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الكلية كلية طب الاسنان
القسم ترميم ومعالجة الاسنان
المرحلة 4
أستاذ المادة احمد غانم مهدي الهلال
4/17/2011 5:27:33 PM
Patient evaluation, diagnosis and treatment plan
Excellence in dental care is achieved through the dentist ability to to assess the patient, determine his need and designs an appropriate treatment plan.
Infection control:
Attention is given to infection control before the examination and diagnosis. The dental staff must wear masks, protective eyewear, gloves and using gowns.
Patient assessment:
Medical history:
this includes aspects of treatment that affect the patient systemic health, it must identify conditions that could alter, complicate or contraindicate dental treatment. The dentist may identify contagious diseases (like hepatitis or aids) tat requires special precautions or procedures, allergies that may contraindicate the use of certain drugs, or systemic disease or heart problems that may demand the use of prophylactic antibiotics or medical referral or consultation before initiating dental treatment.
Chief complain:
Before initiating any treatment, it is important to determine the patient s chief complaint, or the problem that initiated the patient s visit. Record the complaint (by the patient own words) in the dental record. The patient should be encouraged and guided to discuss all aspects of the current problem, including onset, duration, symptoms, and related factors. This information is vital to establish the need for specific diagnostic tests and to determine the cause and treatment of the complaint. By this discussion the dentist accomplishes two purposes:
1. The patient feels that his problem has been recognized.
2. The patient-dentist relationship begins positively.
Dental history:
The dental history consists of reviewing previous dental experiences and current dental problems. Review of the dental history reveals information about past dental problems and treatment. Frequency of dental care and perceptions of that care may be indications of the patient s future behavior. Obviously, if a patient has difficulty tolerating certain types of procedures or has encountered problems with previous dental care, an alteration of the treatment or environment may help avoid future complications. Also, this discussion may lead to identification of other problems such as areas of food impaction, inability to floss, areas of pain, and broken restorations and/or tooth structure. It is critical to understand past experiences to provide optimal care in the future.
Clinical examination:
The intraoral examination involves an examination of the periodontium, dentition and occlusion. It has many elements:
1. Evaluation of dentition:
• Assessment of caries risk and plaque:
the determination of caries risk and plaque levels at the time of examination provides a base for communication with patient and it’s important in determining the prognosis of restorative treatment. The visual examination of dentition should be accomplished in dry field, with adequate light and using mirror and probe.
• Detection of caries:
Pits and fissures caries: it may begin as small defects near DEJ, so it’s difficult to detect early caries by radiograph; tactile examination with firm application of explorer into fissures and pits is helpful. If a sticky sensation felt on the removal of explorer then this is classic sign of pits and fissure caries. This method is not fully reliable because it may give false positive and false negative results, also sharp explorer could cause cavitation in demineralized pits and fissures, thus preventing the possibility of remineralization. Visual observation with magnifiers on clean dry tooth is a good and non destructive method. In general Dental caries is diagnosed by one or all of the following:
(1) visual changes in tooth surface texture or color.
2) tactile sensation when an explorer is used judiciously.
(3) radiographs.
(4) transillumination.
Several technologies have emerged that show promising results for the clinical diagnosis of caries. These include electrical conductance, laser fluorescence and chewing gums.
Smooth surface caries: proximal caries is the most difficult type of caries to be detected clinically, because it’s inaccessible to both visual and tactile examination, proximal lesions in posterior teeth can be detected by radiographs or clinical detection of marginal shadow, while in anterior teeth it can be detected by radiographs, tactile, visual or transillumination. If the smooth caries lies on buccal or lingual surface it’s easily detected by visual and tactile examination.
• Assessment of the pulp: (vitality tests)
A. Application of cold: a cotton pellet saturated with aerosol refrigerant spray such as (tetraflouroethane) is placed on the tooth to determine vitality or a pencil of ice is made by freezing the water inside a sterilized anesthetic cartridge.
B. Electric pulp tester: this test has limitation; it cannot be used in wet teeth or on teeth with large metallic restoration or crown.
C. Test cavity: used when previous cold or electrical tests failed to provide clear picture of pulp vitality and when there is large restoration or crown, in this test we initiate a cavity preparation without anesthesia, if pain or sensitivity is elicited then pulp vitality is confirmed.
D. Percussion test: by gently tapping on the occlusal or incisal surface of the suspected tooth and adjacent teeth with the end of handle of mirror to determine the presence of tenderness. Pain on percussion suggests a possible injury to periodontal ligament or periapical area.
E. Palpation: by rubbing the index finger along the facial and lingual mucosa overlying the apical region of the tooth, tenderness on palpation may suggests alveolar or periapical pathosis.
