 PATIENT’S

ASSESSMENT,
EXAMINATION, DIAGNOSIS
AND TREATMENT
PLANNING
 Patient Assessment includes:
A. General Data (Name, Address, Age, Sex and
Occupation).
B. Chief Complaint
C. Medical review

D. Sociologic & Psychological review

E. Dental History
F. Patient Risk Assessment
 I. Patient Assessment
A) GENERAL DATA
1. Name:
Calling the patient in his name provides a friendly
approach and adds a more ethical communication.
2. Address:
It identifies if the patient is coming from an area known by
epidemic infections or areas of high fluoride intake in
drinking water which needs special precautions. Therefore
the patient recent and old address should be recorded.
 I. Patient Assessment
A) GENERAL DATA

3. Age:
• Size and approximation of the pulp chamber
• Position of the gingival attachment
• Physiologic changes associated with aging
(expholiation, attrition, discoloration)
• Selection of restorative material & technique
 I. Patient Assessment
A) GENERAL DATA

4. Sex:
Certain diseases are related to specific sex, e.g.
A. Gingival inflammation during pregnancy and
menstruation.
B. Palatal erosive lesions due to regurgitation and
hyperacidity during pregnancy.
Selection of restorative material & technique.
 I. Patient Assessment
A) GENERAL DATA

5. Occupation:
Provides an idea about certain occupational defects
for example: notches in anterior teeth of dressmakers
and carpenters.
Erosive lesions as a result of industrial fumes.
Degree of interest of the restorative treatment.
 I. Patient Assessment
B) Chief Complaint.

It is recorded in patient’s dental chart verbatim (in

patient’s own words)
 I. Patient Assessment

C) Medical Review it is carried out by:

1. Filling a comprehensive medical history form.
2. Verbal interview.

It could identify:
Communicable diseases (HIV, HCV, HSV, HZV,
chickenpox, measles, respiratory viruses)
Allergies or medication
Systemic diseases
I. Patient Assessment:
D) Sociologic review and psychological review

 It affects the dentist treatment recommendations and

contributes to the overall success of the dental treatment.
 Psychological review indicates the presence of certain
habits as clenching of teeth, pipe smoking, biting on hard
objects or unusual eating habits.
E- Dental History
It includes the patient's previous dental experience and the
current dental problems.

F- Risk Assessment:
It is the very important as it provides the guide for treatment
plan.
N.B: Caries activity cannot be determined at one time but it
require continuous monitoring over a period of time.
All information must be carefully detailed in patient's
permanent record and should be updated every now and
then.
 Caries risk assessment

 ‘Risk’ is the probability that some harmful event will

occur within a specified period of time.
 Caries risk is the probability that an individual will
develop carious lesions during a specified period of
time.
 If the main etiological factors could be identified,
preventive actions can be directed to those having a
high caries risk, before cavities could develop.
 Caries risk assessment

Caries risk evaluation can be compared to the weather

forecast.
 To produce an accurate weather report one needs
information on several factors such as:
1- direction of the wind 2- wind velocity
3- humidity of the atmosphere 4-Temperature
 When such data are collected and put together, 80 %
risk for strong winds.
 This means that the risk for strong wind was high but
not absolutely certain.
 May be the wind will be less strong in some parts of
the district.
 Caries risk assessment

Cariogram
 A unique PC software draws the Cariogram
 It shows if the patient over all is at high,
intermediate or at low risk for caries.
 It cannot replace the professional judgment of
dental health personnel, but is an analytical tool
that may help in decision-making.
 It is used for clinical purposes, educational and
preventive.
Cariogram-thefivesectors

Caries risk assessment

The Cariogram, a pie circle-diagram, is divided into five sectors in the

following colors:
The dark blue sector ‘Diet’ is based on a combination of diet contents and
diet frequency.
The red sector ‘Bacteria’ is based on a combination of amount of plaque and
mutans streptococci.
The light blue sector ‘Susceptibility’ is based on a combination of fluoride
program, saliva secretion and saliva buffer capacity.
The yellow sector ‘Circumstances’ is based on a combination of past caries
experience and related diseases.
The green sector shows an estimation of the ‘Actual chance to avoid new
cavities’. The green sector is ‘what is left’ when the other factors have taken
their share!
 Caries risk assessment
Cariogram

