95 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

3
Patient Assessment, Examination,
Diagnosis, and Treatment Planning
LEE W. BOUSHELL, DANIEL A. SHUGARS, R. SCOTT EIDSON a

T
his chapter provides an overview of the process through overlooking potentially important parts of the patient’s individual
which a clinician completes patient assessment, clinical needs. hese steps include reasons for seeking care, medical and
examination, diagnosis, and treatment planning for operative dental histories, clinical examination for the detection of abnormali-
dentistry procedures. he chapter assumes that the reader has a ties, establishing diagnoses (which includes assessing risk), and
background in oral medicine and an understanding of how to determining prognosis. All of these steps must occur before a
perform complete (comprehensive) extraoral and intraoral hard sound and appropriate plan of care may be developed and
and soft tissue examinations, as well as an understanding of the recommended.
etiology, characteristics, risk assessment, and management of dental Growing attention to using only the most efective and appropri-
caries as presented in Chapter 2. It is not in the scope of this ate treatment has spawned interest in numerous research eforts.
chapter to incorporate the details of other aspects of a complete Research that provides information on treatments that work best
dental examination, such as periodontal, occlusal, and esthetic in certain situations is expanding the knowledge base of dentistry
examinations. Appropriate textbooks that cover the speciics of and has led to an interest in translating the results of that research
these areas, in health and disease, should be consulted. into practice activities that enhance care for patients. his movement
Any discussion of diagnosis and treatment must begin with an has been termed evidence-based dentistry and is deined as the
appreciation of the role of the dentist in helping patients maintain “conscientious, explicit, and judicious use of current best evidence
their oral health. his role is summarized by the Latin phrase “primum in making decisions about the care of individual patients.”1 Sys-
non nocere,” which means “do no harm.” his phrase represents a tematic reviews emerging from the focus on evidence-based dentistry
fundamental principle continually embraced by those in the healing will provide practitioners with a distillation of the available
arts over many centuries. knowledge about various conditions and treatments. It is incumbent
he implication of this concept for operative dentistry is that, before on the authors of the systematic review to openly discuss the
we recommend treatment, we must be reasonably conident that the strengths and weaknesses of the reviewed studies as well as the
patient will be better of as a result of our intervention. However, relative value of their conclusions for application in dental care.
how can we be reasonably conident when we realize that few, if any, Currently, the American Dental Association (ADA) has developed
of the tests we perform or the assessments of risk that we make are a website (http://ebd.ada.org/) that may be used by dental profes-
completely accurate? To make matters even more challenging, none of sionals for evidence-based dentistry decision making. his website
the treatments we provide is without adverse outcomes and none will helps clinicians identify systematic reviews, describes the preferred
likely last for the life of the patient. he answer is that we must method for assembling the best available scientiic evidence, and
acknowledge that the information or evidence we have is not perfect provides an appraisal of the evidence through critical summaries.
and that we must be clear about the possible consequences of our As evidence-based dentistry continues to expand, professional
decisions. If we are informed and clear about options and their associations will become more active in the development of
consequences, then we reduce the chances of doing any harm. guidelines to assist dentists and their patients in making informed
he success of operative treatment depends heavily on an and appropriate decisions.
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 General Conideration
assessment of the patient’s current conditions and risk for future
problems. his information is then combined with the best available It is diicult to overstate the importance of gaining comprehensive
evidence on approaches to management of the patient’s needs so insight into each patient. Dentistry has, by its very origins, been
that an appropriate plan of care may be ofered. heavily focused on reconstruction of damaged areas. However,
he collection of this information and the determinations based nothing that we design and create has the ability to withstand the
on examination indings should be comprehensive and accomplished wet, warm, salty, thermally cycled, and cyclically loaded environment
in a stepwise manner. Simply put, skipping steps may lead to of the oral cavity for the whole life of the patient. herefore the
emphasis in dentistry has shifted toward understanding and
a
Dr. Eidson was an inactive author in this edition. maintaining conditions consistent with a healthy stomatognathic

95
96 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

system so that steps may be taken to prevent dental disease. he broken restorations or tooth structure. Finally, the date, type, and
speciic circumstances of each individual must be considered in diagnostic quality of available radiographs should be recorded so
light of the known requirements of optimal oral health. Gaining as to ascertain the need for additional radiographs and to minimize
insight into individual circumstances begins with proper patient the patient’s exposure to ionizing radiation.
assessment. Medical and dental health survey questions are excellent
basic tools designed to facilitate this process. Responses to the Chief Concern
broad overview questions (generally referred to as the “medical
history” and “dental history”) then enable speciic exploration of Before initiating any treatment, the patient’s chief concerns, or
previous or current conditions unique to the individual patient, the problems that initiated the patient’s visit, should be identiied
that may represent risk factors or indicators for dental disease, as and clearly understood. Concerns are recorded essentially verbatim
well as the primary reason (i.e., the chief concern) that prompted in the dental record. he patient should be encouraged to discuss
the patient to seek the assistance of the dentist. his interview all aspects (symptoms) of the current problem(s), including onset,
process is then followed by the clinical gathering of additional duration, and related factors they are experiencing. his information
information by means of strategic examination. he examination is vital to establishing which speciic diagnostic tests are required,
is the “hands-on” process of observing the patient’s extraoral and determining the cause, selecting appropriate treatment options for
intraoral structures and detecting of symptoms and signs of abnormal the concerns, and building a sound relationship with the patient.
conditions or disease. During the clinical examination, the dentist
must be keenly sensitive to subtle symptoms (that the patient Examination
reports), signs (that the dentist detects), and variations from normal
to detect pathologic conditions and determine etiologic factors. It is somewhat artiicial to discuss examination as a separate entity
he discovery of additional risk factors/indicators may occur during from patient assessment for aspects of the patient “examination”
the examination. he combined patient assessment and examination begin during initial conversations with the patient. Careful observa-
information is then used to formulate diagnoses (and risk proiles), tion of extraoral symmetry of the patient’s physical appearance of
which are a determination or judgment of health versus disease, the head and neck areas, mandibular movement during speech,
variations from normal, and likelihood for the development of ability to articulate sounds, and tendencies to smile provides vital
additional disease. he dentist must be committed to comprehensive information relative to overall presence or absence of abnormalities
and meticulous attention to detail. or disease. hese observations occur while reviewing/clarifying
information reported in the medical and dental history and while
listening to the patient’s chief concern(s). By deinition, these early
Patient Aement observations are all extraoral in nature.
Many examination data recording systems utilize organizational
Medical Hitory logic that begins with “extraoral examination” followed by “intraoral
he patient or legal guardian completes a standard, comprehensive examination” so as to facilitate the recording of observational
medical history form. his form is an integral part of the preex- information (what the dentist observes while interacting with the
amination patient interview, which helps identify conditions that patient). Utilization of clinical photography to capture full face
could alter, complicate, or contraindicate proposed dental proce- and proile images is particularly useful in this process. Any observa-
dures. he practitioner should identify (1) communicable diseases tions will ultimately be followed by the physical examination neces-
that require special precautions, procedures, or referral; (2) allergies sary to assess extraoral aspects of the muscles of mastication,
or medications, which may contraindicate the use of certain drugs; temporomandibular joints (TMJs), lymphnodes, and other vital
(3) systemic diseases, cardiac abnormalities, or joint replacements, structures, which will then be followed by intraoral examination.
which may require prophylactic antibiotic coverage or other treat-
ment modiications; and (4) physiologic changes associated with Examination of Ethetic Appearance
aging, which may alter clinical presentation and inluence treatment.
he practitioner also might identify a need for medical consultation Examination of esthetic appearance may be described as the evalu-
or referral before initiating dental care. All of this information is ation of tooth color, form, display, and position in relation to the
carefully detailed in the patient’s permanent record and is used, face. Evaluation must include discussion of realistic esthetic
as needed, to shape subsequent treatment recommendations. expectations when considering treatment options with the patient.
Attaining the desired esthetic outcomes may be complicated by
maximum tooth display and excessive or uneven tissue display.
Dental Hitory Risk of patient dissatisfaction with treatment outcomes may be
he dental history is a review of previous dental experiences and lowered by careful attention to the establishment of intrafacial,
current dental problems. Review of the dental history often reveals intraarch, and interarch tooth positions that have been identiied
information about past dental problems, previous dental treatment, as consistent with maximum esthetics. his is accomplished in
and the patient’s responses to treatments. Frequency of dental care light of the reality that when individual teeth are correct in their
and perceptions of previous care may be indications of the patient’s anatomic shape, and positioned in the face and arches for optimum
future behavior. If a patient has diiculty tolerating certain types function, then the overall esthetic result will be optimal (“form
of procedures or has encountered problems with previous dental follows function”). Tooth color evaluation becomes a factor if teeth
care, an alteration of the treatment or environment might help are more visible when smiling or at the resting position of lips.
avoid future complications. It is crucial to understand past experi- Darker colored teeth, teeth with enamel intrinsic staining, and
ences in order to provide optimal care in the future. Also, this conditions such as tetracycline staining all increase the risk for not
discussion might lead to identiication of speciic problems such satisfying the esthetic expectations of patients with tooth color
as areas of food impaction, inability to loss, areas of pain, and concerns. Symmetry of gingival margins becomes very important
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 97

in patients who display a large amount of gingival tissue when grinding or clenching. Nonworking-side excursive contacts are
smiling. Lack of symmetry increases the risk of not meeting the recorded and related to any indings of masticatory muscle myositis
patient’s esthetic expectations. Presence of multiple risk factors and/or ipsilateral TMJ disc issues. Working-side excursive contacts
requires in-depth, careful consideration of the various components/ are recorded and related to areas of cusp fracture development.
relationships of the stomatognathic system, the ability to develop Protrusive contacts on all posterior teeth molars are noted. Heavy
an interdisciplinary treatment plan, and excellent listening skills wear facets on posterior cuspal inclines, mobility of teeth, or fremitus
so as to identify realistic options consistent with the patient’s overall during function is identiied and classiied as primary or secondary
esthetic expectations. All of this must be accomplished without occlusal traumatism. Full analysis of the occlusion may require
compromising the short- and long-term dental health of the patient articulated diagnostic models. Movement of the mandible from
(“do no harm”). In many of these situations, conservative direct or maximum intercuspation to maximum opening is observed and
indirect enamel-supported restorations are more appropriate for maximum unassisted opening is measured; any “clicking or popping”
long-term risk management than are more aggressive preparations of the joint disc(s) during mandibular movements is noted and
that remove relatively more tooth structure. related to any history of trauma, nonworking occlusal interferences,
or other possible pathologic changes. Bimanual loading of the
Examination of Occluion joints and palpation of the condyle lateral poles and retrocondylar
areas (during wide mandibular opening) are completed to further
A careful examination of the patient’s current occlusal scheme, test for tenderness/pain as signs of inlammation. he occlusal
along with potential impact on the muscles of mastication and relationships of the teeth are assessed for the presence of an unusually
TMJs, must occur before planning and implementing restorative tall and narrow cusp (a “plunger cusp”) that “plunges” deep into
care (see Chapter 1). his examination includes identiication of the occlusal plane of the opposing arch. A plunger cusp might
signs of occlusal trauma, such as heavy wear facets, enamel cracks, contact the lower of two adjacent marginal ridges of diferent
or tooth mobility, and notation of occlusal abnormalities that may levels, contacting directly between two adjacent marginal ridges in
be contributing to pathologic conditions such as bone loss. maximum intercuspation, or be positioned in a deep fossa. It may
Identiication of the current relative health of the stomatognathic increase the likelihood of food impaction and tooth or restoration
system then allows consideration of the potential ability of the fracture.
proposed restorative treatment to achieve harmonious function of he results of the occlusal examination should be included in
each component of the system. Careful analysis may identify need the dental record and considered in the restorative treatment plan.
for modiication of the current occlusal scheme prior to the initiation Acceptable aspects of the occlusion must be preserved and not
of any deinitive restorative care. altered during treatment. When possible, improvement of the
he static and dynamic occlusion must be examined carefully occlusion (elimination of interferences), based on knowledge of
(see Chapter 1) in light of the observation that there is no “ideal” the physiologic masticatory muscle response to various relationships,
occlusion and that most patients may have the ability to adapt is desirable; occlusal interferences must not be perpetuated in the
to their occlusion without clinical symptoms. However, the cli- restorative treatment.
nician must understand the normal physiologic response of the
muscles of mastication to various occlusal interrelationships and Examination of Teeth and Retoration
be able to identify where, for a speciic patient, pathology (of
the dentition, muscles of mastication, and/or TMJs) is present Preparation for Clinical Examination
and what modiications may be indicated. A description of the A trained assistant familiar with the terminology, notation system,
patient’s static anatomic occlusion in maximum intercuspation, and charting procedure may survey the patient’s teeth and existing
including the relationship between molars and canines (Angle Class restorations and record the information to save chair time for the
I, II, or III), and the amount of vertical overlap (overbite) and dentist. he dentist subsequently performs the examination and
horizontal overlap (overjet) of anterior teeth should be recorded. conirms the charting. Proper instruments, including a mirror, an
his should include assessment of the presence and speciics of explorer, and a periodontal probe, and the ability to air-dry the
any functional shift from centric relation occlusion to maximum surfaces of the teeth are required. Every accessible surface of each
intercuspation. he presence of missing teeth and the relationship tooth must be inspected for localized changes in color, texture,
of the maxillary and mandibular midlines should be determined. and translucency. A routine for charting should be established,
he appropriateness of the occlusal plane and the positions of such as starting in the upper right quadrant with the most posterior
malposed teeth should be identiied. Supererupted teeth, spacing, tooth and progressing around the maxillary and mandibular arches.
fractured teeth, and marginal ridge discrepancies should be noted. Dental loss is useful in identifying overhanging restorations,
he dynamic functional occlusion in all movements of the mandible improper proximal contours, and open contacts. he clinical
(right, left, forward, and all excursions in between) should be examination is performed systematically in a clean, dry, well-
evaluated. he evaluation also includes assessing the relationship illuminated mouth. A cotton roll in the vestibular space and another
of teeth in centric relation, which is the orthopedic position of the under the tongue maintain dryness and improve visualization of
joint where the condyle head is in its most anterior and superior the teeth and adjacent gingiva (Fig. 3.1). Heavy bioilm accumula-
position against the articular eminence within the glenoid fossa. tion may require lossing and a toothbrush prophylaxis to aid in
Functional movements of the mandible are evaluated to determine the examination process. Occasionally a gross debridement must
if canine guidance or group function exists. he presence and be schedule before inal clinical examination of the teeth may be
amount of anterior guidance is evaluated to note the degree of accomplished.
potential posterior disclusion. Teeth are examined for abnormal
wear patterns that are excessive and not age appropriate. If signs Clinical Examination for Caries
of abnormal or premature wear are present, the patient is queried Contemporary caries management, which encompasses expanded
as to awareness of any contributing parafunction habits such as nonoperative approaches and conservative operative interventions,
 98 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

