Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DefinitionsTheComprehensiveExamination:MultidisciplinaryDiagnosisandTreatment
Planning
TheComprehensiveExamination(axiUmcode01201)isasupervisedstudentprocedure
wherebystudentsareresponsibleforallaspectsofpatientexamination,includingprovidinga
diagnosisofconditionsanddisordersbaseduponallclinicalfindings,andformulatinga
treatmentplanwhichaddresses,inasystematicmanner,andasagreeduponbythepatient
andconfirmedwithcompletionoftheinformedconsentform,findingsofthepatient
examination.Itisamultidisciplinaryapproachtodiagnosisandtreatmentplanning.
Elementsofthecomprehensiveexaminationwouldincludethepatientschiefconcern,health
andmedicationhistory,recordingofvitalsigns,dentalhistory,extraoralandintraoralsoftand
hardtissueexamination,radiographsandotherdiagnostictestingandspecialtyconsultationsas
necessaryandmakingadiagnosis.Thiswouldbefollowedbytheformulationofa
comprehensivetreatmentplan,whichincludesthecompilationofaproblemlist,referstothe
diagnosis,andisbaseduponthepatientschiefconcernandfindingsoftheexamination.
Treatmentoptionsarethenofferedandasystematiccourseoftreatmentisagreeduponbythe
patient.Appointmentschedulingishelpfultoprovideanorganizedroadmaptotreatment.
Treatmentoptionsaregiveninsuchanorderthatfirstaddressesanyurgentcareorprimary
estheticconcernsrequiredbythepatient(PhaseOne).Thisisfollowedbythemedical
managementofanydisordersordiseases(includingcariesmanagement/cariescontrol
protocol),smokingcessationcounseling,immediateoralsurgeryprocedures,stabilizationof
thepatientsperiodontalcondition(inadentatepatient),andfollowsbyaddressingbasic
dentalneedsprovisionofdirectrestorationsandnonsurgicalendodontictherapy.If
necessary,followingtheseinitialtherapyprocedure,areevaluationofthepatientscariesand
periodontalstatusispreformed,andifdeemedstable,definitivefixedandremovable
prosthodonticprocedurescanbeperformed(PhaseTwo).
PhaseTwomayincludeperiodontalsurgery,implantsitepreparation,andfinalrestorative
proceduressingleandmultipleindirectrestorations,implantplacement,fixedandremovable
prostheses,andhabitmanagingappliances(e.g.bruxingguards).
Ifunstable,transitionalformsoftreatmentmaybenecessarypriortoembarkingonPhase
Two.NoPhaseTwotreatmentshouldcommenceifthereisanunstabledentition.
Followingcompletionofdefinitivetreatment,thepatientmaybeplacedonarecurring
scheduleofexaminationandperiodontalmaintenancetherapy(PhaseThree).
OUTCOMESFORALLTHREEPHASESOFTREATMENTSHOULDBERECORDEDONTHELASTPAGE
HOWTOPROPERLYCOMPLETETHEDIAGNOSISANDTREATMENTPLANNINGFORM:
PRIORTOFILLINGOUTTHEFORM,THEPATIENTMEDICALANDDENTALHISTORYMUSTBE
COMPLETEDINAXIUM,ANDAPPROVED(SWIPED)BYANINSTRUCTOR.
CHIEFCONCERN:Inthepatientsownwords,thereason(s)forthepatientattendingthatday.
SUMMARYOFMEDICALHISTORY:AfterreferringtothenewlyenteredmedicalhistoryAxiUm
record,asummaryofsignificantfindings,forquickreference,includingmedicationsandtheir
implicationstodentistry,oralmanifestationsorspecialprecautionsfordentaltreatmentis
recorded.
SUMMARYOFDENTALHISTORY:Asummaryofthesignificantfindingsrelatingtothepatients
pastdentalexperience,includingdailyoralhygieneroutine,extensiverehabilitativedental
treatment,periodontalsurgery,etc.
SUMMARYOFSOCIALHISTORY:Includepertinentinformationthatmayaffectorhashadan
effectondentaltreatment.Alsoincludehistoryoforcurrentuseoftobacco,including
frequency,lengthoftime,andwhetherornotthepatientmaybeamenabletoatobacco
cessationprogram.
