Early fractures may be invisible upon initial assessment. Photog-raphy is an excellent tool for documentation and evaluation. 3-3, F). For most patients, the rst three phases are accomplished simultaneously. Periapical radiographs are helpful in identifying changes in the periapical periodontium that are consistent with periapical abscesses, dental granulomas, or cysts. Shallow ditching less than 0.5 mm deep usually is not a reason for restoration replacement because the area is self-cleaning and not prone to caries development.16 Such a restoration usually looks worse than it really is. Dental history 2. Cumulative exposure to ionizing radiation potentially may result in adverse eects. The clinical examination is performed systematically in a clean, dry, well-illuminated mouth. Appropriate dye materials or transillumination may aid in detecting the line of fracture within the tooth structure. It is important to remember the distinction between primary occlusal grooves and fossae and occlusal fissures and pits. e dental history is a review of previous dental experiences and, information about past dental problems, previous dental tr, care, an alteration of the treatment or envir, discussion might lead to identication of specic problems such, as areas of food impaction, inability to oss, areas of pain, and, during function is identied and classied as primary or secondar, occlusal traumatism. Concerns are recorded essentially verbatim in the dental record. e discoloration may range from white to dark brown, with rapidly progressing caries usually being light in color. J Am Dent Assoc 135: 1413–1426, 2004.32. The patient or legal guardian completes a standard, comprehensive medical history form. Frequent high sucrose content in diet9. J Dent 21:323–331, 1993.5. Many risk assessments use terms such as low risk, medium risk, Contingency Table for Diagnostic Test EvaluationHistologic Gold StandardCariesNo cariesDiagnostic TestCariesTrue positive (TP)False positive (FP)No cariesFalse negative (FN)True negative (TN)Desirable and Undesirable Outcomes Resulting from Diagnostic Tests with Low Sensitivity or SpecicityExample 1Diagnosing 100 teeth (90 healthy and 10 carious) with a diagnostic test having a high sensitivity (0.80) and low specicity (0.50) would result in the following:Desirable outcomes:Correctly detect 8 of 10 carious teeth (TP)Correctly diagnose 45 of 90 healthy teeth (TN)Undesirable outcomes:Fail to detect 2 of 10 carious teeth (FN)Fail to diagnose 45 healthy teeth as carious (FP)Example 2Diagnosing 100 teeth (90 healthy and 10 carious) with a diagnostic test having low sensitivity (0.50) and high specicity (0.80) would result in the following:Desirable outcomes:Correctly detect 5 of 10 carious teeth (TP)Correctly diagnose 72 of 90 healthy teeth (TN)Undesirable outcomes:Fail to detect 5 of 10 carious teeth (FN)Fail to diagnose 18 healthy teeth as carious (FP)Assessing the Accuracy of a Diagnostic Test for Caries• BOX 3.1 ese defective areas are associated with the binge–purge syndrome in bulimia, or with gastroesophageal reux disease (GERD). Binocular loupes typically have Galilean and prismatic optics that provide 2× to 3.5× magnification or even 4× and greater magnification. The dentist subsequently performs the examination, confirms the charting, makes a diagnosis, establishes a risk assessment profile for the patient, establishes a prognosis, and develops the treatment plan in conjunction with the patient’s current needs and desires. When nonsurgical methods fail to provide relief, direct restorative treatment that physically covers the exposed dentin is indicated.have appropriate crown-lengthening surgical procedures performed before the nal restoration is placed. e ongoing self-sealing property of amalgam allows the restoration to continue serving adequately if it can be satisfactorily cleaned and maintained. Most models also have side shields or a wraparound design for eye protection and infection control. Awareness of extreme variations in dental anatomy aids in the identication of fracture-prone areas. It is crucial to understand past experiences to provide optimal care in the future. A plunger cusp might contact the lower of two adjacent marginal ridges of dierent levels, contacting directly between two adjacent marginal ridges in maximum intercuspation, or be positioned in a deep fossa. e presence of caries in these self-cleansing areas usually indicates, that the patient is at high risk of developing additional caries (see, Carious pits and ssures also occur on the occlusal two thirds of, the facial or lingual surface of posterior teeth and on the lingual, e clinical interpretation of subtle changes in the appear, ance of tooth structure is aided by simultaneous consideration of, and indicators, may suggest a prediction of current and fu, e ICDAS uses a two-stage process to recor, the caries lesion. In general, the most frequently fractured cusps are the non-functional cusps (see Chapter 1). When a proposed treatment plan is discussed with the patient, study models are a valuable educational medium in helping the patient understand and visualize existing conditions and the need for the proposed treatment.Caries Detection TechnologiesIn addition to the traditional methods of caries detection, several new technologies have emerged and show promising results for the clinical detection and diagnosis of caries lesions. e elongation of the nerve bers results in depolarization and the perception of pain (see Chapter 1). Consultation with the patient’s physician is highly recommended so as to gain understanding of these medical, mental, and emotional conditions and their potential impact on dental treatment. Another cause of hypocalcication is arrested and remineralized incipient caries, which leaves an opaque, dis-colored, and hard surface. Mobility of teeth8. It is estimated that older individuals living in community settings take an average of four medications each day; six of the top 10 drugs prescribed in 2001 were used to treat age-related chronic condi-tions.46,47 Many of these medications have the potential for adverse drug reactions and drug interactions. Finally, a treatment plan is not a static list of services. History of recurrent caries3. B, Caries lesions on cusp tips. 3. 