• Clinical Examination of Amalgam Restorations:
The following criteria are used to evaluate existing restoration:
A. Structural integrity: involves determining weather the restoration is intact or if portions of amalgam are partially or completely fractured or missing. The presence of fracture line indicates the necessity of replacement of restoration.
B. Marginal gap (opening):Marginal gap or ditching is the deterioration of the amalgam-tooth interface as a result of wear, fracture, or improper tooth preparation. It can be diagnosed visually or by the explorer dropping into an opening as it crosses the margin. Shallow ditching less than 0.5 mm deep usually is not a reason for restoration replacement, because such a restoration usually looks worse than it really is. The eventual self-sealing property of amalgam allows the restoration to continue serving adequately if it can be satisfactorily cleaned and maintained. However, if the ditch is too deep to be cleaned or jeopardizes the integrity of the remaining restoration or tooth structure, the restoration should be replaced. In addition, secondary caries is frequently found around the gap.
C. restoration-related periodontal health:We must assess if there is an effect of restoration on periodontal health, most common problems are (surface roughness and interproximal overhangs). These two conditions can cause inflammation within the periodontium also it could harbor bacterial plaque so generating inflammatory response.
D. amalgam contacts: The proximal contact area of an amalgam restoration should touch the adjacent tooth at the proper contact level and with correct embrasure form. If the proximal contact of any restoration is suspected to be inadequate, it should be evaluated with dental floss or visually by a mouth mirror to reflect light and actually see if there is a space at the contact ("open" contact). For this viewing, the contact must be free of saliva. If the contact is "open" and is associated with poor interproximal tissue health and/or food impaction, the restoration should be classified as defective and replaced. An "open" contact typically is annoying and even distressing to the patient; thus correcting the problem usually is a much appreciated service.
E. Caries: the dentist must use a combination of visual, tactile and radiographical examinations to detect the presence of carious lesion.
F. Esthetic: the esthetic problems include
? Display of metal.
? Discoloration or poor color match.
? Poor contour.
? Poor periodontal tissue health.
. Evaluation of occlusion and occlusal wear:
Occlusion could have significant effects on the restorative treatment plan. The following should be evaluated during occlusal examination:
1. Occlusal interferences.
2. The balance between occlusal contacts.
3. Attrition.
4. Interarch space.
? Evaluation of tooth integrity and fractures:
Cracked tooth syndrome:
is a result of incomplete tooth fracture. Patient suffering from cold sensitivity and sharp pain of short duration during chewing, the most commonly fractured part is the non functional cusps. If the patient have multiple cracked teeth the he probably have parafunctional habits or malocclusion. This syndrome is age related phenomenon, the great occurrence being at 33-50 years of life. This syndrome is often difficult to diagnose and the patient cannot the offending tooth and evaluation tools like radiograph and visual examination are usually useless, there are two helpful tests:
1. Transillumination.
2. Biting test:
the patient bite on wooden stick or cotton roll, this will elicits the symptoms.
?
Esthetic evaluation:
the esthetic of existing restorations and esthetic of entire dentition should be checked, common esthetic problems include:
1. Stained or discolored anterior teeth.
2. Bad contour in anterior teeth.
3. Wrong position or spacing in anterior teeth.
4. Carious lesion or discolored restoration.
5. Unaesthetic color or contour of tissues adjacent to anterior restoration.
2. Evaluation of the periodontium:
The periodontium should be evaluated for two reasons:
A. To determine the effect of periodontal health on our treatment plan.
B. To determine the effect of existing restoration on the periodontium.
Evaluation should include clinical assessment of attachment levels, bone support, tooth mobility, tissue health and radiographic assessment of bony support.
The most appearing clinical indicator of inflammation is bleeding on probing. The periodontal evaluation should include tissue color, texture, contours, edema and sulcular exudates.
3. Evaluation of radiograph:
Radiographs are another valuable aid in assessing periodontal health. Bitewing radiographs, exposed at the proper angulation, are the best means of radiographically assessing bone levels. Vertical bitewing radiographs are recommended for patients with periodontitis involving bone loss. Localized or generalized bone loss, vertical or horizontal, should be noted. Radiographs aid in determining the relationship between the margins of existing or proposed restorations and the bone. The restoration margin should be placed occlusally as far away as possible from the base of the sulcus to foster gingival health. The attachment breakdown and apical migration are in response to the inflammatory process caused by bacterial plaque that accumulates at the inaccessible restoration margins.
Treatment plan:
After completion of clinical examination, the dentist must list the problems related to restorative dentistry. In planning a restoration we need to consider the following factors:
1. Amount and form of remaining tooth structure.
2. The functional need for each tooth.
3. The esthetic need for each tooth.
4. The final objective of our treatment plan.
Treatment sequence:
The sequence of treatment should consider the following:
1. Severity of disease (i.e. the most symptomatic tooth and the tooth with deepest caries is restored).
2. Esthetic need.
3. time consumption.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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