EXTRAORALEXAM:Indicatewhetherfindingsarewithinnormallimits(WNL)orcommenton
anyunusualorabnormalfindings.Seekanoralpathologyconsultasneeded.Areastoconsider
areheadandneck,skinandextremitiesandlips.ThenmovetotheTMJtomakesobservations
onpresenceofclicking/crepitus(checkmark),limitationonopening(inmms.),deviationon
opening/closing(totherightorleft),persistentpresenceofpainoronpalpationof(onrightor
leftside)temporalis,masseter,pterygoid(medial/lateral).Alsonotethepresenceorsuspicion
ofunusualhabits(e.g.clenching,bruxing,nailbiting),andhistoryofthehabit.Makeadditional
commentsasrequired,whichmayincludepresenceofheadaches.
INTRAORALEXAM:IndicatewhetherWNLorcommentonunusualfindingsoflabialand
buccalmucosa,palate(e.g.tori),oropharynx,floorofmouth,tonguedorsalandventral,
Gingivalcolour,contour,consistencyaswellasunusuallocalizedorgeneralizedgingival
changes.Makeadditionalcommentsasnecessary.
OCCLUSION:(Angle'sClassification)Usingthefirstmolarswhenpossibleandthecuspids
whenneeded,classifytheocclusionintoAngle'sClassI,ClassII,DivisionI,DivisionIIorClassIII
forthepatient'srightandleftsides.Overbite:Expressinmillimetersofoverlapoflower
incisorswhichwouldbeapositivemeasurement.Overjet:Expressexcessiveoverjetinmm
(millimeters).Openbite:Expressthisasanegativeamount.Crossbite:Stipulatewhichteethare
involved.Faceting: Althoughsubjective,estimatewhethertheamountofocclusalandincisal
wearisnormalorexcessiveforthepatientinvolved.Alsomakenotationsforobservationsof
teethinvolvedwithattrition,abrasion,anderosion.Otherareastonotearecentricrelation
(CR)andmaximumintercuspation(MI),measurementoftheinterocclusaldistance(IOD),and
significantinterferencesinrightlateral,leftlateralandprotrusiveexcursions.
DiagnosticTesting:Aspartofdiagnosisanddiagnostictesting,radiographswillbeprescribed
dependingonthepatientsneedsandbaseduponALARA(AsLittleAsReasonablyAccepted)
principles.RadiographsarestoredinMiPacsprogram,butthewritteninterpretationisdone
andrecordedinAxiUm.Assummaryofpertinentfindings(boneloss,impactions,possible
cariouslesions,unfavorablecrownrootratios,pathology)iswritteninthespacesprovidedon
theform.Whenconsideringbonelossforperiodontalsituations,thefollowingshouldbe
considered:
A.
BoneLoss:
Generalized:Bonelossin2ormoresextants.
Localized:Bonelossinone,twoorthreeareasinvolvingoneortwo
teeth
Furcationboneloss:Dependinguponthefollowingcriteria,use
symbolssuchasS(slight),M(moderate)orA(advanced)for
furcationboneloss.Furcationboneloss(F):isindicatedbya
radiolucencyinthefurcationarea.Thismaybeslight(S)boneloss
(lessthan1/3ofthedistancefromthedomeofthefurcationtothe
apexoftheroot),moderate(M)(upto2/3ofthedistancefrom
dometotheapex)oradvanced(A)(toorbeyondtheapex).
Horizontalboneloss:Horizontalbonelossisindicatedwhenthe
bone loss interproximally on two adjacent teeth is equidistant
from the cementoenamel junction on each tooth. Use the
following symbols for horizontal bone loss based on the above
criteria:
S =
M =
Moderate<1/3oftherootlength
A =
Advanced1/3ormoreofthelengthoftheroot
Verticalboneloss(V):isindicatedwhenthecrestoftheboneislocated
more apical to the cementoenamel junction of one tooth than to the
adjacenttooth.
B.
OtherRadiographicObservations:
Recordthetoothnumberandsurfacewhereanyofthefollowingareidentified:
furcation, periapical pathology, widened PDL space, poor crown to root ratio,
root proximity, root morphology, impaction, caries, overhang restorations,
calculus,andother.
OtherDiagnostictests,includingspecialtyconsults(asneeded):Eachspecialtyhasprovided
guidelinesastotheprocessesinvolvedwhenrequestingaspecialtyconsultdeterminingwhen
oneisneeded,andtheprerequisiteinformationthatneedstobegatheredpriortorequestinga
consult.Theguidelinesarepostedonthefacultywebsiteat
http://umanitoba.ca/faculties/dentistry/student_resources/index.htmlunderguidelinesfor
consults.Pleaseensurethetraditionalforms/sheetsareusedforendotesting,all
prosthodonticforms(implants,removablepros),estheticevaluation(whenaonelinecomment
isinsufficient),andotherformsthatareavailable.
