Patient Assessment, Examination and Diagnosis, and Treatment Planning

Pretreatment considerations consist of: I. Patient assessment II. Examination and diagnosis III. Treatment planning foundation of sound dental care Evidence-based dentistry - defined as conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Routine initial visit involves in obtaining detailed information for treatment planning. Emergency visit requires collecting basic information and then focusing on the patients chief complaint. Reevaluation appointment requires updating patient information and evaluating previous treatment. Recall appointment demands reviewing the patient assessment information and comparing the patients current status with previous conditions.

Patient record is the principal document of information regarding a patients dental needs and treatment.

I. Patient Assessment

 A. INFECTION CONTROL B. CHIEF COMPLAINT C. MEDICAL REVIEW Medical history form focus of the preexamination patient interview, which helps identify conditions that could alter, complicate, or contraindicate proposed dental procedures

Communicable diseases Allergies or medications Systemic diseases & cardiac abnormalities Physiologic changes associated with aging

D. SOCIOLOGIC AND PSYCHOLOGIC REVIEW E. DENTAL HISTORY F. RISK ASSESSMENT

A. INFECTION CONTROL
Before, during, and after any patient visit, appropriate infection control measures must be instituted.

B. CHIEF COMPLAINT
Determine the problem that initiated the patients visit. Record the complaint verbatim in the dental record.

C. MEDICAL REVIEW
Medical history form focus of the preexamination patient interview, which helps identify conditions that could alter, complicate, or contraindicate proposed dental procedures

1. Communicable diseases
A. herpes simplex virus
one of the most common nonrespiratory viral diseases affecting humans Transmitted through saliva.

Two HSV types: 1. type 1 involves the oral and perioral tissues (above the waist) 2. type 2 involves the genital and surrounding areas ( below the waist)

Oral manifestations of primary HSV infection present as primary herpetic gingivostomatitis, an intraoral condition characterized by intensely red gingiva and small painful vesicles (fluid filledlesons) on the lips, facial mucosa, palate, pharynx, tonsils, or gingiva

Herpetic whitlow - HSV infection of the finger

B. chicken pox (varicella) and shingles (zoster) infection with the varicella-zoster virus (VZV) presents as chicken pox (varicella) during initial exposure and as shingles (zoster) in reactivated (or recurrent) disease.

C. condyloma acuminatum (venereal warts) caused by the human papillomavirus. transmissible and autoinoculable disease affects the anogenital skin and mucosa.

D. respiratory viruses most frequently transmitted diseases within the dental environment common cold E. rubeola (measles) Etiology - rubeola virus mode of transmission - respiratory droplets spreading to lymphoid tissue virus multiplication in the upper respiratory tract and conjunctiva causes podromal symptoms ( dry cough, sore throat, headache, low grade fever and conjunctivitis. Kopliks spots first clinical sign; small spots in buccal mucosa

F. rubella ( german measles) mode of transmission respiratory droplets results from infection with a toga-virus distinct from the causative agent of rubeola. G. mumps (infective parotiditis) bilateral or unilateral enlargement of the parotid, submandibular, and/or sublingual glands. paramyxovirus virus - etiologic agent of mumps

H. infectious mononucleosis primary infection with the EpsteinBarr virus characterized by generalized lyphmadenopathy, mild fever, and petechiae (pin-point subsurface hemorrhages) typically at the border of the hard and soft palates kissing disease mode of transmission direct contact with saliva

I. Hepatitis b virus transmitted through body fluids such as blood and saliva J. hepatitis c virus contagious virus that causes chronic liver disease formerly referred to as non-A, non-B hepatitis K. human immunodeficiency virus

HIV associated lesions: 1. oral candidiasis most prevalent oral infection in HIV-infected individuals 2. hairy leukoplakia adherent, filamentous white plaque that exhibits a characteristics corrugated or hairy appearance. 3. Kaposis sarcoma malignancy involving the endothelial covering of blood vessels walls. Initial manifestations of the severe stage of HIV disease known as acquired immuno deficiency syndrome (AIDS)

4. HIV-associated periodontal diseases - lesions include linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis and necrotizing ulcerative stomatitis. 5. lyphmadenopathy - swollen lymph glands 6. apthous ulcers 7. salivary gland disese

L. tuberculosis highly contagious granulumatous disease caused by the slow growing, rodshaped, acid fast bacillus, Mycobacterium tuberculosis. transmitted via inhalation of respiratory droplets & aerosols ( sputum & saliva), ingestion or direct inoculation. M. gonorrhea Neiseria gonorrhoeae, a gram negative diplococci, etiologic agent for gonorrhea

