Sara Sarraj DDS MS MS FGD

Clinic

Dent 337

 The clinician opinion resulted from the process

of evaluating the patient

 Interview Patient

Gather data
Aanalyse Data Developing Hypotheses

Establish Diagnosis
Formulate Tx Paln Consent form to begins treatment

 S:Subjective information

Objective: Physical findings of the clinician

Analysis : Clinical impression of the condition by

the clinician P:Plan ,recommended management for the condition

Specific treatment 2. Referral to specialist 3. Dismissal as clinically insignificant
1.

 For consultation with another dentist

To reevaluate current treatment

Only when diagnostic information is available

Dental
Medical History

History
Physical Exam
Adjunctive Diagnostic Tools

 Pt Identification

Systemic Disease
Family History Social History

 Name

Age
Gender Race

Address
Phone# & Email

Review: of the medical conditions that have been diagnosed. Immunization Hospitalization Allergies Current Medications

 1.Is a dynamic document that should be updated

annually and for every new patient 2.Taking medical history makes the pt feel that the office provides an optimum treatment. 3.Early recognition of risk improves prognosis ,and reduces complications 4.Dental team often first to identify silent disease(silent killer)

 Standard review of past medical history

Hospitalization: Renal dialysis

Surgery: hip replacement, pace maker, bypass,

Prosthetic heart valve

Illness:IE(infective Endocarditis) Medications:
Rx :bisphosphonates, chemotherapy,

anticoagulants,birthcontrol,steroids OTC,herbal,Diet control

 Highest risk People with the following

conditions are considered to be at the highest risk of developing infective endocarditis(IE). Preventive antibiotics are generally recommended for people with the following conditions before bleeding induced dental procedures
A prosthetic heart valve Valve repair with prosthetic material A prior history of infective endocarditis Many congenital (from birth) heart abnormalities

 antibiotic prophylaxis

might be useful for patients who also have compromised immune systems (due to, for instance, diabetes, rheumatoid arthritis, cancer, chemotherapy, and chronic steroid use), which increases the risk of orthopedic implant infection.

 Chest pain, palpitation, breathlessness(CVD)

Cough, wheeze, breathlessness (RespT)

Bowel Habit: distention, pain, eating And

appetite(Gastrointestinal) Incontinence, straining or drippings (Genitourinary) Seizures ,fainting ,headache (central nervous System)CNS

 Chief Complaint: CC

The statement of why the patient consulted the

dentist It should be in pt own words if possible To assess the dental awareness and the likelihood of raising it

 Anxiety: How do they feel about dental TX

Florid intake: where do u live

Pt experience with GA and LA: if any complication

in the past Caries rate and erosion: what,s your favorite drink

 Assess motivation:How often to go to dentist

Provide clue about the nature of CC : When did u

last see dentist (RCT) Motivation: how often do u brush. Gingival condition TMJ: have had any pain or clicking from your jaw Personality: do grind your teeth , bite nail

 Use introductory words:

What is the problem

When: onset and pattern How: Frequency

What: Exacerbating and relieving factors

 Location: Where

Commencement: When
Character & intensity:

Sharp , shooting ,aching .dull Frequency & Duration Association : what make them worse or better

 Type

Size
Color Location

Surface Texture
consistency

 General

Extra oral Soft Tissue

Intra Oral Soft Tissue

 General Appearance

Gait
Mobility Facial Asymmetry

Lesion or Scar

 Asymmetry

Lymph Nodes
TMJ

 Visual screening

Palpation screening

Exam
Bilateral palpation Extra Oral Exam Visual screening Bimanual Bidigital symmetry

Surgery Inflammation Tumors Congenital

 Induration: fixation to the deeper tissues

Roughness or smooth textures of the lesion

Consistency: fluctuant, soft, hard, Tenderness: if your palpation induces pain

Presence of masses and size of them

 Bilateral

Bimanual
Bidigital

 using both hands to

both sides, like submandibular lymph nodes, TMJ, muscles of mastication, and the two lobes of thyroids

 using both hands to

examine one structure a one side, for submandibular salivary glands to palpate the buccinators muscle to feel any tenderness

 Using two fingers of

one hand to examine one side, for lips, tongue and for buccal mucosa

 Muscle of mastication

Salivary glands
Lymph nodes

 The finger is inserted

medially to the muscle and the muscle is pressed laterally against the inner surface of the mandibular ramus, to elicit tenderness . .

