aused entirely by bruxism or other parafunctional
activities.
 Examination of non carious lesions

Abrasion
Commonly affects the neck of the buccal surfaces of both
anterior and posterior teeth. The etiology is not clear, but
some dentists believe that it is caused by physical wear
from external agents such as:
- Abrasive toothpastes and powders.
- Hard toothbrushes or excessive use of other cleaning aids.
 Examination of non carious lesions

Erosion
a Regurgitation erosion:

Affects palatal surfaces of upper anterior teeth

and occlusal and buccal surfaces of lower posterior
teeth.
 Examination of non carious lesions

Erosion
b Dietary erosion:

Affects the labial surfaces of

upper anterior teeth. Caused
by an excess of food and
drink with a low pH as Citrus
fruits, Pickles and carbonated
drinks.
 Examination of non carious lesions

Erosion
c Industrial erosion:
Commonly affects the labial surfaces of the
upper anterior teeth and may cause pitting.
Caused by industrial processes which produce
acid fumes or droplets.

Abfracion
It is a cervical, wedge shaped defect that
is angular. Occur due to heavy force in
eccentric occlusion. It has the same clinical
features as abrasion but mare aggressive form.
 Examination of non carious lesions

2 Non hereditary developmental enamel

hypocalicification areas

It have man resulted factors

such as childhood fever, trauma
or fluorosis that occurred during
the developmental stages of tooth
formation. It is opaque white and
remain visible regardless if the
tooth is wet or dry.
 Examination of non carious lesions

3- Fracture or craze line

It is usually occurs in teeth with extensive restoration,
weakened cusps and deep developmental fissures
across marginal or cusp ridges. It is detected by dye
material, light reflected from a dental mirror or
transillumination.
 Examination of existing restorations

I Clinical examination of Amalgam restorations

Amalgam restorations can be examined using:

a Visual observation.
b Tactile sense with the explorer.
c Dental floss
d Radiographs (Bitewing).
 Examination of existing restorations

Clinical examination of amalgam restorations may show:

(1) Amalgam blues (2) Proximal overhangs

 Examination of existing restorations

(3) Marginal ditching

It is the deterioration of the
amalgamtooth interface as a result
of wear, fracture or improper tooth
preparation.

(4) Voids
It occurs at the margins of amalgam restorations. It is
at least 0.3 mm deep. Small voids may be corrected
by recontouring or repairing with a small restoration.
 Examination of existing restorations

(5) Fractures

(6) Improper anatomic contours

Proper anatomy Improper anatomy

 Examination of existing restorations

(7) Improper proximal contacts

Proper contact Open contact & incompatible

marginal ridge height
(8) Marginal ridge incompatibility

(9) Recurrent caries

 Examination of existing restorations

Examination of composite restorations

Ideal restoration Recurrent caries

Fractured restoration Marginal discoloration

 Examination of existing restorations

Examination of cast restorations

Proper cast restoration Improper margins

Chipped porcelain
 Adjunctive aids for examination

1 Percussion:
It is done by gentle tapping of
occlusal or incisal surfaces by the
use of mirror handle.

2 Palpation:
It is rubbing the index finger along the facial and
lingual mucosa overlying the apical region to detect
a periapical pathosis in teeth showing tenderness to
Percussion
Adjunctive aids for examination

3 Vitality test
• Cold: ethylchloride or
Thermal pencil of ice
test • Hot: hot gutta percha or
instrument

• No response means pulp

Electric death
pulp tester • Tingling sensation means
vital pulp.
 Adjunctive aids for examination

4 Cavity test:
It used round bur without anesthesia, a cavity
is made through the restoration into dentin.

5 Anesthetic test:
It must be used anesthesia for
the suspected tooth and if the
symptoms subside, so affected
tooth has been identified.
6 Study cast
 Evaluation sheet no 3

1- Mention different types of tooth wear lesions ?

2- Mention 3 items of restoration examination ?

3- Mention 3 of the adjunctive aids?

 Examination of periodontium

Healthy gingival is light pink in color, firm

knife edged and stippled. But unhealthy gingival
is red, soft, edematous and has glazed smooth
surface.