 The bigger the green sector, the better from a dental

health point of view.
 For the other sectors, the smaller the sector, the better
from a dental health point of view.
 The ‘Chance to avoid caries’ (green sector) and caries
risk are explanations for the same process but expressed
inversely.
 When the chance is high, the risk is small and vice versa.
 Caries risk assessment
Cariogram
The Cariogram shows for every individual examined, which
etiological factors are considered responsible for the caries risk.
The results also indicate what targeted actions improve the
situations.
The program, in a normal case, never shows 0 % or 100 % chance to
avoid caries.
 Needless to say, the caries risk assessment is complex and one has
to be cautious when interpreting it.
Caries risk assessment
Cariogram – aims
1. Illustrates the interaction of caries related
factors.
2. Illustrates the chance to avoid caries.
3. Expresses caries risk graphically.
4. Can be used in the clinic.
5. Can be used as an educational program.
6. Recommends targeted preventive actions.
 Examination & Diagnosis
Examination is the process of observing both normal and
abnormal conditions.
Diagnosis is the determination & judgment of variation from
normal.
 a- Extra oral
examination
Clinical
b- Intra oral
examination

a- Periapical
Radiographic b- Bitewing
Examination c- Panoramic
d- Digital
radiography

Adjunctive a-Percussion
b-Palpation
c- Pulp vitality
 The use of all three-examination methods is
helpful in arriving at a final diagnosis.
 Caries also tends to occur bilaterally and on
adjacent proximal surfaces.
a- Extra oral examination:
It includes any abnormality e. g:
• Face presence of any lesions or swellings.
• Lymph node which may be palpable or enlarged
• Exophthalmos in the eyes or enlarged thyroid gland in
the neck.
• Yellowish discoloration of the sclera of the eye.
b- Intra oral examination:
It includes any abnormality in the mucosa, tongue,
cheeks, palate and teeth.
It should be performed under good operatory light.
2- Radiographic examination: as
a- Periapical radiographic
b- Bitewing
c- Panoramic
d- Digital radiography

3- Adjunctive diagnostic aids:

a- Percussion
b- Palpation
c- Pulp vitality
 Clinical examination of teeth:
It may reveal:
A- Caries:
Pit &fissure
Smooth surface (proximal or facial and lingual)
B- Defective Restorations:
Amalgam, cast restoration or tooth colored restoration
C-Non carious defects:
Hypo calcification, abrasion, erosion, attrition, fracture
lines or hypersensitivity.
 Examination of Periodontium and Occlusion:

It should be carried out before any dental procedure.

It detects the presence of faulty occlusion which may

lead to:

1. Abfraction

2. Premature restoration fracture

3. TMJ and periodontal problems

 Diagnosis of caries takes place by the
following methods:
A- Pits and fissures caries (Class I):
Visual changes, tactile sensation and the recent
techniques.
B- Proximal smooth surface caries (Class II, III and IV):
Visual, Visual with temporary tooth separation, tactile
sensation, dental floss method, bitewing radiograph,
transillumination, and the recent techniques.
C-Examination of facial and lingual smooth surface
caries (Class V):
Visual changes, tactile sensation and the recent
techniques.
 Diagnosis of Dental Caries
a) Traditional Techniques

1- Examination of Pits & Fissures Caries:

Discoloration Cavitation Catching

with
Explorer
Visual Tactile
 Examination of pits and fissures caries

1- Visual Method:

It detects changes in tooth surface texture or color.

It requires proper dryness, strong light and magnification.
It should not be confused with non carious grooves
Clinical experience help to define the difference
between initial demineralization and deep non carious
fissure
 Examination of pits and fissures caries

1- Tactile sensation:
• It was previously done using a sharp explorer that is placed into
the suspected pit or fissure and examined for resistance to
removal “catch”.
• This tactile examination is no longer recommended as its
scratching tends to prevent any chances of remineralization of
any early lesion.
• If it has to be done either a slightly blunt probe should be used,
with very little pressure.
“Caries is present when the explorer catches
(resists removal) after insertion into a pit or fissure
with moderate to firm pressure and when this is
accompanied by one or more of the following signs
of caries.
a) Softness at base of the area.
b) Opacity (loss of normal translucency) adjacent to a
pit or fissure as evidence of undermining.

c) Softened enamel adjacent to the pit or fissure that

can be scraped away with the explorer.
What about this fissure?