 Similarly force is

applied to the subjects left jaw to stress the right lateral pterygoid muscle

 Normal:Not palpabable,feel like a pea or lentil,

non tender Abnormal Lymph Nodes: Larger,may be tender,inflammation or drainage of infection Non-tender large lymph nodes: Cancer Lymphoma

 Preauricular

Tonsilar
Submental Submandibular

Anterior & posterior

cervical

suparcalvicular

Methods of palpation of lymph nodes

 Around The ear

At the base of the skull

Under the chin Neck

 Palpate both joint simultaneously ,Gentle

Pressure : Tenderness, swelling , Redness Range of movement: open and close slowly many times .and from one side to another. Also feel for clicking ,locking ,& crepitus Palpate the muscle of mastication for spasm & tenderness Auscultation can be useful too

There are 2 types of joint sound to look out for: Clicks - single explosive noise Crepitus - continuos 'grating' noise

 A joint click probably represents the sudden

distraction of 2 wet surfaces, symptomatic of some kind of disc displacement. The diagnosis of a joint click, and therefore treatment, varies on whether the click is left, right or bilateral, painful or painless, consistent or intermittent. The timing of a click is also significant: a click heard later in the opening cycle may represent a greater degree of disc displacement.

 Crepitus is the continuous noise during

movement of the joint, caused by the articulatory surfaces of the joint being worn. This occurs most commonly in patients with degenerative joint disease.

 Lateral

Range of
Motion <7mm

 Temprature (35,5-37,5C)= (95,5-99,5F)

post operative,infection,transfusion reaction Shock,hypothermia

Pulse:Adult(60-80 beat/min) Child(up to 140

beat/min) Blood Pressure BP :(120-140/60-90) BP =Age BP =Syncope,Hypovolemia Shock Respiratory Rate=12-18 breath/min, increases in the following:
Chest infection Pulmonary edema shock

 Oral Vestibule

Oral cavity proper

space bounded Laterally by cheek and lips Medially by the buccal and labial surfaces of the upper and lower teeth Posteriorly by the Retromolar area

The oral cavity proper

Bounded

Laterally by palatal and

lingual surfaces of the upper and lower teeth

Superiorly

by the palate (hard & soft)

Inferiorly

by the tongue and or the floor of the mouth

Posteriorly by the

isthmus of fauces

Superior boundary
Palate- Parts
Incisive papilla

Palatine Rugae

Median palatine raphe

Maxillary tuberosity

Fovea Palatina

Inferior boundary
The Floor of the mouth Parts Ventral surface of the tongue Lingual Frenum Sublingual fold

Sublingual caruncle Openning of sublingual duct

Ventral side of the tongue

Plica Fimbriata

Sublingual fold

Dorsum of The Tongue

Median fissure fibrous septum Sulcus terminalis: V-shaped ridge, separates? Foramen cecum: (blind opening) at apex of sulcus term. marks the site of ?

Lingual papillae: 4 types filiform smallest & numerous fungiform tip & margins vallate 8-12, in front of ? foliate linear folds, on the sides near terminal sulcus

Exam of lateral side of the tongue(Oral Cancer Screening)

 Soft Tissue of the mouth

Throat
Tongue Gingiva

 Labial mucosa:I nside of the lip

Buccal mucosa: Inside of the cheek

Hard Palate: Firm area of the roof of the mouth Soft Palate: The soft area of the palate

 Linea alba

The linea alba is

usually present bilaterally. It is restricted to dentulous areas. It presents an asymptomatic, linear elevation, with a whitish colour, at the level of the occlusal line of the teeth.

