This document provides an overview of the process for patient assessment, clinical examination, diagnosis, and treatment planning for operative dentistry procedures. It discusses collecting the patient's chief complaint, medical history, and dental history. The examination involves assessing the teeth, occlusion, esthetic appearance, and taking radiographs and photographs. Risk factors for caries are identified. The ADA caries classification system is used to categorize lesions. The information gathered is used to develop an appropriate treatment plan.

1. Patient Assessment,
Diagnosis &Treatment
Planning in Operative
Dentistry

2. • Any discussion of diagnosis and treatment must
begin with an appreciation of the role of the
dentist in helping patients maintain their oral
health.
• This role is summarized by the Latin phrase
“primum non nocere,” which means “do no
harm.”
• This phrase represents a fundamental principle
continually embraced by those in the healing arts
over many centuries.

3. • This chapter provides an overview of the process through
which a clinician completes patient assessment, clinical
examination, diagnosis, and treatment plan for operative
dentistry procedures.
• The success of operative treatment depends heavily on an
appropriate plan of care, comprehensive analysis of the
patient’s reasons for seeking care and on a systematic
assessment of the patient’s current conditions and risk for
future problems.

4. • This information is then combined with the
best available evidence on approaches to
management of the patient’s needs so that an
appropriate plan of care may be offered.

5. EVIDENCE BASED DENTISTRY
• Evidence-based dentistry is defined as the
“conscientious, explicit, and judicious use of
current best evidence in making decisions
about the care of individual patients.”
• Systematic reviews emerging from the focus
on evidence-based dentistry will provide
practitioners with a distillation of the available
knowledge about various conditions and
treatments.

8. PATIENT ASSESSMENT
• Chief Complaint
 Symptoms
• Medical History
 Communicable Disease,
 Allergies or Medications,
 Cardiac abnormalities,
 Physiologic changes associated with
aging
• Dental History

9. Chief complaint
• The patient’s chief complaint, or the chief concerns
that initiated the patient’s visit, should be identified
and clearly understood.
• Concerns are recorded essentially verbatim in the
dental record.
• The patient should be encouraged to discuss all
aspects (symptoms) of the current problem(s),
including onset, duration, and related factors they are
experiencing.
• This information is vital to establishing which specific
diagnostic tests are required, determining the cause,
selecting appropriate treatment options for the
concerns, and building a sound relationship with the
patient.

10. MEDICAL HISTORY
• Medical history is an integral part of the pre-
examination patient interview, which helps
identify conditions that could alter,
complicate, or contraindicate proposed dental
procedures.

11. • The practitioner should identify: (1)
communicable diseases that require special
precautions, procedures, or referral; (2)
allergies or medications, which may
contraindicate the use of certain drugs; (3)
systemic diseases, cardiac abnormalities, or
joint replacements, which may require
prophylactic antibiotic coverage or other
treatment modifications; and (4) physiologic
changes associated with aging, which may
alter clinical presentation and influence
treatment.

12. DENTAL HISTORY
• DENTAL history is review of previous dental experiences and
current dental problems.
• Reveals information about past dental problems, previous
dental treatment, and the patient’s responses to treatments.
• Frequency of dental care and perceptions of previous care
may be indications of the patient’s future behavior.
• 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
might help avoid future complications.
• The date, type, and diagnostic quality of available
radiographs should be recorded so as to ascertain the need
for additional radiographs and to minimize the patient’s
exposure to ionizing radiation.

13. EXAMINATION
• Two types: intraoral and extraoral
• Utilization of clinical photography to capture full face and
profile images is particularly useful in this process.
• Any observations will ultimately be followed by the physical
examination necessary to assess extraoral aspects of the
muscles of mastication, temporomandibular joints (TMJs),
lymphnodes, and other vital structures, which will then be
followed by intraoral examination.

14. Examination of Esthetic Appearance
• Examination of esthetic appearance may be described as
the evaluation of tooth color, form, display, and position
in relation to the face.
• “Form follows function”.
• Tooth color evaluation becomes a factor if teeth are more
visible when smiling or at the resting position of lips.
• Darker colored teeth, teeth with enamel intrinsic staining,
and conditions such as tetracycline staining all increase
the risk for not satisfying the esthetic expectations of
patients with tooth color concerns.
• Symmetry of gingival margins becomes very important
in patients who display a large amount of gingival tissue
when smiling.