Healthy gingiva Inflamed gingiva

 Examination of periodontium

A Assessment of attachment level by using:

1. Straight probe for determination of vertical depth.

2. Curved probe to explore root and furcation areas.

B- Tooth mobility:

It is indicated for loss of bone support or the

result of improper occlusal forces.
 Examination of periodontium

C Presence of plaque, debris or inflammation:

The periodontal health and the patient oral hygiene
may affect the prognosis of any operative treatment.

D Radiographic examination:
Vertical bitewing radiographs are recommended
for assessment of bone levels e.g. Localized or
Generalized, vertical or horizontal sbone loss.
 Examination of occlusion

Most people have some difference between

the positions of centric relation and maximum
intercuspation and have no pathosis.

But it may have a problem when there are:

1- Signs and symptoms e.g. mobility, wear facets,
enamel cracks or periodontal problems.

2- The need to restore the majority of the posterior

occlusion.
 Examination of patient in pain

Patients in pain should be examined by:

a) Subjective information from the patient.
b) Objective information from clinical examination
Supplemented with appropriate diagnostic tests.

The dentist should apply certain tests to verify

such diagnoses e.g. transillumination , percussion,
palpation and pulp testing.
 Treatment Planning
Treatment planning have two types:
1 Ideal treatment plan:
It is the plan where the best forms of
treatment are done irrespective to the patient
and dentist limitations.

2 Optional treatment plan:

It is the plan where the maximum form
of treatment is done in relation to the patient
general and oral conditions as well as the dentist
knowledge and experience.
 Treatment Plan Sequencing

1 Urgent Phase:

The phase at which acute problem should be managed

such as swelling, pain, bleeding or infection. These
problems managed as soon as possible and before
initiation of subsequent phases.

2 Control Phase:

This phase removes etiological factors and stabilizes

the patient health including elimination of active diseases
as caries and inflammation, elimination of pain, remove
conditions prevent maintenance e.g. overhanging margins.
3 Reevaluation Phase:
The holding phase is a time between the control
and definitive phase that allows for resolution of
the inflammation and time for healing.

4 Definitive Phase:
This includes other specialities as endodontics,
Periodontics orthodontics, oral surgery and
operative procedures prior to fixed or removable
prosthetic treatment.

5 Maintenance Phase:
Regular recall examinations that may reveal the
need for further adjustment and reinforcement of
home cares.
 Evaluation sheet no 4

1- Mention 3 methods of periodontium examination ?

2- Mention 2 clinical signs of abnormal occlusion ?

3- Mention phases of treatment planning?

 Indications for operative treatment

Restoration of incipient lesions:

Although caries preventive program is the treatment of choice
for managing incipient carious lesions. Several criteria
indicate that tooth must be prepared and restored as:

1 Poor oral hygiene.

2 Distinct variation in tooth color upon transillumination.
3 Presence of caries or numerous restorations.
4 Radiographic evidence of a lesion extends to the DEJ.
5 Degree of caries susceptibility and patient's age.
 Indications for operative treatment

Treatment of root surface caries and sensitivity:

Root surface caries should be restored in case of actual
cavitation (Active caries). But when there's arrested caries or
sclerotic dentin, it is hard and darken and so his arrested
lesion may be not restored with good oral hygiene.

Many forms of treatment used to produce relief such as:

a Topical fluoride.
b Fluoride rinses.
c Oxalate solutions.
d Dentin bonding agents.
e Sealants.
f Iontophoresis and desensitizing toothpastes.
 Indications for operative treatment

Treatment of abrasion, erosion and attrition:

These areas should be considered for restoration only
if one or more of the following exists:

1 The area is cariously involved.

2 Deep defect which affect integrity of the tooth.
3 The defect contributes to a periodontal problem.
4 The area is involved in a design of removable
partial denture.
5 The patient need to improve the esthetic.
6 The depth of lesions are to be close to the pulp.
7 When the lesion is associated with tooth hypersensitivity.
 Indications for operative treatment

Esthetic treatment:

Recently we have an improve in the conservative

Esthetic treatment such as:

A- Recontouring of anterior teeth.

B- Microbrasion.
C- Diastma can be closed by
direct composite restorations.
D- Laminate veneers.
 Treatment plan approval

The patient must be informed about the

alternative treatment available to manage
their oral conditions. There is usually more
than one alternative. We must discuss
advantage and disadvantage and cost for
every one.