PATIENT EVALUATION,DIAGNOSIS

AND TREATMENT PLANING

PRESENTED BY;ABDUL VAJID M

To provide best treatment and patient satisfaction , thorough clinical history , examination and diagnostic aids are required.

Diagnosis is defined as utilization of scientific knowledge for identifying a disease process and to differentiate from other disease process.

INTRODUCTION;

The diagnostic process actually consists of four steps;

First step ; assemble all the available facts gathered from chief complaints, medical and dental history, diagnostic test and investigations.

Second step ; analyze and interpret assembled clues each and the tentative or provisional diagnosis.

Third step ; make differential diagnosis of all possible disease.

Fourth step ; select the closest possible choice.

PATIENT EVALUATION

Case history is defined as;planned,professional conversation between the patient and the clinician in which the patient reveals his/her symptoms fears, or feelings to the clinician so that the nature of the real or suspected illness and mental attitude to it may be determined.

The purpose of recording patients history and conducting a clinical examination is to arrive at a logical diagnosis to the patients chief compliant and to institute a suitable treatment plan.

CASE HISTORY

It is the description of the problems for which the patient seeks treatment.

It should be recorded in patients own words and should not be recorded in medical terminology.

CHIEF COMPLAINT

It is the detailed description of chief complaint. Examples for the type of questions asked by

clinician 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..

HISTORY OF PRESENT ILLNESS;

The most common toothache may arise either from pulp or from PDL.

Mild to moderate type of pain can be of pulpal or periodontal origin.

If pain from PDL ,teeth will be sensitive to percussion.

Pulpal pain will be sharp and depends on the pulpal fibres involved.

This helps to know any previous dental experience, and past restorations.

PAST DENTAL HISTORY

For a proper medical history, importance should be given to the following;

1. Allergies and medications(allergic to local anaesthetics)

2. Communicable diseases(HIV , hepatitis)3. Systemic diseases( valvular heart diseases,

oral lesions , immunocompromised patients)4. Psychological problem associated with

aging.(gingival recession,staining,decreased salivary flow)

MEDICAL HISTORY

CHECKLIST FOR MEDICAL HISTORY(SCULLY AND CAWSON)

BLEEDING DISORDER

CARDIORESPRIRATORY DISEASES

ENDOCRINE DISEASES

GASROINTESTINAL DISTURBANCES

INFECTIONS

JAUNDICE

KIDNEY DISEASES

PREGNANCY

DRUG TREATMENT AND ALLERGIES

1. Diet.2. Oral habits like smoking and alcohol.3. Bowel and bladder.4. Apatite.5. Oral hygiene methods.

Personal history

Patient is asked about the health of other members of his/her family.

Genetic and hereditary diseases are ruled out.

1. Diabetes2. Hypertension3. Bleeding disorder4. Flurosis etc..

Family history

Clinical examination- extra oral and intraoral examination.

EXAMINATION AND DIAGNOSIS

1. Inspection2. Palpation3. Percussion4. Auscultation5. Exploration

CLINICAL EXAMINATION

Intraoral examination include;1. Hard tissue examination2. Soft tissue examinationExtra oral examination(head & neck )

INSPECTION&PALPATION;

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 major glands, dryness

of mouth, quantity and character of secretion)

EXTRAORAL EXAMINATION;

Palpating submandibular salivary gland Palpation of T M J

1. Teeth present2. Missing teeth3. Dental caries4. Dental caries with pulpal involvement5. Root stumps6. Wasting diseases7. Mobility8. Occlusion9. Deposits10. Fractured teeth11. Others (hypoplasia , malposition etc…)

INTRAORAL EXAMINATION (HARD TISSUE)

WASTING DISEASES;

ABRASSIONEROSION

ATTRISION

Percussion of tooth indicates inflammation in PDL due to trauma, sinusitis or PDL disease.

PERCUSSION OF A TOOTH1. Tapping over tooth using blunt handle of

mouth mirror2. Each tooth to be percussed on all surfaces

of tooth.3. Degree of response to percussion is

directly proportional to degree of inflammation.

PERCUSSION;

TOOTH PERCUSSION USING AN EXPLORER

Intraoraly of less importance. But useful in assessing movement of

tempromandibuar joints.