15. EXAMINATION OF OCCLUSION
• A careful examination of the patient’s current occlusal
scheme, along with potential impact on the muscles of
mastication and TMJs, must occur before planning and
implementing restorative care.

16. • This examination includes :
1. signs of occlusal trauma, such as heavy wear
facets, enamel cracks, or
2. tooth mobility, and
3. notation of occlusal abnormalities that may be
contributing to pathologic conditions such as bone
loss.

17. • A description of the patient’s static anatomic occlusion in
maximum intercuspation, including the relationship between
molars and canines (Angle Class I, II, or III), and the amount of
vertical overlap (overbite) and horizontal overlap (overjet) of
anterior teeth should be recorded.
• This should include assessment of the presence and specifics
of any functional shift from centric relation occlusion to
maximum intercuspation.

19. • The presence of missing teeth and the
relationship of the maxillary and mandibular
midlines should be determined.
• The appropriateness of the occlusal plane and
the positions of malposed teeth should be
identified.
• Supererupted teeth, spacing, fractured teeth, and
marginal ridge discrepancies should be noted.
• The dynamic functional occlusion in all
movements of the mandible (right, left, forward,
and all excursions in between) should be
evaluated.

20. • The evaluation also includes assessing the
relationship of teeth in centric relation, which is
the orthopedic position of the joint where the
condyle head is in its most anterior and superior
position against the articular eminence within the
glenoid fossa.
• Functional movements of the mandible are
evaluated to determine if canine guidance or
group function exists.
• The presence and amount of anterior guidance
is evaluated to note the degree of potential
posterior disclusion.

21. • Teeth are examined for abnormal wear patterns that
are excessive and not age appropriate. If signs of
abnormal or premature wear are present, the
patient is queried as to awareness of any
contributing parafunction habits such as grinding or
clenching.
• Nonworking-side excursive contacts are recorded
and related to any findings of masticatory muscle
myositis and/or ipsilateral TMJ disc issues.
• Working-side excursive contacts are recorded and
related to areas of cusp fracture development.
• Protrusive contacts on all posterior teeth molars are
noted

22. • Heavy wear facets on posterior cuspal inclines,
mobility of teeth, or fremitus during function is
identified and classified as primary or secondary
occlusal traumatism.
• Full analysis of the occlusion may require
articulated diagnostic models.
• Movement of the mandible from maximum
intercuspation to maximum opening is observed
and maximum unassisted opening is measured;
any “clicking or popping” of the joint disc(s)
during mandibular movements is noted and
related to any history of trauma, nonworking
occlusal interferences, or other possible
pathologic changes.

23. • Bimanual loading of the joints and palpation of the
condyle lateral poles and retrocondylar areas (during
wide mandibular opening) are completed to further
test for tenderness/pain as signs of inflammation.
• The occlusal relationships of the teeth are assessed for
the presence of an unusually tall and narrow cusp (a
“plunger cusp”) that “plunges” deep into the occlusal
plane of the opposing arch. A plunger cusp might
contact the lower of two adjacent marginal ridges of
diferent levels, contacting directly between two
adjacent marginal ridges in maximum intercuspation,
or be positioned in a deep fossa. It may increase the
likelihood of food impaction and tooth or restoration
fracture.

24. • Magnification
• Photography in Operative
dentistry
Examination of Teeth and
Restoration

26. AMERICAN DENTAL ASSOCIATION CARIES CLASSIFICATION
SYSTEM

27. • Advantages:
 Easy to use
 We can document current esthetic condition of
patient
 Notice changes in existing pits and fissures
 Photographs of treatment of deep carious lesion
aid in future diagnosis of tooth
 For digital documentation it is easier and cost
effective.