DIAGNOSTICRECORDS:Pleasecheckoffwhetherphotoshavebeentakenandcastshave
beenmade.
SPECIALTYCONSULT:Consultantscomments,signatureanddateinspaceprovided
ADDITIONALCONSIDERATIONS,andcommentswritteninspaceprovided.
MissingteethmustberecordedintheAxiUmodontogramaswell.Thisisimportant,asinthe
caseofafixedbridgereplacingamissingtooth,unlessthetoothismarkedasmissing,AxiUm
willnotallowthefeeforabridgetogothrough.
ODONTOGRAM:Chartingtoinclude:Existingrestorations/defectiverestorationsopen
margins,overhangs,caries(visible+radiologicalevidenceof),missing,impacted,chipped,
fractured,wornteeth,etc.
Periodontalcharting:Thefollowingshouldbeclearlyindicated:
Missingteeth:Crossoutmissingteethwithaverticalline.
e.g.
18
17
16
B
L
PocketBleedingIndex:
(PBI): Bleeding on probing will be recorded as present if the
gingivalunit(pocket)bleedswithin30secondsafterinitialprobing
(Vandervelden,1979).Thelocationofthebleedingisdocumented
inred.Thetotalnumberofbleedingsites(n)isdividedbythetotal
numberofunitsprobed(n#teethX4)toobtainthePBI.
e.g.
18
17
B
L
ProbingDepth:
Probingdepthshouldberecordedforeachtooth,(BuccalMBDand
LingualMLD).Recordmeasurementsof4mmandgreater.
Recession:
Apparentgingivalrecessionshouldberecordedforeachtooth.The
extent of recession is measured from the CEJ to the free gingival
margin.ThegreatestmmreadingfortheBuccalandfortheLingual
isrecorded.
E.g.
18
17
2 mm
2 mm
3 mm
2 mm
Furcation:Classificationoffurcationinvolvementshouldberecordedinthefollowing
manner:
ClassI(Dip):Furcationconcavityispresent.Furcationconcavitycan
be detected with the probe; however, the furcation probe cannot
enterthefurcationarea.Inmanycases,thistypeofdefectcannot
be detected radiographically. Charted as I in appropriate box on
diagram.
ClassIII(Tunnel):Itisessentiallyathroughandthroughortunnel
lesion. Furcation probe will pass between the roots through the
entire furcation. In this type of furcation involvement, the inter
radicularboneiscompletelyabsent.Adefiniteradiolucencyinthe
furcationareaisusuallyvisibleontheradiograph.ChartedasIIIin
appropriateboxondiagram.
*Please note that this is a classification of the extent of furcation
involvement.ThenumeralsI,II,andIIIdonotrepresentmillimeter
measurements.
e.g.
B
L
I
I
II
II/D
II/S
II
III
III
Mobility:
Mobilityisrecordedforeachtooth.
Normal = movementofthecrownofthetooth,lessthan.5mm
inbuccallingualdirection
ClassI
ClassII = movementofthecrownofthetooth1.0mmto2.0
mminbuccallingualdirection
ClassIII = movementofmorethan2.0mminmedialdistalor
buccallingualdirectionand/orverticaldepression.
= movementofthecrownofthetooth.5mmto1.0mm
inbuccallingualdirection
e.g.
18
I
17
II
PlaqueControl
Record:
(PCR):Thepresenceofdentalplaqueisrecordedonfoursurfacesof
eachtooth(DBML).If,afterswishingwithaplaquedisclosingtablet,
disclosedplaqueincontactwiththegingivalmargincanberemoved
withtheexplorer/probefromthetoothsurface,thatsurfaceshould
bedocumentedinblackontherecordform.
PROBLEMLISTING:Thisisaproblemlistwhichsummarizesthepatientsneedsandclinical
findingsoftheexam.Itwillhelptoformulatethediagnoses.
Periodontalclassification(circle):PSR1PSR2
PSR3PSR4
PeriodontalClassification: Circleappropriateclassification:
PSR2=slightchronicperiodontitis
PSR3=moderatechronicperiodontitis
PSR4=advancedchronicperiodontitis/aggressiveperiodontitis
PSR1 =
gingivitis
PeriodontalScreeningandRecording(PS&RSystem)
Description:
Theobjectiveofthisscreeningsystemistoexamineeverytoothindividually.Implants
are examined in the same manner as naturally occurring teeth. For screening, the
dentitionisdividedintosextantsasshown:
Theuseofaperiodontalprobeismandatory.Therecommendedprobehasaballend
0.5mmindiameter.Acolorcodedareaextendsfrom3.5to5.5mm.Agentleprobing
forceshouldbeused.
