Care must be taken to correctly evaluate any such line, however, especially if it is in the mid-occlusal area because this may be an interface line, a manifestation of two abutted restorations accomplished at separate appointments (see Fig. Specically, the most frequently fractured teeth are mandibular molars and second premolars, with the lingual (nonfunctional) cusps fracturing more often than the facial (functional) cusps. Smoking reduces the taste of foods by causing physical coating of the tongue and regression of the taste buds on the tongue and olfactory receptors in the roof of the nasal cavity over time. 116 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planningoutcomes require meticulous attention to detail with regard to the enamel/dentin substrate and the properties of the specic adhesive system/composite resin being used. Develop your skills in evaluation and dental treatment planning for all types of patients! If periodontal surgical procedures are required, indirect restorations such as inlays or onlays, crowns, and prostheses should be delayed until the surgical phase is completed. Bader JD, Martin JA, Shugars DA: Incidence rates for complete cusp fracture. This lesson will also serve as an introduction to the care of the medical patient. ** Patients with one (or more) cavitated lesion(s) and xerostomia are extreme-risk patients. 3.3A). Newwitter DS, Katz RV, Clive JM: Detection of root caries: Sensitivity and specicity of a modied explorer. Treatment methods that reduce rapid uid shifts, by partially or totally occluding the ends of the exposed dentinal tubules, may help reduce the perceived sensitivity.Dentinal hypersensitivity may become a problem when peri-odontal surgery causes clinical exposure of root surfaces (such that dentinal tubules are exposed and open). is information is then combined with the best available, evidence on approaches to management of the patient’, that an appropriate plan of care may be oer, e collection of this information and the determinations based, on examination ndings should be comprehensive and accomplished, overlooking potentially important parts of the patient’, needs. 3.6B).e marginal ridge portion of the amalgam restoration should be compatible with the adjacent marginal ridge. Mertz-Fairhurst EJ, Call-Smith KM, Shuster GS, et al: Clinical performance of sealed composite restorations placed over caries compared with sealed and unsealed amalgam restorations. Generally, microscopes include five or six magnification stops that typically range from 2.5× to 20×. Cell B contains all cases for which a positive finding from the diagnostic test is present, but where the actual condition is negative. Approaches to patient care using risk assessments and disease management such as CAMBRA are becoming the recognized standard of care. … Growing evidence suggests that the removal and replacement of restorations result in the cycle of re-restoration, which leads to increasingly larger tooth preparations and the resultant trauma to the tooth and supporting structures.39 In addition, resurfacing or repair of composites and repair of cast restorations has been shown to be eective.42-44 Also, amalgam restorations with localized defects may be repaired with amalgam or with sealant resins.17,42 If a restora-tion has an isolated carious defect, and complete removal of the caries lesion has been conrmed, then it is acceptable and often preferable to restore the isolated area without replacement of the whole restoration. Study OPERATIVE Patient Assessment, Examination, Diagnosis, and Treatment Planning flashcards from Maggie Rodriguez's class online, or in Brainscape's iPhone or … The simplest magnifiers are the diopter single-lens loupes, which are single-piece plastic pairs of lenses that clip onto eyeglass frames. Although no clinical criteria are universally accepted for the diagnosis of root caries, it is generally agreed that softened cemental or dentinal tooth structure compared with the surrounding surface is characteristic.13 Active root caries is detected by the presence of softening and cavitation.14,15 Although root-surface caries may be detected on radiographic examination, a careful, thorough clinical examination is crucial. F, Root-surface caries. J Am Dent Assoc 126(Special Suppl):1995.35. Voids that are usually localized and are caused by poor condensation of the amalgam can also occur at the margins of amalgam restorations. Therefore responsible handling is important. 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. Magnication aids such as loupes provide a larger image size for improved visual acuity, while allowing proper upright posture to be maintained with less eye fatigue.When choosing loupes, several parameters should be considered.27-29 Magnication (power) describes the increase in image size. e most widely accepted explanation of this phenomenon is the hydrodynamic theory. 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. J Dent Educ 65:960–968, 2001.3. is is accomplished in light of the reality that when individual teeth are correct in their anatomic shape, and positioned in the face and arches for optimum function, then the overall esthetic result will be optimal (“form follows function”). e treatment plan is also inuenced by the dentist’s knowledge, experience, and training; laboratory support; dentist–patient compatibility; availability of specialists; and the patient’s functional, esthetic, and technical demands. Cochran Database of Systematic Reviews (3):Art. C, Rounded cervical lesions associated with toothbrush abrasion. Compend Cont Educ Dent 19:595–612, 1998.30. The 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. 