CHAPTER 3 PART I: PATIENT ASSESSMENT EXAMINATION

comprehensive medical history

essential for identifying conditions impacting dental procedures

informs practitioner of communicable diseases, allergies, medications, systemic diseases, cardiac issues, joint replacements, age-related changes

documented in patient's permanent record for treatment recommendations

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'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

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

ICDAS code 2

distinct visual change in enamel

seen when wet

white or colored

wider than the fissure / fossa

sealant, partial

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

ICDAS code 4

dentinal shadow (not cavitated into dentin)

underlying dark shadow from dentin

with or without localized enamel breakdown

amalgam restoration

ICDAS code 5

distinct cavity with visible dentin

frank cavitation involving less than half of a tooth surface

stainless steel restoration

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

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

not indicative of pathology

no signs of decay or cavitation

tooth surface usually intact and hard

uniform radiolucency lacks defined borders

normal tooth anatomy results in thin root structure allowing more X-rays

commonly seen in mesial or distal aspects of teeth at cemento-enamel junction

radiographic artifact appearing near cervical region of teeth, often between enamel and alveolar bone.

cervical caries

dentinal decay affecting cementum or dentin

presents as localized radiolucency with irregular border

can have visible cavitation on radiographs or clinically

found at CEJ or apically due to gingival recession or attachment loss

caused by plaque accumulation, poor oral hygiene, dry mouth, and dietary habits

clinical examination reveals softened or cavitated surface, requiring restorative intervention