relies on enhanced risk assessment and improved lesion detection

and classiication. Clinical caries lesion detection has been found
lacking; thus improvement is needed.2 One means of addressing
these concerns has been the development of a visual system for
caries lesion detection and classiication. he 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. 3.2). 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. he ICDAS
has been further condensed by the American Dental Association
into the Caries Classiication System (ADA CCS)3 (see Fig. 3.2).
Assessment of dental caries also requires identiication of caries
• Fig. 3.1 Accurate clinical examination requires a clean, dry, well-illu- lesion activity so as to make decisions relative to treatment recom-
minated mouth. Cotton rolls are placed in the vestibular space and under mendations (Table 3.1). he objective of improved detection and
the tongue to maintain dryness and enhance visibility. classiication systems is to accurately identify those early enamel
lesions that are most likely to be reversed by remineralization.
herefore appropriate nonoperative care may be attempted, and
lesions that require operative treatment may be identiied as early
as possible in the disease process. With this approach, restoration

ADA CCS Initial Moderate Extensive

Occlusal Protocol ***

ICDAS code 0 1 2 3 4 5 6

Definitions Sound tooth surface; First visual change Distinct visual change Localized enamel Underlying dark Distinct cavity with Extensive distinct
no caries change in enamel; seen only in enamel; seen when breakdown with no shadow from dentin, visible dentin; frank cavity with dentin;
after air drying (5 after air drying or wet, white or colored, visible dentin or with or without cavitation involving cavity is deep and
sec); or hypoplasia, colored, change “thin” “wider” than the underlying shadow; localized enamel less than half of a wide involving more
wear, erosion, and limited to the confines fissure/fossa discontinuity of breakdown tooth surface than half of the tooth
other noncaries of the pit and fissure surface enamel,
phenomena area widening of fissure

Histologic depth Lesion depth in P/F Lesion depth in P/F Lesion depth in P/F Lesion depth in P/F Lesion depth in P/F Lesion depth in P/F
was 90% in the outer was 50% inner enamel with 77% in dentin with 88% into dentin with 100% in dentin 100% reaching inner
enamel with only 10% and 50% into the 1/3 dentin
into dentin outer 1/3 dentin

Sealant/restoration Sealant optional Sealant optional Sealant optional or Sealant or minimally Minimally invasive Minimally invasive Minimally invasive
Recommendation DIAGNOdent may DIAGNOdent may caries biopsy if invasive restoration restoration restoration restoration
for low risk be helpful be helpful DIAGNOdent is 20-30 needed

Sealant/restoration Sealant optional Sealant recommended Sealant optional or Sealant or minimally Minimally invasive Minimally invasive Minimally invasive
Recommendation DIAGNOdent may DIAGNOdent may be caries biopsy if invasive restoration restoration restoration restoration
for moderate risk be helpful helpful DIAGNOdent is 20-30 needed

Sealant/restoration Sealant recommended Sealant recommended Sealant optional or Sealant or minimally Minimally invasive Minimally invasive Minimally invasive
Recommendation DIAGNOdent may be DIAGNOdent may be caries biopsy if invasive restoration restoration restoration restoration
for high risk * and helpful helpful DIAGNOdent is 20-30 needed
extreme risk **
* Patients with one (or more) cavitated lesion(s) are high-risk patients. ** Patients with one (or more) cavitated lesion(s) and xerostomia are extreme-risk patients.

*** All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined to enamel. Restoration is defined as in dentin. A two-surface restoration is defined as a
preparation that has one part of the preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to be in dentin). A sealant can be either resin-based or glass
ionomer. Resin-based sealants should have the most conservatively prepared fissures for proper bonding. 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. Patients should be given a choice in material selection.

• Fig. 3.2 American Dental Association Caries Classiication System (ADA CCS) and International Caries
Detection and Assessment System (ICDAS) chart showing visual caries detection. (Modiied from Young
DA, Nový BB, Zeller GG, et al.: The American Dental Association Caries Classiication System for Clinical
Practice, A report of the American Dental Association Council on Scientiic Affairs, J Am Dent Assoc
146(2):79–86, 2015; and Jenson L, Budenz AW, Featherstone JD, et al.: Clinical protocols for caries
management by risk assessment, J Calif Dent Assoc 35:714, 2007.)
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 99

TABLE 3.1 Characteristics of Active and Inactive frequently are cleansed by the rubbing action of food during
Caries Lesions mastication. Conversely, occlusal issures and pits are deep, tight
crevices or holes in enamel, where the lobes failed to coalesce
CARIES LESION ACTIVITY partially or completely. Fissures and pits are detected visually and
ASSESSMENT DESCRIPTORS may frequently be stained but not diseased.
Activity Assessment Likely to Be As noted earlier, sharp explorers previously have been used
Factor Inactive/Arrested Likely to Be Active to evaluate issures and pits in an attempt to diagnose issure/
pit caries. However, numerous studies have found that the use
Location of the Lesion is not in a Lesion is in a plaque
Lesion plaque stagnation stagnation area
of a sharp explorer for this purpose did not increase diagnostic
area (pit/issure, validity compared with visual inspection alone.4-7 he use of the
approximal, dental explorer for this purpose was found to fracture enamel
gingival) and serve as a source for transferring pathogenic bacteria among
various teeth.8,9 herefore the use of a sharp explorer in diagnosing
Plaque Over the Not thick or sticky Thick and/or sticky pit-and-issure caries is contraindicated as part of the detection
Lesion
process.
Surface Appearance Shiny; color: Matte/opaque/loss of An occlusal surface is examined visually and radiographically.10,11
brown-black luster; color: he visual examination is conducted in a dry, well-illuminated
white-yellow ield. Direct vision is used to observe how light passes into the
Tactile Feeling Smooth, hard enamel/ Rough enamel/soft surface of the tooth structure. he occlusal surface is diagnosed
hard dentin dentin as diseased if external chalkiness (enamel caries) or subsurface
opacity (dentin caries) or cavitation of tooth structure, forming
Gingival Status (If the No inlammation, no Inlammation, the issure or pit, is seen. At times a brown-gray discoloration,
Lesion is Located bleeding on bleeding on
Near the Gingiva) probing probing
radiating peripherally from the issure or pit, is present (see Fig.
3.3A, enamel area adjacent to the central pit/lingual issure)
From Young DA, Nový BB, Zeller GG, et al.: The American Dental Association Caries Classiication indicating caries progression in dentin below the translucent enamel.
System for Clinical Practice, A report of the American Dental Association Council on Scientiic In contrast, it is common to observe nondiseased occlusal surfaces
Affairs, J Am Dent Assoc 146(2):79–86, 2015. with narrow grooves or fossae that exhibit supericial staining, but
no visual changes in light relection through the enamel immediately
adjacent (see Fig. 3.3A, distal aspect of central groove and distal
fossa area) and with no radiographic evidence of caries. The
supericial staining is extrinsic and occurs over several years of oral
will result in the removal of the minimum amount of tooth exposure in a person with low caries risk. Caries lesions occasionally
structure. develop on cusp tips (see Fig. 3.3B). Typically, these are the result
Caries lesions may be detected by visual changes in tooth surface of developmental enamel defects or following loss of enamel
texture or color or in tactile sensation when an explorer is used (exposure of dentin) due to erosion, abrasion, or parafunction.
judiciously to detect surface roughness by gently stroking across he presence of caries in these self-cleansing areas usually indicates
the tooth surface. Current thinking inds that the use of an explorer that the patient is at high risk of developing additional caries (see
in this manner might have some relevance for assessing caries Risk Assessments and Proiles in the Diagnosis section to come).
activity. However, it cannot be overemphasized that the explorer Carious pits and issures also occur on the occlusal two thirds of
must not be used to determine a “stick” (i.e., a resistance to withdrawal the facial or lingual surface of posterior teeth and on the lingual
from a issure or pit). his improper use of a sharp explorer has surface of maxillary incisors.
been shown to irreversibly damage the tooth by turning a sound, he clinical interpretation of subtle changes in the appear-
remineralizable subsurface lesion into a possible cavitation that is ance of tooth structure is aided by simultaneous consideration of
prone to progression. Forcing an explorer into pits and issures the patient’s overall caries risk, along with the patient’s previous
also theoretically risks cross-contamination from one probing site patterns of susceptibility. he patient’s medical history, dental
to another. In contrast, for assessment of root caries, an explorer history, oral hygiene, diet, and age, among other caries risk factors
is valuable for detecting root surface softness. Additional methods and indicators, may suggest a prediction of current and future
used in caries lesion identiication include radiographs, which show caries activity. In addition, occlusal caries lesions tend to occur
changes in tooth density from normal, and adjunctive tests that bilaterally.
use various technologies to aid in caries lesion detection and caries he ICDAS uses a two-stage process to record the status of
activity (discussed in later sections). the caries lesion. he irst is a code for the severity of the caries
lesion and the second is for the restorative status of the tooth.
Occlual Surface he status of the caries severity is determined visually on a scale
Caries lesions are most prevalent in the faulty pits and issures of of 0 to 6:
the occlusal surfaces where the developmental enamel lobes of
posterior teeth partially or completely failed to coalesce (Fig. 3.3A). 0 = sound tooth structure
It is important to remember the distinction between primary occlusal 1 = irst visual change in enamel
grooves and fossae and occlusal issures and pits. Primary occlusal 2 = distinct visual change in enamel
grooves and fossae are smooth “valley or saucer” landmarks that 3 = enamel breakdown, no dentin visible
result from complete coalescence of developmental enamel lobes 4 = dentinal shadow (not cavitated into dentin)
(see Chapter 1). Normally, such grooves and fossae are not sus- 5 = distinct cavity with visible dentin
ceptible to caries because they are not niches for bioilm and 6 = extensive distinct cavity with visible dentin
100 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

A B

C D

E F
• Fig. 3.3 Caries may be diagnosed clinically by careful inspection. A, Loss of translucency and change
in color of occlusal enamel resulting from a carious issure. B, Caries lesions on cusp tips. C, White chalky
appearance or shadow under marginal ridge (distal #4 and mesial #5). D, Incipient smooth-surface caries
lesion, or a white spot, has intact surface. E, Smooth-surface caries may appear white or dark, depending
on the degree of extrinsic staining. F, Root-surface caries.

his severity code is paired with a restorative/sealant code 0 4 = amalgam restoration

to 8: 5 = stainless steel restoration
6 = ceramic, gold, PFM (porcelain-fused-to-metal) crown or
0 = not sealed or restored veneer
2 = sealant, partial 7 = lost or broken restoration
3 = sealant, full; tooth-colored restoration 8 = temporary restoration
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 101

a b b a

d
A B
c

C D d

• Fig. 3.4 Caries may be diagnosed radiographically as translucencies in the enamel or dentin. A and
B, Proximal caries tends to occur bilaterally (a) and on adjacent surfaces (b). C, Occlusal caries (c). D,
Recurrent caries gingival to an existing restoration (d). This same recurrent caries (d) also is shown in B.
Note that there are additional radiolucencies (consistent with caries lesion development) that are not
identiied with arrows.