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. 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. One exception to this general guideline is the lesion that is deemed arrested.Treatment Plan Sequencing/PhasingProper sequencing is a crucial component of a successful treatment plan. ese inaccuracies result in false-positive and false-negative ndings. Studies have shown that the average lifespan of a restoration ranges from 5 to more than 15 years.38 When the restoration is subsequently replaced additional tooth structure is removed, regardless of how carefully the operator removes the existing restoration. :CD005620, 2014.46. Successful caries arrest usually occurs in patients whose oral hygiene or diet has improved such that the balance between demineralization and remineralization has become favorable. Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecic gingivitis) can be identied clinically.Not applicablePatient for monitoring of growth and developmentClinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development.Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development. Remineralization is also recommended for root-surface lesions in which a break in the surface contour of the exposed root surface has not occurred. Previously limited primarily to endodontic practices, dental microscopes now are being used in some restorative dentistry practices. Such studies compare the results of a diagnostic test with the results obtained from a “gold standard” (knowledge of the actual condition) to determine how well a test identies the “true,” or actual, condition. 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. Generally, microscopes include ve or six levels of magnication that typically range from 2.5× to 20×. Occasionally, the staining is supercial and may be removed by resurfacing or removal of restoration excess extending beyond the preparation margins.Clinical Examination of Dental Implants and Implant-Supported RestorationsBaseline radiographs that reveal the initial levels of implant bone support should be obtained when the implant is restored. 3.4A and B). Therefore, the next step is to determine the present activity of the lesions. Title: Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients 1 Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients. Any deviation from normal should be noted. Erosion processes may also be involved in the loss of the tooth structure with a clinical presentation of “cupped-out” areas on occlusal surfaces. e International Caries Detection and Assessment System (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. Teaches the knowledge and skills required to continue the assessment and treatment of the patient. us the clinician must take all of the available diagnostic information together—visual, tactile, radiographic, and so on—along with the respective reported levels of accuracy and combine that with an assessment of the patient’s overall caries status to make a nal diagnosis of the presence and extent of a caries lesion.DiagnosisDental Disease; Interpretation and Use of Diagnostic FindingsAs discussed in Chapter 2, dental caries is a multifactorial, transmis-sible, infectious oral disease caused primarily by the complex interaction of cariogenic oral ora (biolm) with fermentable dietary carbohydrates on the tooth surface over time. e resulting defective surface is usually smooth. In addition, any teeth requiring restorations that may encroach on the biologic width of the periodontium should Urgent Phasee urgent phase of care begins with a thorough review of the patient’s medical history and current condition. 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 position against the articular eminence within the glenoid fossa. When interpreting the radiographic presentation of proximal tooth surfaces, it is necessary to know the normal anatomic picture presented in a radiograph before any abnormalities may be diagnosed. If the lesion is determined to be progressing and the patient’s risk factors are not changed, some intervention, either surgical or nonsurgical, is indicated. In the United States, the Caries Management by Risk Assessment (CAMBRA) movement, as discussed in Chapter 2, embraces the principles of the ICDAS for visual examination and assessment of caries lesions. Previous periodontal or endodontic treatment2. In a radiograph, a proximal caries lesion usually appears as a dark area or a radiolucency in the enamel slightly apical to the contact (see Fig. Risk assessments for erosion should be included in the assessment of the patient, as indicated. Lesson 3-5 Detailed Physical Exam. A combination of root exposure, dietary changes, systemic diseases, and medications that affect the amount and character of saliva can predispose a patient, especially an older individual, to root-surface caries. but more acceptable if the treatment is non-invasive and temporary. Gen Dent 52:128–131, 2004.23. Caries Res 32:204–209, 1998.13. In contrast, it is common to observe nondiseased occlusal surfaces with narrow grooves or fossae that exhibit supercial staining, but no visual changes in light reection through the enamel immediately adjacent (see Fig. ese are the conserva-tive restoration of choice for compromised teeth in high stress areas. 