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 identication of cavitated carious lesions in contacting approximal surfaces. 3.6D). Once the dentist of cavitation or dentin penetration before recommending irreversible operative treatment.ese concepts are widely used in medical practice. Pre-carious or carious pits are occasionally present on cusp tips (see Fig. Eating disorders17. A treatment plan should allow for reevaluation and be adaptable to meet the changing needs, preferences, and health conditions of the patient.In the context of planning dental treatment, the clinician should recommend invasive operative treatment only when the benets outweigh the risks of adverse outcomes. CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning 117 in older patients.49 Perceptions of salty and bitter tastes and olfactory function decline with age, whereas perceptions of sweet and sour tastes do not. Ineective plaque removal, xerostomia, soft sugar-rich diets, xed and removable prostheses, abrasions at the CEJ, gingival recession, and chronic periodontal inammation (with increased activity of collagenolytic enzymes) make root surfaces more prone to caries compared with other surfaces. Positive Clinical Symptoms/Signs1. These concepts are widely used in medical practice. erefore the, emphasis in dentistry has shifted toward understanding and, maintaining conditions consistent with a healthy stomatognathic, broken restorations or tooth structure. Small early enamel lesions may be detectable only on the radiograph. e fre-quency of reevaluation examinations depends, in large part, on the patient’s risk for dental disease. fossa area) and with no radiographic evidence of caries. During the clinical examination, the dentist must be keenly sensitive to subtle signs, symptoms, and variations from normal to detect pathologic conditions and etiologic factors. Developmental or acquired disability12. 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. All of this must be accomplished without, compromising the short- and long-term dental health of the patient, indirect enamel-supported restorations are mor, long-term risk management than are more aggr, along with potential impact on the muscles of mastication and, TMJs, must occur before planning and implementing restorativ. : The American Dental Association Caries Classication System for Clinical Practice, A report of the American Dental Association Council on Scientic Affairs, J Am Dent Assoc 146(2):79–86, 2015. Powered rotation–oscillation toothbrushes and manual toothbrushes with larger handles, for easier gripping, are recommended for patients with decreased manual dexterity. Supererupted teeth, spacing, fractured teeth, and marginal ridge discrepancies should be noted. e clinical examination is performed systematically in a clean, dry, well-illuminated mouth. In addition, every patient has a dierent set of risk factors. However, because the sensitivity of radiographs for dentinal lesions on the occlusal surface is rather low (50%), the absence of a radiolucency does not mean that a lesion is not present. e dental professional may need to spend more time educating and training the caregiver, rather than the patient, in the importance of oral hygiene and eective plaque removal techniques.Treatment Plan ApprovalInforming patients well about their conditions and treatment options and then obtaining their consent has become an integral part of contemporary dental practice.51 One aspect of informed consent is to provide patients with the necessary information about the alternative therapies available to manage their oral conditions. Large amalgam or composite foundation restorations must have secondary retention features (grooves, slots, pins) placed further from the external surface of the tooth so that the retention of the foundation material is not compromised during preparation for the indirect restoration. >> Comprehensive assessment of patient's current health status, history of disease and risk characteristics in order to determine periodontal diagnosis. These lesions are inactive lesions but remain susceptible to new caries activity in the future. … e resulting defective surface is usually smooth. finishing of porcelain restoration margins, identifying minute decay, and minimizing the removal of sound tooth structure. The dental history is a review of previous dental experiences and current dental problems. Advanced smooth-surface caries exhibits discoloration and demin-eralization and feels soft as the explorer is translated across the suspicious area. Forcing an explorer into pits and fissures also theoretically risks cross-contamination from one probing site to another. is information is vital to establishing which specic diagnostic tests are required, determining the cause, selecting appropriate treatment options for the concerns, and building a sound relationship with the patient.ExaminationIt is somewhat articial to discuss examination as a separate entity from patient assessment for aspects of the patient “examination” begin during initial conversations with the patient. Remineralization, and training to use the system with an online tutorial, are available. Typically, the lower the magnification, the greater is the depth of focus. 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 biolm accumulation gingival to the height of contour and resultant inammation 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 inammation of impacted gingival papilla; (6) recurrent caries that cannot be treated adequately by a repair restoration; and (7) supercial 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 supercial 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. Teeth with active, symptomatic fractures should be considered for full coverage of the occlusal surface. Many choices of magnification loupes are currently available for dentistry. A patient with a low risk prole may have longer intervals (e.g., 9–12 months) between recall visits. e second is that their diagnostic accuracy has not been rmly established. 