See Fig. 3.2 for examples of ADA CCS and ICDAS coding for area along the marginal ridge when the light is directed through
caries lesion severity. he details of the ICDAS system for detection, the tooth. In addition to transillumination, tactile exploration of
and training to use the system with an online tutorial, are available anterior teeth is appropriate to detect cavitation because the proximal
at www.icdas.org. surfaces generally are more visible and accessible than in the posterior
regions.
Proximal Surface Another form of smooth-surface caries may occur on the facial
Early proximal surface caries, one form of smooth-surface caries, and lingual surfaces of the teeth of patients with high caries activity,
is usually diagnosed radiographically (Fig. 3.4A and B). It also particularly in the cervical areas that are less accessible for cleaning.
may be detected by careful visual examination after tooth separation he earliest clinical evidence of early enamel lesions on these surfaces
or through iberoptic transillumination.12 When the caries lesion is a white spot that is visually diferent from the adjacent translucent
has progressed through the proximal surface enamel and has enamel that appears when the surface is dried. Rewetting results
demineralized dentin, a white opaque appearance or a shadow in partial or total disappearance. his appearing–disappearing
under the marginal ridge may become evident (see Fig. 3.3C). phenomenon distinguishes the smooth-surface early enamel lesion
Careful probing with an explorer on the proximal surface may from the enamel white spot that results from nonhereditary enamel
detect cavitation, which is deined as a break in the surface contour hypocalciication (see section on clinical examination for additional
of enamel. he combined use of all examination methods may be defects). Both types of white spots are undetectable tactilely because
helpful in arriving at an accurate inal diagnosis. the surface is intact, smooth, and hard. For white spot lesions,
Brown spots on intact, hard proximal surface enamel adjacent nonsurgical remineralization therapies (discussed in Chapter 2)
to and usually gingival to the contact area are often seen in older should be instituted to promote remineralization.
patients, in whom caries activity is low. hese discolored areas are he presence of several facial (or lingual) smooth-surface caries
a result of extrinsic staining during earlier caries demineralizing lesions within a patient’s dentition suggests a high caries rate,
episodes, each followed by a remineralization episode. hese areas which means that if the existing risk factors are not addressed, the
are no longer carious and are usually more resistant to caries as a patient is at high risk for developing more lesions in the future.
result of luorohydroxyapatite formation. Restorative treatment of In a caries-susceptible patient, the gingival third of the facial surfaces
these areas is not indicated. Inactive proximal caries lesions of maxillary posterior teeth and the gingival third of the facial and
sometimes are diicult to correctly diagnose because of faint lingual surfaces of mandibular posterior teeth should be evaluated
radiographic evidence revealing previous mineral loss. carefully because these surfaces are often at a greater risk for caries.
Proximal surface caries in anterior teeth may be identiied by Advanced smooth-surface caries exhibits discoloration and demin-
radiographic examination, visual inspection (with optional transil- eralization and feels soft as the explorer is translated across the
lumination), or probing with an explorer. Transillumination is suspicious area. he discoloration may range from white to dark
accomplished by placing the mirror or light source on the lingual brown, with rapidly progressing caries usually being light in color.
aspect of teeth and directing the light through teeth. Small early Slowly progressing caries, in a patient with low caries activity,
enamel proximal lesions may be detectable only on the radiograph darkens over time because of extrinsic staining and physical changes
(see Fig. 3.4B). More advanced proximal lesions appear as a dark in the structure of the dentin collagen matrix. Remineralization
102 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

of the decalciied tooth structure will return the tactile hardness

of the lesion and is an evidence that the caries has been arrested.
he dentin in an arrested remineralized lesion has become sclerotic
(see Chapter 1). Such an arrested lesion at times may be rough,
although cleanable, and restoration is not indicated except to address
the esthetic concerns of the patient or to assist with patient control
of bioilm accumulation. hese lesions are inactive but remain
susceptible to new caries activity in the future.

Cervical Area
In patients with attachment loss, extra care must be taken to inspect • Fig. 3.5 Proximal restoration overhang (a) may be diagnosed
for root-surface caries. A combination of root exposure, dietary radiographically.
changes, systemic diseases, and medications that afect the amount
and character of saliva may predispose a patient, especially an older
individual, to root-surface caries. Lesions are often found at the Proximal overhangs are diagnosed visually, tactilely, and radio-
cementoenamel junction (CEJ) or more apically on cementum or graphically (Fig. 3.5). he amalgam–tooth junction is evaluated
exposed dentin in older patients or in patients who have undergone by moving the explorer back and forth across it. If the explorer
periodontal surgery (see Fig. 3.3F). Early in its development, root stops at the junction and then moves outwardly onto the amalgam,
caries appears as a well-deined, discolored area adjacent to the an overhang is present. Overhangs also may be conirmed by the
gingival margin, typically near the CEJ. Root caries is softer than catching or tearing of unwaxed dental loss. Such an overhang
the adjacent tooth structure, and lesions typically spread laterally likely represents an area of bioilm accumulation, provides an
around the CEJ. Although no clinical criteria are universally accepted obstacle to good oral hygiene, and may contribute to chronic
for the diagnosis of root caries, it is generally agreed that softened inlammation of adjacent soft tissue. his type of overhang should
cemental or dentinal tooth structure compared with the surrounding be corrected, and often indicates the need for restoration
surface is characteristic.13 Active root caries is detected by the replacement.
presence of softening and cavitation.14,15 Although root-surface caries Marginal gap formation (or “ditching”) is the deterioration of
may be detected on radiographic examination, a careful, thorough the amalgam–tooth interface as a result of enamel wear and/or
clinical examination is crucial. A diicult diagnostic challenge is the restoration edge fracture (Fig. 3.6A). Improper tooth preparation
patient who has attachment loss with no gingival recession, limiting may predispose an amalgam restoration to ditching. It can be
accessibility for clinical inspection of the proximal root surfaces. diagnosed visually or by the explorer dropping into an opening
Proximal root-surface lesions often progress rapidly and are best as it crosses the margin. Shallow ditching less than 0.5 mm deep
diagnosed using quality bitewing radiographs. Diferentiation of usually is not a reason for restoration replacement because the area
a caries lesion from a radiolucent artifact created by radiographic is self-cleaning and not prone to caries development.16 Such a
cervical burnout is, however, essential.12,13 restoration usually looks worse than it really is. he ongoing self-
sealing property of amalgam allows the restoration to continue
Clinical Examination of Amalgam Restorations serving adequately if it can be satisfactorily cleaned and maintained.
Evaluation of existing restorations should be accomplished systemati- If the ditch is too deep to be cleaned or jeopardizes the integrity
cally in a clean, dry, well-lit ield. Clinical evaluation of amalgam of the remaining restoration or tooth structure, the restoration
restorations requires visual observation, application of tactile sense should be replaced.16 However, marginal gaps near the gingival
with the explorer, use of dental loss, interpretation of radiographs, wall frequently become areas of secondary caries development and
and knowledge of the probabilities that a given condition is sound correction of these areas is indicated.17
or at risk for further breakdown. At least 11 distinct conditions Localized voids, which result from poor condensation of the
might be encountered when amalgam restorations are evaluated: amalgam, may also occur at the margins of amalgam restorations.
(1) amalgam “blues,” (2) proximal overhangs, (3) marginal ditching, If the void is at least 0.3 mm deep and is located in the gingival
(4) voids, (5) fracture lines, (6) lines indicating the interface between third of the tooth crown, the restoration is judged as defective and
abutted amalgam restorations placed at separate times, (7) improper should be repaired or replaced. Accessible small voids in other
anatomic contours, (8) marginal ridge incompatibility, (9) improper marginal areas where the enamel is thicker may be corrected by
proximal contacts, (10) improper occlusal contacts, and (11) enamel recontouring or repairing with a small restoration.
recurrent caries lesions. A careful clinical examination is able to detect the presence of
Discolored areas or “amalgam blues” are often seen through a fracture line across the occlusal portion of an amalgam restoration.
the enamel in teeth that have amalgam restorations. his bluish A line that occurs in the isthmus region generally indicates a
hue results either from the leaching of amalgam corrosion products fractured amalgam, and the defective restoration must be replaced
into the dentinal tubules or from the color of underlying amalgam (Fig. 3.7A). Procedures involved with replacement must ensure
seen through translucent enamel. he latter occurs when the enamel adequate thickness of the amalgam restoration and rounding of
has little or no dentin support, such as in undermined cusps, the internal line angles (e.g., the axiopulpal line angle) so as to
marginal ridges, and regions adjacent to proximal margins. When limit the likelihood of recurrence of a fracture on the occlusal
other aspects of the restoration are sound, amalgam blues do not surface (see Fig. 3.7B). Care must be taken to correctly evaluate
indicate caries, do not warrant classifying the restoration as defective, any such line, however, especially if it is in the midocclusal area
and require no further treatment. Replacement of the restoration because this may be an interface line, a manifestation of two abutted
may be considered, however, for elective improvement of esthetics restorations accomplished at separate appointments (see Fig. 3.7A).
or for areas under heavy functional stress that may require a cusp If other aspects of the abutted restorations are satisfactory, replace-
coverage restoration designed to prevent possible tooth fracture. ment is unnecessary.
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 103

A B

C D
• Fig. 3.6 Restorations may be diagnosed clinically as being defective by observing the following. A,
Deep marginal ditching. B, Improper contour. C, Recurrent caries. D, Esthetically unappealing dark
staining.

A B
• Fig. 3.7 Lines across the occlusal surface of an amalgam restoration. A, Fracture line indicates
replacement. An interface line (arrow) indicates two restorations placed at separate appointments, which,
by itself, is insuficient indication for replacement. B, Radiograph revealing thin amalgam area, which
allowed material lexure and subsequent fracture.
104 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

Amalgam restorations should duplicate the normal anatomic staining that is judged to be noncarious may be corrected by a
contours of teeth. Restorations that impinge on soft tissue, have small repair restoration along the margin. Occasionally, the staining
inadequate embrasure form or proximal contact, or prevent the is supericial and may be removed by resurfacing or removal of
use of dental loss should be classiied as defective, indicating restoration excess extending beyond the preparation margins.
recontouring or replacement (see Fig. 3.6B).
he marginal ridge portion of the amalgam restoration should Clinical Examination of Dental Implants and
be compatible with the adjacent marginal ridge. Both ridges should Implant-Supported Restorations
be at approximately the same level and display correct occlusal Baseline radiographs that reveal the initial levels of implant bone
embrasure form for passage of food to the facial and lingual surfaces support should be obtained when the implant is restored. Percussion
and for proper proximal contact area (see Chapter 1). If the marginal of the restoration should reveal a clinical sound consistent with
ridges are incompatible and are associated with poor tissue health, integration. Probing depths associated with the implant ixture
food impaction, or the inability of the patient to loss, the restoration should be consistent with the thickness of the local gingival tissue.
is defective and should be recontoured or replaced. he gingival tissue should be assessed for signs of inlammation
he proximal surface of an amalgam restoration should recreate (redness, edema, tenderness, bleeding on probing). he marginal
the normal height of contour such that it comes into contact with adaptation between implant restorations and their abutments should
the adjacent tooth at the proper occlusogingival and faciolingual allow for optimal bioilm removal. Any deviation from normal
area with correct adjacent embrasure form (a “closed” contact). should be noted. Many edentulous areas receive implants that are
he use of loss is helpful in assessing the intensity of a closed generally smaller than the roots of the teeth they are replacing.
contact. If the proximal contact of any restoration is suspected to herefore the restorations of the implants require modiied cervical
be inadequate, it should be evaluated visually by trial angulations contours. Implant restorations should be evaluated for proper
of a mouth mirror (held lingually when viewing from the facial cervical (especially proximal) contours that limit food impaction
aspect, etc.) to relect light and see if a space where the contact or bioilm accumulation.
should occur (“open” contact) is present. For this viewing, the Chronic inflammation (periimplantitis), secondary to the
contact must be free of saliva. If the contact is open and is associated presence of residual dental cement or bioilm accumulation, of
with poor interproximal tissue health, food impaction, or both, the tissue immediately adjacent to the implant ixture/restoration
the restoration should be classiied as defective and should be may lead to localized bone loss around an implant and impact its
replaced or repaired. An open contact typically is annoying to the long-term survival. Periimplantitis has a multifactorial etiology.
patient, so correcting the problem usually is an appreciated service. See Chapter 11, and a textbook dedicated to dental implantology,
Recurrent caries adjacent to the marginal area of the restoration for additional information.
is detected visually, tactilely, or radiographically and is an indication
for repair or replacement (see Figs. 3.4D and 3.6C). he same Clinical Examination for Additional Defects
criteria for initial proximal and occlusal caries lesions apply for A thorough clinical examination occasionally identiies localized
the diagnosis of and intervention for recurrent caries lesions around noncavitated, hard white areas on the facial (Fig. 3.8) or lingual
restorations. surfaces or on the cusp tips of teeth. Generally, these are hypocalci-
Improper occlusal contacts on an amalgam restoration may ied areas of enamel resulting from childhood fever, trauma, or
cause deleterious occlusal loading (and predisposition to fracture luorosis that occurred during the developmental stages of tooth
or pain on biting from hyperocclusion), undesirable tooth move- formation. hese areas are diagnosed as nonhereditary developmental
ment, or both. Premature occlusal contacts may be seen as a “shiny” enamel hypoplasia. Another cause of hypocalciication is arrested
spot on the surface of the restoration or detected by occlusal marking and remineralized incipient caries, which leaves an opaque, dis-
paper. Such a condition warrants correction by selective occlusal colored, and hard surface. When smooth and cleanable, such areas
adjustment. do not warrant restorative intervention unless they are esthetically
ofensive to the patient. hese areas remain visible whether the
Clinical Examination of Indirect Metal Restorations tooth is wet or dry, and should not be confused with the opaque
Indirect metal restorations should be evaluated clinically in the white smooth-surface incipient caries lesions that appear when
same manner as amalgam restorations. Any aspect of the restoration
that is not satisfactory, that is causing harm to tissue or occlusal
function, should be noted and considered for recontouring, repair,
or replacement.

