Introduction. Patient assessment. a) General data. b) Medical review. c) Dental history. Examination and diagnosis. 1 Diagnosis of dental caries.

. a) Determination of risk factors: b) Clinical examination of caries: 1. Visual. 2. Tactile. 3. Radiographic. 4. Transillumination. 5. Digitizers. 6. Laser topography. 1. Examination of caries in pits and fissures. 2. Examination of caries in smooth proximal surfaces. 3. Examination of caries in smooth cervical surfaces. 1 Clinical examination of amalgam restoration. 1. Amalgam blues. 2. Amalgam overhangs. 3. Ditching.

4. Voids. 5. Fracture line. 6. Improper anatomical contour. 7. Marginal ridge discrepancy. 8. Proximal contact defect. 9. Recurrent caries. 1 Clinical examination of cast restoration. 1 Clinical examination of esthetic restoration. 1 Adjunctive aids for examining teeth and restorations. 1. Percussion. 2. Palpation. 3. Vitality test. 4. Cavity test. 5. Study cast. 6. Additional aids. 1 Treatment planning. Types: 1. Ideal treatment planning. 2. Optional treatment planning. Sequence of treatment plan: 1. Control phase. 2. Holding phase. 3. Defintive phase. 4. Maintenance phase.

Introduction
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For proper treatment planning we must do the followings: I. Proper infection control. II. Over view of the patient including: 1. Printed questionnaire for personal and medical history. 2. Review of medical history.
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Clinical examination of oro-facial soft tissues followed by examination of dental caries and other teeth problems including erosion and abrasion, then examination of previous restorations.

Patient assessment a) General data: 1. Patient full name. 2. Address and telephone number: To postpone the appointment if needed and to send him a bill of fees. 3. Age: Gives an idea about: a) Size of the pulp.
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The position of the gingival attachment.

c) The depth of the cavity and the biological principles. 4. Sex: Certain diseases are related to specific sex, e.g. gingival enlargement during pregnancy and menstruation. 5. Occupation: Gives an idea about certain occupational defects, e.g. notches in anterior teeth of dressmakers and carpenters. Gives an idea about the material of choice for restoring a tooth. b) Medical review:
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This helps in identification of any condition that may alter, complicate or contraindicate the proposed dental procedures. Certain systemic diseases may need consultation with specialist before starting treatment, e.g. cardiac patient. Another condition needs hospitalization, e.g. hemophilia. Others need certain precautions to prevent cross infection, e.g. hepatitis.

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Conditions that may alter or interfere with treatment, e.g. diabetes. Allergic manifestations to certain drugs, e.g. L.A.

c) Dental history: 1) Past dental history:

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Frequency of dental treatment and problems were met during past interference, should be recorded. Past dental experience for the same problem (Chief complaint) should be discussed with the patient in order to not to repeat disagreeable procedures.

2) Present dental history:

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The patients present problem (chief complaint) should be recorded in the chart. The onset, duration and the related factors of the chief complaint should be recorded. The date and type of available radiographs should be recorded to determine the need for additional radiograph and to minimize the patient exposure to necessary ionizing radiation.

Examination and diagnosis

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Examination: The process of observing both normal and abnormal conditions. Diagnosis: The determination and judgment of variations from normal. Clinical examination procedures should be proceeded by review of the general oral condition and the type of occlusion using examination rubber gloves for all steps.

Diagnosis of dental caries

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Diagnosis of dental caries should include:

a) Determination of risk factors. b) Clinical examination of dental caries. a) Determination of risk factors:
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Risk factors predisposing for dental caries are either: genetic role.

1) Non-oral factors including: Age. Sex, medical condition and general health, fluoride and

2) Oral factors including: Tooth anatomy, oral flora, oral hygiene, previous restorations and reduced salivation. Caries risk assessment:
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It means categorization of individuals according to their liability to caries occurrence, either of high or low risk. This is done by counting 2 types of bacterial species per mm3 of saliva. This is known as Differential bacterial count. The two types of bacteria are st.coccus mutans and lactobacilli. More than 106/mm3 the patient is classified as high risk. Less than 105/mm3 the patient is classified as low risk.

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b) Clinical examination of caries: 1. 2. 3. 4. 5. Visual examination: Changes in texture and color of the tooth surface. Cavitation. Tactile: catching with probe or explorer. Radiographic: radiolucent area appears in bite wing or periapical view. Transillumination: Dark area appeared when the tooth is subjected to fiber-optic light. Digitizers: a) Scanning usual radiographs. b) Direct using R.V.G. c) Indirect using Digora.
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Scanning usual radiographs: Analyzing the degree of radiolucency of the carious lesion to estimate its extent by subtracting old from new radiographs.

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Direct using R.V.G.: There is no film but a special intra-oral sensor is used instead of the conventional X-ray film, which transmits the image to a computer monitor.

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Indirect using Digora: The radiograph is analyzed using a computer system, which could differentiate between different gray tones of the radiograph.

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Laser tomography: CO2 gas laser with spectroscopy. Mechanism Enamel has decreased water and carbon contents and increased content of minerals, so it shows decreased effect of CO2 gas laser.

Caries has increased water and carbon contents and decreased minerals, so it is very sensitive to CO2 gas laser. When caries is exposed to CO2 gas laser, its water contents will be evaporated leaving black carbonized residue.

Caries tends to occur bilaterally and adjacent proximal surfaces may be affected, i.e. if the caries is found in the occlusal or proximal surface in one tooth on one side, then the changes increased for the same location.

