CLINICAL DIAGNOSIS AND TREATMENT PLAN

1. CLINICAL DIAGNOSIS AND TREATMENT PLAN

2. CONTENTS • Introduction • Diagnostic procedure • Basic techniques of examination • Personal information and history • General examination • Extraoral examination • Intraoral examination • Gingival examination • Periodontal examination • Hard tissue examination • Investigations • Treatment plan • Conclusion • References

3. INTRODUCTION • One of the first steps in the management of a patient with periodontal disease is to take thorough medical and dental histories and to perform a complete oral/periodontal examination. On the basis of the information collected, a diagnosis ( Greek: dia – ‘‘through”, gnosis - “knowledge” ) can be made. • The goal of periodontal diagnosis is to classify periodontal diseases in some biologically meaningful way that will aid in the selection of the most optimal therapeutic modality and will help to develop a realistic prognosis.

4. The basis for an accurate diagnosis and treatment plan is the systematic collection of data about the patient that are relevant to the prevention or treatment of periodontal disease. • A comprehensive examination should include the case history, the clinical examination, the diagnosis and the treatment plan.

5. The focus of interest should be on the patient who has the disease and not simply on the disease itself. • Diagnosis must therefore include a general evaluation of the patient and consideration of the oral cavity.

6. Case History: A planned professional conversation which enables the patient to communicate their symptoms and fears to the clinician so that nature of the patient’s real and suspected illness and mental attitudes may be determined.

7. The objectives of the case history are directed toward forming a tentative diagnosis and determining any systemic factors that might affect the diagnosis or influence the treatment plan. • The taking of the history is usually the first opportunity for communication between the dentist and the patient.

8. There are 5 basic categories of information to be obtained in the course of every formal history. • Identification of the problem (chief complaint). • Clarification of the circumstances surrounding the onset and development of the problem (history of the present illness). • Documentation of the diseases or conditions in the past (past medical history).

9. Investigations into possible genetic, social or environmental factors influencing the problem (family health, personal and social history). • Summary of additional symptoms by organ system. (review of systems).

10. Diagnostic Procedure The procedure can be divided into: • Personal information. • Taking and recording history. • Examining the patient. • Establishing a provisional diagnosis on the basis ofhistory and examination. • Conducting the necessary investigation. • Formulation of final diagnosis on the basis of the results of the investigations. • Making a plan of treatment and medical risk assessment for dental patient.

11. Examination of the dental patient should include an overall assessment of the patient, recording of vital signs, and a complete head and neck examination. • Each patient should receive a thorough facial, oral, nasal, and neck examination in addition to recording of blood pressure, pulse, and respiration. • The examination involves the routine application of observation, inspection, palpation, percussion and auscultation.

12. Basic techniques • Visual inspection • Colour changes • Dryness • Oedema • Size • Shape • Symmetry

13. Palpation • Examiner feels or presses the structures examined. • Gives more details about things inspected visually and reveals information that cannot be seen. • Texture. • Dimension. • Consistency. • Temperature and functional events.

14. Probing • Is the palpation with an instrument. • Most important diagnostic technique in dentistry. • Dental caries. • Periodontal pockets. • Fistulous tracts.

15. Percussion • Is the technique of striking the tissues with the fingers or an instrument. • The examiner then listens to the resulting sounds and observes the response of the patient. Auscultation • Act of listening for sounds within the body.

16. PERSONAL INFORMATION NAME: • Identification. • To maintain record. • Communication. • Psychological benefit. AGE: • Diagnosis. • Treatment planning. • Drug dose.

17. SEX: • Diagnosis. • Treatment planning. • Esthetic. • Emotion. • Child abuse. • Drug dose.

18. ADDRESS: • For future correspondence. • Geographical prevalence of the disease. OCCUPATION: • Financial status. • Disease. REGISTRATION NUMBER: • Maintain record.

19. CHIEF COMPLAINT • Description by the patient of the symptoms related to the disease for which treatment is being sought. • From the standpoint of periodontal disease, it does not usually relate to a symptom, except in the presence of ANUG or periodontal abscess.