Clinical Examination of Composite and Other

Tooth-Colored Restorations
Tooth-colored restorations (direct and indirect) should be evaluated
clinically in the same manner as amalgam and cast-metal restora-
tions. he presence of improper contour or inadequate proximal
contact, overhanging margin, recurrent caries, or occlusal interfer-
ence should be noted and considered for correction. Corrective
procedures include recontouring, polishing, repairing, or replacement
of the restoration.
One of the main concerns with anterior teeth is esthetics. If a
tooth-colored restoration has dark marginal staining or is discolored • Fig. 3.8 Nonhereditary hypocalciied areas on facial surfaces. These
to the extent that it is esthetically unappealing to the patient, the areas may result from numerous factors but do not warrant restorative
restoration should be judged as defective (see Fig. 3.6D). Marginal intervention unless they are esthetically offensive or cavitation is present.
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 105

teeth are air-dried. Care must be exercised in distinguishing is generally referred to as erosive tooth wear. It is necessary to docu-
nonhereditary developmental enamel hypoplasia from an early ment the severity of the tooth structure loss and the speciic areas
enamel caries lesion. that have been afected. If the defects are only on the lingual of
Rare genetic disorders afecting enamel and dentin may be upper teeth, the diagnosis would be diferent from inding defects
discovered during clinical examination. Defective enamel organiza- on the occlusal surfaces of lower molars. Exogenous acidic agents
tion and calciication, which results in teeth that are compromised such as lemon juice (through sucking on lemons) may cause
in appearance and strength, is referred to as amelogenesis imperfecta. crescent-shaped or dished defects (rounded as opposed to angular)
Defective dentin formation and a compromised dentinoenamel on the surfaces of teeth exposed to the agent (see Fig. 3.9A),
junction (DEJ) resulting in early loss of clinically normal enamel whereas endogenous acidic agents, such as gastric luids, cause
is referred to as dentinogenesis imperfecta. Additional information generalized erosion on the lingual, incisal, and occlusal surfaces
on these genetic disorders may be found in textbooks on oral (see Fig. 3.9B). Erosion processes may also be involved in the loss
pathology. of the tooth structure with a clinical presentation of “cupped-out”
he loss of surface tooth structure by chemical action in the areas on occlusal surfaces. hese defective areas are associated with
continued presence of demineralizing agents with low pH (Fig. the binge–purge syndrome in bulimia, or with gastroesophageal
3.9) is deined as erosion. he resulting defective surface is usually relux disease (GERD). Many patients with GERD are often not
smooth. Although erosive agents are the predominant causative aware of their gastric symptoms or do not associate them with the
factors, it is thought that toothbrushing and/or other abrasive problems with their teeth. Consultation with a physician to obtain
agents in the diet may accelerate the loss of tooth structure, which a proper diagnosis of GERD may assist in the diagnosis and

A B

C D

E F
• Fig. 3.9 Erosion. A, Crescent-shaped defects on enamel facial surfaces caused by exogenous demin-
eralizing agent (from sucking on lemons several years previous to the time of the photograph). B, General-
ized erosion caused by endogenous luids. C, Rounded cervical lesions associated with toothbrush
abrasion. D, Idiopathic erosion lesions in cervical areas are hypothesized to be associated with abnormal
occlusal forces. E, Generalized attrition caused by excessive functional or parafunctional mandibular
movements. F, Enamel craze lines.
106 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

management of erosion. Other sources of erosion may be use of surrounding enamel, though there may also be an erosive component
sports drinks, herbal teas, and vomiting associated with chemo- to the process. Sometimes, these areas are an annoyance because
therapy, and, in the case of alcoholism, the presence of stomach of food retention or the presence of peripheral, ragged, sharp
contents in the mouth during periods of excessive alcohol consump- enamel edges. he sharp edges may result in tongue or cheek
tion. It is necessary to document the erosion process as it progresses biting; rounding these edges does not completely resolve the problem
over time through the use accurate study models, photography, but may improve comfort. Slowing such wear by appropriate
and/or digital scanning technology. Risk assessments for erosion restorative treatment may be indicated.
should be included in the assessment of the patient, as indicated. he examination process may reveal areas of horizontal or verti-
he low and bufering capacity of the individual patient’s saliva cal fracture development. Awareness of extreme variations in dental
impact the rate of progression of erosive tooth wear. Understanding, anatomy aids in the identiication of fracture-prone areas. For
identifying, and diagnosing tooth damage secondary to erosion example, deep developmental issures that cross between marginal
(erosive tooth wear) is essential if management of the disease process or cusp ridges may predispose posterior teeth to fracture. Early
is to be successful.18 fractures may be invisible upon initial assessment. Appropriate
Abnormal tooth surface loss resulting from direct frictional dye materials or transillumination may aid in detecting the line of
forces between teeth and external objects or from frictional forces fracture within the tooth structure. Cusp isolation/loading devices
between contacting teeth in the presence of an abrasive medium and techniques must be utilized so as to identify fractures that
is termed abrasion. Habitual chewing on hard objects (e.g., paper involve the dentin and are symptomatic (i.e., fractures that are
clips, pens, pencils) or chronic use of agents with high abrasivity actively propagating). Teeth with active, symptomatic fractures
(e.g., smokeless tobacco, inadequately washed vegetables) may should be considered for full coverage of the occlusal surface.
result in loss of occlusal-surface tooth structure. Fractures that have been present for a period of time become
he loss of tooth structure in the cervical areas (abrasion) is stained and thereby visible during examination; they should be
commonly seen as a rounded notch in the gingival portion of the considered at risk for further propagation into dentin. Any tooth
facial aspects of teeth (see Fig. 3.9C). In contrast to cervical lesions that has extensive caries, or restoration, and remaining cusps with
that develop from abrasion processes, idiopathic erosion lesions little dentin support should be identiied as being susceptible to
(“abfractions”) are cervical, wedge-shaped defects (angular as opposed future fracture and considered for a cusp-protecting restoration (Fig.
to rounded) similar to the defects customarily associated with 3.10). Complete cusp fracture is a common occurrence in posterior
abrasion but in which one of the possible causative factors may teeth. In general, the most frequently fractured cusps are the non-
include excessive lexure of the tooth as a result of heavy, eccentric functional cusps (see Chapter 1). Speciically, the most frequently
occlusal forces (see Fig. 3.9D). he heavy occlusal loading may fractured teeth are mandibular molars and second premolars, with
also lead to the development of a pronounced occlusal wear facet. the lingual (nonfunctional) cusps fracturing more often than the
It is hypothesized that the lexural force produces tension stress facial (functional) cusps. Maxillary premolars also frequently
in the afected wedge-shaped region on the tooth side away from fracture, and similar to mandibular teeth, the facial (nonfunctional)
the tooth-bending direction, resulting in loss of the surface tooth cusps fracture more often than the lingual (functional) cusps. he
structure by microfractures, which is termed abfracture.19 Proponents mesiofacial (nonfunctional) and distolingual (small functional)
of this hypothesis add that microfractures may increase the rate cusps are the most commonly fractured cusps in maxillary molars.21
of tooth structure loss during abrasion from tooth brushing and/ A study of fracture severity found that 95% of the fractures
or from acids in the diet or bioilm. 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). he general consensus among
experts is that the etiology of these lesions is multifactorial and
that well-designed clinical research studies are required to gain
better understanding relative to the etiology of cervical abrasion
and abfraction defects, which are generally referred to as noncarious
cervical lesions (NCCLs).20 he presence of such defects does not
automatically warrant intervention.
he mechanical wear of the incisal or occlusal tooth structure
that results from functional or parafunctional movements of the
mandible is termed attrition. Although a certain degree of attrition
is expected with age, it is important to note abnormally advanced
attrition (see Fig. 3.9E). 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). Heavy occlusal loading from
clenching may result in the presence of “craze lines” that are limited
to enamel (i.e., do not progress through the DEJ into dentin; see
Fig. 3.9F). Craze lines are not sensitive and do not require treatment
but may be evidence of excessive masticatory muscle activity (see
Chapter 1). he etiology of the parafunction may include stress,
airway issues, and/or sleep apnea. In some older patients, the enamel • Fig. 3.10 Extensively restored teeth with weakened and fractured
of the cusp tips (or incisal edges) is worn of, resulting in cupped-out cusps. Note the distal developmental issure in the second molar, which
areas because the exposed, softer dentin wears faster than the further predisposes the distal cusps to fracture.
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 107

exposed dentin, 25% were below the CEJ, and 3% resulted in For diagnosis of proximal surface caries, restoration overhangs,
pulp exposure. he consequences of posterior tooth fracture were or poorly contoured restorations, posterior bitewing and anterior
found to vary, with maxillary premolar and mandibular molar periapical radiographs are most helpful. When interpreting the
fractures being generally more severe. Most fractures were treated radiographic presentation of proximal tooth surfaces, it is necessary
with direct or indirect restorations or recontouring and polish- to know the normal anatomic picture presented in a radiograph
ing; 3% of the fractured teeth were extracted, and 4% received before any abnormalities may be diagnosed. In a radiograph, a
endodontic treatment.22 Risk factors for nontraumatic fracture proximal caries lesion usually appears as a dark area or a radiolucency
of posterior teeth were found to be the presence of a stained in the enamel slightly apical to the contact (see Fig. 3.4A). his
fracture in enamel and an increase in the proportion of the volume radiolucency is typically triangular and has its apex toward the
of the natural tooth crown occupied by a restoration.23,24 he DEJ.
examination process should notate the presence and activity of all Moderate-to-deep occlusal caries lesions may be seen as a
fracture areas. radiolucency extending into dentin (see Fig. 3.4C). Because the
he dental examination also may reveal dental anomalies that speciicity of radiographs for detecting dentinal lesions on occlusal
include variations in size, shape, structure, or number of teeth—such surfaces is relatively good at 80% (very few false positives), when
as dens in dente, macrodontia, microdontia, gemination, concres- a radiolucency is apparent beneath the occlusal enamel surface
cence, dilaceration, amelogenesis imperfecta, and dentinogenesis emanating from the DEJ a diagnosis of caries is appropriate.
imperfecta. An in-depth discussion of these anomalies is beyond However, because the sensitivity of radiographs for dentinal lesions
the scope of this text. he reader should consult an oral pathology on the occlusal surface is rather low (50%), the absence of a
textbook for additional information. radiolucency does not mean that a lesion is not present. In these
situations, the clinician should rely more on the results of the
Radiographic Examination of Teeth and Restorations visual examination and the indings of any adjunctive tests (discussed
Radiographs are an indispensable part of the contemporary dentist’s later).
diagnostic armamentarium. he use of diagnostic ionizing radiation Some defective aspects of restorations, including improper
is, however, not without risks. Cumulative exposure to ionizing contour, overhangs (see Fig. 3.5), and recurrent caries lesions gingival
radiation potentially may result in adverse efects. he diagnostic to restorations (see Fig. 3.4D), may also be identiied radiographi-
yield or potential beneit that might be gained from a radiograph cally. he height and integrity of the marginal periodontium may
must be weighed against the inancial costs and the potential adverse be evaluated using bitewing radiographs. Pulpal abnormalities such
efects of exposure to radiation. Several technologies, particularly as pulp stones and internal resorption may be identiied in various
digital radiography, are now available and are designed to enhance radiographs. Periapical radiographs are helpful in identifying changes
diagnostic yield and reduce radiation exposure. in the periapical periodontium that are consistent with periapical
he ADA, in collaboration with the Food and Drug Administra- abscesses, dental granulomas, or cysts. Impacted third molars,
tion (FDA), developed guidelines for the prescription of dental supernumerary teeth, and other congenital or acquired abnormalities
radiographic examinations to serve as an adjunct to the dentist’s also may be discovered on periapical radiographic examination.
professional judgment with regard to the best use of diagnostic he sensitivity and speciicity of dental radiographs vary, however,
imaging. Radiographs help the dental practitioner evaluate and according to the diagnostic task (e.g., surface of the tooth being
deinitively diagnose many oral diseases and conditions. However, examined, proximal versus occlusal; and depth, enamel versus
the dentist must weigh the beneits of taking dental radiographs dentin).
against the risk of exposing a patient to ionizing radiation, the Radiographs aid in determining the relationship between the
efects of which accumulate from multiple sources over time. he margins of existing or proposed restorations and bone. A biologic
dentist, being aware of the patient’s health history and vulnerability width of at least 2 mm is required for the junctional epithelium
to oral disease, is in the best position to make this judgment. For and the connective tissue attachments located between the base
this reason, guidelines are intended to serve as a resource for the of the sulcus and the alveolar bone crest (Fig. 3.11A). In addition
practitioner and are not intended to be standards of care, require- to this physiologic dimension, the restoration margin should be
ments, or regulations. he ADA/FDA guidelines help direct the placed occlusally as far away as possible from the base of the sulcus.
type and frequency of radiographs needed according to patient Restoration margins that encroach on the biologic width, by being
condition and risk factors (Table 3.2). placed deep in the sulcus, are inaccessible for bioilm removal and
Generally, patients at higher risk for caries or periodontal disease result in chronic inlammation. he inlammatory state may be
should receive more frequent and more extensive radiographic clinically detected as clinical redness, swelling, and bleeding on
surveys. A systematic review of methods of diagnosing dental caries probing or lossing in the area. Localized loss of osseous support
lesions found that although radiographs were useful in detecting will occur and the biologic width will reorganize further apically.
lesions, they do have limitations.25 For the examination of occlusal he osseous loss and reorganization will result in deeper periodontal
surfaces, radiographs had moderate sensitivity and good speciicity probing depths, which in turn will further limit efective bioilm
for diagnosing dentinal lesions; however, for enamel lesions, the removal. For these reasons, the inal position of a proposed gingival
sensitivity was poor and the speciicity was reduced (see the section margin, which is dictated by the existing restoration, caries, or
on Diagnosis for description of these terms). Studies of the retention features, must be estimated before restoration to determine
radiographic examination of proximal surfaces found that there if crown-lengthening procedures are indicated (see Fig. 3.11B).
was moderate sensitivity and good speciicity for the detection of Surgical crown lengthening procedures involve the surgical removal
cavitated lesions and low to moderate sensitivity and moderate to of the gingiva, bone, or both to create a longer clinical crown and
high speciicity for enamel or dentinal lesions. Before rendering a provide more tooth structure for placing the restoration margin
diagnosis and deciding on treatment, information obtained from and for increasing retention form. Another possible treatment
radiographs should be conirmed or augmented through clinical option may be to orthodontically extrude the tooth so that the
examination indings if at all possible. restoration margins do not violate the biologic width. Restorative
108 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

procedures must be accomplished such that the periodontal health than it appears radiographically, it is estimated that over half of
may be maintained. radiographically detected proximal lesions (in the outer half of
Dental radiographs should always be interpreted cautiously. dentin) are likely to be noncavitated and treatable with remineraliza-
he dental radiograph is a two-dimensional image of a three- tion measures.26 Radiographic indings must always be clinically
dimensional mass; thus a facial or lingual lesion (or radiolucent veriied (if possible) prior to the inalization of a diagnosis and
tooth-colored restoration) may be radiographically superimposed treatment plan.
over the proximal area, mimicking a proximal caries lesion (false
positive). he general inding that approximately 25% mineral Adjunctive Aid for Examining Teeth
loss has to occur before a radiolucency begins to appear on a and Retoration
radiograph means that a caries lesion may be present and not
detected (false negative). Misdiagnosis may occur when cervical Magniication in Operative Dentistry
burnout (the radiographic picture of the normal structure and Clinical dentistry often requires the viewing and evaluation of
contour of the cervical third of the crown) mimics a caries lesion. small details in teeth, intraoral and perioral tissues, restorations,
Finally, although a caries lesion may be more extensive clinically and study casts. Unaided vision is often inadequate to view details

TABLE 3.2 Guidelines for Prescribing Dental Radiographs

The recommendations in this chart are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after
reviewing the patient’s health history and completing a clinical examination. Because every precaution should be taken to minimize radiation exposure,
protective thyroid collars and aprons should be used, whenever possible. This practice is strongly recommended for children, women of childbearing age,
and pregnant women.