29. • Preparation Of Clinical Examinations
 Clean, dry, Well illuminated mouth that’s why initial scaling, flossing,
tooth brushing is required
 Proper examination instruments
 Cotton rolls should be placed
 Floss is good for determining over hanging, improper contours and
open contacts
 Starting from the upper right quadrant with posterior tooth and then
moving to maxillary and mandibular arches

30. Risk assessment
Risk Indicators

32. • Categorization according to the above
factors

34. • Identify early
lesion
• Visual changes
• Tactile sensation
• But explorers are discouraged
Why???
Clinical Examination of Caries

35. • Good for root surface
caries
• Radiographs are also good
• Primary Occlusal grooves
and Fossa are less
prone
• Occlusal fissures and pits
are more prone

36. • Chalkiness or softening or cavitations of
tooth structure
• Brown gray discoloration radiating
peripherally from pit and fissure
•Carious pits
Causes
 Developmental defects
 Erosion or Abrasion
Occurrence
 Occlusal two-third of Facial and lingual surface of tooth
 May be on the palatal side of Maxillary tooth

37. ICDAS(International caries Detection
and Assessment system)

38. • Histological depth
1= 90% in outer enamel & 10% into dentin
2=50% inner enamel & 50% into outer one
third dentin
3=77% dentin
4=88% dentin
5=100% dentin
6=100% dentin into one third of inner
dentin

40. • Proximal surface
caries
Diagnosed
 Radio graphically
 Visually by separating contact
 Fiber optic transillumination
• Brown Spots
 Remineralized lesion less prone
to caries rather more resistant to
caries.
•Proximal Surface Caries
in anterior teeth
Diagnosed
 Radio graphically
 Visually
 Fiber optic transillumination
 Probing or explorer

41. • Cervical Caries
 White spot early enamel lesion
 Dry and wet is distinguishing test
 Diagnosed tacitly
• Root surface Caries
 Root exposure, dietary changes, Systemic disease,
Xerostomia
 Lesion at C.E.J
 Soft and spread laterally around C.E.J
 Active lesion is soft and cavitated
 Best diagnosed by vertical bite wing radiographs
• New Methods For Diagnosing
caries
 DIAGNOdent
 Spectra Camera
 Carie ScanPro

42. • DIAGNOdent
device
• Major disadvantage is false positive
test

43. • Spectra
Camera
• High energy violet or blue light on tooth
surface
• It stimulate porphyrins metabolites which
make carious lesion red while enamel
appear green
• It has scale 0-5

44. • Carie Scan PRO
 Caries detection by alternating current
impedance spectroscopy(ACIST)
 Detects early carious lesion
 Provide color and numerical scale for severity of
caries

45. Clinical examination Of
Amalgam Restorations
• Amalgam blues
• Proximal overhangs
• Marginal Ditching
• Voids
• Fracture lines
• Lines indicating the interface b/w abutted
restorations
• Improper anatomic contours
• Marginal ridge incompatibility
• Improper proximal contacts
• Recurrent Caries
• Improper occlusal contacts

47. Clinical examination of indirect tooth
colored restorations
• Should be evaluated clinically in the same
manner as amalgam restorations.
• Any aspect of the restoration that is not
satisfactory, that is causing harm to tissue or
occlusal function, should be noted and
considered for recontouring, repair, or
replacement.

48. Clinical Examination Of Composite and
other tooth colored
Restorations
Check for Corrective procedures
• Recontouring,
• Polishing,
• Repairing, or
• Replacement of the
restoration
• Proximal Over hangs
• Marginal ditching
• Recurrent caries
• Improper contour
• Voids

50. Clinical Examination of
Dental implants and Implant
Supported Restorations
• In molars it is difficult to
replace three roots with one
implant
• Vertical loss of bone support
prior to implant placement
makes vertical space making
crown implant ratio difficult
• Peri-implantitis
• Occlusion is difficult to maintain
due to lack of cushioning
• Restoration should confined in
the middle with no deflections

51. Clinical examination of Additional
Defects
• Non hereditary hypo calcified areas of enamel
• Amelogenesis imperfecta
• Dentonogenesis imperfecta
• Chemical erosion
• Idiopathic Erosion
• Abrasion
• Attrition
• Fracture –horizontal or vertical
• Craze line
• Dental anomalies – variation in size, shape, structure, and or
number teeth

52. Non-hereditary hypocalcified areas on facial surfaces.
These areas may result from numerous factors but do not
warrant restorative intervention unless they are esthetically offensive
or cavitation is present.