AUSCULTATION;

Clinical examination of tooth is done by using explorer or a probe.

EXPLORATION

Periodontal condition can be assessed by palpation , percussion, mobility of tooth and probing.

Periodontal examination shows change in colour , contour,form,density,level of attachment and bleeding tendency.

PERIODONTAL EVALUATION

Grade0-physiological mobility. Grade 1-faciolingual Grade2-faciolingual with mesiodistal

direction. Grade3-apical direction

Miller’s grading for mobility

1. Visual changes in tooth surface2. Tactile sensation while using explorer3. Radiography4. Transillumination

EVALUATION OFCARIOUS LESIONS

Radiograph help to diagnose tooth related problems like caries, fracture , root canal treatment , previous restorations, abnormal appearance of pulpal or periradicular diseases,PDL diseases etc…

Uses of radiograph1. Establishing diagnosis2. Determining prognosis of tooth3. Thickness of PDL4. Status of lamina dura5. Lesion associated with toot6. Status of root canals7. Obstructions of pulp space

RADIOGRAPHS

Study casts are used as adjuvant to develop the proper treatment plan . study cast help in study of following;

1. To educate patient2. Occlusal relationship3. Cross bite4. Tilted teeth

STUDY CAST

Most common investigations include;1. TLC2. DLC3. BT4. CT etc…

LABORATORY INVESTIGATIONS

This test diagnose both vitality and pathological status of pulp.

Various test include;1. Thermal test2. Electric pulp testing3. Test cavity4. Anaesthesia testing5. Bite test

PULP VITALITY TEST

Response of pulp to heat and cold is noted.

Here patients respond to thermal stimuli and reports sensation.

Cold test Perfumed using;1. Spraying with cold air2. Pellet saturated with ethyl chloride3. Dry iceHeat test4. Warm air5. Heated gutta percha stick6. Deliver warm water

Thermal test

Electric pulp tester is used for evaluation of condition of pulp by electrical excitations by neural elements within pulp.

Electric pulp testing

Used when all other methods are inconclusive.

Here a cavity within the tooth is made with a bur without anaesthetized.

Patient is asked to respond if at all there is any sensation.

Sensitivity indicates pulp vitality.

Test cavity

Used when other methods are inconclusive. Main objective of this test is to anesthetise

a single tooth at a time until the pain is eliminated.

If the pain persist even after tooth has been fully anaesthetised repeat the procedure to next tooth.

ANESTHESIA TESTING;

This test help if patient complaints of pain on mastication.

Patient is allowed to bite over the surface of tooth prick or orangewood stick.

Sensitivity indicates vital pulp.

BITE TEST

1. LASER DOPPLER FLOWMETRY2. PULP OXIMETRY3. DUAL WAVELENGTHH

SPECTROPHOTOMETRY4. MEASURMENT OF TEMPRATURE OF TOOTH

SURFAVE5. XENON 1336. GAS DESATURATION7. ELECTROMAGNETIC FLOWMETRY

ADVANCMENT IN PULP VITALITY TEST

LASER DOPLER FLOWMETRY

PULP OXIMETRY

Consists of many phases;1. Urgent phase2. Control phase3. Holding phase4. Definitive phase5. Maintenance phase

TREATMENT PLANING;

Aims in providing relief from symptoms. Example incision and drainage of an

abscess for acute irreversible pulpits,

URGENT PHASE

Aims in halting the progress of primary disease.

Example-caries or periodontal problem by removing etiological factors.

Helps in long term prevention of dental caries

CONTROL PHASE

Comes between control phase and definitive phase.

Advice patient to have home care habits' For example-advice an amalgam restored

patient not to have food with restored part for 24 hrs.

HOLDING PHASE

Regular recall, examination of the patient is done.

Helps in prevention of recurrence of the condition

Recall visit depends on severity of disease among various patients.

MAINTANANCE PHASE

Includes procedures like endodontic ,orthodontic , periodontic,operative procedure prior to further treatment.

DEFINITIVE PHASE

All procedures done from initial to final stage has to recorded with date.

Maintenance of record is also a legal document.

TREATMENT RECORD