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1. Aquino, Karl Yveth A.
Mertola, Charmell B.
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2. • To provide best treatment 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.
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3. 1.General Consideration
2.Chief Complaint
3.Medical History
4.Dental History
5.Magnification in Operative Dentistry
6.Photography in Operative Dentistry
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4.  The patient or legal guardian completes a standard,
comprehensive medical history form.
• This form is an integral part of the pre-examination
patient interview, which helps identify
conditions that could alter, complicate, or contraindicate proposed
dental procedures.
 The practitioner should identify
(1) communicable diseases that require special precautions,
procedures, or referral;
(2) allergies or medications, which can contraindicate the
use of certain drugs;
(3) systemic diseases, cardiac abnormalities, or joint
replacements, which require prophylactic antibiotic
coverage or other treatment modifications; 4

5. 4) physiologic changes associated with aging,
which may alter clinical presentation and
influence treatment.
The practitioner also might identify a need for
medical consultation or referral before
initiating dental care.
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6. requires the viewing and evaluation of
small details in teeth, intraoral and perioral
tissues, restorations, and study casts.
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7.  Photography in dentistry has many uses and with newer
digital technologies, photography is becoming
mainstream in dental practice. Just as radiographs provide
a historical look at a patient’s situation, photography is an
excellent tool for documentation and evaluation.
 Intraoral cameras and SLR (single-lens reflex) digital
cameras that are easy to use provide opportunities to
document existing esthetic conditions such as color,
shape, and position of teeth. Close-up images of existing
pits and fissures can provide the opportunity to see
changes that cannot be documented in any other way for
re-evaluation in the future.
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8. • Photographs of preparations of deep caries lesions
provide documentation to aid in future diagnosis of
tooth conditions. Without preparation photographic
documentation, this information would no longer be
available once the restoration has been placed.
• Digital documentation with photographs is easier and
more cost effective with the current quality of digital
photography and ability to process and store images in
an electronic patient record.
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9. 9
 An accurate examination is possible
only when teeth are clean and dry.
This may require initial scaling,
flossing, and a toothbrushing
prophylaxis before final clinical
examination of teeth.
 A cotton roll in the vestibular space
and another under the tongue maintain
dryness and improve vision
Dental floss is useful in identifying
overhanging restorations, improper
proximal contours, and open contacts.

10. Caries lesion can be detected by visual
changes in tooth surface texture or color in
tactile sensation when an explorer is used
judiciously to detect surface roughness by
gently across the tooth surface.
Forcing an explorer into pit and fissure also
theoretically risk cross-contamination from
one probing site to another
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11. Clinical Examination for Caries
 Caries lesions are most prevalent in the
faulty pits and fissures of the occlusal
surfaces where the developmental lobes
of posterior teeth failed to coalesce,
partially or completely
 It is important to remember the
distinction between primary occlusal
grooves and fossae and occlusal fissures
and pits. Primary occlusal grooves and
fossae are smooth “valley or saucer”
landmarks indicating the region of
complete coalescence of
developmental lobes. Normally, such
grooves and fossae are not susceptible
to caries because they are not niches for
biofilm and frequently are cleansed by
the rubbing action of food during
mastication.
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12. • Clinical caries lesion detection has been found lacking
and improvement is needed.
• One means of addressing these concerns has been the
development of a visual system for caries lesion
detection and classification.
• The ICDAS was developed to serve as a guide for
standardized visual caries assessment that could be
used for clinical practice, clinical research, education,
and epidemiology .
• In the United States, the Caries Management by
Risk Assessment (CAMBRA) movement, embraces
the principles of the ICDAS for visual examination
and assessment of caries lesions.
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13. 13

14. International Caries Detection
and Assessment System
(ICDAS)
 Developed in the year 2001 by the effort of
large group of researchers, epidemiologists
and restorative dentists to find a common
caries assessment system based on of
insights gained from a systematic review of
the literature on clinical caries detection
systems.
Ismail 2004
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15. International Caries Detection
and Assessment System
(ICDAS)
To lead to better quality information to inform
decisions about the appropriate diagnosis,
prognosis and clinical management of dental
caries at both the individual and public health
levels.
Pitts, 2004
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16. International Caries Detection and
Assessment System
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ICDAS II (2009)ICDAS I (2001)
Modified by ICDAS
coordinating committee in
2009 which describes both
coronal caries and caries
associated with restorations
and sealants (CARS) and root
caries.
Include (D) component for
caries detection and (A)
component for assessment of
caries process (whether
cavitated or non-cavitated and
active or arrested caries). Root
caries were not included due to
lack of consensus and need for
further discussions.