Type of Encounter Patient Age and Dental Developmental Stage

Child With Primary Dentition Child With Transitional Adolescent With Adult, Dentate Adult,
(Prior to Eruption of First Dentition (After Permanent Dentition or Partially Edentulous
Permanent Tooth) Eruption of First (Prior to Eruption of Edentulous
Permanent Tooth) Third Molars)
New patient* being Individualized radiographic Individualized Individualized radiographic exam consisting Individualized
evaluated for dental exam consisting of selected radiographic exam of posterior bitewings with panoramic radiographic
diseases and dental periapical/occlusal views consisting of exam or posterior bitewings and selected exam, based
development and/or posterior bitewings if posterior bitewings periapical images. on clinical
proximal surfaces cannot be with panoramic A full mouth intraoral radiographic exam is signs and
visualized or probed. exam or posterior preferred when the patient has clinical symptoms.
Patients without evidence of bitewings and evidence of generalized dental disease
disease and with open selected periapical or a history of extensive dental
proximal contacts may not images. treatment.
require a radiographic exam
at this time.
Recall patient* with clinical Posterior bitewing exam at 6- to 12-month intervals if proximal surfaces cannot be Posterior bitewing Not applicable
caries or at increased risk examined visually or with a probe. exam at 6- to
for caries** 18-month
intervals.
Recall patient* with no Posterior bitewing exam at 12- to 24-month intervals if Posterior bitewing Posterior bitewing Not applicable
clinical caries and not at proximal surfaces cannot be examined visually or with exam at 18- to exam at 24- to
increased risk for caries** a probe. 36-month intervals. 36-month
intervals.
Recall patient* with Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal Not applicable
periodontal disease disease. Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of
areas where periodontal disease (other than nonspeciic gingivitis) can be identiied clinically.
Patient for monitoring of Clinical judgment as to need for and type of radiographic Clinical judgment as to Usually not indicated
growth and development images for evaluation and/or monitoring of dentofacial need for and type of
growth and development. radiographic images
for evaluation and/
or monitoring of
dentofacial growth
and development.
Panoramic or
periapical exam to
assess developing
third molars.
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 109

TABLE 3.2 Guidelines for Prescribing Dental Radiographs—cont’d

Patient with other Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these circumstances.
circumstances including,
but not limited to,
proposed or existing
implants, pathology,
restorative/endodontic
needs, treated periodontal
disease, and caries
remineralization

*Clinical situations for which radiographs may be indicated include but are not limited to: 18. Unexplained sensitivity of teeth
A. Positive Historical Findings 19. Unusual eruption, spacing, or migration of teeth
1. Previous periodontal or endodontic treatment 20. Unusual tooth morphology, calciication, or color
2. History of pain or trauma 21. Unexplained absence of teeth
3. Familial history of dental anomalies 22. Clinical erosion
4. Postoperative evaluation of healing **Factors increasing risk for caries may include but are not limited to:
5. Remineralization monitoring 1. High level of caries experience or demineralization
6. Presence of implants or evaluation for implant placement 2. History of recurrent caries
B. Positive Clinical Symptoms/Signs 3. High titers of cariogenic bacteria
1. Clinical evidence of periodontal disease 4. Existing restoration(s) of poor quality
2. Large or deep restorations 5. Poor oral hygiene
3. Deep caries lesions 6. Inadequate luoride exposure
4. Malposed or clinically impacted teeth 7. Prolonged nursing (bottle or breast)
5. Swelling 8. Frequent high sucrose content in diet
6. Evidence of dental/facial trauma 9. Poor family dental health
7. Mobility of teeth 10. Developmental or acquired enamel defects
8. Sinus tract (“istula”) 11. Developmental or acquired disability
9. Clinically suspected sinus pathology 12. Xerostomia
10. Growth abnormalities 13. Genetic abnormality of teeth
11. Oral involvement in known or suspected systemic disease 14. Many multisurface restorations
12. Positive neurologic indings in the head and neck 15. Chemotherapy/radiation therapy
13. Evidence of foreign objects 16. Eating disorders
14. Pain and/or dysfunction of the temporomandibular joint and/or muscles of mastication 17. Drug/alcohol abuse
15. Facial asymmetry 18. Irregular dental care
16. Abutment teeth for ixed or removable partial prosthesis From American Dental Association, US Food and Drug Administration: The selection of patients
17. Unexplained bleeding for dental radiograph examinations. Available on www.ada.org. Document created November 2004.

needed to make treatment decisions. Magniication aids such as Many choices of magniication loupes are currently available
loupes provide a larger image size for improved visual acuity, while for dentistry. he simplest magniiers are the diopter single-lens
allowing proper upright posture to be maintained with less eye loupes, which are single-piece plastic pairs of lenses that clip onto
fatigue. eyeglass frames. hese loupes are inexpensive and lightweight and
When choosing loupes, several parameters should be may provide magniication of up to 2.5×. However, images may
considered.27-29 Magniication (power) describes the increase in be distorted, and working lengths less than ideal. he more com-
image size. Most dentists use magniications of 2× to 4×. he lower monly used dental loupe is binocular with lenses mounted on an
power systems of 2× to 2.5× allow multiple quadrants to be viewed, eyeglass frame. Binocular loupes typically have Galilean and
whereas the higher power systems of 3× to 4× enable viewing of prismatic optics that provide 2×, 3.5×, 4×, and greater magniication.
several teeth or a single tooth. In general, higher magniication Prescription lenses may be placed in the eyeglass frames for all
systems are heavier, have a narrower ield of view, are more expensive, loupe types. Most models also have side shields or a wraparound
and require more light than lower power systems. he use of small, design for eye protection and infection control. Two mounting
lightweight light-emitting diode (LED) headlamps attached to the systems are currently available for binocular loupes: (1) lip-up
eyeglass frame or headband ofer the considerable visual advantage and (2) ixed or through-the-lens types.
of added illumination when used with loupes. Dental microscopes, though limited primarily to endodontic
Working distance (focal length) is the distance from the eye to practices in the past, are now being used in some restorative dentistry
the object when the object is in focus. his parameter should be practices. Compared with high powered loupes, dental microscopes
considered carefully before selecting loupes because the desired allow the clinician to view intraoral structures at a higher level of
working distance depends on the dentist’s height, arm length, and magniication while maintaining a broader ield of view. Because
seating preferences. Dentists of average height typically choose a very small areas may be seen, microscopes are used in detail-oriented
working distance of 13 to 14 inches (33–35 cm), whereas tall procedures such as the inishing of porcelain restoration margins,
dentists and those who prefer to work farther away from the patient identifying minute caries lesions, and minimizing the removal of
use working distances of 14 to 16 inches (35–40 cm). sound tooth structure. Generally, microscopes include ive or six
Depth of focus, or the diference between the far and near focus levels of magniication that typically range from 2.5× to 20×.
limits of the working distance, depends on the magniication. Manufacturers of dental microscopes include Carl Zeiss, Inc.
Typically, the lower the magniication, the greater is the depth of (Dublin, CA); Global Surgical Corporation (St. Louis, MO); and
focus. Seiler Precision Microscope Instrument Company (St. Louis, MO).
110 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

evaluation of the plane of occlusion; tilted, rotated, or extruded

teeth; crossbites; plunger cusps; wear facets and defective restorations;
coronal contours; proximal contacts; and embrasure spaces between
teeth. he ability to obtain virtual study models via digital impres-
b
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
c patients with a hyperactive gag relex). Combined with clinical
and radiographic indings, study casts allow the practitioner to
d carefully relect on indings and develop a treatment plan without
a
e
the patient present, thus saving valuable chair time. When a
proposed treatment plan is discussed with the patient, study models
are a valuable educational medium in helping the patient understand
f and visualize existing conditions and the need for the proposed
A treatment.
Caries Detection Technologies
In 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. hese devices
may have the potential to replace the tactile portion of caries
detection, where explorers are used to try to estimate the depth
of the caries lesions into the pits and issures. However, these
devices have two limitations. he irst is that they are only indicated
for use on unrestored pits and issures. he second is that their
B
diagnostic accuracy has not been irmly established. he technologies
• Fig. 3.11 A, Biologic width (a) is the physiologic dimension needed for currently approved by the FDA include laser-induced luorescence,
the junctional epithelium (d) and the connective tissue attachment (e), light-induced luorescence, and alternating current (AC) impedance
which is measured from the base of the sulcus (c) to the level of the bone spectroscopy (ACIST).10,30
crest (f). The margin of the restoration (b) must not violate this dimension. he DIAGNOdent device (KaVo Dental Corporation, Charlotte,
B, Tooth with an existing restoration (g) that encroaches on the biologic NC) uses laser luorescence technology, with the intention of
width requires crown-lengthening procedures before placement of a new detecting and measuring bacterial products and changes in tooth
restoration. structure in a caries lesion. his compact and portable device,
which requires a clean, dry occlusal surface, yields a numerical
score from 0 to 99. he manufacturer has recommended threshold
Cost, size of the equipment, and perceived lack of value to the scores that represent the presence and extent of a lesion. A systematic
clinician are factors that have limited the use of microscopes in review found that the “device is clearly more sensitive than tradi-
operative dentistry practice. tional diagnostic methods, but the increased likelihood of false-
positive diagnoses limits its usefulness as a principal diagnostic
Photography in Operative Dentistry method.”31
Photography in dentistry has many uses and, with newer digital Another system currently available for caries lesion detection
technologies, is becoming mainstream in dental practice. Photog- is the CamX Spectra Caries Detection Aid (Air Techniques, Melville,
raphy is an excellent tool for documentation and evaluation. NY). his system claims to detect caries lesions by measuring
Intraoral cameras and single-lens relex (SLR) digital cameras provide increased light-induced luorescence. Special LEDs project high-
opportunities to document existing esthetic conditions such as energy violet or blue light onto the tooth surface. Light of this
color, shape, and position of teeth. Close-up images of existing wavelength supposedly stimulates porphyrins—metabolites unique
pits and issures provide the opportunity to image current conditions to cariogenic bacteria—to appear distinctly red, while healthy
for the purpose of future reevaluation and detection of changes enamel luoresces to appear green. Using this luorescent technology,
that may be developing. Photographs of preparations of deep caries the data captured by the Spectra system are analyzed by imaging
lesions provide documentation to aid in future diagnosis of tooth software, which highlights the lesions in diferent color ranges and
conditions. Digital documentation with photographs, and ability deines the potential caries activity on a scale of 0 to 5.
to process and store images in an electronic patient record, is easy he CarieScan PRO (CarieScan, LLC, Charlotte, NC) is a
and cost efective. device for the detection and monitoring of caries by the application
and analysis of ACIST (AC Impedance Spectroscopy Technology).
Diagnostic Study Models he CarieScan PRO claims to enable clinicians to evaluate demin-
Study models are helpful in evaluating a patient’s clinical status eralized tooth structure using ACIST by providing information
in many situations. Study models are able to provide an understand- about tissue being healthy, in the early stages of demineralization,
ing of occlusal relationships, help in developing the treatment or already signiicantly decayed. he device provides a color scale
plan, and serve as a tool for educating the patient. Accurately and a numerical scale to determine the severity of the caries lesion
mounted study models provide an opportunity for a thorough and is accompanied by management recommendations that range
evaluation of the tooth interdigitation, the functional occlusion, from therapeutic prevention to operative intervention appropriate
and any occlusal abnormalities. Study models allow further for the extent of the demineralization.
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 111

