Faculty of Dentistry

DDS
Family Dentistry (2306)
By: Prof. Dr. Tara Bai bt. Taiyeb Ali (profdrtara@mahsa.edu.my)
 SUBJECT TITLE
FAMILY DENTISTRY
LESSON 1: Lesson
Examination Title 1 & 2
& Diagnosis

EXAMINATION, DIAGNOSIS
& TREATMENT PLANNING I
& II

PROF TARA TAIYEB ALI

 FAMILY DENTISTRY
E&D

LEARNING OUTCOMES
1. Comprehend about History taking of a Patient
(C2)
2. Understand the significance of Medical,
Social, Dental and Family History (C2)
3. Relate various components of Examination
and Diagnosis in Primary Dental Care (C6)
4. Understand and relate the importance of
Examination including General, Extra Oral, Intra
Oral examinations in relation to Provisional
Diagnosis, Investigations, Definitive Diagnosis,
and formulate Treatment Plan (C6)
CONTENTS
1. How to take a detailed Case History
2. Significance of Medical, Drug, Past
Dental, Social and Family History
3. Essential contents of E & D
4. Examination which includes General
examination, Extra-oral Examination and
Intra Oral examinations (hard and soft
tissues)
5. How to arrive at a Provisional Diagnosis
6. Relevant Investigations
7. Definitive Diagnosis after investigations
8. Treatment plan and different phases of
treatment
EXAMINATION
History Taking & Clinical Examination

INTRODUCTION
1. Thorough History Taking
2. Systematic Oral Examination

SYMPTOMS
 Clinical Characteristics – alternations in the mucosa,
gingiva and teeth
 Radiographic Changes –alveolar bone, dentition
Examination

Examination
1. To identify sites with pathology/breakdown
2. Extent of soft and hard tissue breakdown
3.  include all parts of oral cavity and dentition

HISTORY
Enable clinical picture to be related to
 Predisposing factors
 Previous Rx
History

Present Complain
Symptoms from gums – bleeding, swelling,
pain, suppuration
Teeth – mobility, spacing  /
drifting, cavities
Halitosis

History of Complain
 Further information of above symptoms
History

Medical History
1. No. of medical problems – influence tissue
response to plaque, bleeding, healing
2. Enable T.P. – compatible with medical
background + drug therapy
3. Systemic Diseases – PD interrelationships,
OML

Past Dental History

To relate to presenting dental problems &
patient’s dental consciousness and past Rx
History

Social History & Habits

 Occupation, Family – related to stress
 Smoking – duration, intensity
Parafunctional habits -  occlusal loading

Oral Homecare (OH Methods)

 Tooth & interproximal cleansing e.g. ?
Frequency, method, type
Examination
GENERAL EXAMINATION
 Gait
 Stature
 Skin
 etc.

EXTRAORAL EXAMINATION
 Site of Complain
 Face,
 lips,
 lymph nodes,
 TMJ, mandible movements
# Site, size (extent), shape, number
# Borders
# Surface & color of the overlying
skin
# Pulsation

Tenderness
# Temperature
# Consistency
# If soft, fluctuation
# Mobility with respect to the
overlying skin and underlying
tissues
Examination

INTRA-ORAL EXAMINATION

 Site of Complain
 Mucosa - ?OML
 Gingiva (FG, AG, Papilla)
 Visual Examination – colour, contour,
consistency, surface texture, abscess,
sinus
 Palpation – suppuration
 Probing – BPE chart
- PS
Oral Mucosa
Oral Mucosa
Examination

Oral Hygiene Status

Plaque – detected with disclosing agent / probe
- noted in plaque chart, PS calculated
Calculus – supra + subgingival
Defective restorative margins – recorded

Teeth –Caries status

 Recorded on Dental ICDAS chart

 Teeth – mobility, bifurcation involvement,

caries, restorations, non-vital teeth, spacing,
drifting, tilting, abrasions, food impaction,
impacted teeth
Basic Periodontal Examination
(BPE)