3-6). Chemotherapy/radiation therapy16. e details of the ICDAS system for detection, and training to use the system with an online tutorial, are available at www.icdas.org.Proximal SurfacesEarly proximal surface caries, one form of smooth-surface caries, is usually diagnosed radiographically (Fig. 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. Cusp isolation/loading devices and techniques must be utilized so as to identify fractures that involve the dentin and are symptomatic (i.e., fractures that are actively propagating). CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning 109 Many choices of magnication loupes are currently available for dentistry. Cell C includes the cases identified by the diagnostic test as not being diseased, but actually are diseased, as determined by the “gold standard.” Findings in this cell are termed false negatives. e sensitivity and specicity of dental radiographs vary, however, according to the diagnostic task (e.g., surface of the tooth being examined, proximal versus occlusal; and depth, enamel versus dentin).Radiographs aid in determining the relationship between the margins of existing or proposed restorations and bone. Tooth color evaluation becomes a factor if teeth are more visible when smiling or at the resting position of lips. Remineraliza-tion requires a shift in the delicate balance of the oral biolm and therefore depends heavily on changes in patient behavior (e.g., improved home care, diet) and the timely application of antimicrobial agents, uoride, and other remineralizing agents. position against the articular eminence within the glenoid fossa. 1 For a child who has not had an earlier dental examination, the new environment, new people, and manipulation of … Older individuals used dental services infrequently because most were edentulous, had limited nancial resources, and delayed unmet dental needs until they became symptomatic. 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. Dental oss is useful in identifying overhanging restorations, improper proximal contours, and open contacts. examination of other tooth defects 188 ii.d. A line that occurs in the isthmus region generally indicates fractured amalgam, and the defective restoration that must be replaced (. If abnormal attrition is present, the patient’s functional movements should be evaluated and inquiry made with regard to potential parafunctional habits such as tooth grinding or clenching/grinding (bruxism). 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. is is accomplished in, light of the reality that when individual teeth are corr, anatomic shape, and positioned in the face and ar, are more visible when smiling or at the r, conditions such as tetracycline staining all increase the risk for not, satisfying the esthetic expectations of patients with tooth color, concerns. ese alternatives, with their advantages and disad-vantages, should be presented to the patient. Dental treatment in any one of the abovemen-tioned areas may improve risk status in that area but at a cost of increased risk in another area. If a tooth-colored restoration has dark marginal staining or is discolored to the extent that it is esthetically unappealing to the patient, the restoration should be judged as defective (see Fig. Two mounting systems are currently available for binocular loupes: (1) ip-up and (2) xed or through-the-lens types.Dental microscopes, though limited primarily to endodontic practices in the past, are now being used in some restorative dentistry practices. Sealants are defined as confined to enamel. Ekstrand K, Qvist V, ylstrup A: Light microscope study of the eect of probing occlusal surfaces. Even these intentional eorts are part of a treatment plan and must be included in the informed consent process. Root-surface restorations are challenging to suc-cessfully perform and are at risk of recurrent decay in the future. DeBiase CB, Austin SL: Oral health and older adults. is 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. Lack of symmetry increases the risk of not meeting the patient’s esthetic expectations. Transillumination is accomplished by placing the mirror or light source on the lingual aspect of teeth and directing the light through teeth. e presence and amount of anterior guidance is evaluated to note the degree of potential posterior disclusion. If it causes problems, an overhang should be corrected, and this often indicates the need for restoration replacement. Corrective procedures include recontouring, polishing, repairing, or replacement of the restoration.One of the main concerns with anterior teeth is esthetics. 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. Both types of white spots are undetectable tactilely because the surface is intact, smooth, and hard. 