Oral Exam

a proper oral exam from your dentist (DDS or DMD) is warranted at least yearly and should be performed when your teeth are cleaned during routine visits - the dentist or hygienist should be visually and physically evaluating the tongue's dorsal (top), ventral (bottom), and lateral (side) surfaces through palpations and observations. A "larger tongue" is termed hyperglossia and the "corrugated" sides of the tongue are termed scalloped tongue, where there are indeed what appears to be indents from the adjacent teeth on the lateral borders of the tongue. Both of these are common variations of normal that are seen quite frequently and usually appear together. Other things that could cause hyperglossia besides being congenital (from birth) or medication-induced would be a dietary/nutrient insufficiency. Do not hesitate to contact your dentist or physician, both would be happy to give you any more information.

Morsciatio labium
MorsciatioBuccarum Morsciatio(labiorum)

Morsciatio (linguarum),

 Radiographs Vitality tests Thermal tests EPT Selective anesthesia

Percussion test Other tests Transillumination Wedging and staining Periodontal probing

Test cavity
Laser Doppler flowmetry Pulse oximetry Other signs of vitality Color Sinus tract

Mobility test

 Intraoral:PA,BW,Occlusal

Extraoral:Panoramic,Posterior

anterior,cephalometry

 Documenting

Periodontal and

periapical disease Tooth orientation Root shapes

X ray
Detects interproximal

caries in both arches simultaneously Level of crestal bone Intermediate screening tools before taking PA.

Upper Occlusal
Detecting Palatal

Lower occlusal
Document expansion

lesions Reveal impacted or extra teeth

of mandible Salivary stones in the duct of submandibular duct

 Maxillary Occlusal

x ray

Mandibular Occlusal X ray

 Cover both Jaws

Detect developmental abnormalities

Pathological lesion of teeth and bones Evaluation of edentulous pt before prostheses

Third molar position

Less valuable diagnostic evaluation due to lower

resolution and superimposition of the structures

 Soft tissue Palpation

Alveolar hard tissue palpation

 Indicates infalmmation in the periodontal

ligament. Cause: could beTrauma,Occlusal prematurities,periodontal disease,extension of pulpal disease to PDL. Discriminates the affected tooth from its neighbors, due to the proprioceptive nerve receptors

 Prelude(inform Patient) for the test for more

accurate results. The test should be repeated to make sure its reproducible This test reflects an advance stage of pulp disease . It doesnt reflect the tooth vitality

 Simple & reliable methods to indentify individual

tooth when group of teeth are involved Abrupt pressure to the periapical area Increased intensity of discomfort indicates inflammation is present Light tap is adequate Tap normal and suspected teeth Ankylosed teeth produce different sound than normal teeth(Trauma,deciduous,ortho,inflammation,rei mplantation)

 This test detects the inflammation in the PDL,

which results in pain, and the tooth is then called tender to percussion (TTP)
TTP could be the result of Toxins from a necrotic pulp reaching PDL Trauma Periodontal abscess

 It s an indication of a

Trauma

compromised periodontal attachment when +1>mm . Its a relative exam

Occlusal trauma
Parafunctional habits Periodontitis

Root fracture
Rapid orthodontic

movement PDL Infection of pulpal origin

Pulp vitality is defined by the retention of blood supply. This should be differentiated from sensibility Thermal tests Cold test Heat tests Electric pulp tests Selective anesthesia Test cavity Pulse oximeter Laser doppler flowmetry Other signs of vitality Color Sinus tract

 Test the suspected tooth

Similar tooth controls should be used

Replicate patients symptoms

 To detects incipient cracks

Test involved tooth in centric and lateral

occlusion.

 Patients who complain from pain during mastication

may be actually suffering from the wedging force Cracked tooth syndrome Patients usually complain of sharp sporadic pain while chewing, along with occasional pain from cold food or drink. Sometimes the patient may indicate that the pain occurs minutes after chewing or upon releasing from clenching Wedging is a test where the patient is asked to bite on a Tooth Slooth on successive cusps until the offending cusp is located Staining is done by the application of methylene blue or erythrosine dye (cottonwood stick or IRM)

 Flurorescence procedures are based

on illustrating certain fluorescence substances like porphyrins, which grow in bacterial populated areas. When the area is stimulated with light of a certain wavelength, the molecules absorb the light energy and release part of the light energy with a different wavelength.

