Patient evaluation,diagnosis and treatment planing in conservative
PRESENTED BY;ABDUL VAJID M
To provide best treatment and patientsatisfaction , thorough clinical history, examination and diagnostic aids arerequired. Diagnosis is defined as utilization of scientificknowledge for identifying a disease processand to differentiate from other diseaseprocess.
The diagnostic process actually consists of foursteps; First step ; assemble all the available factsgathered from chief complaints, medical anddental history, diagnostic test and investigations. Second step ; analyze and interpret assembledclues each and the tentative or provisionaldiagnosis. Third step ; make differential diagnosis of allpossible disease. Fourth step ; select the closest possible choice.
Case history is definedas;planned,professional conversationbetween the patient and the clinician inwhich the patient reveals his/hersymptoms fears, or feelings to theclinician so that the nature of the realor suspected illness and mental attitudeto it may be determined. The purpose of recording patients history andconducting a clinical examination is to arriveat a logical diagnosis to the patients chiefcompliant and to institute a suitabletreatment plan.
It is the description of the problems for whichthe patient seeks treatment. It should be recorded in patients own wordsand should not be recorded in medicalterminology.
It is the detailed description of chief complaint. Examples for the type of questions asked byclinician include1. How long you had the pain?2. Do you know which tooth it is?3. What initiate pain?4. How would you describe pain?5. When was the problem first noticed?6. Mode of onset7. Associated symptoms etc..
The most common toothache may arise eitherfrom pulp or from PDL. Mild to moderate type of pain can be ofpulpal or periodontal origin. If pain from PDL ,teeth will be sensitive topercussion. Pulpal pain will be sharp and depends on thepulpal fibres involved.
This helps to know any previous dentalexperience, and past restorations.
For a proper medical history, importanceshould be given to the following;1. Allergies and medications(allergic to localanaesthetics)2. Communicable diseases(HIV , hepatitis)3. Systemic diseases( valvular heartdiseases, oral lesions, immunocompromised patients)4. Psychological problem associated withaging.(gingival recession,staining,decreasedsalivary flow)
CHECKLIST FOR MEDICAL HISTORY(SCULLY AND CAWSON)BLEEDING DISORDERCARDIORESPRIRATORY DISEASESENDOCRINE DISEASESGASROINTESTINAL DISTURBANCESINFECTIONSJAUNDICEKIDNEY DISEASESPREGNANCYDRUG TREATMENT AND ALLERGIES
1. Diet.2. Oral habits like smoking and alcohol.3. Bowel and bladder.4. Apatite.5. Oral hygiene methods.
Patient is asked about the health of othermembers of his/her family. Genetic and hereditary diseases are ruled out.1. Diabetes2. Hypertension3. Bleeding disorder4. Flurosis etc..
Clinical examination- extra oral and intraoralexamination.
Face (gross abnormality) Skin(pallor , pigmentation and cyanosis) Hair(alopecia ,hirrusitism ) Nails(clubbing) Eyes( anaemia and jaundice) Nose(nasal deviations) T M J (deviation of mandible , any mass over TMJ, tenderness on palpation, clicking sounds) Lymph nodes of head and neck (site, size, number, consistency , tenderness ,fixity ) Salivary gland( enlargement of majorglands, dryness of mouth, quantity andcharacter of secretion)
Palpating submandibular salivary gland Palpation of T M J
Percussion of tooth indicates inflammation inPDL due to trauma, sinusitis or PDL disease. PERCUSSION OF A TOOTH1. Tapping over tooth using blunt handle ofmouth mirror2. Each tooth to be percussed on all surfacesof tooth.3. Degree of response to percussion is directlyproportional to degree of inflammation.
Intraoraly of less importance. But useful in assessing movement oftempromandibuar joints.
Clinical examination of tooth is done by usingexplorer or a probe.
Periodontal condition can be assessed bypalpation , percussion, mobility of tooth andprobing. Periodontal examination shows change incolour , contour,form,density,level ofattachment and bleeding tendency.
Grade0-physiological mobility. Grade 1-faciolingual Grade2-faciolingual with mesiodistaldirection. Grade3-apical direction
1. Visual changes in tooth surface2. Tactile sensation while using explorer3. Radiography4. Transillumination
Radiograph help to diagnosetooth related problems likecaries, fracture , root canaltreatment , previousrestorations, abnormalappearance of pulpal orperiradicular diseases,PDLdiseases etc… Uses of radiograph1. Establishing diagnosis2. Determining prognosis oftooth3. Thickness of PDL4. Status of lamina dura5. Lesion associated with toot6. Status of root canals7. Obstructions of pulp space
Study casts are used as adjuvant to developthe proper treatment plan . study cast help instudy of following;1. To educate patient2. Occlusal relationship3. Cross bite4. Tilted teeth
Most common investigations include;1. TLC2. DLC3. BT4. CT etc…
This test diagnose both vitality andpathological status of pulp. Various test include;1. Thermal test2. Electric pulp testing3. Test cavity4. Anaesthesia testing5. Bite test
Response of pulp to heat and coldis noted. Here patients respond to thermalstimuli and reports sensation. Cold test Perfumed using;1. Spraying with cold air2. Pellet saturated with ethylchloride3. Dry iceHeat test1. Warm air2. Heated gutta percha stick3. Deliver warm water
Electric pulp tester is used for evaluation ofcondition of pulp by electrical excitations byneural elements within pulp.
Used when all other methods areinconclusive. Here a cavity within the tooth is made with abur without anaesthetized. Patient is asked to respond if at all there isany sensation. Sensitivity indicates pulp vitality.
Used when other methods are inconclusive. Main objective of this test is to anesthetise asingle tooth at a time until the pain iseliminated. If the pain persist even after tooth has beenfully anaesthetised repeat the procedure tonext tooth.
This test help if patient complaints of pain onmastication. Patient is allowed to bite over the surface oftooth prick or orangewood stick. Sensitivity indicates vital pulp.
1. LASER DOPPLER FLOWMETRY2. PULP OXIMETRY3. DUAL WAVELENGTHHSPECTROPHOTOMETRY4. MEASURMENT OF TEMPRATURE OF TOOTHSURFAVE5. XENON 1336. GAS DESATURATION7. ELECTROMAGNETIC FLOWMETRY
Consists of many phases;1. Urgent phase2. Control phase3. Holding phase4. Definitive phase5. Maintenance phase
Aims in providing relief from symptoms. Example incision and drainage of an abscessfor acute irreversible pulpits,
Aims in halting the progress of primarydisease. Example-caries or periodontal problem byremoving etiological factors. Helps in long term prevention of dental caries
Comes between control phase and definitivephase. Advice patient to have home care habits For example-advice an amalgam restoredpatient not to have food with restored partfor 24 hrs.
Regular recall, examination of the patient isdone. Helps in prevention of recurrence of thecondition Recall visit depends on severity of diseaseamong various patients.
Includes procedures like endodontic,orthodontic , periodontic,operativeprocedure prior to further treatment.
All procedures done from initial to final stagehas to recorded with date.Maintenance of record is also a legaldocument.