53. Radiographic Examination of Teeth
and Restorations
Indications of Radiographs
• Proximal caries, overhang, poorly
contoured restorations
• Pulpal abnormalities
• Periapical changes in peridontium
• Impacted tooth or congenital
abnormality
• False positive and negative diagnosis

54. Guide lines for Prescribing Dental Radiographs
For Dentate Adults
New
Patients

55. • Recall Patient
• Clinically caries present or High
risk
• No Clinically Caries or No Risk
Factors
• Periodontal
disease

56. Adjunctive Aids in diagnosis of teeth and
Restorations
• Percussion
• Palpation
• Vitality Test
 Hot test
 Cold test
 Electric pulp
tester
 Test Cavity
• Study Cast

57. Examination Of Occlusion
• Signs of enamel cracks, occlusal trauma
• Potential effect of restoration on occlusion
• Class of occlusion
• Over jet
• Over bite
• Midline shifts
• Position of malposed teeth, super erupted,
spacing
• Dynamic occlusion should be evaluated
• Relation should also be assessed in centric
relation
• Canine guidance or group function exist
• Presence and amount of anterior guidance
• Non working side contacts
• Abnormal wear should be checked
• Plunger cusp

58. Review Of Peridontium
Clinical Examination
• Gingival color,shape,texture
• Depth of sulcus
• Instrument used for measuring
depth
• Six locations
• Normal sulcus depth
• Involvement of furcation
• Gingival recession
• Mobility
• Plaque presence
• Proper contoured restorations

59. Radiographic
Examination
• Bitewing are good for assessing bone
level
• What is Biologic width?
• Normal value?
• What will happen if restoration
encroach biologic width?
• What method is done to avoid
these condition?

61. Prognosis
• Prognosis is the term used to describe the prediction of the
probable course and outcome of a disease or condition as
well as the outcome expected from an intervention, be it
preventive or operative.
• In operative dentistry, prognosis may be used to describe the
likelihood of success of a particular treatment procedure in
terms of time of service, functional value, comfort, and
esthetic value for the patient.
• A prognosis may be described as excellent, good, fair, poor, or
even hopeless

63. Treatment Planning
• General Consideration
• Treatment plan Sequencing/ phasing
• Interdisciplinary Consideration
 Endodontic
 Periodontics
 Orthodontics
 Oral Surgery
 Fixed and Removable prosthodontics
• Indications for Operative Treatment
• Preventive treatment
• Restoration of incipient lesion

64. • Treatment Of Abrasion, Erosion and
Attrition
• Root surface Sensitivity
• Repairing of Restoration
• Replacement of Restorations
• Indication of Amalgam Restoration
• Indication of Direct Composites
• Indication of Indirect tooth Color
restoration
• Geriatric Patient

66. Sequencing

67. URGENT PHASE
• Begins with a thorough review of the patient’s
medical history and current condition.
• A patient presenting with swelling, pain,
bleeding, or infection should have these
problems managed as soon as possible, before
initiation of subsequent phases.

68. CONTROL PHASE
• A control phase is appropriate when the
patient presents with multiple pressing
problems and extensive active disease or
when the prognosis is unclear.
• The goals of this phase are to remove
aetiologic factors, eliminate the ecologic
niches of pathogens, and stabilize the
patient’s dental health.

69. • These goals are accomplished by
I. Removal of active disease such that
inflammation may resolve,
II. Correction of conditions that prevent or limit
hygiene efforts,
III. Elimination of potential causes of disease,
and
IV. Initiation of preventive activities.

70. Re-evaluation phase
• The re-evaluation phase allows time between
the control and definitive phases for
resolution of inflammation and healing.
• Initial treatment and pulpal responses are
reevaluated during this phase as the relative
effectiveness of control phase treatment may
influence and modify the definitive phase
treatment plan.

71. • This phase is used to reinforce home care
habits and assess motivation for further
treatment.
• Low profile cases – minor alterations in diet,
behaviour and exposure to remineralization
phase.

72. Definitive phase
• Patient enters the definitive phase of
treatment only after the dentist reassesses
initial efforts to control disease and, with the
patient, determines the need for further care.
• Includes endodontic, periodontal,
orthodontic, and surgical procedures.
• The patient’s active disease must be under
control, and preventive efforts habitually
established, before fixed or removable
prosthodontic treatment.

73. Maintenance (re-assessment and
recare) phase
• The maintenance phase includes regular
reassessment (synonyms include re-
evaluation, periodic examinations) that may
reveal the need for adjustments to prevent
future breakdown, provide an opportunity to
reinforce home care, and plan recare
treatment steps where disease has returned.