3-6). ese inaccuracies result in false-positive and false-negative ndings. In contrast, for assessment of root caries, an explorer is valuable to evaluate root surface softness. Advanced smooth-surface caries exhibits discoloration and demineralization and feels soft to penetration by the explorer. If a patient has difficulty tolerating certain types of procedures or has encountered problems with previous dental care, an alteration of the treatment or environment might help avoid future complications. 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. Many patients with GERD are often not aware of their gastric symptoms or do not associate them with the problems with their teeth. EC Dental Science 18.5 (2019): 975-988. This chapter provides an overview of the process through which a clinician completes patient assessment, clinical examination, diagnosis, and treatment plan for operative dentistry procedures. fractured teeth, and marginal ridge discrepancies should be noted. Every accessible surface of each tooth must be inspected for localized changes in color, texture, and translucency. Conversely, occlusal ssures and pits are deep, tight crevices or holes in enamel, where the lobes failed to coalesce partially or completely. Care must be exercised, however, to distinguish the active from the arrested (inactive) root-surface lesion. These loupes are inexpensive and lightweight and can provide magnification of up to 2.5×. Very few tests have both high sensitivity and high specificity, so trade-offs are inevitable. 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 identies the “true,” or actual, condition. 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. 3.11B). Restorations can be diagnosed clinically as being defective by observing the following. However, it cannot be over-emphasized that the, Caries lesions are most prevalent in the faulty pits and fissures of the occlusal surfaces where the developmental lobes of posterior teeth failed to coalesce, partially or completely (. in making decisions about the care of individual patients. Careful observa, tion of extraoral symmetry of the patient’, ability to articulate sounds, and tendencies to smile provides vital, or disease. If the contact is open and is associated with poor interproximal tissue health, food impaction, or both, the restoration should be classified as defective and should be replaced or repaired. e arrested root-surface lesion may have sclerotic dentin that has darkened from extrinsic staining, is rm to the touch of an explorer, may be rough but is cleanable. Teaches the knowledge and skills required to continue the assessment and treatment of the patient. Frequency of dental care and perceptions of previous care may be indications of the patient’s future behavior. erefore the restorations of the implants require modied cervical contours. 3.9D). Christensen GJ: Educating patients: a new necessity. Heavy wear facets on posterior cuspal inclines, mobility of teeth, or fremitus during function is identied and classied as primary or secondary occlusal traumatism. Reliablity, validity, specicity, and sensitivity of diagnostic procedures. e reader should consult an oral pathology textbook for additional information.Radiographic Examination of Teeth and RestorationsRadiographs are an indispensable part of the contemporary dentist’s diagnostic armamentarium. Success of the treatment plan is determined by its ability to meet the patient’s initial and long-term needs. Rather, these statistics indicate what proportions of existing disease and absence of disease will be correctly identied 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. J Am Dent Assoc 124:86–87, 1993.53. The more commonly used dental loupe is the binocular loupe with lenses mounted on an eyeglass frame. e height and integrity of the marginal periodontium may be evaluated using bitewing radiographs. e mesiofacial (nonfunctional) and distolingual (small functional) cusps are the most commonly fractured cusps in maxillary molars.21 A study of fracture severity found that 95% of the fractures management of erosion. is phase may include endodontic, periodontal, orthodontic, and surgical procedures. Carious pits and fissures also occur on the occlusal two thirds of the facial or lingual surface of posterior teeth and on the lingual surface of maxillary incisors. 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. to and usually gingival to the contact area ar, a result of extrinsic staining during earlier caries demineralizing, are no longer carious and are usually mor, sometimes are dicult to correctly diagnose because of faint, radiographic examination, visual inspection (with optional transil, accomplished by placing the mirror or light source on the lingual, aspect of teeth and directing the light through teeth. 