The probe tip is gently inserted into the gingival crevice until resistance is met. The
depthofinsertionisreadagainstthecolorcoding.Thetotalextentofthecreviceshould
beexploredbywalkingtheprobearoundthecrevice.Atleastsixareaineachtooth
should be examined: mesiofacial, midfacial, distofacial, and the corresponding
lingual/palatalareas.
Foreachsextantwithoneormoreteethorimplants,onlythehighestscoreisrecorded.
AnXisrecordedifthesextantisedentulous.Asimpleboxchartisusedtorecordthe
scoresforeachsextant(seeFig.1).
Code0:
Coloredareaofproberemainscompletelyvisibleinthedeepestcrevicein
thesextant.Nocalculusordefectivemarginsaredetected.Gingivaltissues
arehealthywithnobleedingaftergentleprobing.
Code1:
Coloredareasofproberemainscompletelyvisibleinthedeepestprobing
depth in the sextant. No calculus or margins are detected. There is
bleedingaftergentleprobing.
Code2:
Code3:
Coloredareaofproberemainspartlyvisibleinthedeepestprobingdepth
inthesextant.
Code4:
Coloredareaofprobecompletelydisappears,indicatingprobingdepthof
greaterthan5.5mm.
TheexaminermaypasstothenextsextantwheneverCode4isrecordedorthesextantis
completelyexamined.
Inadditiontothesescores,thesymbol*shouldbeaddedtothesextantscorewhenever
individualfindingsindicateclinicalabnormalities.
Code*:
Denotesclinicalabnormalitiesincludingbutnotlimitedto:
a)
furcationinvolvement
b)
mobility
c)
mucogingivalproblems
d) recessionextendingtothecoloredareaoftheprobe(3.5mmor
greater)
Themanagementofpatientsaccordingtotheirsextantscoresshouldbeatthediscretion
oftheexaminingdentist.Thepractitionersclinicaljudgmentwilldeterminetheneedfor
consultation with a periodontist. The following guidelines for patient management are
suggested:
Code0:
Appropriatepreventivecare.
Code1:
Oralhygieneinstruction(OHI)andappropriatetherapy,includingsubgingival
plaqueremoval.
Code2:
Patients whose scores for all sextants are Codes 0, 1, and 2 should be screened in
conjunctionwitheveryoralexamination.
Code3:
Code4:
Code*:
Prosthodonticclassification(circle)ACP1ACP2ACP3ACP4theACPclassificationsystemby
McGarryetalcanbefoundbyfollowingthislink:
http://www.gotoapro.org/prosthodonticresources/improveyourpractice
lab/prosthodonticdiagnosticindex/
Cariesriskassessment(fromcompletedform):LOWMEDIUMHIGH
DIAGNOSES,INCLUDINGDIFFERENTIALDIAGNOSES:foreveryproblemlisted,pleaseoffera
diagnosisordifferentialdiagnosisandrelateitdirectlytotheproblem.
TREATMENTOPTIONSANDCOSTS:Foreachproblem,offereveryreasonabletreatment
option,withalternatives,available,includingnotreatment.Foreachoption,proposea
prognosis,eithergood,fairorpoor,(perioalsoaddsquestionableandhopeless),andan
estimatedcostrangeforeachoptionoffered.Itishelpfultouseaworksheetatthisstageto
formulateyourtreatmentoptionspriortorecordingontheform.
FINALIZEDSEQUENCEDTREATMENTPLAN,COSTSANDDATECOMPLETED:Treatmentplans
aredividedintothreebroadphases,1,2and3.
ALLPLANNEDTREATMENTMUSTBEENTEREDINTOAXIUMASP
Phase1,managementofdiseasesanddisorders,includes,inorderandasnecessary:
Consultationwiththepatientsphysician
Othernecessarytreatmentconsiderationsforsystemicdisease,suchaspremedication
needs,stressandfearmanagement.
Acutetreatmentaddressingurgentcareneedsforpainorinfection
Treatmentofurgentchiefcomplaint
Diseasemanagementpatienteducationre:cariesandperiodontaldisease;cariesrisk
assessment;medicalmanagementofcaries;addressparafuntionalandotherhabits
Removalofhopelessteeth
Cariescontrol,provisionaldirectrestorations
Remove/replacedefectiverestorations
Initialperiodontaltherapyscalingandrootplanning
OralHygieneinstructionsOHI
Occlusaladjustment
Endodontictherapyincasesofpulpalpathology
Placementofdefinitivedirectrestorations(alloy,composite,GIC)
Placementofotherprovisionalrestorations(partialorfullcoverage)toallowfor
stabilizationofteeth
REASSESSMENTOFPHASEONETREATMENTISMANDATORYTODETERMINESUCCESSAND
FEASABILITYOFPROCEEDINGTOPHASE2.
