Clinical Operative Dentistry ( I )
Diagnosis &
Treatment Planning
Lecture 1
Pretreatment considerations are the foundation of sound dental
care consisting of:
Patient Assessment
Examination
Diagnosis
Treatment planning
These considerations follow a stepwise progression in that the diagnosis & treatment
plan depends on a thorough examination & patient assessment
Examination: is the process of observing
both normal & abnormal conditions
Diagnosis: is the determination & judgment
of examined variations from the normal based
on scientific knowledge
TREATMENT PLANNING
In reality, however, ideal treatment plan rarely occur.
Instead they are modified into optimal treatment plan by:
• Patient Systemic health
• Priorities and financial capabilities
• The dentist’s knowledge, experience, and training,
laboratory support
• Other functional, esthetic, & technical demands
TREATMENT PLAN SEQUENCING
• is the process of scheduling the needed
procedures into a time frame
• Certain treatments must naturally follow
others in a logical order
Complex treatment plans often should
be sequenced in phases
Patient Assessment
All the collected data from the patient must be
registered in the patient chart which should be:
• uncomplicated
• comprehensive
• accessible
• updated
The chart is divided into sections that deals with
Personal data of the patient
Past & present medical history
Past dental history
Chief complaint
(Current dental problem)
Patient coming to the clinic
Patient in pain Esthetic Patient Patient with dental
problems
1- Personal data
• Name : for better communication and administrative
purposes.
• Age: Some diseases affect certain age groups.
• Gender: certain diseases or conditions related to gender
• Address : patients live near factories may suffer of
pulmonary, heart disease.
• Occupation: some occupations may cause wear to hard
dental tissues.
2- Past and present medical history
• contagious diseases (e.g., hepatitis).
• allergies to certain drugs.
• systemic diseases and heart problems (e.g. rheumatic heart
disease or valvular transplant) that demand prophylactic
antibiotics coverage
3- Past dental history
• It is important to understand past experiences in
order to provide optimal care in the future.
• indications of the patient’s future behavior.
• if a patient has difficulty encountered problems with
previous dental care an alteration of the treatment or
environment may help to avoid future complication.
4- Current dental problems and Chief complaint
• Chief complaint recorded with the patient
own words including onset, duration, and
related factors.
• This information is vital in determining the
need for additional diagnostic tests as well as
the cause and treatment of the complaint
Clinical examination of caries
Visual
Tactile
Radiographic
Visual
• Detection of changes in color or translucency
• Proven to be effective method in caries detection in anterior,
posterior, smooth surface, pits & fissure caries
• One of its drawback is subjectivity between different practitioners
• Can be aided with specific caries index for different degrees of
variation from normal – ICDAS
• As a supplement to tactile examination, occlusal enamel
can be evaluated for loss of translucency and change in
color, which are characteristics of caries.
Visual
Early caries with no visible cavity can be visually detected as change
in color:
• Chalky white, white spot in demineralization
• Brownish in arrested lesions from staining of fluoride
• In translucency (opaque in demineralized lesion)
Visual
To distinguish smooth surface early white spot caries (incipient) from
white spot due to hypocalcification:
• Drying will show both white spot lesions distinguishable from
translucent enamel
• In case of early caries (demineralization), wetting will cause the
lesion to partially or totally disappear
• In case of early caries (demineralization), re-drying will show the
lesion again
Visual
Pit & Fissure
Tactile
• when an explorer placed into a pit or fissure provides tug-back or
resistance to removal. Generally this “catch” or resistance indicates
a fissure that either has become carious or has the probability of
becoming carious.