 The Basic Periodontal Index (BPE) is based on the

CPITN examination index which was widely used by
the WHO.
 The BPE is a screening system which identifies
individuals who require a more detailed periodontal
examination.
 It should be carried out for
 All new patients
 Patients who have not received periodontal
examination for more than 1 year
 It is not a monitoring tool for periodontal disease but a
screening one.
Basic Periodontal Examination (BPE)

1. The use of a periodontal probe is mandatory (e.g.

: Williams, No. 14; UNC 15; WHO / CPITN)
2. However, the recommended probe is the WHO/
CPITN probe which
 has a ball-end 0.5mm ø; and
 a colour-coded area which extends from 3.5mm
to 5.5mm.
Basic Periodontal Examination (BPE)

3. The probing force is 20-25gms

4. The mouth is divided into sextants (Excluding
8’s) and is represented by a single box chart
for each sextant.

17-14 13-23 24-27

47-44 43-33 34-37

5. The probe is introduced into the gingival

sulcus and walked around the buccal and then
the lingual /palatal surfaces of the sextants.
At least 6 points on each tooth should be
examined : mesiobuccal, mid-buccal,
distobuccal, mesio-lingual(palatal), mid-
lingual(palatal) and disto-lingual(palatal).
Basic Periodontal Examination (BPE)

WHO probe is walked around the sextant

6. A sextant with only one tooth remaining is
recorded as missing and the tooth score is included
into the adjacent sextant.
7. For each sextant only the highest score is
recorded
i.e. 0< 1< 2< 3< 4< *
 Example:
* 4 3

2 1 X

 (X denotes missing teeth)

Codes
Code Healthy gingival tissues
0 No bleeding on probing (BOP)
Mx: No treatment
Code Coloured area of probe remains completely visible in
1 the deepest pocket of the sextant
No calculus or defective margins
There is BOP
Mx: Oral hygiene instruction (OHI)
Code Coloured area of probe remains completely visible in
2 the deepest pocket of the sextant
Supra/subgingival calculus detected or defective
margin of crown/restoration
Mx: OHI
Removal of retentive factors
Screen after 1 year
Codes
Code Coloured area of probe remains partly visible in the deepest part
3 of the pocket
Mx: Plaque and bleeding scores pre and post Rx
OHI
Removal of retentive factors
Probing depth for sextants with Code 3 post Rx
Re-record Plaque and Bleeding scores as well as probing
depths for that sextant in the same year. BPE screening for
other sextants.
Code Coloured area of probe disappears completely into pocket
4 indicating probing depths of at least 6mm
Mx: Plaque and bleeding score pre-Rx
Full mouth periodontal pocket charting
OHI & remove retentive factors
Root planning
Furcation Rx
Re-examine and new charting
Refer specialist Rx
Code ii) Presence of a furcation involvement
Examination

Teeth & Occlusion

 Occlusion – noted
- occlusal discrepancies, attrition,
crowding / rotation, loss of posterior
support, etc

Appliances / Dentures – assessed

 Removable P/P have been associated with
periodontal breakdown (? Risk factor)
Examination

Mobility
 B-L force with 2 instruments
 Score: 0 – no mobility
1 – B-L mobility  1mm
2 – B-L mobility > 1mm
3 – B-L & vertical mobility into socket

 Assess degree & cause

 Causes: 1)PD 2)Overloading of teeth
3)Occlusal trauma 4)P/A lesions
5)Post-perio surgery
Teeth

ICDAS charting
ICDAS Codes
Examination

Investigations
 EPT
 X-Rays
 Blood Investigations
RADIOGRAPHIC INTERPRETATION IN
DIAGNOSIS OF ORAL CAVITY
Examination

Radiographic Analysis
OPG or IOPA
Alveolar bone loss (rate + degree)
- horizontal
- vertical
Degree – related to the root height

Follow-ups need reproducible roentgenograms

for comparative analysis – use Eggen device

Teeth: Furcation involvement, widening of

periodontal space, P/A radiolucency,
RCT, caries, overhanging restorations,
calculus
DETERMINATION OF DIAGNOSIS,
AETIOLOGY & CONTRIBUTING
FACTORS, PROGNOSIS
DIAGNOSIS
Information obtained from examination
procedure  → basis for proper diagnosis

Diagnoses
Oral Mucosal Lesions
Periodontal Disease
Caries / other dental pathology
P/A lesion, Endo-Perio lesion, Non-vitality
Occlusal discrepancies
TMJ dysfunction
Periodontal Diagnosis
 A general diagnosis is first made for the entire
oral cavity:

 Gingivitis:
Acute, chronic; hyperplastic; hormonal or
influenced by medications; as a side reaction to
systemic diseases etc.