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. The use of small, lightweight LED (light-emitting diode) headlamps attached to the eyeglass frame or attached to a headband offer the considerable visual advantage of added illumination when used with loupes. Katz RV: e clinical identication of root caries. Skas PM: Informed consent and the law. Risk of patient dissatisfaction with treatment outcomes may be lowered by careful attention to the establishment of intrafacial, intraarch, and interarch tooth positions that have been identied as consistent with maximum esthetics. Hintze H, Wenzel A, Danielsen B, et al: Reliability of visual examina-tion, ber-optic transillumination, and bite-wing radiography, and reproducibility of direct visual examination following tooth separation for the identication of cavitated carious lesions in contacting approximal surfaces. A description of the patient’s static anatomic occlusion in maximum intercuspation, including the relationship between molars and canines (Angle Class I, II, or III), and the amount of vertical overlap (overbite) and horizontal overlap (overjet) of anterior teeth should be recorded. In addition to this physiologic dimension, the restoration margin should be placed occlusally as far away as possible from the base of the sulcus. Patient Assessment, Examination and Diagnosis, and Treatment Planning. Typically, the lower the magnication, the greater is the depth of focus.Patient with other circumstances including, but not limited to, proposed or existing implants, pathology, restorative/endodontic needs, treated periodontal disease, and caries remineralizationClinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these circumstances. 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. (Modied from Young DA, Nový BB, Zeller GG, et al. e dentist, being aware of the patient’s health history and vulnerability to oral disease, is in the best position to make this judgment. 3.9E). Diagnosis and Treatment Planning For RPD Dr. Ashraf Gebreel 2 I. is radiolucency is typically triangular and has its apex toward the DEJ.Moderate-to-deep occlusal caries lesions may be seen as a radiolucency extending into dentin (see Fig. Bader J, Shugars D: Systematic review of the performance of the DIAGNOdent device for caries detection. e ADA/FDA guidelines help direct the type and frequency of radiographs needed according to patient condition and risk factors (Table 3.2).Generally, patients at higher risk for caries or periodontal disease should receive more frequent and more extensive radiographic surveys. These areas are no longer carious and are usually more resistant to caries as a result of fluorohydroxyapatite formation. to evaluate ssures and pits in an attempt to diagnose ssur. This role is summarized by the Latin phrase “primum non nocere,” which means “do no harm.” This phrase represents a fundamental principle of the healing arts over many centuries. Your doctor will try to rule out physical problems that could cause your symptoms. 3-2). examination of cracked tooth 245 expected time: 120 min 6 c o n t e n t s 6. This Web site helps clinicians identify systematic reviews, describes the preferred method for assembling the best available scientific evidence, and provides an appraisal of the evidence through critical summaries. The first is that they are only indicated for use on unrestored pits and fissures. 118 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planningis available. Misdiagnosis may occur when cervical burnout (the radiographic picture of the normal structure and contour of the cervical third of the crown) mimics a caries lesion. Unusual eruption, spacing, or migration of teeth20. Direct vision is used to observe how light passes into the, surface of the tooth structure. Through direct vision and reflecting light through the occlusal surface of the tooth, the occlusal surface is diagnosed as diseased if chalkiness or apparent softening or cavitation of tooth structure, forming the fissure or pit, is seen or a brown-gray discoloration, radiating peripherally from the fissure or pit, is present. Finally, a treatment plan is not a static list of services. 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. Dove SB: Radiographic diagnosis of caries. e dentist subsequently performs the examination and, tooth must be inspected for localized changes in color, such as starting in the upper right quadrant with the most posterior. Oral involvement in known or suspected systemic disease12. 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 Fig. As a result, the dentist must work with caregivers who provide dental care for patients in the home, assisted living facility, nursing home, and hospital settings. The dental history is a review of previous dental experiences and current dental problems. Clinical caries lesion detection has been found lacking and improvement is needed. An accurate clinical examination requires a clean, dry, well-illuminated mouth. However, images may be distorted, and working lengths less than ideal. 