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Diagnosis, Examination and

Treatment Planning

by : Artemio E. Usana Jr.,DDM


Dental Implantology
Affiliate Member
Endodontic Society of the Philippines
I. Patient Assessment

a. Chief Complaint
the problem that initiated the
patients visit
record the complaint verbatim in the dental record
the patient should be encouraged and guided to discuss
all aspects of the current problem: a) onset; b) duration;
c) symptoms; d) related factors
Information is vital to establish the need for specific
diagnostic tests and to determine the cause and
treatment of the complaint
I. Patient Assessment
b. Medical Condition and History
Helps to identify conditions that could alter, complicate or
contraindicate the proposed dental procedures
Communicable diseases which require special precautions ,
procedures, or referral. Affects patient management and may
contribute potential transmission hazards within the dental practice
Allergies or medications that may contraindicate the use of
certain drugs
Systemic diseases and cardiac
abnormalities which demands less
strenuous procedures or prophylactic
antibiotic coverage
Physiologic changes associated with
aging which may alter clinical presentation
and influence treatment
I. Patient Assessment

c. Sociologic and Psychologic Review


Patients attitudes, priorities, expectations,
and motivations regarding dental care.
Assessment of the patients dental appreciation,
educability, habits, parental history, occupation and
financial situation can indicate the patients commitment
to dental care.
I. Patient Assessment
d. Dental History
Reviewing previous dental experiences and current dental
problems:
Frequency of dental visits / perceptions of that care
patients future behavior
Types of care received / past dental experiences
Difficulties with past treatment or complications
Adverse reactions to local anesthetics,
latex, rubber dam
Date of most recent dental
radiographic examination
II. Examination / Diagnosis

a. Orofacial soft tissues


Examining the submandibular glands and cervical
nodes for abnormalities in size, texture, mobility, and
sensitivity to palpation
II. Examination / Diagnosis

b. Teeth
Visual changes in tooth surface texture and color
Tactile sensation when an explorer is used judiciously
Radiographs
Transillumination
- for Caries Diagnosis
II. Examination / Diagnosis
Caries Diagnosis:

1. Precarious / Carious pits


2. Proximal surface caries / smooth surface caries
3. Brown spots can be seen in an intact, large proximal surface
enamel adjacent and usually gingival to the contact area
- usually seen in older patient whose caries activity is low
- result of extrinsic staining during earlier caries demineralizing
episodes, each followed by remineralization episode
- aka arrested lesion, usually more resistant to caries due to
fluorohydroxyapatite formation
- the dentin in an arrested remineralized lesion is termed
eburnated or sclerotic
II. Examination / Diagnosis

4. Proximal surface caries in anterior teeth radiographic/visual


examination (transillumination)
5. Smooth surface caries on the facial and lingual (on the
gingival areas) that are less accessible for cleaning
- the earliest clinical evidence of incipient caries on these
surfaces is white spot which will partially or totally disappear from
vision by wetting. Drying again will cause to reappear vs. non-
hereditary enamel calcification
6. Root surface caries carious lesion on the cemental area in
patients with attachment loss
- predisposing factors: cemental exposure, dietary changes,
systemic diseases, medications affecting the amount and
characteristic of saliva
II. Examination / Diagnosis
c. Restorations
Evaluation must be done in clean, dry, well-lighted field
Clinical evaluation requires:
1) visual observation, 2) application of tactile sense with explorer,
3) use of dental floss, 4) interpretation of radiographs, 5) knowledge
of the probabilities that a given condition is sound or at risk for
further breakdown.
Common conditions that may be encountered with amalgam
restoration:
1) amalgam blues, 2) proximal overhangs, 3) marginal ditching,
4) voids, 5) fracture lines, 6) lines indicating the interface between
abutted restoration, 7) improper anatomic contours, 8) marginal
ridge incompatibility, 9) improper proximal contacts, 10) recurrent
caries, 11) improper occlusal contacts
II. Examination / Diagnosis

1. Amalgam blues
bluish hue results from 1) leaching of corrosion products of
amalgam into dentinal tubules: 2) colors of underlying amalgam as
seen through enamel (occurs when the enamel has no dentin
support e.g. undermined cusps, marginal ridges)
- For replacement: 1) elective improvement of esthetics, 2) areas
under heavy functional stress rearing cusp capping