 Treat with Confidence

Laser Fluorescence technology

Small lesions can be detected reliably without

exposure to ionizing radiation No damage to enamel by sharp-edged probes Optional Perio-Probe detects calculus concrements 9mm in periodontal pockets

 DIAGNOdent uses laser technology to detect and quantify hidden or

sub-surface caries by measuring laser fluorescence within the tooth structure. The device operates at a wavelength of 655 nm. At this specific wavelength, clean healthy tooth structure exhibits little or no fluorescence, resulting in very low scale readings on the display. Altered tooth substances and bacteria, including caries, will fluoresce. The DIAGNOdent will react with elevated scale readings on the display. An audio tone allows the operator to hear changes in the scale values. This enables the user to focus on the patient not solely on the device. The DIAGNOdent is an extremely accurate, reliable and noninvasive method to aid in caries detection. The device has been successfully used by more than 20,000 dental professionals in the United States and is integrated into the curriculum by a growing number of dental schools.

Generally, conventional hand instruments may not be used to probe within drop-shaped fissures.

The DIAGNOdent pen offers the advantage of measuring fluorescence deep within the fissure pattern, since LASER light easily penetrates the enamel and is reflected by even the smallest lesion. Measurement is indicated with an acoustic signal and numerical value.

 ionic change across the neural membrane,

The circuit is completed via the patient wearing

a lip clip or by touching the probe handle with his/her hand individual age, pain perception, tooth surface conduction, and resistance Tip of EPT placed labially within the incisal or occlusal two-thirds of the crown gave more consistent results .

False positive
Patient anxiety Saliva conducting the

False negative
Premedication with drugs

stimulus to the gingiva Metallic restorations conducting the stimulus to the adjacent teeth Liqueficative necrosis conducting the stimulus to the attachment apparatus

or alcohol Immature teeth Trauma Poor contact with the tooth Inadequate media Partial necrosis with vital pulp remaining in the apical portion of the root Individual patients with atrophied pulps or high pain thresholds

 unreliable in many instances, producing false

results in healthy immature teeth . Newly erupted teeth may take five years before the maximum number of myelinated fibres reaches the pulpdentine border at the plexus of Rashkow. This is also when apical root maturation occurs Teeth with pulp canal calcification (PCC) and patients suffering from primary hyperthyroidism frequently have an increased sensory response threshold to EPT. False response healthy pulps undergoing orthodontic treatment

 Also traumatized teeth

when two adjacent teeth have contacting

proximal metallic restorations Periodontal tissues, breakdown products from pulps undergoing necrosis, and remnants of inflamed pulp tissues Cause false response

 is a last resort in a tooth

where no other means can ascertain the pulp status . Cutting into dentine using a high or low speed bur without local anesthetic nonetheless considered invasive and irreversible,and would be rejected by apprehensive patients

 Mixed responses to vitality tests indicate false

negative or false positive results A test cavity is done in a concealed area of the tooth, without anesthesia, where the patient fully understands the test and knows what to expect Crowned teeth

 This technique has been used to detect vascular

integrity in the tooth. Relates the absorption of light by a solute to its concentration and optical properties at a given light wavelength. It also depends on the absorbance characteristics of hemoglobin in the red and infra-red range. the red region, oxyhemoglobin absorbs less light than deoxyhemoglobin and vice versa in the infrared region]. Oxygenated hemoglobin and deoxygenated hemoglobin are different in color and therefore absorb different amounts of red and infrared light.