20. The most commonly reported chief complaint as an indicator of periodontal disease includes: • Bleeding gums. • Loose teeth. • Spreading of the teeth with the appearance of spaces where none existed before. • Foul taste in the mouth. • Itchy feelings in the gums, relieved by digging with a tooth pick.

21. Vague feeling of discomfort • Pus discharge. • Complain of pain of varied type and duration. • Sensitivity when chewing. • Sensitivity to heat and cold.

22. HISTORY OF PRESENT ILLNESS • It is a chronological account of the problem indicated by the chief complaint. • In relation to chief complaint, previous diagnosis and treatment rendered, as well as the effectiveness of those treatments should be noted here. • It commences from the beginning of the first symptom and extends to the time of examination.

23. It includes: • Mode of onset. • Cause of onset. • Duration. • Progress and referred pain. • Relapse and remission. • Treatment. • Negative history.

24. PAST DENTAL HISTORY • Attitude towards dental treatment. • Details of previous dental treatment. • Patients reaction to his/her dentist and the treatment. • History of previous periodontal problems including nature of the condition & if previously treated, the type of treatment received & approximate period of termination of previous treatment. • Any orthodontic treatment should be noted, including duration and approximate date of termination.

25. MEDICAL HISTORY Little and King in 1971 have presented the reasons for an evaluation of general health in the dental office. 1)To identify patients with undetected systemic disease. 2)To identify patients who are taking drugs or indications that could adversely interact with drugs prescribed or complicate dental treatment.

26. 3)To provide information for the dentist to modify the treatment plan for the patient in light of any systemic disease or potential drug interactions. 4)To enable dentist to select and communicate with physician. • 5)To help establish good patient-doctor relationship.

27. The health history can be obtained verbally by questioning the patient & recording his/her responses on a blank piece of paper or by means of a printed questionnaire The patient should be made aware of the following: • The role that some systemic diseases, conditions or behavioral factors may play in the cause of periodontal disease. • The powerful influence that oral infection may have on the occurrence and severity of a variety of systemic diseases and conditions.

28. The four major complexes of complications encountered in patients may be prevented by checking the medical history with respect to: • Cardiovascular and circulatory risks, • Bleeding disorders, • Infective risks and • Allergic reactions.

29. FAMILY HISTORY • To determine if there is a familial predisposition to disease or if there are diseases in which inheritance is an important factor. e.g. Diabetes mellitus. • A patient with a strong family history of diabetes mellitus, with no apparent signs or symptoms should be evaluated periodically since clinical features may appear later in life. • The dentist should inquire specifically about a family history of cancer, heart diseases, mental disorders, seizure disorders and high blood pressure.

30. PERSONAL HISTORY May assist in determining the patient's response to the demands & conflicts of modern society. It includes: • Diet. • Use of alcohol, tobacco/ pan, drugs. • Oral hygiene practices: • Type of brush • Dentifrice • Frequency • Technique • Other cleansing aids

31. Habits: An important factor in the initiation and progression of periodontal disease. • Defined as the tendency towards an act that has become a repetitive performance, relatively fixed, consistent and easy to perform by the individual.

32. Classification I. Useful habits Harmful habits II. Empty habits Meaningful habits III. Pressure habits Non-pressure habits Biting habits IV. Compulsive habits Non-compulsive habits

33. Habits of significance in the etiology of periodontal disease • Neuroses (lip biting, cheek biting, tongue thrusting, fingernail biting). • Occupational habits (holding of nails in the mouth as practiced by cobblers, upholsterers, carpenters) • Miscellaneous habits(pipe or cigarette smoking, tobacco chewing, incorrect methods of tooth brushing, mouth-breathing)

34. Bruxism • It is the clenching or grinding of teeth when the individual is not chewing or swallowing. • Occur as rhythmic side to side movements or through a sustained clench. • 5% of individuals brux to a pathologic extent (Rugh 1988). • May lead to tooth wear fracture of the teeth or dental restorations , or muscle hypertrophy.