74. • Examinations for reassessment most
frequently occur as part of strategically
planned (recall) appointments for biofilm
removal (dental prophylaxis).
• frequency of re-evaluation examinations
depends on the patient’s risk for dental
disease.

75. • low-risk profile - longer intervals (e.g. 9–12
months) between recall visits.
• high-risk profile - recalled and examined much
more frequently (e.g. 3–4 months).

76. Interdisciplinary considerations
• Following is a discussion on sequencing
operative care with endodontic, periodontal,
orthodontic, surgical, and prosthodontic
treatments.

77. Endodontics
• All teeth to be restored with large restorations
should have a pulpal and periapical
evaluation.
• Endodontically treated teeth - shows no
evidence of healing or has an inadequate
filling or a filling exposed to oral fluids,
should be evaluated for retreatment before
restorative therapy is initiated.

78. Periodontics
• Periodontal treatment should precede operative care-
improved oral hygiene and initial scaling/root planing
procedures create (through reduction of gingival
inflammation) a more desirable environment for performing
operative treatment.
• Treatment of deep carious lesion often requires caries control
– management of deep caries using temporization , creating
foundation or root canal therapy/foundation can done before
periodontal treatment.

79. • If periodontal surgical procedures are required
- indirect restorations such as inlays or onlays,
crowns, and prostheses should be delayed
until the surgical phase is completed.
• Patients with gingivitis and early periodontitis
generally respond favourably to improved oral
hygiene and scaling/ root planing procedures.

80. • Patients with more advanced periodontitis
might - require removal (or at least
minimization) of associated risk
factors/indicators through surgical steps that
eliminate/reduce sulcular depths or various
regenerative procedures to resolve their
periodontal disease.

81. • Steps to increase the zones of attached gingiva
and eliminate abnormal frenal tension should be
achieved by corrective periodontal surgical
procedures around teeth receiving restorations
with sub-gingival margins.
• Any teeth requiring restorations that may
encroach on the biologic width of the
periodontium should have appropriate crown-
lengthening surgical procedures performed
before the final restoration is placed.

82. • Minimum of 6 weeks is required after the
surgery before final restorative procedures are
undertaken.
• A tooth with a questionable periodontal
prognosis should not receive an extensive
restoration until periodontal treatment
provides a more favourable prognosis

83. Inter-disciplinary Consideration
in Operative treatment
• Pulpal or periapical Pathology
• Endodontically treated tooth show no evidence
of healing,
• Inadequate fill
• Fillings exposed to oral fluids
• Precede operative treatment
• Poor periodontal prognosis=no
extensive restoration
• Good health = Before or after
• Surgical procedure indicated= before permanent
restorations
• Biological width: Crown lengthening ( 6 week
after surgery)

84. • Extrusion
• Realignment
• Impacted, Unerupted
• Grossly carious tooth should be extracted
especially 2nd molars whose has to receive
cast restoration are damaged due to
removal of 3rd molars
• Core buildup can be done from
amalgam or composite
• Preparation for receiving clasp, rests in
removable prosthesis

85. Treatment Of Abrasion, Erosion,
Abfraction and Attrition
Considered for restoration only
• Area is affected by caries
• Defect is sufficiently deep compromise
structural integrity of tooth
• Intolerable sensitivity
• Defect continue to peridontal problem
• Area is to be involved in design of partial
denture
• Involving the pulp
• Actively progressing
• Desire for esthetic improvement

86. Treatment of root surface caries
• Arrested lesion not need to be restored until for
aesthetic purposes
• Active lesion can be restored by tooth color
restorations
Treatment of root surface sensitivity
• Fluoride varnishes
• Oxalate solutions
• Resin based adhesives
• Desensitizing tooth paste contain Potassium nitrate
• Restorative treatment

87. Replacement of Existing
restoration
• Marginal void
• Gingival overhang
• Marginal ridge
discrepancy
• Over contouring of facial
and lingual surface
• Poor proximal Contact
• Recurrent Caries
• Ditching deeper than
0.5mm
Non tooth color restoration Tooth color restoration
• Improper contour
that cannot be
repaired
• Large voids
• Deep marginal
staining
• Recurrent caries
• Unacceptable
aesthetics