17. Tooth status: first number A two-number coding system will be
used to identify restorations. The system is as follows:
0 = Sound (use with the codes for primary caries)
1 = Sealant, partial
2 = Sealant, full
3 = Tooth colored restoration
4 = Amalgam restoration
5 = Stainless steel crown
6 = Porcelain or gold or PFM crown or veneer
7 = Lost or broken restoration
8 = Temporary restoration
9 = Used for the following conditions
97 = Tooth extracted because of caries (all tooth surfaces will be coded 97)
98 = Tooth extracted for reasons other than caries (all tooth surfaces
coded 98)
99 = Unerupted (all tooth surfaces coded 99)
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18. Caries status: Second number
0 = Sound
1 = First visual change in enamel (whitespot seen after 5 seconds air drying).
2 = Distinct visual change in enamel (whitespot seen without air drying).
3 = Localized enamel breakdown due to caries with no visible dentin
4 = Non-cavitated surface with underlying dark shadow from dentin
5 = Distinct cavity with visible dentin
6 = Extensive distinct cavity with visible dentin. An extensive cavity involves at
least half of a tooth surface and possibly reaching the pulp.
7 = Tooth extracted because of caries (tooth surfaces will be coded 97)
8 = Tooth extracted for reasons other than caries (tooth surfaces will be
coded 98)
9 = Unerupted (tooth surfaces coded 99)
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19. C. Root Caries (New in
ICDAS II)
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20.  Clinical evaluation of amalgam restorations requires
visual observation, application of tactile sense with
the explorer, use of dental floss, interpretation of
radiographs, and knowledge of the probabilities that
a given condition is sound or at risk for further
breakdown.
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21. 21
lines indicating the
interface between
abutted restorations

22. Clinical Examination of Composite and
Other Tooth-Colored Restorations
 Tooth-colored restorations should be evaluated
clinically in the same manner as amalgam and cast-
metal restorations. In the presence of an improper
contour or proximal contact, an overhanging margin,
recurrent caries, or other condition that impairs
cleaning or harms the soft tissue, the restoration
is considered defective.
 Corrective procedures include recontouring,
polishing, repairing, or replacing.
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23. Clinical Examination of Composite
and
Other Tooth-Colored Restorations
 One of the main concerns
with anterior teeth is
esthetics. If a tooth-colored
restoration has dark
marginal staining or is
discolored to the extent
that it is esthetically
unappealing and the
patient is unhappy with
the appearance.
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24. Clinical Examination for Additional
Defects
• A thorough clinical examination occasionally discloses
localized intact, hard white areas on the facial or lingual
surfaces or on the cusp tips of teeth.
• Generally, these are hypocalcified areas of enamel
resulting from childhood fever, trauma, or fluorosis that
occurred during the developmental stages of tooth
formation. Another cause of hypocalcification is
arrested and remineralized incipient caries, which
leaves an opaque, discolored, and hard surface.
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25. 25
ABFRACTION ATTRITION ABRASION
•Loss of tooth structure
caused by occlusal forces
such as bruxing.
•This structural loss occurs
on the sides of the teeth,
usually at the gumline level;
not on the occlusal surfaces.
•Causes notches in the tooth
along the gumline.
•The part by the gumline is
the part that starts to break
away
•is mechanical wear of the
incisal or occlusal tooth
structure as a result of
functional or parafunctional
movements of the mandible.
•Limited to the contacting
surfaces of the teeth.
•Bruxism can cause attrition
of the occlusal/incisal
surfaces.
•is abnormal tooth surface
loss resulting from direct
frictional forces between
teeth and external objects or
from frictional forces
between contacting teeth in
the presence of an abrasive
medium
•Loss of tooth structure due
to mechanical action of a
foreign element, such as a
hard bristle toothbrush or a
lip piercing.
•This can occur anywhere
that the foreign object rubs
on the teeth.

26. • The dental examination also may reveal dental
anomalies that include variations in size,
shape, structure, or number of teeth,
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27. Radiographic Examination of Teeth
and Restorations
• Radiographs are an indispensable part of the
contemporary dentist’s diagnostic
armamentarium. The use of diagnostic ionizing
radiation is, however, not without risks.
Cumulative exposure to ionizing radiation
potentially can result in adverse effects.
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28. • However, the dentist must weigh the benefits
of taking dental radiographs against the risk of
exposing a patient to radiographs, the effects
of which accumulate from multiple sources
over time. The dentist, being aware of the
patient’s health history and vulnerability to
oral disease, is in the best position to make this
judgment.
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29. • For the examination of occlusal surfaces,
radiographs had moderate sensitivity and good
specificity for diagnosing dentinal lesions;
however, for enamel lesions, the sensitivity was
poor, and the specificity was reduced. Studies of
the radiographic examination of proximal
surfaces found that there was moderate sensitivity
and good specificity for the detection of cavitated
lesions and low to moderate sensitivity and
moderate to high specificity for enamel or
dentinal lesions.
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30. • For diagnosis of proximal surface caries,
restoration overhangs, or poorly contoured
restorations, posterior bitewing and anterior
periapical radiographs are most helpful. In a
radiograph, a proximal caries lesion usually
appears as a dark area or a radiolucency in the
enamel at or apical to the contact
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31. • The height and integrity of the marginal
periodontium may be evaluated from bitewing
radiographs. Periapical radiographs are helpful
in diagnosing changes in the periapical
periodontium such as periapical abscesses,
dental granulomas, or cysts. Impacted third
molars, supernumerary teeth, and other
congenital or acquired abnormalities also may
be discovered on periapical radiographic
examination.
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32. Adjunctive Aids for Examining Teeth
and Restorations
• Study casts are helpful in
evaluating a patient’s
clinical status in many
situations. Study casts can
be useful, as they provide
an understanding of
occlusal relationships,
help in developing the
treatment plan, and serve
as a tool for educating the
patient.
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33. Examination of OCCLUSION
Molar

