CHAPTER 3 PART I: PATIENT ASSESSMENT EXAMINATION

comprehensive medical history

a form completed by the patient or legal guardian is essential for identifying conditions that could impact dental procedures

it informs the practitioner of any communicable diseases, allergies, medications, systemic diseases, cardiac issues, joint replacements, and age-related changes that may require special precautions, treatment modifications, or prophylactic measures

this information is documented in the patient’s permanent record and guides treatment recommendations

medical history form

completed by the patient or guardian before examination

identification of risks

helps detect communicable diseases, allergies, medications, systemic issues, and age-related changes

treatment adjustments

identifies the need for special precautions or modifications in treatment

prophylactic measures

determines necessity for antibiotics or other pre-treatment actions

medical consultation

may indicate the need for further medical advice or referral

documentation

all findings are recorded in the patient's permanent record to guide future treatments

recording concerns verbatim in the dental record

dental history

reviews past dental experiences and current issues, revealing previous problems, treatments, and patient responses.

understanding this history helps predict future behavior and tailor treatments to avoid complications.

it also identifies specific problems like pain or broken restorations.

additionally, documenting the type and quality of existing radiographs helps determine the need for new ones, minimizing radiation exposure.

patient responses

assesses tolerance to procedures and reactions to past care

review past experiences

includes previous dental problems and treatments

tailored treatment

adjustments based on past difficulties to prevent complications

identification of issues

detects specific current dental problems

radiograph review

Ensures only necessary additional radiographs are taken, reducing radiation exposure.

patient's chief concerns

identifying and understanding this is essential before treatment

these concerns are documented verbatim, and patients should be encouraged to discuss symptoms, onset, duration, and related factors

this information is crucial for diagnosing the issue, selecting appropriate treatments, and fostering a strong patient- dentist relationship

detailed discussion

Encouraging the patient to elaborate on symptoms and related factors.

diagnostic guidance

helps determine necessary tests and appropriate treatments

patient relationship

builds trust and understanding with the patient

factors included in examination

integrated process — examination starts with patient interactions

extraoral observations — includes symmetry, speech, and facial expressions

structured recording — follows a sequence from extraoral to intraoral examination

clinical photography — helps document findings

physical assessment — involves evaluating muscles, TMJs, and lymph nodes

factors under examination of esthetic appearance

assessment areas — tooth color, form, display, and position

patient expectations — discuss realistic esthetic outcomes

key factors — tooth visibility, color, and gingival symmetry

risk management — emphasizes conservative treatments

interdisciplinary approach — necessary for complex cases

factors under examination of occlusion

Assessment Areas — Static and dynamic occlusion, mandibular movements, occlusal abnormalities.

Signs of Trauma — Wear facets, enamel cracks, tooth mobility.

Occlusal Relationships — Includes maximum intercuspation, vertical/horizontal overlap, and midline alignment.

Functional Evaluation — Observing movements for guidance and disclusion.

Documentation — Recording findings to guide restorative planning, ensuring preservation or improvement of occlusion.

factors under examination of teeth & occlusion: preparation

assistant’s role — Preliminary charting to save dentist’s time.

instruments — Mirror, explorer, periodontal probe, and air-drying tools.

charting routine — Systematic approach starting from the upper right quadrant.

mouth preparation — Keeping the mouth clean, dry, and well-lit.

biofilm management — Flossing, brushing, or debridement as needed.

factors under examination of teeth & occlusion: clinical exam for caries

caries management — focus on risk assessment and conservative treatments

detection systems — ICDAS and ADA CCS standardize visual assessment

early detection — identifying early enamel lesions for nonoperative care

explorer use — gentle use for surface roughness, avoiding forceful probing

additional methods — radiographs and technologies for caries detection

factors under examination of teeth & occlusion: occlusal caries

Caries Location — Pits and fissures are common sites

Examination Methods — Visual and radiographic tools are essential; explorers should be used cautiously.

Visual Indicators — Changes in tooth texture and color signal caries.

ICDAS Grading — Caries severity is classified on a scale from 0 to 6.

factors under examination of teeth & occlusion: proximal caries

Diagnosis Methods — Radiographs, visual inspection, and transillumination are primary tools for detecting proximal caries.

Visual Indicators — White spots or shadows signal early caries, while brown spots in older patients indicate past caries activity.

Caries Progression — Advanced lesions show discoloration and softness, with slowly progressing caries darkening over time.