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). A, Deep marginal ditching. Evidence of foreign objects14. If the ditch is too deep to be cleaned or jeopardizes the integrity of the remaining restoration or tooth structure, the restoration should be replaced.12 In addition, secondary caries is frequently found around marginal gaps near the gingival wall and warrants replacement.22. Marginal • Fig. Heavy wear facets on posterior cuspal inclines, mobility of teeth, or fremitus during function is identied and classied as primary or secondary occlusal traumatism. Herb seasonings may enhance the avor of foods in lieu of sugar and salt. Currently, the American Dental Association (ADA) has developed a Web site (ebd.ada.org/) that can be used by dental professionals for evidence-based dentistry decision making. Super. The second is that their diagnostic accuracy has not been firmly established. Unaided vision is often inadequate to view details needed to make treatment decisions. Most fractures were treated with direct or indirect restorations or recontouring and polish-ing; 3% of the fractured teeth were extracted, and 4% received endodontic treatment.22 Risk factors for nontraumatic fracture of posterior teeth were found to be the presence of a stained fracture in enamel and an increase in the proportion of the volume of the natural tooth crown occupied by a restoration.23,24 e examination process should notate the presence and activity of all fracture areas.e dental examination also may reveal dental anomalies that include variations in size, shape, structure, or number of teeth—such as dens in dente, macrodontia, microdontia, gemination, concres-cence, dilaceration, amelogenesis imperfecta, and dentinogenesis imperfecta. Although erosive agents are the predominant causative factors, it is thought that toothbrushing and/or other abrasive agents in the diet may accelerate the loss of tooth structure, which EFABCD• Fig. Occasionally a gross debridement must be schedule before nal clinical examination of the teeth may be accomplished.Clinical Examination for CariesContemporary caries management, which encompasses expanded nonoperative approaches and conservative operative interventions, in patients who display a large amount of gingival tissue when smiling. e technologies currently approved by the FDA include laser-induced uorescence, light-induced uorescence, and alternating current (AC) impedance spectroscopy (ACIST).10,30e DIAGNOdent device (KaVo Dental Corporation, Charlotte, NC) uses laser uorescence technology, with the intention of detecting and measuring bacterial products and changes in tooth structure in a caries lesion. carefully because these surfaces are often at a greater risk for caries. Br Dent J 176:135–139, 1994.12. If lesion progression is detected at recall, then operative intervention is warranted.ere are exceptions to the general rule of managing non-cavitated enamel lesions with remineralization. • The documentation of each patient encounter should include the: o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic results o Assessment, clinical impression, or diagnosis o Medical plan of care o Date and legible identity of the observer. helpful in arriving at an accurate nal diagnosis. The margin of the restoration (b) must not violate this dimension. Typically, the lower the magnification, the greater is the depth of focus. Steps to increase the zones of attached gingiva and eliminate abnormal frenal tension should be achieved by corrective periodontal surgical procedures around teeth receiving restorations with sub-gingival margins. Determination of patient caries risk is important when considering the use of composite resin-based restorations. The patient’s medical history, dental history, oral hygiene, diet, and age, among other caries risk factors and indicators, can suggest a prediction of current and future caries activity. Familial history of dental anomalies4. The marginal ridge portion of the amalgam restoration should be compatible with the adjacent marginal ridge. However, the dentist must weigh the benets of taking dental radiographs against the risk of exposing a patient to ionizing radiation, the eects of which accumulate from multiple sources over time. >> Extra- and intraoral examination >> Examination and assessment of teeth and supporting structures The first is that they are only indicated for use on unrestored pits and fissures. Ettinger RL: e unique oral health needs of an aging population. Patient evaluation, diagnosis and treatment planning 1. Ho, nician must understand the normal physiologic response of the, muscles of mastication to various occlusal interrelationships and, be able to identify where, for a specic patient, pathology (of, the dentition, muscles of mastication, and/or, I, II, or III), and the amount of vertical overlap (o, is should include assessment of the presence and specics of, any functional shift from centric relation occlusion to maximum, intercuspation. 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. 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. In addition, soft tissue lesions, complicating exostoses, and improperly contoured ridge areas should be eliminated or corrected before nal restorative care.Fixed, Removable, and Implant ProsthodonticsDirect restorations should be completed, if possible, before placing indirect restorations. 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 Fig. A cotton roll in the vestibular space and another under the tongue maintain dryness and improve vision (Fig. It is recommended that appropriate preventive steps, such as improvement in diet/oral hygiene and uoride treatment (with or without cementoplasty/dentinoplasty to eliminate surface roughness), be taken so as to limit carious breakdown and the need for restoration.Treatment of Root-Surface SensitivityIt is not unusual for patients to complain of root-surface sensitivity, which is an annoying sharp pain usually associated with gingival recession and exposed root surfaces. e discoloration may range from white to dark, in the structure of the dentin collagen matrix. Percussion of the restoration should reveal a clinical sound consistent with integration. e ability to obtain virtual study models via digital impres-sion technology has increased the ease and level of diagnostic evaluation, especially in situations where the use of conventional impression techniques/materials may not be an option (such as in patients with a hyperactive gag reex). 