The fissure was stained, but

there was no active caries
present
(Dormant caries)
Types of fissures
 Traditional fissure caries model

Probe does not stick

“No caries”
Traditional fissure caries model

Enamel
decalcification
Probe will
now stick
 Modern fissure caries model

Once the organic

Fissure walls
are in close
plug fails, bacteria apposition
have access to the
depths of the
fissure A probe will
be unable to
detect caries
Decalcification here
 Modern Fissure Caries Model
(Summary of realistic ‘coke bottle ‘ shape)

4-Decalcified
1-Organic plug enamel
2- This area (caries in this
may not be zone is
decalcified undetectable
thus a probe by probe)
won’t stick
3- Enamel
defects in 5- De-
fissure wall mineralized
dentin
 Examination ofproximalsmooth surfacecaries:

1- Visual Method:
A white chalky appearance or a shadow under the
marginal ridge .
2- Visual with temporary tooth separation:
3- Tactile examination:
Probing with a curved explorer may detect cavitation
occlusal or cervical to the contact area
4- Radiograph: Bitewing x-ray is usually used to
diagnose proximal caries.
 Examination of proximal smooth surface caries:

5- Transillumination:

• It is accomplished by placing light source on the lingual

side of the anterior teeth and directing the light through
the teeth.
• Proximal surface caries, shows up as a dark area along the
marginal ridge (carious lesion absorb more light).
 Examination of proximal smooth
surface caries:

6- Dental floss method:

• The practitioner should pass the unwaxed dental floss
interproximally .
• If one or two adjacent teeth are carious the floss will
be threaded or frayed due to rough margin of the
carious cavity.
 Diagnosis of Dental Caries
a) Traditional Techniques

2- Examination of Smooth Proximal Surface Caries:

Chalky white Dark Cavitation

discoloration discoloration
of marginal of marginal
ridge ridge
Visual
 Diagnosis of Dental Caries
a) Traditional Techniques

2- Examination of Smooth Proximal Surface

Caries:

Catch with cow-horn Threading of unwaxed

explorer dental floss

Tactile
 Diagnosis of Dental Caries
a) Traditional Techniques

2- Examination of Smooth Proximal Surface Caries:

Radiolucent area Dark cone

Radiographic Transillumination
 Arrested caries:

 Brown spots on intact hard surfaces of enamel adjacent to and

usually gingival to contact area.
 They are often seen in older patients whose caries activity is
low.
 They are old carious enamel lesions that have been
remineralized and it does not interfere with esthetics.
 Restorative treatment usually is not indicated if the enamel
surface is smooth and intact.
 2-Examination of Teeth & Restorations:

It is carried out through several traditional methods:

A. Visual
B. Visual- tactile
C. Radiograph (Bitewing)
Proximal D. Visual with temporary tooth separation
decay
E. Dental Floss
F. Transillumination
 Examination of facial and lingual
smooth surface caries:

1- Visual method:
 White spot is the earliest clinical evidence of incipient
caries .
 It will dis- appear from vision by wetting.
 Drying again will cause it to reappear.
 This disappearing reappearing phenomenon differentiate
it from the developmental hypocalcification .
 The discoloration can range from white to dark brown,
acute (rapid) caries being lighter in color.
Examination of facial and lingual
smooth surface caries:
2- Tactile examination:
 It occurs at the gingival 1/3 of the facial and lingual
surfaces of all teeth except the palatal surface of upper
anterior teeth.
 Usually demineralized and discolored soft carious lesion
will be found and can be penetrated by the explorer.
 Examination:

2- Radiographic examination: as
a- Periapical radiographic
b- Bitewing
c- Panoramic
d- Digital radiography
3- Adjunctive diagnostic aids:
a- Percussion
b- Palpation
c- Pulp vitality
Caries is regularly found beneath a seemingly intact enamel surface
Frequently the diagnosis of occlusal caries is not straight forward
1mm deep “cavity”
2mm deep “cavity”
3mm deep “cavity”
4mm deep total decalcification or cavity that is
widened to 1/3 occlusal width may appear on X ray

4mm 1/3
occlusal
width
 Contact point caries is much easier to be
detected radiographically
 X-RA
Y

 1/ 3r
d

 Digitally created
 Caries Classification

I M A
A

I = Incipient (Stage I)
M = Moderate (Stage II)
A = Advanced (Stage III) S
S = Severe (Stage IV)
 Interproximal Caries
(Incipient)

Up to half the thickness of enamel

Usually not restored unless patient has high
level of caries activity (high risk).
It is treated with fluoride and oral hygiene
measures.
The arrow points to incipient lesions on the mesial of #
19 and the distal of # 20.
 Interproximal Caries
(Moderate)

More than halfway through the enamel

(up to DEJ)
The bottom arrow points to a moderate lesion on the
distal of # 20. The upper arrow points to one of several
incipient lesions on the molar and premolars.
Moderate lesion seen on previous film
Class III moderate lesion seen in the anterior
region
Advanced Caries

A
A
Advanced lesion identified by arrows.
Advanced lesions seen on previous film
Advanced lesion
Advanced lesion
Incipient
Moderate
Advanced
 Limitation of radiograph:
• Radiographic image is a two-dimensional
representation of 3D object so great care must be
taken during interpretation of the radiograph.
• Also some elongation or shortening may result from
changing vertical angulations of the cone.
• Processing of the film is greatly susceptible to
human variables and problems.
• In cases of diagnosis of proximal lesions , bitewing
film should be used to avoid horizontal overlapping
of adjacent teeth at this area.
Digital Radiography

 Indirect,
using
Direct, using charged phosphorus plates
coupled device detector
followed by scanning
 “Digora system”
 Advantages of Digital
Radiography:
1. Color coding
2. Density assessment
3. No film processing
4. Lower radiation exposure
5. Magnification
6. Sensitivity up to 1024 gray level
7. Permanent patient record
 Recent Diagnostic Modalities include:
1. Intraoral camera (magnification)
2. Optical caries Monitor and Sporolife (visible light)

3. Digital imaging Fibro-optic transillumination

4. Digital Radiograph (radiography)
5. DIAGNOdent and quantified laser fluorescence (LASER )
6. Electrical Caries Monitor (electrical current)
7. Ultra Sound
8. Caries Detecting Dyes
Laser-Based device (DIAGNOdent)
 DIAGNOdent laser
• 655 nm diode laser
• The device works on the fluorescing bacterial
metabolic by-products
• The readings are related to the degree and
intensity of enamel demineralization, rather
than the depth of the lesion
 DIAGNOdent laser

Limitations:
• It has a poor sensitivity for early lesions confined to
enamel.
• It detects lesions after which the decay has
penetrated into the dentin and accumulated a
considerable amount of bacterial by products.
 Scanning the Fissures

Rotate the tip to “read” the fissure walls

DIAGNOdent pen:
 Examination of the existing
restorations
1. Amalgam blues
2. Defective Contact and Voids
3. Fracture
4. Isthmus Fracture
5. Incorrect margins and contour
6. Overhanging
7. Recurrent Caries
 1- Amalgam blues
Thin or undermined enamel that shows dark
blue discoloration of amalgam metallic ions
and corrosive products.
2- Overhang
3- Recurrent Caries
4- Fracture
4- Isthmus Fracture
5- Incorrect margins and contour
6- Defective Contact and Voids
Tooth colored restorations
Discoloration
 Discoloration
A- Marginal discoloration due to impaired
adaptation and gross leakage.
B- Surface discoloration due to rough restoration
surface, material contamination during
manipulation or smoking
C- Bulk discoloration due to contamination of
restorative material, excessive air voids,
incompletely cured restoration, expired products
and water sorption.
3- Adjunctive diagnostic aids:

 a- Percussion test
b- Palpation Test
 c- Pulp Vitality testing

Teeth to be examined should be dry and any adjacent soft

tissue should be retracted.
Reading of adjacent or contralateral unaffected teeth should be
carried out.
Thermal pulp testing

Cold testing using Heat application using

Ethyl chloride gutta percha stick
The most reliable

 Hotor cold
 water bath
-Thermal pulp testing

Healthy pulp normal response subside within few seconds

Hyperemia pain of less than 10 seconds duration it is a
reversible condition.