1) Examination of caries in pits and fissures:

These are the most caries susceptible areas where the developmental lobes of calcification fail to coalesce. Methods: 1. Discoloration and any changes in color by visual examination. 2. Probe catch by tactile examination. Examination of caries in smooth proximal surfaces: Visual examination: Chalky appearance or shadow under the marginal ridge. Observable cavitation in deep cavities. Tactile examination: By passing dental floss along side the proximal surface, tearing of dental floss fibers indicating caries. Transillumination: Dark cone in proximal surface in bite wing film is a true indicator for proximal caries.

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3) Examination of caries in smooth cervical surfaces:

Visual examination: Chalky appearance of the cervical 1/3 may denote caries. Disappearing-reappearing phenomenon, the chalky white appearance of carious lesion disappears with wetting and appears with dryness. Tactile examination: Sensitivity to probing.

Clinical examination of amalgam restoration 1. Amalgam blues:

Bluish discoloration seen through enamel that may be due to: 1. Corrosive products leaching out from amalgam. 2. Amalgam seen through undermined enamel.

2. Amalgam overhangs:

Could be diagnosed by: 1. 2. 3. 4. Visual: buccal, lingual or occlusal overhangs. Tactile: using explorer. Radiographic: for proximal overhangs. Dental floss: threading of the floss when passed proximally.

3. Ditching:

Can be diagnosed visually or by probing which drops at the tooth/restoration interface. When ditching is deep it can not be smoothened, amalgam should be replaced.

4. Voids:

Represents surface discrepancies rather than ditches. If more than 0.2 mm the restoration should be considered as defective one and should be replaced.

5. Fracture line:

Using visual and tactile method, careful examination should be done to locate fracture line. Amalgam should be replaced.

6. Improper anatomical contour:

When inadequate embrasure or misplaced contact area should consider the restoration is defective and should be replaced.

7. Marginal ridge discrepancy:

The proper position and height of marginal ridge should be inspected and compared with the neighboring tooth, other wise the restoration should be considered defective and replaced.

8. Proximal contact defects:

Using dental floss or passing light between the teeth may indicate the contact area relation of amalgam restoration. Open contact or tight contact may lead to gingival and periodontal problems.

9. Recurrent caries:

Could be detected visually, tactile or radiographic as primary caries.

Clinical examination of cast restoration

The same as amalgam restoration.

Clinical examination of esthetic restoration

The same as amalgam in addition to discoloration. Discoloration: Should be observed whether marginal, surface or bulk type of discoloration and the restoration should be considered defective.

Adjunctive aids for examining teeth and restorations 1) Percussion:

Done by gentle tapping the occlusal or incisal surface of the teeth by the use of mirror handle to determine the presence of tenderness indicating periapical involvement. Pain on vertical percussion indicating periapical involvement. Pain on lateral percussion indicating periodontal involvement. Care must be taken with maxillary teeth due to close relation to maxillary sinus. Percussion should be done out of sequence to avoid patient concentration with the affected tooth.

2) Palpation:

Done with teeth tender to percussion to determine the presence of periapical or periodontal abscess. It is performed by rubbing any swelling between index finger and bone to feel fluctuation. Any abscess or cyst in advanced stage may reveal tenderness to palpation.

3) Vitality test:

Thermal: Either hot or cold. Sensitivity to hot with exaggerated response indicates acute pulpitis. Sensitivity to hot which disappears after removal of stimulus indicates hyperemia. Sensitivity to hot, which persists, indicates pulpitis or pulp gangrene.

Electric: Using electric pulp tester (EPT). It causes tingling effect when pulp is vital. No response to EPT indicates pulp death. It is important to obtain readings on adjacent and contra-lateral teeth to evaluate the affected tooth response.

4) Cavity test:

Done when there is no other means to diagnose the pulp vitality. Using round bur without anesthesia, a cavity is made through the restoration into dentin. Lack of sensitivity indicating non-vital pulp.

5) Study casts:

They are helpful in providing an understanding of the occlusion and planning of treatment. They are also useful for explaining the treatment for the patient.

6) Additional aids:

Transillumination. Mobility test, for periodontal examination. Anesthesia test, for diagnosis of referred pain. Occlusal analysis, for any defects in occlusion. Review of periodontium as operative procedures must continually performed with respect, understanding and concern of the periodontium.

Treatment planning Types: 1) Ideal treatment plan:

It is the plan where the best forms of treatment are done irrespective to the patient and dentist limitations.

2) Optional treatment plan:

It is the plan where the maximum form of treatment is done in relation to the patient general and oral conditions as well as the dentist knowledge and experience.

Sequence of treatment planning: 1) Control phase:

This phase removes etiological factors and stabilizes the patient health including: 1. 2. 3. 4. 5. Elimination of pain. Elimination of active disease such as caries and inflammation. Removal of conditions preventing maintenance e.g. overhanged restoration. Elimination of the potential disease causes e.g. impacted third molar. Starting preventive dentistry instructions.

2) Holding phase:

The holding phase is a time between the control and definitive phase that allows for resolution of the inflammation and time for healing: 1. 2. 3. Home care habits are reinforced. Motivation for further treatment is assessed. Initial treatment is reassessed before starting definitive care.

3) Definitive phase:

After reassessment of the initial treatment the need for further care should be determined. This includes some forms of endodontics, periodontics, orthodontics, oral surgery, and operative procedures prior to fixed or removable prosthetic treatment.

4) Maintenance phase:

Regular recalls examinations that may reveal the need for further adjustment. Reinforcement of home cares.