 (a) LED-emitting red

light at 660 nm. (b) LED emitting infrared light at 940 nm. (c) Photodetector. (d) Pulse oximeter monitor. (e) Pulse oximeter sensor. (f) Custom-made pulse oximeter sensor holder. HbO2, oxygenated hemoglobin; HbR, deoxygenated hemoglobin; SpO2, oxygen saturation of arterial blood

 1.Effective and objective method of evaluating dental

pulp vitality. 2.Useful in cases of impact injury where the blood supply remains intact but the nerve supply is damaged. 3.Pulpal circulation can be detected independent of gingival circulation. 4.Pulp pulse readings are reproducible. 5.Smaller and cheaper commercial oximeters are now available for routine clinical use in an average dental office

 1.Background absorption associated with venous

blood and tissue constituents is not differentiated. 2.Probes should be specific for the anatomy of a tooth as the oxygen saturation values from the teeth routinely register lower than the readings from the patient's finger.

 (LDF) is a noninvasive, painless, electro optical

technique, which It measures blood flow even in the very small blood vessels of the microvasculature. estimates the velocity of red blood cells in capillaries

 Red light is emitted from a light source; if the

light beam is scattered-off of stationary tissue or cells, there is no shift in the light spectrum. If, however, the light hits a moving cell in a blood vessel there is a shift in the light spectrum of the scattered light according to the Doppler flowmetry

 Accurate

Reliable
Reproducible Non painful

Luxation injuries
Useful in young children whose responses are

unreliable and its noninvasive nature helps to promote patient cooperation and acceptance

 Too expensive The sensor should be maintained motionless and in

constant contact with the tooth for accurate readings. The laser beam must interact with the moving cells within the pulpal vasculature It is generally agreed that LDF assessment for human teeth should be performed at 4 weeks following the initial trauma and repeated at regular intervals until 3 months. Blood pigments within a discolored tooth crown can also interfere with laser light transmission. Care must be taken to ensure that the false positive results are not obtained from the stimulation of supporting tissues.

 Cold Test

Hot test

 Simple ,does not need armamentarium, except

rubber dam to avoid + response Can be used on Crowned teeth Has 86%accuracy ,compared with,81%Electric pulp test,71%heat test. Vital teeth respond quickly, wherase false postive reading respond more slowly

 Ice

Frozen Carbon Dioxide (CO2 )

Refrigerant Spray: tetrafluoroethane which has

zero ozone depletion potential The last two methods are superior to other cold test

 Utilizes a strong light source which identifies

colour changes that may indicate pulp pathosis and caries.

 It can help to identify cracks in teeth.

Limited result in teeth with large restoration

 Detects endodontically involved teeth

Should be conducted buccally, labially , and

lingually , palatally. Reveal s fistulas and swelling

 Used when other test are inconclusive

When pain is referred

Start at posterior teeth toward the anterior PDL injection applied

Mobility test

Handles of mirrors

Other Vitality Test

Color Non-vital teeth may become darker and less translucent Sinus tract Its presence is a strong evidence of having a necrotic pulp in a nearby tooth It usually discharges close to the apex of the offending tooth Insertion of a gutta percha cone into the sinus and exposing a radiograph traces the sinus to its origin

Sinus Tract

Satining

Staining is done by the application of methylene blue or erythrosine dye (cottonwood stick or IRM

 Ability of the test to identify diseased tooth

83%Cold test,86% heat test,72% EPT

 The ability of the test to identify healthy tooth

93% cold and EPT

41% heat test

Periodontal charting: plaque index Probing depth bleeding points gingival level tooth mobility

charting caries & existingrestorations Palmer 8-1 1-8 8-1 1-8 Letter code UR1-8 UL1-8 LR1-8 LL1-8 FDI 1(1-8) 2(1-8) 4(1-8) 3(1-8) Universal 1 16 32 17

FDI World Dental Federation notation (International System)

Universal Numbering System for Primary Dentition Phase Universal Numbering System for Permanent Dentition Phase

 Contract between Patient & Dentist

 The Art and Science of Operative Dentistry

Clifford & John Sturdevant

Oxford Handbook of clinical dentistry Pickard,s Manual of Operative Dentistry

 20 of July
40 /100 All previous lectures are required

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