Although these technologies appear promising, the standard of the “gold standard.” Findings in this cell are termed false negatives.
care remains visual inspection of well-illuminated, clean and dry he inal cell, cell D, includes true negatives, where the diagnostic
teeth, with use of radiographs as indicated.32 An ideal diagnostic test accurately identiies nondiseased cases that are truly negative
test accurately detects when a tooth surface is healthy (speciicity); as conirmed by the “gold standard.” A perfect diagnostic test
when a lesion or demineralization is present (sensitivity); and if would result in all cases being assigned to cells A or D with no
demineralization is present, whether or not it is active and whether false positives (cell B) or false negatives (cell C).
or not it has cavitated the surface (see section on Diagnosis). Except When the basics of this table are understood, the information
for the presence of frank cavitation in more advanced lesions, none it yields may be put to good use by the diagnostician. he irst
of the available approaches to detecting caries or determining lesion concept is test sensitivity, which is calculated as the number of
activity is completely accurate. hus the clinician must take all of true positives (A) divided by the number of total positive cases (A
the available diagnostic information together—visual, tactile, + C, i.e., the number of times where disease was actually present
radiographic, and so on—along with the respective reported levels regardless of the diagnostic test results). Sensitivity indicates the
of accuracy and combine that with an assessment of the patient’s proportion of individuals with disease in any group or population
overall caries status to make a inal diagnosis of the presence and that is identiied positively by the test. In contrast, speciicity refers
extent of a caries lesion. to the proportion of individuals without disease properly classiied
by the diagnostic test and is the ratio of true negatives (D) to all
Diagnoi negatives (B + D). Sensitivity and speciicity will not vary on the
basis of the prevalence of disease, that is, the proportion of cases
Dental Dieae; Interpretation and Ue of in a population. Rather, these statistics indicate what proportions
of existing disease and absence of disease will be correctly identiied
Diagnotic Finding in any group of individuals.
As discussed in Chapter 2, dental caries is a multifactorial, transmis- A test with low sensitivity indicates that a high probability
sible, infectious oral disease caused primarily by the complex exists that many of the individuals with negative results have the
interaction of cariogenic oral lora (bioilm) with fermentable dietary disease and go undiagnosed. Conversely, a test with high sensitivity
carbohydrates on the tooth surface over time. Caries lesions are the means that most of those who actually have disease will be identiied
result of the caries disease process, not the cause. as such. Tests with high speciicity suggest that patients without
he diagnostic efort of health care professionals has been the disease are highly likely to test negative. Tests with low speciicity
enhanced by the use of principles adopted from clinical epidemiol- will misclassify a sizable proportion as diseased when many are
ogy. his analytic approach relies on “2 × 2” contingency tables actually free of disease.
(Fig. 3.12) derived from clinical trials data. Such studies compare Very few tests have both high sensitivity and high speciicity, so
the results of a diagnostic test with the results obtained from a trade-ofs are inevitable. he clinician must weigh the seriousness
“gold standard” (knowledge of the actual condition) to determine of the disease that is left untreated (in cases of low sensitivity)
how well a test identiies the “true,” or actual, condition. he against the invasiveness of the treatment (in cases of low speciic-
results of the diagnostic test, positive or negative, are shown across ity). In the former, low sensitivity may be acceptable for tests
the rows of the table, and the results of a “gold standard” or the diagnosing slowly progressing, nonfatal conditions but unacceptable
“truth” are displayed in the columns. Cell A of the table contains for conditions that progress rapidly or are life threatening. In the
the cases that the test identiies as being positive (or diseased) that latter, low speciicity may not be acceptable if the treatment is
actually are positive (i.e., conirmed by the “gold standard”). hese invasive and irreversible, but more acceptable if the treatment is
cases are termed true positives. Cell B contains all cases for which noninvasive and temporary. In the case of dental caries, all things
a positive inding from the diagnostic test is present, but where being equal, this means that the clinician may accept a less sensitive
the actual condition is negative. herefore this cell denotes false test (i.e., miss some initial lesions [cell C]) because caries usually
positives. Cell C includes the cases identiied by the diagnostic test progresses slowly over years. But given that operative treatment
as not being diseased, but actually are diseased, as determined by is invasive and irreversible, a highly speciic test (i.e., few false
positives [cell B]) means that fewer healthy teeth will be incorrectly
treated.
Gold Standard he dentist should be mindful of the fact that except in cases
  of relatively large caries lesions, the accuracy of the methods used to
detect lesions (visual inspection, radiographs, caries detection devices,
etc.) are all prone to inaccuracies (Box 3.1). hese inaccuracies result
 A B in false-positive and false-negative indings. his situation raises
the question, “What are the implications of these inaccuracies for
Diagnostic
Test
clinical decision making?” False-positive indings may result in the
Results surgical treatment of a sound tooth, and false-negative indings
will result in a diseased surface receiving remineralization treatment
 C D instead of operative treatment. he former situation is irreversible
and should be avoided, whenever possible. In the latter situation,
false negatives will receive remineralization therapy, regular monitor-
Cell A  true positives ing, and, if a lesion develops, may be treated operatively at a later
Cell B  false positives time, if needed. his reasonable approach takes into consideration
Cell C  false negatives that caries lesions generally do not progress rapidly.33-35 hus the
Cell D  true negatives clinician should strive to reduce the number of false positives by
• Fig. 3.12 Contingency table for interpretation of diagnostic tests. making sure that strong diagnostic evidence supports the presence
112 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

• BOX 3.1 Assessing the Accuracy of a Diagnostic and high risk to associate a level of risk with a category. his is
Test for Caries sometimes expressed by using color-coded categories: red for high
risk, yellow for medium risk, and green for low risk. Categories
Contingency Table for Diagnostic Test Evaluation simplify the concept for the patient, as they are easily understood
Histologic Gold Standard while discussing assessments and their implications for treatment
Caries recommendations.
No caries Patients who possess risk factors and risk indicators should be
Diagnostic Test considered to be at risk for dental caries even if the examination
Caries
does not reveal any caries lesions.33 A patient at high risk for dental
True positive (TP)
False positive (FP)
caries should receive aggressive intervention to remove or alter as
No caries many risk factors as possible. Alternatively, regular monitoring
False negative (FN) and reassessment might be appropriate for a patient at low risk
True negative (TN) for dental caries. Risk assessment is a relatively young science in
Desirable and Undesirable Outcomes Resulting from Diagnostic Tests the dental profession, but as more research is completed, evidence
with Low Sensitivity or Speciicity is quickly validating this approach to patient care. Approaches to
Example 1 patient care using risk assessments and disease management such
Diagnosing 100 teeth (90 healthy and 10 carious) with a diagnostic test as CAMBRA are becoming the recognized standard of care. he
having a high sensitivity (0.80) and low speciicity (0.50) would result CAMBRA guidelines were developed over several years as an
in the following:
evidence-based approach to preventing, reversing, and, when
Desirable outcomes:
Correctly detect 8 of 10 carious teeth (TP)
necessary, repairing early damage to teeth caused by caries. Refer
Correctly diagnose 45 of 90 healthy teeth (TN) to Chapter 2 for more information on how CAMBRA is used to
Undesirable outcomes: determine caries risk and how this determination helps the clinician
Fail to detect 2 of 10 carious teeth (FN) in the decision-making process for surgical or nonsurgical therapeutic
Fail to diagnose 45 healthy teeth as carious (FP) interventions.
Example 2 In relation to operative dentistry, risk assessments are made for
Diagnosing 100 teeth (90 healthy and 10 carious) with a diagnostic test caries, erosive tooth wear, and structural problems of teeth such
having low sensitivity (0.50) and high speciicity (0.80) would result in as fractures. However, risk assessments should be established for
the following: other areas of the stomatognathic system such as periodontal disease,
Desirable outcomes:
functional occlusal and TMJ issues, and for the “risk” involved in
Correctly detect 5 of 10 carious teeth (TP)
Correctly diagnose 72 of 90 healthy teeth (TN)
satisfying the patient’s esthetic expectations. All treatment for
Undesirable outcomes: patients should be designed to lower their risk for problems in
Fail to detect 5 of 10 carious teeth (FN) each of these areas. Dental treatment in any one of the abovemen-
Fail to diagnose 18 healthy teeth as carious (FP) tioned areas may improve risk status in that area but at a cost of
increased risk in another area. For example, preparation of teeth
for full-coverage crowns might reduce occlusal or esthetic risk but
at a cost of increasing risk for future caries or pulpal pathology.
of cavitation or dentin penetration before recommending irreversible Taken together, risk assessments provide a risk proile that helps
operative treatment. guide preventive and operative recommendations that are made
hese concepts are widely used in medical practice. Although to the patient with the goal of mitigating as many risk factors as
many of the necessary research studies have not been conducted possible.
to develop probabilities for dental conditions, interest in the use
of clinical epidemiology in the dental profession has been growing. Prognoi
In the future, more research studies will be conducted so as to
provide this information to clinicians, and one should be prepared Prognosis is the term used to describe the prediction of the probable
to take advantage of their use. course and outcome of a disease or condition as well as the outcome
expected from an intervention, be it preventive or operative.
Prognosis may also be used to estimate the likelihood of recovery
Rik Aement and Proiles from a disease or condition. In operative dentistry, prognosis may
he patient assessment and examination process allows opportunity be used to describe the likelihood of success of a particular treatment
to identify factors and indicators that increase likelihood (risk) of procedure in terms of time of service, functional value, comfort,
future problems, given the patient’s current behaviors, clinical and esthetic value for the patient. A prognosis may be described
conditions, and so on (see Chapter 2).36,37 Risk assessments help as excellent, good, fair, poor, or even hopeless. Prognosis for a disease
organize the data relative to multiple causative factors. Few diseases or condition is largely dependent on the risk factors and indicators
or dental conditions are caused by a single factor. Rather, most that are present in the patient. However, other variables, such as
diseases and dental conditions have been shown to be associated the skill of the dentist and the current status of the disease before
with numerous behavioral or sociodemographic, physical or beginning treatment, also have an efect on the prognosis. For
environmental, microbiologic, or host factors. In addition, every example, a patient with severe caries may be willing to eliminate
patient has a diferent set of risk factors. his presents a challenge all of the modiiable risk factors, but if the disease is too advanced,
to determining the likelihood that a disease or condition would the long-term prognosis for the afected teeth may still be poor.
occur in the future or that some form of dental treatment or It is important for the clinician to take into account the entire
therapeutics would decrease the chances of disease occurrence. risk proile of the patient in all areas of the person’s medical and
Many risk assessments use terms such as low risk, medium risk, dental health when trying to establish a prognosis. Once the dentist
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 113

and the patient have a good understanding of the current multiphase and dynamic series of activities. Success of the treatment
condition(s), the patient’s risk proile, and all associated prognoses, plan is determined by its ability to meet the patient’s initial and
they will be able to work together as a team to identify treatment long-term needs. A treatment plan should allow for reevaluation
options and establish a treatment plan. 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
Treatment Planning recommend invasive operative treatment only when the beneits
General Conideration outweigh the risks of adverse outcomes. Restorations that require
permanent removal of tooth structure have a limited lifespan.
Patient assessment, examination, and diagnosis result in a listing Studies have shown that the average lifespan of a restoration ranges
of dental problems, an inventory of existing risk factors (or indica- from 5 to more than 15 years.38 When the restoration is subsequently
tors), and an accurate prognosis for each tooth and for the patient’s replaced additional tooth structure is removed, regardless of how
overall oral health. he dentist then begins to consider various carefully the operator removes the existing restoration. his situation
options in light of the paramount principle in dentistry: to do no results in what has been termed the cycle of re-restoration, which
harm. Clinicians must have a sound knowledge of the current leads to larger and more invasive restorations over the course of a
evidence relative to the risks and beneits of their treatment recom- patient’s life.39
mendations. One option that must always be included is recommend As a general rule, remineralization therapies, as well as sealants
that there not be any intervention. Another consideration, based in the case of pits and issures, are the preferred methods of managing
on the patient–dentist interaction, particular needs/desires of the coronal lesions that are neither cavitated nor involve dentin.
patient, and/or the skill/comfort level of the dentist, is to recommend Remineralization is also recommended for root-surface lesions in
referral to another practitioner. With regard to operative dentistry which a break in the surface contour of the exposed root surface
procedures, the decision to recommend surgical or nonsurgical has not occurred. However, it is very important to note that
intervention depends on the determination that a tooth is diseased, remineralization requires a high level of patient compliance with the
a restoration is defective, or the tooth or restoration is at some therapeutic regimen and frequent recall visits to assess the success of
increased risk of further deterioration if the intervention does not the treatment. If lesion progression is detected at recall, then operative
occur. If any of these conditions exists, intervention is recommended intervention is warranted.
to the patient. here may be multiple possible means by which here are exceptions to the general rule of managing non-
to resolve the diagnosed disease or defect. Identiication of treatment cavitated enamel lesions with remineralization. Remineraliza-
alternatives involves establishing a list of one or more reasonable tion requires a shift in the delicate balance of the oral bioilm
interventions from the set of possible alternatives. Treatment and therefore depends heavily on changes in patient behavior
alternatives for a speciic condition may include, for example, (e.g., improved home care, diet) and the timely application of
periodic reevaluation to monitor the condition, chemotherapeutics antimicrobial agents, luoride, and other remineralizing agents.
(e.g., applications of luoride to promote remineralization or hus, when it is clear that the patient is unwilling or unable to
antimicrobials to reduce bacteria), recontouring defective restorations follow the prescribed remineralization regimen of home care and
or irregular tooth surfaces, repair of an existing restoration, and professional care, it is often appropriate to remove the lesion(s)
restoration of caries lesions or other defects. he list of reasonable surgically and restore the defect or to seek to arrest the lesion (see
treatment alternatives is based on current evidence of the efective- Chapter 2).
ness of treatments, prevailing standards of care, and clinical and If conirmed cavitation of the enamel or demineralization
nonclinical patient factors. If the decision is made to recommend penetrating into the dentin on coronal surfaces is present or a
intervention then identiication and selection among treatment break exists in the contour of exposed root and softening of the
alternatives, with the patient’s involvement, enables creation of surface, then operative treatment is usually recommended. One
the treatment plan. exception to this general guideline is the lesion that is deemed
he treatment plan is a carefully sequenced series of services arrested.
designed to eliminate or control etiologic factors, repair existing
damage, and create a functional, maintainable environment. An Treatment Plan Sequencing/Phaing
appropriate treatment plan depends on thorough evaluation of
the patient, the expertise of the dentist, and a prediction of the Proper sequencing is a crucial component of a successful treatment
patient’s response to treatment. he treatment plan will also include plan. Certain treatments must follow others in a logical order,
strategies designed to reduce the patient’s risk for future caries whereas other treatments may or must occur concurrently and
or other oral disease. Selection of speciic components of the require coordination. Complex treatment plans often are sequenced
treatment plan is accomplished in consultation with the patient. in phases, including an urgent phase, a control phase, a reevaluation
he patient is advised of the reasonable treatment alternatives phase, a deinitive phase, and a maintenance phase (that includes
and related risks and beneits. After the patient is fully informed, reassessment and recare). For most patients, the irst three phases
the dentist and patient select a course of action that is most are accomplished simultaneously. Generally, the principle of “greatest
appropriate. need” guides the order in which treatment is sequenced. his
Treatment plans are inluenced by many factors, including principle suggests that what the patient needs most is performed
patient preferences, motivation, systemic health, emotional status, irst—with pain, bleeding, and swelling at the beginning of the
and inancial resources. he treatment plan is also inluenced by treatment plan and elective esthetic procedures at the end. he
the dentist’s knowledge, experience, and training; laboratory support; process of treatment planning requires that the dentist develop an
dentist–patient compatibility; availability of specialists; and the ever-increasing, comprehensive knowledge of dental disease manage-
patient’s functional, esthetic, and technical demands. Finally, a ment in the context of individualized patient care. Study of textbooks
treatment plan is not a static list of services. Rather, it is often a devoted to this discipline is indicated.40
114 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