Irreversible pulpitis, intense pain lasting for longer

duration from ice or from heat but quickly relieved by ice .
Adjacent or contralateral unaffected teeth should be
tested as baseline.
- Electric pulp testing
 Electric pulp testing

Hyperemia, response at a slightly lower grade than

normal
Acute pulpitis, response at a very low grade of current
intensity
Delayed response or pain at high current intensity
indicates pulp degeneration or chronic inflammation
 Electric pulp testing
Disadvantage:
1. the possibility of false readings either positive or
negative.
2. Not possible in teeth with large or full-coverage
restoration.

3. Should not be the sole basis for pulpal diagnosis

4. Contraindicated for patients with pacemakers
Test cavity
- Checking occlusion
 Study Casts
 T-scan

study casts
 T-scan
 Used to measure dental occlusal
forces and quantify how well-
balanced a patient's occlusion is.
 Evaluating occlusal forces is as
simple as having a patient bite
down on an ultra-thin sensor
while the computer analyzes and
displays the data.
 Treatment planning:

Sequential series of services designed to eliminate or

control etiologic factors, repair existing damage and
create functional and maintainable environment.
Factors Modifying the Treatment Plan

Are related to:

• The Patient

• The Dentist
Treatment plan depends on:
• Thorough patient evaluation,
• Dental expertise,
• Understanding of indications and
contraindications, and
• Prediction of the patient’s response to
treatment
 Treatment Plan:
Ideal Treatment Plan

Optimal Treatment Plan

 Treatment Planning
Types

a) Ideal Treatment Plan:

It is the plan where the best forms of treatment are done

irrespective to the patient and dentist limitations.

b) 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.
Modified by:

Patient motivation, systemic health,

priorities, emotional status, and financial
capabilities.

Dentist’s knowledge, experience, and

training, laboratory support.
 2. Optimal treatment plan:
• Even when modification is necessary, the
practitioner should provide the best level of care.
(It does not give the dentist license to perform an
inadequate restoration)
• The treatment plan is not static but a dynamic
process.
 Treatment plan Sequencing:

1. Urgent Phase

2. Control Phase
3. Holding Phase

4. Definitive Phase

5. Maintenance Phase
 Treatment Planning Sequence

a) Urgent Phase:
Emergency treatment is carried out to
eliminate pain, swelling or any acute condition.
 Treatment Planning Sequence

a) Control Phase:
This phase removes etiological factors and
stabilizes the patient health including:
1. Elimination of pain.
2. Elimination of active disease such as caries
and inflammation.
3. Elimination of the potential disease causes
e.g. impacted third molar.
4. Removal of conditions preventing
maintenance e.g. overhanging restoration.
5. Starting preventive dentistry instructions.
 Treatment Planning Sequence
b) Holding Phase:

The holding phase is a time between the control

and definitive phase that allows for resolution of
the inflammation and time for healing
1. Home care habits are reinforced.
2. Motivation for further treatment is assessed.

3. Initial treatment is reassessed before starting

definitive care.
 Treatment Planning Sequence
c) Definitive Phase:
 After reassessment of the initial treatment the
need for further care should be determined.
 This includes some forms of endodontics,
periodontics, orthodontics, oral surgery, and
operative procedures prior to fixed or
removable prosthetic treatment.
 Treatment Planning Sequence

d) Maintenance Phase:
 Regular recalls examinations that may reveal
the need for further adjustment.
 Reinforcement of home cares.
Which one first?

 surgery  Periodontal
ttt

Operative

 Endodontics Ortho