35. Diagnosis • History and clinical examination. • Wear from bruxism, usually seen as facet patterns. • Confirmed by observing excessive tooth wear, fracture of teeth and restorations. • History of sore or stiff jaws and muscle pain in the morning and TMJ pain and discomfort. • Electromyographic examination to check for hyperactivity of muscles.

36. Mouth breathing Mouth breathers can be classified into 3 types. Obstructive Habitual Anatomic Gingivitis is often associated with mouth breathing. Changes include: Erythema, edema, enlargement and a diffuse surface shininess in the exposed areas. The maxillary anterior region is the common site of such involvement.

37. Diagnosis: History Mirror test. Cotton test. Water test.

38. Tongue thrusting • It entails persistent, forceful wedging of the tongue against the teeth, particularly in the anterior region. • Instead of the dorsum of the tongue being placed against the palate with the tip behind the maxillary teeth during swallowing, the tongue is thrust forward against the anterior teeth, which tilt and also spread laterally.

39. Causes excessive lateral pressure, which may be traumatic to the periodontium. • It also causes spreading and tilting of the anterior teeth, with an open bite anteriorly, posteriorly, or in the premolar area.

40. secondary sequelae • The antagonism between forces that direct the tooth labially and inward pressure from the lip may lead to tooth mobility. • The altered inclination of the teeth also interferes with food excursion and favors the accumulation of food debris at the gingival margin. • The loss of proximal contact leads to food impaction. • Tongue thrusting is an important contributing factor in pathologic tooth migration.

41. Use of tobacco • There is increasing scientific evidence that smoking has a detrimental effect on the progression of periodontal disease and healing after periodontal therapy. • Heat and the accumulated products of combustion are local irritants that are particularly undesirable in periods of post treatment healing.

42. Brownish, tar-like deposits and discoloration of tooth structure. Nicotine and its major metabolite, cotinine, are deposited on root surfaces. • Diffuse grayish discoloration and leukoplakia of the gingiva may occur. • "Smoker's palate" characterized by prominent mucous glands with inflammation of the orifices and a diffuse erythema or by a wrinkled, "cobblestone" surface, may occur.

43. The correlation between tobacco smoking and acute necrotizing ulcerative gingivitis (ANUG) has been shown. • Gingivitis toxica characterized by destruction of the gingiva and underlying bone, has been attributed to the chewing of tobacco.

44. Toothbrush trauma • Alterations in the gingiva as well as abrasions of the teeth may result from aggressive brushing in a horizontal or rotary fashion. • The deleterious effect of abusive brushing is accentuated when excessively abrasive dentifrices are used. • acute or chronic.

45. Punctate lesions are produced by penetration of the gingiva by perpendicularly aligned bristles. • Painful vesicle formation. • Diffuse erythema and denudation of the attached gingiva throughout the mouth may be striking sequelae of overzealous brushing.

46. The acute gingival changes noted commonly occur when the patient uses a new brush. • A toothbrush bristle forcibly embedded and retained in the gingiva is a common cause of acute gingival abscess.

47. EXAMINATION OF THE PATIENT Includes: • Observation of patient’s general health and appearance. • Extraoral Examination. • Intraoral Examination. GENERAL EXAMINATION Stature (height and build). Nutritional status ( evaluation of degree of obesity or emaciation). Gait (The way one walks). Posture(Position of the body).

48. Body weight (Recent weight loss may indicate serious underlying pathology). • Excessive weight may suggest risk of heart attack or stroke, Type 2 diabetes mellitus. • Breathlessness after minor exertion, (may indicate cardiac orlung disease).

49. Awkward gait (Degenerative joint disease, a nervous system disorder such as multiple sclerosis or a muscle problem). • Pallor, icterus, cyanosis,clubbing and oedema should be noted.

50. Vital signs • Temperature • Pulse • Blood pressure • Respiratory rate