Tactile
Despite the sharp explorer is one of the most classical caries detection
methods, it has proven to have many disadvantages
• Inability to detect early forms of caries
• Mechanical binding of an explorer in pits & fissures may be due to
non-carious cause, like shape of fissure, sharpness of explorer or
force of application
Tactile
• Sharp edge of an explorer may fracture the demineralized enamel
initiating cavitation in a tooth which – if left alone – could have
been re-mineralized & reverted to normal without any cavitation or
even induce cavity within a healthy pit or fissure
Tactile
Shifting to gentle detection of surface discontinuities in enamel or
microcavitations by a WHO Probe (ball-ended with a sphere
presenting 0.5 mm (without injury to tissues)
Radiographic
Radiographs can detect
• Proximal caries (appear as triangular radiolucency that has its apex
towards DEJ
• Moderate to deep occlusal caries ( can be seen as radiolucency in
dentin)
Radiographic
Radiographs can detect
• Defective aspects of restorations ( improper contour, overhangs,
recurrent caries gingival to restoration)
• Pulp abnormalities (pulp stones, internal resorption)
• Periapical radiographs are helpful in diagnosing periapical
abscesses, dental granulomas or cyst
• Impacted third molar, supernumerary teeth (discovered)
Radiographic
Radiographic examination Limitations
• 2D image for a 3D object
• Caries is deeper clinically than it appears radiographically
• Projection errors
• Anatomic limitations
• Processing errors
ICEBERG PHENOMENON OF DENTAL CARIES
No care advise: (NCA) Low caries risk value
Preventive care advising: (PCA) Patient is at risk & has initial
lesions that could be treated by non-surgical model
( biological/ medical model)
Operative care advised: (OCA) Lesions are irreversible & must
be treated operatively
Caries Detection
• Caries detection is the art of detecting the
disease from its signs and symptoms.
• Detection based on:
1- Visual.
2-Tactile (e.g. explorer).
Dental caries is
3-Radiographic inspection.
diagnosed by one or all
4-Recent Diagnostic tools.
Advances in visual technique
Transillumination
FOTI (Fiber- Optic Transillumination)
Longitudinal tooth fracture
DIFOTI (Digital Imaging Fiber- Optic Transillumination)
DIFOTI (Digital Imaging Fiber- Optic
Transillumination)
• A high-intensity light is shone through
the tooth and the transilluminated image
of the tooth is captured on a charge –
coupled device (CDD) intra-oral camera,
analyzed by computer software and
displayed on a computer screen for
diagnosis.
DIGITAL DENTAL
EXAMINATION
Advances in visual technique
Magnification
• Magnifying loupes
• Microscope
• Intra-oral camera
Loupes
• They are similar in appearance to
eyeglasses and allow a magnification in
the range of 2X- 5X.
• The lenses are built into the line of sight
of the eyewear and should be customized
to the user.
Magnifying Loupes
• Enhanced vision for improved
patient care.
• Reviewing and evaluating
details of teeth, and soft tissue
requires visual acuity – which is
improved through magnification.
• Helps the dentist to sit upright.
Caplan, Stuart A. "Magnification in dentistry." Journal of Esthetic and Restorative Dentistry 2.1 (1990): 17-21.
Microscopes
• They allow a magnification in the
range of 10X- 25X.
• Microscopes are either fixed (wall-
mounted or ceiling-mounted) or
mobile
Dental Microscope
• The magnification aspect
allows dentists to detect, in
detail, emerging cracks and
caries on teeth far easier than in
the past.
• Helps the dentist to sit
upright with no deviation and
stresses on muscles.
Caplan, Stuart A. "Magnification in dentistry." Journal of Esthetic and Restorative Dentistry 2.1 (1990): 17-21.
Caplan, Stuart A. "Magnification in dentistry." Journal of Esthetic and Restorative Dentistry 2.1 (1990): 17-21.
• Working under magnification is awakening
the interest of doctors of other specialties
also, especially during conservative
treatments or surgical interventions.
• More private practices should invest in
young general practitioners should be
motivated in using it during dental treatments.
Intraoral camera
• It’s a camera placed inside the oral cavity
to allow display of intraoral images of
exceptional quality on a computer.
Intraoral Examination