Urgent Phase appointments for bioilm removal (dental prophylaxis). he fre-

he urgent phase of care begins with a thorough review of the quency of reevaluation examinations depends, in large part, on
patient’s medical history and current condition. A patient presenting the patient’s risk for dental disease. A patient with a low risk proile
with swelling, pain, bleeding, or infection should have these may have longer intervals (e.g., 9–12 months) between recall visits.
problems managed as soon as possible, before initiation of subse- In contrast, patients at high risk proile should be recalled and
quent phases. examined much more frequently (e.g., 3–4 months).
Control Phase
Interdiciplinary Conideration in Operative
A control phase is appropriate when the patient presents with
multiple pressing problems and extensive active disease or when Treatment Planning
the prognosis is unclear. he goals of this phase are to remove When an operative procedure is performed during the control or
etiologic factors, eliminate the ecologic niches of pathogens, and deinitive phases, general guidelines help determine when the
stabilize the patient’s dental health. hese goals are accomplished operative treatment should occur relative to other forms of care.
by (1) removal of active disease such that inlammation may resolve, Following is a discussion on sequencing operative care with
(2) correction of conditions that prevent or limit hygiene eforts, endodontic, periodontal, orthodontic, surgical, and prosthodontic
(3) elimination of potential causes of disease, and (4) initiation of treatments.
preventive activities. Examples of control phase treatment include
extractions, endodontics, periodontal debridement and scaling, Endodontics
occlusal adjustment, caries arrest and/or removal, replacement or All teeth to be restored with large restorations should have a pulpal
repair of defective restorations such as those with gingival overhangs, and periapical evaluation. If indicated, teeth should have endodontic
and use of caries control measures, as discussed in Chapter 2. treatment before restoration is completed. Also, a tooth previously
he dentist should develop a plan for the management and endodontically treated, that shows no evidence of healing or has
prevention of dental caries as part of the control phase. After the an inadequate illing or a illing exposed to oral luids, should be
patient’s caries status and caries risk have been determined, chemical, evaluated for retreatment before restorative therapy is initiated.41
surgical, behavioral, mechanical, and dietary techniques may be
used to improve host resistance and alter the oral lora.40 Chapter Periodontics
2 presents a detailed discussion of caries diagnosis, prevention, Generally, periodontal treatment should precede operative care,
treatment, and control. especially when improved oral hygiene and initial scaling/root
planing procedures create (through reduction of gingival inlam-
Reevaluation Phase mation) a more desirable environment for performing operative
he reevaluation phase allows time between the control and deini- treatment. A tooth with a questionable periodontal prognosis should
tive phases for resolution of inlammation and healing. Initial not receive an extensive restoration until periodontal treatment
treatment and pulpal responses are reevaluated during this phase provides a more favorable prognosis. If a tooth has a good peri-
as the relative efectiveness of control phase treatment may inluence odontal prognosis, then operative treatment may occur before or
and modify the deinitive phase treatment plan. his phase is used after periodontal therapy, as long as the operative treatment is not
to reinforce home care habits and assess motivation for further compromised by the existing tissue condition. Treatment of deep
treatment. caries lesions often requires caries control (see Chapter 2). Caries
Patients with an overall low risk proile, who only require minor control may utilize temporization, creation of a foundation, or
alterations in diet, behaviors, and exposure to remineralization root canal therapy/foundation before periodontal therapy. he
agents, may not require a formal control phase/reevaluation phase correction of gross restorative defects in restoration contours (e.g.,
process. he treatment plan for these patients may start with a open contact resulting from restoration undercontour, gingival
plan to deinitively address immediate concerns while simultaneously overhang, poor embrasure form, occlusal interference resulting in
implementing minor changes and reinforcing habits consistent increased mobility) is considered a part of initial periodontal therapy,
with dental health. and such corrections enable a more favorable tissue response. If
periodontal surgical procedures are required, indirect restorations
Deinitive Phase such as inlays or onlays, crowns, and prostheses should be delayed
he patient enters the deinitive phase of treatment only after the until the surgical phase is completed. Teeth planned for cast restora-
dentist reassesses initial eforts to control disease and, with the tions may, however, be prepared and temporized before periodontal
patient, determines the need for further care. his phase may include surgery. his approach permits conirmation of the restored tooth
endodontic, periodontal, orthodontic, and surgical procedures. he prognosis before surgery and allows improved access for the surgical
patient’s active disease must be under control, and preventive eforts procedure.
habitually established, before ixed or removable prosthodontic Patients with gingivitis and early periodontitis generally respond
treatment. his phase is discussed in more detail in the section on favorably to improved oral hygiene and scaling/root planing
interdisciplinary considerations in operative treatment planning. procedures. Patients with more advanced periodontitis might require
removal (or at least minimization) of associated risk factors/indicators
Maintenance (Reassessment and Recare) Phase through surgical steps that eliminate/reduce sulcular depths or
he maintenance phase includes regular reassessment (synonyms various regenerative procedures to resolve their periodontal disease.
include reevaluation, periodic) examinations that may reveal the Steps to increase the zones of attached gingiva and eliminate
need for adjustments to prevent future breakdown, provide an abnormal frenal tension should be achieved by corrective periodontal
opportunity to reinforce home care, and plan recare treatment surgical procedures around teeth receiving restorations with sub-
steps where disease has returned. Examinations for reassessment gingival margins. In addition, any teeth requiring restorations that
most frequently occur as part of strategically planned (recall) may encroach on the biologic width of the periodontium should
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 115

have appropriate crown-lengthening surgical procedures performed creation of an occlusal guard, for nocturnal use, may be indicated
before the inal restoration is placed. Usually, a minimum of 6 with a diagnosis of sleep-related bruxism. A treatment plan for
weeks is required after the surgery before inal restorative procedures deinitive indirect restorations must include an occlusal analysis
are undertaken. (which requires articulated diagnostic models) as part of the
comprehensive examination. Careful consideration of related
Orthodontics information from the patient assessment and examination process
Orthodontic therapy, such as realignment or extrusion, may be is essential if all aspects of the etiology are to be identiied and
required to provide improved interdental spacing, stress distribution, risk factors reduced. Also, occlusal guard therapy should be con-
function, and esthetics. All caries lesions should be corrected with sidered for nocturnal protection of indirect restorations completed
amalgam or composite restorations before orthodontic treatment as part of the deinitive phase.
begins. Few indications exist for cast restorations before orthodontic
treatment is completed. In addition, patients undergoing orthodon- Treatment of Root-Surface Carie
tic treatment should receive more intense focus (especially by the
orthodontist) on the minimization/elimination of risk factors for Root caries is common in older adults and in patients who have
caries and gingival/periodontal disease. he orthodontic treatment had periodontal therapy. Increases in the number of older patients
plan should include shorter recall intervals for bioilm removal, in the patient population and tooth retention have contributed
examination, and oral hygiene reinforcement. to this growing problem. Areas with root-surface caries usually
should be restored when clinical and/or radiographic evidence of
Oral Surgery cavitation exists. Care must be exercised, however, to distinguish
In most instances, impacted, unerupted, and/or hopelessly diseased the active from the arrested (inactive) root-surface lesion. he
teeth should be removed before operative treatment. Oral surgery arrested root-surface lesion may have sclerotic dentin that has
procedural steps required for third molar removal may jeopardize darkened from extrinsic staining, is irm to the touch of an explorer,
new restorations placed on second molars. In addition, soft tissue may be rough but is cleanable. Successful caries arrest usually
lesions, complicating exostoses, and improperly contoured ridge occurs in patients whose oral hygiene or diet has improved such
areas should be eliminated or corrected before inal restorative care. that the balance between demineralization and remineralization
has become favorable. Generally, these lesions should not be restored
Fixed, Removable, and Implant Prosthodontics except when the patient expresses esthetic concerns. If it is deter-
Direct restorations should be completed, if possible, before placing mined that the lesion needs restoration, it may be restored with
indirect restorations. Large amalgam or composite foundation tooth-colored materials or amalgam, depending on demands of
restorations must have secondary retention features (grooves, slots, the restorative material, preferences of the patient, and caries risk.
pins) placed further from the external surface of the tooth so that Prevention is preferred over restoration. It is recommended that
the retention of the foundation material is not compromised during appropriate preventive steps, such as improvement in diet/oral
preparation for the indirect restoration. In removable prosthodontics, hygiene and luoride treatment (with or without cementoplasty/
tooth preparations and restorations should allow for the design of dentinoplasty to eliminate surface roughness), be taken so as to
the removable partial denture. his includes allowance for rests, limit carious breakdown and the need for restoration.
guide planes, and clasps. he design of the direct restoration and
the selection of appropriate restorative materials must be compat- Treatment of Root-Surface Senitivity
ible with the design of the contemplated removable prosthesis. In
cases where dental implants have been or will be placed, direct It is not unusual for patients to complain of root-surface sensitivity,
restorations should be planned and executed to allow necessary which is an annoying sharp pain usually associated with gingival
mesial, distal, and vertical (occlusal) space for implant-supported recession and exposed root surfaces. he most widely accepted
indirect restorations. Implant restorations may sometimes have explanation of this phenomenon is the hydrodynamic theory. his
unusual proximal contours, and adjacent amalgam or composite theory postulates that rapid dentinal tubule luid movement toward
restorations should be designed to allow the best possible proximal the external surface of the tooth elongates odontoblastic processes
contact relationships. (which extend from the pulp through the predentin and into
dentin) and associated aferent nerve ibers. he elongation of the
Treatment of Abraion, Eroion, Abfraction, nerve ibers results in depolarization and the perception of pain
(see Chapter 1). Causes of such luid shifts include temperature
and Attrition changes, air-drying, and extreme osmotic gradients. Treatment
Abraded or eroded areas should be considered for restoration only methods that reduce rapid luid shifts, by partially or totally
if one or more of the following is true: (1) he area is afected by occluding the ends of the exposed dentinal tubules, may help
caries, (2) the defect is suiciently deep to compromise the structural reduce the perceived sensitivity.
integrity of the tooth, (3) intolerable sensitivity exists and is Dentinal hypersensitivity may become a problem when peri-
unresponsive to conservative desensitizing measures, (4) the defect odontal surgery causes clinical exposure of root surfaces (such that
contributes to a gingival or periodontal problem (chronic bioilm dentinal tubules are exposed and open). Numerous forms of
accumulation), (5) the area is to be involved in the design of a nonsurgical treatment, such as luoride varnishes, oxalate solutions,
removable partial denture, (6) the depth of the defect is such that glutaraldehyde/HEMA-based desensitizers, resin-based adhesives,
there is increased risk of pulpal involvement, (7) the defect is sealants, and desensitizing toothpastes that contain potassium
actively progressing, or (8) the patient desires esthetic improvement. nitrate, have been used to occlude the open tubules and, thereby,
Areas of signiicant occlusal attrition that have exposed dentin, provide relief. When nonsurgical methods fail to provide relief,
are sensitive, or annoying should be considered for restoration or direct restorative treatment that physically covers the exposed dentin
at least protection from additional loss of tooth structure. he is indicated.
116 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