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. Root caries is softer than the adjacent tooth structure, and lesions typically spread laterally around the CEJ. Thus, the clinician must take all of the available diagnostic information together—visual, tactile, radiographic, and so on—along with the respective reported levels of accuracy and combine that with an assessment of the patient’s overall caries status to make a final diagnosis to the presence and extent of a caries lesion. Clinical examination is the “hands-on” process of observing the patient’s oral structures and detecting signs and symptoms of abnormal conditions or disease. Although the use of amalgam is considered safe by multiple independent agencies, the release of elemental mercury does contribute to environmental levels. Review of the dental history often reveals information about past dental problems, previous dental treatment, and the patient’s responses to treatments. Mobility of teeth8. Ineective plaque removal, xerostomia, soft sugar-rich diets, xed and removable prostheses, abrasions at the CEJ, gingival recession, and chronic periodontal inammation (with increased activity of collagenolytic enzymes) make root surfaces more prone to caries compared with other surfaces. 3.3C). In patients with attachment loss, extra care must be taken to inspect for root-surface caries. Clinical erosion**Factors increasing risk for caries may include but are not limited to: 1. The chapter assumes that the reader has a background in oral medicine and an understanding of how to perform complete extraoral hard and soft tissue examinations along with intraoral cancer screening, as well as an understanding of the etiology, characteristics, risk assessment, and nonoperative management of dental caries as presented in Chapter 2. e occlusal, relationships of the teeth are assessed for the pr, contact the lower of two adjacent marginal ridges of dier, levels, contacting directly between two adjacent marginal ridges in, maximum intercuspation, or be positioned in a deep fossa. e clinician must weigh the seriousness of the disease that is left untreated (in cases of low sensitivity) against the invasiveness of the treatment (in cases of low specic-ity). Current thinking nds that the use of an explor, in this manner might have some relevance for assessing caries, from a ssure or pit). fossa area) and with no radiographic evidence of caries. During the clinical examination, the dentist, must be keenly sensitive to subtle symptoms (that the patient, reports), signs (that the dentist detects), and variations from normal, to detect pathologic conditions and determine etiologic, e discovery of additional risk factors/indicators may occur during, the examination. Intraoral cameras and SLR (single-lens reflex) digital cameras that are easy to use provide opportunities to document existing esthetic conditions such as color, shape, and position of teeth. In addition, patients undergoing orthodon-tic treatment should receive more intense focus (especially by the orthodontist) on the minimization/elimination of risk factors for caries and gingival/periodontal disease. Simply put, skipping steps may lead to overlooking potentially important parts of the patient’s individual needs. Clinical evaluation of amalgam restorations requires visual observation, application of tactile sense with the explorer, use of dental floss, interpretation of radiographs, and knowledge of the, Proximal overhangs are diagnosed visually, tactilely, and radiographically (, Marginal gap or ditching is the deterioration of the amalgam–tooth interface as a result of wear, fracture, or improper tooth preparation (. Generally, microscopes include five or six magnification stops that typically range from 2.5× to 20×. Areas of signicant occlusal attrition that have exposed dentin, are sensitive, or annoying should be considered for restoration or at least protection from additional loss of tooth structure. Rather, these statistics indicate what proportions of existing disease and absence of disease will be correctly identied in any group of individuals.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 examination, intraoral structures and detecting of symptoms a, conditions or disease. This section describes examination, diagnosis, risk assessment, and prognosis. Dentists of average height typically choose a working distance of 13 to 14 inches (33–35 cm), whereas tall dentists and those who prefer to work farther away from the patient use working distances of 14 to 16 inches (35–40 cm). Ashley PF, Blinkhorn AS, Davies RM: Occlusal caries diagnosis: An in vitro histological validation of the Electronic Caries Monitor (ECM) and other methods. Caries can be diagnosed radiographically as translucencies in the enamel or dentin. Such an overhang can provide an obstacle to good oral hygiene and result in inflammation of adjacent soft tissue. Finally, the date and type of available radiographs should be recorded to ascertain the need for additional radiographs and to minimize the patient’s exposure to unnecessary ionizing radiation. 