Arrested Lesions — Indicate remineralization, are cleanable, and may not require restoration unless for aesthetic or biofilm management.

factors under examination of teeth & occlusion: cervical caries

risk factors — root-surface caries are more common in older patients or those with attachment loss and saliva-altering conditions

location and appearance — lesions typically appear near the CEJ, are discolored, and softer than surrounding structures

diagnostic methods — clinical inspection and quality bitewing radiographs are crucial, with a need to distinguish between caries and artifacts like cervical burnout

2 stages of ICDAS code

uses a two-stage process to record the status of the caries lesion

the status of the caries severity is determined visually on a scale of 0 to 6:

1st stage

a code for the severity of the caries lesion

2nd stage

for the restorative status of the tooth

ICDAS code 0

sound tooth surface structure

no caries change after air drying (5 sec.)

hypoplasia, wear, erosion, & other noncaries phenomena

ICDAS code 1

first visual change in enamel

seen only after air drying or colored

change “thin” limited to the confines of the pit & fissure area

not sealed or restored

lesion depth of ICDAS code 1 in P/F

was 90% in the outer enamel with only 10% into dentin

ICDAS code 2

distinct visual change in enamel

seen when wet

white or colored

wider than the fissure / fossa

sealant, partial

lesion depth of ICDAS code 2 in P/F

was 50% inner enamel & 50% into the outer 1/3 dentin

ICDAS code 3

enamel breakdown, no dentin visible

widening of fissure

discontinuity of surface enamel

localized enamel breakdown with no visible dentin or underlying shadow

sealant, full; tooth-colored restoration

lesion depth of ICDAS code 3 in P/F

with 77% in dentin

ICDAS code 4

dentinal shadow (not cavitated into dentin)

underlying dark shadow from dentin

with or without localized enamel breakdown

amalgam restoration

lesion depth of ICDAS code 4 in P/F

with 88% into dentin

ICDAS code 5

distinct cavity with visible dentin

frank cavitation involving less than half of a tooth surface

stainless steel restoration

lesion depth of ICDAS code 5 in P/F

with 100% in dentin

ICDAS code 6

extensive distinct cavity with visible dentin

cavity is deep & wide involving more than half of the tooth

ceramic, gold, PFM (porcelain-fused-to-metal) crown or veneer

code 7

lost or broken restoration

code 8

temporary restoration

lesion depth of ICDAS code 6 in P/F

100% reaching inner 1/3 dentin

likely to be inactive / arrested caries

shiny

not thick or sticky

color brown-black

no inflammation, no BOP

smooth, hard enamel / hard dentin

lesion is not in a plaque stagnation area

likely to be active caries

thick & sticky

color white-yellow

rough enamel, soft dentin

inflammation, there is BOP

matte / opaque / loss of luster

lesion is in a plaque stagnation area (pit / fissure, approximal, gingiva)

high-risk patients

px with 1 or more cavitated lesions

extreme-risk patients

px with 1 or more cavitated lesions & xerostomia

sealants

defined as confined to enamel

can either be resin-based / 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 whatever fissure preparation is not desired, or where rubber dam isolation is not possible

restorations

defined as in dentin

two-surface restoration

defined as a preparation that has one part of the preparation in dentin and the preparation extends to a second surface

2nd surface — does not have to be in dentin

cervical burnout

is a radiographic artifact that appears as a radiolucent area near the cervical region of teeth, often between the enamel and alveolar bone

appearance of cervical burnout

a diffuse

uniform radiolucency that lacks defined borders

follows the shape of the root

location of cervical burnout

commonly seen in the mesial or distal aspects of teeth at the cemento-enamel junction (CEJ)

cause of cervical burnout

results from the normal anatomy of the tooth, where the thinness of the root structure at the cervical area allows more X-rays to pass through, creating a radiolucent appearance

clinical relevance of cervical burnout

it is a benign artifact, not indicative of pathology

no clinical signs of decay or cavitation are present, and the tooth surface is usually intact and hard

cervical caries

are actual dental caries (decay) occurring at or near the CEJ, often affecting the cementum or dentin

appearance of cervical caries

presents as a localized, well-defined radiolucency with irregular borders

sometimes with cavitation visible on radiographs or clinically

location of cervical caries

found at the CEJ or more apically, often in areas exposed due to gingival recession or attachment loss

cause of cervical caries

caused by the accumulation of plaque, poor oral hygiene, and factors like dry mouth or dietary habits that promote demineralization

clinical relevance of cervical caries

indicates an active or arrested disease process

clinical examination reveals a softened or cavitated surface, often requiring restorative intervention