 Periodontitis:
Stage, severity (clinical attachment loss),
dissemination
 recession
Diagnosis & Aetiology
 Gingivitis: Inflammation of the gingiva characterized clinically
by gingival hyperplasia, oedema, retractibility, no true
pocketing and no radiographic evidence of bone loss.

 Periodontitis Early Stage: Progression of gingival inflammation

into the alveolar bone crest and radiographic evidence of early
bone loss (up to coronal ⅓ of root length)

 Periodontitis Moderate Stage: Bone loss involves about half of

root length and F1 furcation involvements.

 Periodontitis Advanced Stage: Bone loss involves more than ½

of the root length, angular defects and Grade F2 and F3
furcation involvement and/or M3 mobility.
Diagnosis & Aetiology

 Example: refer to Examination findings

a. Generalised chronic periodontitis moderate to advanced

stage with furcation involvement on teeth 26, 27 and 46.
b. Periodontal abscess (caused by occlusal trauma and
plaque) on 23
c. Endo-perio lesion on 34
d. Denture stomatitis associated with ill-fitting denture
e. Caries on 26, 44 and 48

 Aetiology for a, b and c is dental biofilm/ plaque.

 Aetiology for d is candidal infection.
 Contributing factor for all: Ill –fitting denture
Diagnosis & Aetiology

Examples of other diagnosis for PD:

 Gingivitis
 Pregnancy gingivitis
 Acute periodontal abscess
 Acute necrotizing ulcerative gingivitis
 Aggressive periodontitis
 Recession (generalized/ localized; aetiological factor)
 Dentine hypersensitivity
 Periodontitis associated with systemic factors
 Gingival enlargement/ overgrowth
 Contributing Factors
 Poor Oral Hygiene
 Diet , Smoking
 General Systemic Health e.g. Diabetes
 Local Factors e.g. dental appliance / dentures /
overhanging margins, impacted teeth, crowding
of teeth etc.
Prognosis
 Remaining attachment (root length)
 Tooth mobility in relation to bone loss
 Extent of caries in relation to tooth structure /
restorability / # / ?RCT
 Function and position of tooth e.g. impacted
tooth / non-functional

Categories
 Poor Prognosis
 “Guarded” or Moderate Prognosis
 Good Prognosis
TREATMENT PLANNING IN A DENTAL
SETUP
Treatment Goals
1. Treatment of OML

2. Reduction or resolution of gingivitis (bleeding on

probing; BOP, Reduction in probing pocket depth
(PPD)

3. Elimination of carious lesions, restorations of

damaged teeth.

4. Individually satisfactory esthetics and function

5. Maintenance of oral health

TREATMENT PLANNING
PDs and Caries are disorders associated with
bacterial colonization
Rx – elimination / control of dental biofilm

Plaque control measures  dental/ periodontal

health
 arrest disease progression
5 Different Measures
1. Emergency Measures
2. Systemic Phase
3. Initial therapy(treatment)
4. Advanced treatment
5. Maintenance Phase
Emergency Treatment
To eliminate pain, discomfort, swelling or
presenting complain before proceeding.

Emergency treatment if necessary for acute

conditions like:

1. Apthous Ulcer
2. Acute periodontal abscess
3. Pulp hyperaemia/ pulpitis/ large caries
4. Dentine hypersensitivity
5. Acute dento-alveolar abscess (Perio-endo
lesion)
6. Occlusal trauma with pain
Systemic Phase
 To refer for Medical conditions(Diabetes
mellitus, Hypertension etc.) and other systemic
influence (e.g smoking cessation) follow-up.