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. J Dent 21:323–331, 1993.5. 3.7 Lines across the occlusal surface of an amalgam restoration. In many instances, recontouring or resurfacing the existing restoration may delay replacement and is an acceptable form of treatment.Treatment by Replacement of Existing RestorationsIndications for replacing restorations include the following: (1) marginal void(s), especially in the gingival one third, that cannot be repaired and predispose to caries formation; (2) poor proximal contour or a gingival overhang that contributes to periodontal breakdown; (3) a marginal ridge discrepancy that contributes to food impaction; (4) overcontouring of a facial or lingual surface resulting in biolm accumulation gingival to the height of contour and resultant inammation of gingiva overprotected from the cleansing action of food bolus or toothbrush; (5) poor proximal contact that is either open or improper in location or size, resulting in interproximal food impaction and inammation of impacted gingival papilla; (6) recurrent caries that cannot be treated adequately by a repair restoration; and (7) supercial marginal gap formation (ditching) deeper than 0.5 mm that predisposes to caries.44Indications for replacing tooth-colored restorations include (1) improper contours that cannot be repaired, (2) large voids, (3) deep marginal staining, (4) recurrent caries, and (5) unacceptable esthetics.44 Bonded restorations that have supercial marginal staining may be corrected by shallow, narrow, marginal repair.Treatment With Amalgam RestorationsDental amalgam still is recognized as one of the most successful direct restorative materials and is especially indicated for patients deemed to be moderate or high caries risk.45 Inaccurate information with regard to the safety of amalgam has resulted in controversy among health care providers, environmentalists, legislators, and the general population. The earliest clinical evidence of early enamel lesions on these surfaces is a white spot that is visually different from the adjacent translucent enamel and partially or totally disappears with wetting. Just as radiographs provide a historical look at a patient’s situation, photography is an excellent tool for documentation and evaluation. The objective of improved detection and classification systems is to accurately identify those early enamel lesions that are most likely to be reversed and remineralized. A line that occurs in the isthmus region generally indicates a fractured amalgam, and the defective restoration must be replaced (Fig. This includes four distinct processes: (1) understanding the patient’s desires or chief concerns/complaints regarding his or her condition (including its history) through a systematic interview process, (2) ascertaining the patient’s dental needs through a diagnostic clinical examination, (3) developing a treatment plan that reflects the best management of desires and needs (with influences unique to the medical condition … Assessment of dental caries also requires identication of caries lesion activity so as to make decisions relative to treatment recom-mendations (Table 3.1). Glass ionomer should be considered where the enamel is immature, or where fissure preparation is not desired, or where rubber dam isolation is not possible. The Spectra system claims to detect caries lesions by measuring increased light-induced fluorescence. However, the cli-nician must understand the normal physiologic response of the muscles of mastication to various occlusal interrelationships and be able to identify where, for a specic patient, pathology (of the dentition, muscles of mastication, and/or TMJs) is present and what modications may be indicated. Such an arrested lesion at times may be rough, although cleanable, and a restoration is not indicated except to address the esthetic concerns of the patient. Describes and demonstrates the method of assessing patients with medical complaints or signs and symptoms. Clinical evaluation of amalgam restorations requires visual observation, application of tactile sense with the explorer, use of dental floss, interpretation of radiographs, and knowledge of the probabilities that a given condition is sound or at risk for further breakdown. J Dent Educ 65:985–990, 2001.27. Panoramic or periapical exam to assess developing third molars.Usually not indicatedTABLE 3.2 Another cause of hypocalcication is arrested and remineralized incipient caries, which leaves an opaque, dis-colored, and hard surface. 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”). e osseous loss and reorganization will result in deeper periodontal probing depths, which in turn will further limit eective biolm removal. lesion and the second is for the restorative status of the tooth. As a result, food may become tasteless and unap-petizing, and more sugars, fats, and salts are added in an attempt to increase avor. 104 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planningstaining that is judged to be noncarious may be corrected by a small repair restoration along the margin. 3-3, B). Fissures and pits are detected visually and may frequently be stained but not diseased.As noted earlier, sharp explorers previously have been used to evaluate ssures and pits in an attempt to diagnose ssure/pit caries. Diet 3. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _____ data. The success of operative treatment depends heavily on an appropriate plan of care, which, in turn, is based on a comprehensive analysis of the patient’s reasons for seeking care and on a systematic assesssment of the patient’s current conditions and risk for future problems. are all prone to inaccuracies (Box 3.1). Senna P, Del Bel Cury A, Rösing C: Non-carious cervical lesions and occlusion: a systematic review of clinical studies. The first concept is test, A trained assistant familiar with the terminology, notation system, and charting procedure can survey the patient’s teeth and existing restorations and record the information to save chair time for the dentist. 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. *** All sealants and restorations to be done with a minimally invasive philosophy in mind. information is then used to formulate diagnoses (and risk proles). ese areas are diagnosed as nonhereditary developmental enamel hypoplasia. supercial staining is extrinsic and occurs over sev, exposure in a person with low caries risk. Risk factors should be identified at least on an annual basis. J Oral Rehab 39(6):450–462, 2012, doi:10.1111/j.1365-2842.2012.02290.x.21. 3.2). Many choices of magnification loupes are currently available for dentistry. Photographs of preparations of deep caries lesions provide documentation to aid in future diagnosis of tooth conditions. See Chapter 11, and a textbook dedicated to dental implantology, for additional information.Clinical Examination for Additional DefectsA thorough clinical examination occasionally identies localized noncavitated, hard white areas on the facial (Fig. If the marginal ridges are incompatible and are associated with poor tissue health, food impaction, or the inability of the patient to oss, the restoration is defective and should be recontoured or replaced.e proximal surface of an amalgam restoration should recreate the normal height of contour such that it comes into contact with the adjacent tooth at the proper occlusogingival and faciolingual area with correct adjacent embrasure form (a “closed” contact). Clinical evaluation of amalgam restorations requires visual observation, application of tactile sense with the explorer, use of dental oss, interpretation of radiographs, and knowledge of the probabilities that a given condition is sound or at risk for further breakdown. History of pain or trauma3. erefore this cell denotes false positives. ese steps include reasons for seeking care, medical and dental histories, clinical examination for the detection of abnormali-ties, establishing diagnoses (which includes assessing risk), and determining prognosis. 3.9B). 3.1 Accurate clinical examination requires a clean, dry, well-illu-minated mouth. examination is performed systematically in a clean, dry, illuminated mouth. Early fractures may be invisible upon initial assessment. indicated except to address the esthetic concerns of the patient. Concerns are recor, in the dental record. However, there are currently no published long-term randomized, controlled clinical trials verifying this to actually be the case. 3-1) derived from clinical trials data. Is the lesion progressing, or is the lesion arrested? 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. Sometimes, these areas are an annoyance because of food retention or the presence of peripheral, ragged, sharp enamel edges. 3-4). e occlusal surface is diagnosed as diseased if external chalkiness (enamel caries) or subsurface opacity (dentin caries) or cavitation of tooth structure, forming the ssure or pit, is seen. As a result, a range of treatments has been developed to manage a wide array of esthetic concerns. Gerodontology 5:21–24, 1986.14. Eur Arch Paediatr Dent 17(1):13–25, 2016.33. Postoperative evaluation of healing5. 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. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination. Generally, these lesions should not be restored except when the patient expresses esthetic concerns. which are a determination or judgment of health versus disease, variations from normal, and likelihood for the development of, additional disease. Light of this wavelength supposedly stimulates porphyrins—metabolites unique to cariogenic bacteria—to appear distinctly red, while healthy enamel uoresces to appear green. 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. Hunter PB: Risk factors in dental caries. ese loupes are inexpensive and lightweight and may provide magnication of up to 2.5×. The superficial staining is extrinsic and occurs over several years of oral exposure in a person with low caries risk. Some restorative dentistry practices of ssure caries are experiencing rerestora-tion lead to the patients, trade-offs... Materials or transillumination may aid in the future test with high specicity suggest patients... Not a static list of one or more reasonable interventions from the set of possible alternatives from patient assessment,... Compact and portable device, which, by its ability to meet the new patient assessment, examination and diagnosis and treatment planning greater! 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patient assessment, examination and diagnosis and treatment planning