Phase2MajorRehabilitativeProcedures:FollowingtheevaluationofPhaseone,andafter
determiningthesuccessofinitialtherapyandthestabilityofthepatientsdentition,phasetwo
canbeaddressed.Oftentimes,proceduresplannedinPhasetwowillbedependentonthe
successfuloutcomeofphaseonetreatment.Lesssuccessfulresultsinphaseonewilldictate
lesscomplextreatment,ifanyatall,tobeperformedinphasetwo.
Majorrehabilitativeproceduresarecarriedoutinphasetwo.Thisisintheformofdefinitive
treatment,whichincludes,inorderandasnecessary:
Periodontalsurgeryandotheradvancedperiodontaltherapy
Occlusalstabilizationthroughvariousmeans
Orthodonticororthognathictreatment
Electiveremovalofasymptomaticteeth
ElectiveEndodontictreatment
Definitiverestorationofindividualteethendodonticallytreatedandotherkeyteeth
prioritized
Fixedandremovableprosthodonticsforreplacementofmissingteeth,includingesthetic
dentistry.
POSTTREATMENTASSESSMENTOFPHASETWOPROCEDURES.
Phase3Maintenance:Determinationoftypeandfrequencyofperiodicrecallvisits,including
examinationsandsupportiveperiodontaltherapy.Itisimportantthatarecallschedulebe
established,andthatthepatientunderstandstheobligationofcontinuedcare.
Fornewpatients,orforthosethatrequirenewcomprehensivetreatmentplans,forperio
purposes,NPP(NewPeriodontalPatients)(PreviouslycalledPSRPatients)
CLASSIFICATIONOFNPP
o NPP0,NPP1,NPP2,NPP3,NPP4
BasedonPeriodontalScoringRecord(PSR)Classification
FeetoincludeInitialTherapyand1moreevaluation
Whenreevalexam&treatmentiscompleted,dispositionoptionsinclude:
NPPAdditionalAppointment(additionalchargestoapply)
PutonSPT(atdesignatedmonthlyinterval1,3,6,9,12mo)
RefertoGraduatePeriodontics
SPT(SupportivePeriodontalTherapy)Patients
o NewandexistingpatientswhorequireongoingSPTtomaintainperiodontalhealth
SPT0,SPT1,SPT2,SPT3,SPT4,basedonPSRClassification
SPTINTERVALS1mo,3mo,6mo,9mo,12mo
o Individualizedaccordingtotreatmentneeds
o IntervalisdeterminedondaythatSPTtreatmentis
completed
o IntervalisenteredintoAxiumwhenSPTscalingis
complete
o Axiumdropdownmenuoptionswillinclude:
SPT01mo,3mo,6mo,12mo(12modefault)
SPT11mo,3mo,6mo,12mo (6modefault)
SPT21mo,3mo,6mo,12mo (6modefault)
SPT31mo,3mo,6mo,12mo,NPP3,ReferGradPerio
(3modefault)
SPT41mo,3mo,6mo,12mo,NPP4,ReferGrad
Perio(3modefault)
INFORMEDCONSENT:Althoughatreatmentplanhasbeenformulatedandtheprocedures
withcostshasnowbeensignedbythepatient,theprocessofinformedconsentmustbe
formalizedtoensurethatthereisaclearunderstandingbythepatientoftheproposed
treatmentrisksandcostsinvolved.Itissuggestedthatthepatientcompletestheinformed
consentdocumentintheirownwords,asitisoftensurprisingtodiscoverthatthereisnota
clearunderstandingofthesituationbythepatient.Ifthepatientcannotcompletetheformon
theirownorintheirownhandwriting,thedentalstudentmayassistwiththis.Onlythen
shouldtreatmentbecommenced.
APPOINTMENTSCHEDULE:Thisprovidestheboththestudentandthepatientaroadmapfor
treatmentthatthereisaclearunderstandingofthestepsinvolvedintreatmentandthetime
neededfortreatment.Thisway,thepatientwillhaveaclearunderstandingofwhatisrequired
intheprocess,andwillhopefullynothaveanyunrealisticexpectationsinthetimeline.
TREATMENTEVALUATION:Aseachphaseoftreatmentiscompleted,areflectiononandan
evaluationofthefinishedtreatmentshouldberecorded.Thisisnotonlygoodrecordkeeping
policy,butisarequirementoftheaccreditationprocess.
____