2. Proximal overhang
diagnosed visually, tactilely and radiographically
- amalgam-tooth junction; evaluated by: 1) moving explorer back &
forth across it confirmed by catching or 2) tearing of dental floss
- effect: plaque trap
II. Examination / Diagnosis
3. Marginal gap or ditching
deterioration of the amalgam-tooth interface as a result of wear,
fracture or improper tooth preparation
- explorer dropping into an opening as it crosses the margin
- shallow ditching of less 0.5mm deep may not a reason for
replacement because of the eventual self sealing property of
amalgam allows the restoration to serve adequately.
- if the ditch is too deep needs replacement
- Why? 1) it jeopardizes the integrity of the remaining restoration;
2) secondary caries frequently found around marginal gaps
near the gingival wall
II. Examination / Diagnosis
4. Voids
other than ditching at the margins of the restoration
- If void is at least 0.3mm deep and is located in the gingival third of
the tooth crown the restoration is defective and should be repaired
or replaced

5. Fracture line
across the occlusal portion of the amalgam restoration specifically
isthmus region

6. Faulty anatomic contours


restoration impinging the soft tissues with inadequate embrasure
form or proximal contact preventing the use of dental floss
- management: recontouring / replacement
II. Examination / Diagnosis
7. Compatible with the adjacent marginal ridge
a. at approximate the same level
b. correct occlusal embrasure 1) for passage of food to
the facial and lingual surface 2) for proper proximal
contact area
-management: recontouring / replacement (if marginal
ridge not compatible which may lead to poor tissue
health, food impaction and inability to floss)
8. Proximal contact area a closed contact with the
adjacent tooth at the proper contact level and with
correct embrasure form
II. Examination / Diagnosis

9. Recurrent caries marginal area is detected visually,


tactilely, or radiographically
10. Inadequate occlusal contacts may cause improper,
deleterious occlusal functioning or undesirable tooth
movement correction or replacement
Periodontium
Occlusion
III. Treatment Planning
Three pretreatment considerations medical review,
examination, and diagnosis are necessary during each of the
patient visit.
Types of Treatment Plan:
1. Routine initial visit involves obtaining detailed information
for treatment planning.
2. Emergency visit requires collecting basic information and
then focusing on the patients chief complaint.
3. Re-evaluation appoinment updates the patients
information and evaluating previous treatment.
4. Recall appoinment reviews the patient assessment
information, comparing the patients current status with previous
conditions
Treatment Plan Sequencing
Treatment plan sequencing is the process of scheduling the
needed procedures into a time frame. Proper sequencing is a
crucial component of a successful treatment plan. Complex
treatment plans often should be sequenced in phases:

1. Urgent Phase begins with a thorough review of the patients


medical condition and history. A patient presenting with pain,
swelling, bleeding or infection should be managed as soon as
possible, before initiation of subsequent phases.
2. Control Phase this phase meant to: a) eliminate active disease
e.g. caries and inflammation, b) remove conditions preventing
maintenance, c) eliminate potential cause of disease, and 4) begin
preventive dentistry activities.
- the goals of this phase are to remove etiologic factors and
stabilize the pxs dental health e.g. Exo, Endo., Perio. Debridement
& scaling, restoration and replacement of defective fillings.
Treatment Plan Sequencing
3. Re-evaluation Phase holding phase is a time between the
control and definitive phases that allows the resolution of
inflammation and time for healing.
- Home care habits are reinforced, motivation for further treatment is
assessed, and initial treatment and pulpal responses are re-
evaluated before definitive care is begun.
4. Definitive Phase this phase may include endodontic, periodontic,
orthodontic, oral surgical, and operative procedures before fixed or
removable prosthodontic treatment.
5. Maintenance Phase includes the regular recall examinations that
1) may reveal the needs for adjustments to prevent future
breakdown and 2) provide an opportunity to reinforce homecare.
Treatment Plan Sequencing

General Considerations:
1. Infection Control
2. Charting and Records
a. Uncomplicated easily understood by dentist and
staff
b. Comprehensive noting all normal and abnormal
dental conditions; including a detailed representation
and location, nature, and size of all restorations.
c. Accessible
d. Current / Updated
Treatment Plan Sequencing
The exact location and condition of all teeth, restorations,
defects, caries, and soft and hard tissues are necessary for many
reasons, including the following:
Proper care: thorough charting provides basic information for an
accurate, comprehensive treatment plan.
Third-party communication: accurate records of the patients
conditions are useful in communicating with third-party payment
agencies.
Practice audits and quality assessment
Legal proceedings: the dental record is considered legal,
admissible, evidence in arbitration of contended negligence or
malpractice.
Forensic uses: the dental record is the only means of
identifying a deceased person.
3. Tooth denotation system
Thank you

by : Artemio E. Usana Jr.,DDM


Dental Implantology
Affiliate Member
Endodontic Society of the
Philippines