N. syphilis etiology: treponema pallidum Mode of transmission: primarily by sexual contact with skin or mucous membranes Three stages of syphilis a. Primary stage: single granulomatous lesion at point of contact (chancre) (1) asymptomatic (2) highly contagious (3) lasts 3 to 5 weeks, heals spontaneously with no scar. Treatment: antibiotic such as penicillin

b. Secondary stage: patient maybe asymptomatic for 2 to 6 months before symptoms occur (1) flulike symptoms (2) shallow painless ulcers mucous patches on lips, soft palate and tongue that are highly contagious (3) swollen lymphnodes (4) maculopapular rashes on face, hands , feet

c. Tertiary stage: may take years to develop (1) Gumma inflammatory granulomatous lesions on tongue, perforating palate, facial bones (2) gumma is not contagious, usually asymptomatic (3) central nervous system involvement leads to loss of motor coordination, personality changes (4) major cause of death cardiovascular system involvement

2. Allergies or Medications 3. Systematic diseases & cardiac abnormalities 4. Physiologic changes associated with aging

D. SOCIOLOGIC AND PSYCHOLOGIC REVIEW

Attitudinal informations combined with assessment of patients dental appreciation, educability, habits, parental history, occupation, & financial situation Social history gathering personal information about the patient such as essential data for an appointment & legal implication ( e.g. care of a minor) Example: This client is a sophomore in school & lives at home. The client works as a waitress. She is a single mother of 2 children. She reports being under stress due to financial problems.

E. DENTAL HISTORY
Gathering past & present dental information

. Example: The clients radiograph indicate extensive interproximal caries, with one tooth requiring endodontic therapy. She brushes twice a day and flosses once a day.

F. RISK ASSESSMENT
Determination of the patients risk for developing dental caries helps to prevent the caries from developing by beginning appropriate preventive measures

Risk factors attributes or exposures that increase probability that a disease will occur. Causes: environmental conditions, habits, or other diseases that increase or decrease patients susceptibility to infection. Identification: analyze information obtained from oral examination, medical/dental histories

II. Examination and Diagnosis

Clinical examination hands-on process of observing both normal and abnormal conditions Diagnosis is the determination and judgment of variations from normal. Intraoral examination observation and palpation of structures within oral cavity. Extraoral examination observation and palpation of structures of the head and neck outside of oral cavity.

Palpation methods of the oral cavity: a) bilateral useexamination at the Palpation is an of both hands technique in which the examiner same time to examine corresponding uses the on opposite sides to structures fingers and hands of body feel for texture, size, and b) bimanual use finger(s) and/or thumb consistency of hard and soft from each hand; apply simultaneously tissue. c) digital use single finger d) bidigital use finger and thumb of same hand

Charting and records

Identification data- includes all of the patient personal information such as telephone number, whom to contact in case of emergency; medical history; dental history; clinical examination; diagnosis; treatment planning; documentation of informed consent; progress notes; and completion notes Tooth Denotation System Two digit system Preparation for clinical examination Interpretation and use of diagnostic tests

a.

b.

Examination of orofacial soft tissues Examination of teeth and restorations Clinical examination for caries: 1. visual changes in tooth surface texture or color 2. tactile sensation 3. radiographs 4. transillumination

c.

Review of periodontium healthy gingiva - light pink in color, firm, knife-edged and stippled unhealthy gingiva red; soft; edematous; and has a glazed, smooth surface

III. Treatment planning

Carefully sequenced series of services designed to eliminate or control etiologic factors, repair existing damage, and create a functional , maintainable environment. Four steps in the development of a dental treatment plan: 1. examination and problem identification 2. decisions to recommend intervention 3. identification of treatment alternatives 4. selection of treatment with the patients involvement

Treatment plan sequencing - process of scheduling the needed procedures into a time frame. a. urgent phase thorough review of the patients medical condition and history. b. control phase Goals of control phase: 1. remove etiologic factors 2. stabilize the patients dental health examples: extractions, periodontal debridement and scaling; occlusal adjusment is needed; caries removal; replacement or repair of defective restorations; use of control caries measures

c. reevaluation phase time between the control and definitive phases that allows for resolution of inflammation and time for healing. d. definitive phase may include endodontics, periodontic, orthodontic, oral surgical, and operative procedures before fixed or removable prosthodontic treatment. e. maintenance phase regular recall examinations

Patients own words When, why, and how did your patient become ill?

F D O/I L M
C Cl-3

Cl-1

Dental caries, alveolar abscess Oral prophylaxis, restorations, extractions

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VLC

11/21/05

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Class 1 amalgam