Systemic Phase
- to eliminate or decrease the influence of systemic
conditions on the outcomes of therapy (eg: smoking
cessation, referral to physician to manage/ control systemic
diseases like diabetes, infectious diseases, patients on
anticoagulants, patients requiring prophylactic antibiotic
cover, etc).
Treatment Planning

Initial Therapy
a) Case Presentation, Motivation & OHI for patients
b) F/M scaling & prophylaxis
c) Extractions of hopeless teeth (immediate P/P)
d) RCT of non-vital teeth
e) Excavation & restoration of carious lesions
f) Relining of dentures, to redo ill-fitting dentures
(under advanced tx)

g) Reassessment after 4-6 wks

h) Perio assessment - Root Debridement for
pockets ≥ 5mm

Reassessment after 6-8 wks for Advanced

/Corrective Rx
Initial treatment

•Motivation of patient and oral hygiene instructions

1.Show the patient the condition of his periodontal and dental disease (eg:
signs of inflammation: pocketing, bleeding on probing, swelling, caries etc.)

2.Disclose plaque with disclosing dye & show patient. Explain how plaque
is the aetiology of the disease and what his/her contributing factors are.

3.Ask patient to brush his/her teeth (patient has to be told to bring his/her
toothbrush) and show the plaque that still remains.

4.Role of patient- explain their role in stopping and preventing the

progression of disease.

5.Demonstrate brushing technique (Bass or Roll technique) on models and

in the patient’s mouth. (Flossing/ interdental aids can be shown at the next
visit). Patient performs the demonstrated technique in his mouth.

6.Role of the operator- explain to the patient the sequence of treatment

that you are providing.

7.Stress the importance of follow-up treatment.

Motivation & OHI

Disclose Plaque
Toothbrushes
Toothbrushing Technique
 Scaling / Prophylaxis
 Scaling is a procedure which aims at the removal of
plaque and calculus (microbial biofilm and calcified
biofilm) from the tooth surfaces

 Root debridement is a removal of plaque and or

calculus from the root surface without intentional
removal of tooth structure

 Non-surgical periodontal therapy a variety of

methods including hand, sonic, ultrasonic scalers,
and laser therapy, antimicrobial therapy, SPT/SPC
Hand instruments for Scaling

 Curettes, hoes or scalers

 Have a sharp working tip, which is used to
mechanically break the calculus
 Is time consuming and physically demanding
 Direct tactile control
New design, new
machine in non
surgical therapy

From left to right, Standard,

Rigid, Mini-five, After Five,
Ohta type curettes (Hu-Friedy
Co. Ltd).

From left to right, Standard 11-

12, Fit 11-12, Fit 13-14 (Hu-
Friedy Co. Ltd.).
Power-driven instruments for Scaling

 Relatively blunt and rely on the acceleration of

the vibrating tip
 Need cooling water
 Vibrations may also generate cavitation
 Easier to use and less time needed
 Disadvantage is that the clinician may lose
tactile control
 Clinicians and patients choose power-driven
scalers
(left) a P-style piezoelectric
tip and (right) a TFI-3 Ball-ended ultrasonic inserts for
magnetostrictive tip. use in furcation
Root Debridement
Treatment Planning

Corrective Measures (Advanced

Phase) (PS & GS <20%)
a) Periodontal Surgery (Refer if necessary)
b) RCT (Refer if necessary)
c) Advanced Restorative procedures (Refer if
necessary)
d) Prosthetic Rx (Refer if necessary)
e) Reassessment for Maintenance phase

 In cooperative patients
 Alternatives in TP should be presented
Treatment Planning

Maintenance Phase
Aim: Prevention of disease recurrence
Recall System designed (3/12, 6/12, 1yr.)

a) Monitor self-performed plaque control &

RPC
b) Comprehensive examination 1/yr
c) Rescaling & RD (if necessary)
d) F- application, etc
e) Regular control of prior restorative Rx.
Preferred sequence of therapy.
FAMILY DENTISTRY

ALL THE BEST

More Examples &
Exercise of
Radiographs