Treatment by Repair and Recontour of outcomes require meticulous attention to detail with regard to
the enamel/dentin substrate and the properties of the speciic
Exiting Retoration adhesive system/composite resin being used. Correct application
Amalgam, composite, or indirect restorations often may be repaired will result in the rewarding creation of form, function, and lifelike
or recontoured as opposed to completely removed and replaced. appearance of missing tooth structure. Determination of patient
Growing evidence suggests that the removal and replacement of caries risk is important when considering the use of composite
restorations result in the cycle of re-restoration, which leads to resin-based restorations. A systematic review has identiied that
increasingly larger tooth preparations and the resultant trauma to the likelihood of development of recurrent caries adjacent to
the tooth and supporting structures.39 In addition, resurfacing or composite resin restorations is at least twice that of amalgam
repair of composites and repair of cast restorations has been shown restorations in high caries risk patients.45 Detailed indications for
to be efective.42-44 Also, amalgam restorations with localized defects composite and other tooth-colored restorations are presented in
may be repaired with amalgam or with sealant resins.17,42 If a restora- Chapter 8.
tion has an isolated carious defect, and complete removal of the
caries lesion has been conirmed, then it is acceptable and often Treatment With Indirect Cat-Metal Retoration
preferable to restore the isolated area without replacement of the
whole restoration. In many instances, recontouring or resurfacing Partial- or full-coverage indirect cast-metal (primarily gold alloy)
the existing restoration may delay replacement and is an acceptable onlay restorations still remain among the most predictable and
form of treatment. dependable restorations available to dentistry. hese are the conserva-
tive restoration of choice for compromised teeth in high stress
Treatment by Replacement of areas. he beneit of these restorations is that they cover and reinforce
cusps without removal of healthy tooth structure in the middle
Exiting Retoration and cervical areas of the facial and lingual surfaces (see Online
Indications for replacing restorations include the following: (1) Chapter 18). Indirect cast-metal restoration of the total clinical
marginal void(s), especially in the gingival one third, that cannot crown of teeth allows complete control of all contours and, thereby,
be repaired and predispose to caries formation; (2) poor proximal the creation of anatomic shape consistent with optimal occlusal
contour or a gingival overhang that contributes to periodontal function and gingival health.
breakdown; (3) a marginal ridge discrepancy that contributes to
food impaction; (4) overcontouring of a facial or lingual surface Treatment With Indirect
resulting in bioilm accumulation gingival to the height of contour
and resultant inlammation of gingiva overprotected from the Tooth-Colored Retoration
cleansing action of food bolus or toothbrush; (5) poor proximal Properly designed porcelain-fused-to-metal (PFM) indirect restora-
contact that is either open or improper in location or size, resulting tions have clinically proven, long-term success in the restoration
in interproximal food impaction and inlammation of impacted of individual teeth and edentulous areas. he use of ceramic materials
gingival papilla; (6) recurrent caries that cannot be treated adequately without metal substrates has steadily increased in recent years.
by a repair restoration; and (7) supericial marginal gap formation Partial-coverage bonded indirect tooth-colored restorations may
(ditching) deeper than 0.5 mm that predisposes to caries.44 be indicated for the restoration of large defects in low stress areas
Indications for replacing tooth-colored restorations include (1) when esthetics and optimal control of contours is necessary. Full-
improper contours that cannot be repaired, (2) large voids, (3) coverage bonded indirect tooth-colored restorations also may be
deep marginal staining, (4) recurrent caries, and (5) unacceptable selected for the conservative restoration of weakened posterior
esthetics.44 Bonded restorations that have supericial marginal teeth in low stress, esthetically critical areas.
staining may be corrected by shallow, narrow, marginal repair. he use of tooth-colored, zirconia-based, indirect restorations
has steadily increased over the last two decades. In vitro and short-
term in vivo research studies suggest that the clinical durability of
Treatment With Amalgam Retoration these crowns may allow use as an alternative to indirect cast-metal
Dental amalgam still is recognized as one of the most successful or PFM restorations. However, there are currently no published
direct restorative materials and is especially indicated for patients long-term randomized, controlled clinical trials verifying this to
deemed to be moderate or high caries risk.45 Inaccurate information actually be the case. hese restorations may be generated through
with regard to the safety of amalgam has resulted in controversy the use of traditional impression/dental laboratory techniques or
among health care providers, environmentalists, legislators, and through the use of computer-assisted digital impression, design
the general population. Although the use of amalgam is considered and manufacturing processes. Indirect tooth-colored restorations
safe by multiple independent agencies, the release of elemental are covered in more detail in Chapter 12.
mercury does contribute to environmental levels. Therefore
responsible handling is important. Chapter 10 presents the current Treatment of Ethetic Concern
indications for amalgam restorations and Chapter 13 presents a
more complete discussion of legitimate mercury concerns and the Interest in smile esthetics is growing among many segments of the
safe use of dental amalgam. population. As a result, a range of treatments has been developed
to manage a wide array of esthetic concerns. Chapter 9 describes
Treatment With Direct Compoite and Other conservative esthetic treatments, which include selective recontouring
of anterior teeth, vital bleaching, and microabrasion. hese conserva-
Tooth-Colored Retoration tive approaches have well-documented outcomes. In addition to
Direct composite restorations are indicated for the treatment of these conservative techniques, advances in direct composite restora-
many lesions in anterior and posterior teeth. Successful treatment tions have permitted the closure of diastemas, recontouring of
 CHAPTER 3 Patient Aement, Examination, Diagnoi, and Treatment Planning 117

teeth, and other tooth additions by means other than extensive in older patients.49 Perceptions of salty and bitter tastes and olfactory
full-coverage indirect restorations. function decline with age, whereas perceptions of sweet and sour
tastes do not. As a result, food may become tasteless and unap-
petizing, and more sugars, fats, and salts are added in an attempt
Treatment Conideration for Older Patient to increase lavor. Undernourished individuals are encouraged to
In the past, older adults constituted a relatively minor proportion consume calorie-rich, complete-nutrition beverages, which also
of the population. Older individuals used dental services infrequently are rich in reined carbohydrates. Smoking reduces the taste of
because most were edentulous, had limited inancial resources, foods by causing physical coating of the tongue and regression of
and delayed unmet dental needs until they became symptomatic. the taste buds on the tongue and olfactory receptors in the roof
Today, individuals 65 years and older represent a rapidly growing of the nasal cavity over time. Inadequate luid intake may lead to
segment of the population. Older individuals now are better chronic dehydration and altered taste perception. hese practices
educated consumers, have greater inancial resources, are more increase the risk of dental disease in this population. Dietary
prevention minded, and have retained more teeth as compared assessment and counseling are crucial in older patients to identify
with their predecessors. However, older individuals are living with inadequate diets and suggest modiications that enhance taste and
increasingly more complex medical, mental, emotional, and social smell while lowering the risks of dental disease. Herb seasonings
conditions that afect their ability to care for their dentition and may enhance the lavor of foods in lieu of sugar and salt. Salivary
periodontium. hese conditions must be considered when planning stimulants, citrus-lavored candies containing xylitol or other sugar
dental treatment. Financial and social barriers prevent some older replacements, tongue brushing or scraping, and smoking cessation
individuals from seeking oral health care. Although, as a group, are some additional measures that may promote taste and olfactory
older adults enjoy greater inancial resources, many remain on perception in older adults.
restricted budgets and are faced with tough decisions regarding Dental and periodontal diseases may progress more rapidly in
the spending of limited resources. Transportation to and from the older adults.47 Dental caries, particularly root caries, is the most
dental oice becomes complicated for those who no longer drive. signiicant reason for tooth loss in older adults. Inefective plaque
A comprehensive review of geriatric dentistry is beyond the scope removal, xerostomia, soft sugar-rich diets, ixed and removable
of this chapter; rather, some issues that are important for treatment prostheses, abrasions at the CEJ, gingival recession, and chronic
planning for older patients are highlighted.46-48 periodontal inlammation (with increased activity of collagenolytic
Clear and efective communication is crucial. Many older adults enzymes) make root surfaces more prone to caries compared with
have hearing loss and dentists must speak more distinctly and at other surfaces. Root-surface restorations are challenging to suc-
a higher volume. Patients with memory loss appreciate written cessfully perform and are at risk of recurrent decay in the future.
summaries and instructions that assist them in remembering details Careful selection of restoration design, materials, and inishing is
of the visit and planned treatment when they leave the dental essential if the patient is to be able to perform successful bioilm
oice. he use of large simple fonts in written communications removal and thereby maximize the longevity of restorations. Also,
is particularly helpful to patients with diminished visual acuity. many dental practitioners prefer to intervene more aggressively
An accurate medical history, risk assessment, and integration with dental treatment rather than take a “watchful waiting”
of dental and medical care are particularly important considerations approach. As more teeth are being retained and have large restora-
for older patients. Many chronic diseases of the cardiovascular, tions at risk of fracture or recurrent decay, attention must be placed
respiratory, endocrine, renal, gastrointestinal, musculoskeletal, on developing cost-efective and innovative means of restoring
immune, and neurologic systems are associated with aging, inluence teeth, particularly for older individuals on a limited budget. he
dental disease, and complicate dental treatment decision making. cost-efective use of silver diamine luoride (SDF) to arrest caries,
Cardiovascular disease, Alzheimer disease, depression, osteoarthritis, even though the treated area becomes darkly stained, may be an
rheumatoid arthritis, osteoporosis, cancer, and diabetes are a few optimal treatment option in this population (see Chapter 2).
of the diseases that commonly afect older adults, and their medical Prevention of dental disease increases in importance but becomes
management increases in complexity with advancing years. It is more challenging in older adults. Physical limitations such as
estimated that older individuals living in community settings take arthritis, Parkinson disease, vision impairment, and other chronic
an average of four medications each day; six of the top 10 drugs illnesses reduce the patients’ ability to clean their teeth and peri-
prescribed in 2001 were used to treat age-related chronic condi- odontal tissues efectively. Powered rotation–oscillation toothbrushes
tions.46,47 Many of these medications have the potential for adverse and manual toothbrushes with larger handles, for easier gripping,
drug reactions and drug interactions. Oral adverse efects include are recommended for patients with decreased manual dexterity.
dry mouth (xerostomia), increased bleeding of tissues, lichenoid Consistent use of luoride-containing dentifrices and other rem-
reactions, tissue overgrowth, and hypersensitivity reactions. he ineralization products, antimicrobial mouthrinses, oral pH manage-
dentist must be aware of the impact these medications may have ment, lossing, oral irrigation, and chewing of xylitol gum may
on dental treatment planning and management. Consultation with reduce the risk of developing dental caries and periodontal
the patient’s physician is highly recommended so as to gain infection.50 Written reminders are useful to serve as aids for older
understanding of these medical, mental, and emotional conditions patients who forget to brush their teeth because of memory loss
and their potential impact on dental treatment. he dentist should associated with Alzheimer disease. Because many older individuals
recognize the impact of polypharmacy on salivary low, especially may have never been taught how to efectively clean their teeth,
the use of xerostomic medications, and discuss with the physician the dentist must observe their technique and instruct them in
the potential substitution of medications with fewer xerostomic proper oral hygiene procedures to be performed after each meal.
efects. Dentists must carefully inform patients in the proper application
Oral changes associated with undernourishment, immunosup- method of 5000-ppm luoride toothpastes. Incorrect application
pression, dehydration, smoking, alcohol use, disease, medications, (e.g., rinsing/eating/drinking immediately after brushing) severely
and dental problems lead to a depressed sense of taste and smell limits any potential beneit.
118 C HA P T E R 3 Patient Aement, Examination, Diagnoi, and Treatment Planning

A unique aspect of aging is an increasing reliance on the assistance is available. hese alternatives, with their advantages and disad-
of caregivers with activities of daily living. As a result, the dentist vantages, should be presented to the patient. In addition, the
must work with caregivers who provide dental care for patients in patient should be informed of the risks associated with each
the home, assisted living facility, nursing home, and hospital settings. alternative therapy. Dentists must remember that a reasonable
he dental professional may need to spend more time educating alternative often is not to intervene directly with restorative care.
and training the caregiver, rather than the patient, in the importance Rather, based on the nature of dental disease progression, elimination
of oral hygiene and efective plaque removal techniques. or reduction of risk factors/indicators may need to be the initial
focus while monitoring the condition. Even these intentional eforts
Treatment Plan Approval are part of a treatment plan and must be included in the informed
consent process. Proactive conservative steps, in the case of caries,
Informing patients well about their conditions and treatment options may be to attempt to remineralize or arrest the lesion(s). Finally,
and then obtaining their consent has become an integral part of the cost of treatment alternatives should be discussed with the
contemporary dental practice.51 One aspect of informed consent patient. Treatment may proceed when the dentist is sure that the
is to provide patients with the necessary information about the patient has a full and complete understanding of the alternative
alternative therapies available to manage their oral conditions. For treatments, their associated risks and beneits, and the results of
nearly all conditions, usually more than one treatment alternative possible nontreatment.51-53

Summary
Proper assessment, examination, diagnosis, and treatment planning a sequenced approach that its the desires/needs of the individual.
play a crucial role in the delivery of quality dental care. Each Patients must have an active role in the process; they must be
patient must be evaluated (examined) individually in a thorough informed of the indings, advised of the risks and beneits of
and systematic fashion. After the patient’s preferences, risks, and proposed treatment, and given the opportunity to decide the course
condition(s) are understood and recorded, a treatment plan may of treatment. he process of patient assessment, examination,
be developed and implemented. A successful treatment plan carefully diagnosis, and treatment planning represents one of the greatest
sequences and integrates all necessary procedures indicated for the challenges in dentistry and is rewarding for both the patient and
patient. Few absolutes exist in treatment planning; the available the dentist if done properly (i.e., thoroughly and with the patient’s
information must be considered carefully and incorporated into best interests in mind).

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