3-3, B). Sinus tract (“stula”)9. is compact and portable device, which requires a clean, dry occlusal surface, yields a numerical score from 0 to 99. Full-coverage bonded indirect tooth-colored restorations also may be selected for the conservative restoration of weakened posterior teeth in low stress, esthetically critical areas.e use of tooth-colored, zirconia-based, indirect restorations has steadily increased over the last two decades. Corrective procedures include recontouring, polishing, repairing, or replacement of the restoration.One of the main concerns with anterior teeth is esthetics. examination of other tooth defects 188 ii.d. Personal details are necessary for identification and commu-nication with the patient. Drying again causes it to reappear. Restorations that impinge on soft tissue, have inadequate embrasure form or proximal contact, or prevent the use of dental floss should be classified as defective, indicating recontouring or replacement (see, 2: Dental Caries: Etiology, Clinical Characteristics, Risk Assessment, and Management, 6: Instruments and Equipment for Tooth Preparation, 12: Additional Conservative Esthetic Procedures, 23: Additional Information on Instruments and Equipment for Tooth Preparation, 1: Clinical Significance of Dental Anatomy, Histology, Physiology, and Occlusion, 4: Fundamental Concepts of Enamel and Dentin Adhesion, 7: Preliminary Considerations for Operative Dentistry, Sturdevants Art & Science of Operative Dentistry 6e. These devices have two limitations. It details the examination of teeth and restorations using visual examination, radiographic examination, and adjunctive aids to detect caries and assess the structural integrity of teeth. is is sometimes expressed by using color-coded categories: red for high risk, yellow for medium risk, and green for low risk. Gaining insight into individual circumstances begins with proper patient assessment. ese areas remain visible whether the tooth is wet or dry, and should not be confused with the opaque white smooth-surface incipient caries lesions that appear when Amalgam restorations should duplicate the normal anatomic contours of teeth. Probing depths associated with the implant xture should be consistent with the thickness of the local gingival tissue. e patient is advised of the reasonable treatment alternatives and related risks and benets. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _____ data. e marginal adaptation between implant restorations and their abutments should allow for optimal biolm removal. Patients must have an active role in the process; they must be informed of the ndings, advised of the risks and benets of proposed treatment, and given the opportunity to decide the course of treatment. If the marginal ridges are incompatible and are associated with poor tissue health, food impaction, or the inability of the patient to floss, the restoration is defective and should be recontoured or replaced. Most models also have side shields or a wraparound design for universal precautions and ease of infection control. Review of the dental history often reveals information about past dental problems, previous dental treatment, and the patient’s responses to treatments. to evaluate ssures and pits in an attempt to diagnose ssur. As described earlier, an ideal diagnostic test accurately detects when a tooth surface is healthy (specificity); when a lesion or demineralization is present (sensitivity); and if demineralization is present, whether or not it is active and whether or not it has cavitated the surface. A prognosis may be described as excellent, good, fair, poor, or even hopeless. J Am Dent Assoc 126:371–372, 1995.25. 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). Voids that are usually localized and are caused by poor condensation of the amalgam can also occur at the margins of amalgam restorations. e examination is the “hands-on” process of observing the patient’s extraoral and intraoral structures and detecting of symptoms and signs of abnormal conditions or disease. 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. However, these devices have two limitations. (Modied from Young DA, Nový BB, Zeller GG, et al. 3.2). Assessment Methods. Family's history is reliable and the following signs are e objective of improved detection and classication systems is to accurately identify those early enamel lesions that are most likely to be reversed by remineralization. D, Recurrent caries gingival to an existing restoration (d). 3.6B).e marginal ridge portion of the amalgam restoration should be compatible with the adjacent marginal ridge. Caries lesions are most prevalent in the faulty pits and fissures of the occlusal surfaces where the developmental lobes of posterior teeth failed to coalesce, partially or completely (Fig. 100 CHAPTER 3 Patient Assessment, Examination, Diagnosis, and Treatment Planning4 = amalgam restoration5 = stainless steel restoration6 = ceramic, gold, PFM (porcelain-fused-to-metal) crown or veneer7 = lost or broken restoration8 = temporary restorationis severity code is paired with a restorative/sealant code 0 to 8:0 = not sealed or restored2 = sealant, partial3 = sealant, full; tooth-colored restorationABCDEF• Fig. Prescription lenses may be placed in the eyeglass frames for all loupe types. The comprehensive examination— the initial patient engagement—focuses the clinician and patient on the variables most likely to ensure a predictable and excellent outcome. With slowly progressing caries in a patient with low caries activity, darkening occurs over time because of extrinsic staining, and remineralization of the decalcified tooth structure occasionally may harden the lesion. Unexplained absence of teeth22. Close-up images of existing pits and fissures can provide the opportunity to see changes that cannot be documented in any other way for re-evaluation in the future. Therefore, appropriate non-operative care can be attempted, and lesions that require operative treatment can be identified as early as possible in the disease process. 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 oer, 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. 3.10). In addition to transillumination, tactile exploration of anterior teeth is appropriate to detect cavitation because the proximal surfaces generally are more visible and accessible than in the posterior regions.Another form of smooth-surface caries may occur on the facial and lingual surfaces of the teeth of patients with high caries activity, particularly in the cervical areas that are less accessible for cleaning. Remineraliza-tion requires a shift in the delicate balance of the oral biolm 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.
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