34. Canine

35. Incisor

36. MIDLINE DEVIATION
CROSSBITE

37. Examination for Esthetic
Considerations
• the evaluation of tooth color, tooth display, and
ideal tooth position in relation to the face.
• Attaining the desired esthetic outcomes may be
complicated by maximum tooth display and
excessive or uneven tissue display.
• Risk can be lowered primarily by establishing
ideal intrafacial tooth position and secondarily, by
establishing intra-arch tooth position.
• Tooth color evaluation becomes a factor as teeth
are more visible when smiling or at the resting
position of lips.
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38. • Darker colored teeth, teeth with enamel
intrinsic staining, and conditions such as
tetracycline staining all increase the risk for
not satisfying the esthetic expectations of
patients with tooth color concerns. Gingival
symmetry also becomes very important in
maximum display situations, and lack of
symmetry increases the risk of not meeting the
patient’s esthetic expectations.
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39. RISK PROFILE
• After the examination and data collection are
completed, the next step is to assess the risk or
likelihood of future problems, given the patient’s
current behaviors, clinical conditions, and so on.
• addition to caries risk assessments, risk assessment
profiles should be established in other areas of
patient care, such as tooth structural concerns,
periodontal disease, functional occlusal and
temporomandibular joint (TMJ) issues, and for the
“risk” involved in satisfying the patient’s esthetic
expectations. 39

40. PROGNOSIS
• Prognosis is the term used to describe the
prediction of the probable course and
outcome of a disease or condition as well as
the outcome expected from an intervention, be
it preventive or operative.
• Prognosis can also be used to estimate the
likelihood of recovery from a disease or
condition.
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41. • In operative dentistry, prognosis can be used to
describe the likelihood of success of a
particular treatment procedure in terms of :
– time of service,
– functional value to the patient
– comfort for the patient,and
– esthetic value for the patient
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42. • A prognosis can be described as excellent,
good, fair, poor, or even hopeless. Prognosis
for a disease or condition is largely dependent
on the risk factors and disease indicators that
are present in the patient. However, other
factors such as the skill of the dentist and the
current status of the disease before beginning
treatment also have an effect on the
prognosis.
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43. TREATMENT
PLANNING
• A treatment plan is a carefully sequenced series of
services designed to eliminate or control etiologic
factors, repair existing damage, and create a functional,
maintainable environment.
• An appropriate treatment plan depends on thorough
evaluation of the patient, the expertise of the dentist,
and a prediction of the patient’s response to treatment.
• An accurate prognosis for each tooth and for the
patient’s overall oral health is central to a successful
treatment plan.
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44. Four steps in the Development of
Treatment Plan
1
• Examination, Problem Identification, and Risk
Assessment
2
• Decision to Recommend Intervention
3
• Identification of Treatment Alternatives
4
• Selection of Treatment with the Patient’s Involvement
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45. • The success of the treatment plan is
determined by its ability to meet the patient’s
initial and long-term needs.
• A treatment plan should allow for re-
evaluation and be adaptable to meet the
changing needs, preferences, and health
conditions of the patient
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46. 46
TREATMENT PLAN SEQUENCING
Urgent Phase Re-evaluation Phase Definitive Phase
Recare and Re-
assessment Phase
•thorough review
of the patient’s
medical condition
and history
This phase allows time
between the control
and definitive phases
for resolution of
inflammation and
healing. Home care
habits are reinforced,
motivation for further
treatment is assessed,
and initial treatment
and pulpal responses
are re-evaluated before
definitive care is
begun.
•This phase may include
endodontic, periodontal,
orthodontic, and surgical
procedures before fixed
or removable
prosthodontic treatment.
•This phase is discussed
in detail in the section on
interdisciplinary
considerations in
operative treatment
planning.
The re-assessment
phase includes
regular re-
evaluation
examinations that
(1) may reveal the
need for
adjustments to
prevent future
breakdown
(2) provide an
opportunity to
reinforce home
care.

47. • The goals of this phase are to remove etiologic
factors and stabilize the patient’s dental
health. These goals are accomplished by
(1) eliminating active disease such as caries
and inflammation,
(2) removing conditions preventing
maintenance,
(3) eliminating potential causes of disease, and
(4) beginning preventive activities.
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48. During the maintenance phase depends, in large
part, on the patient’s risk for dental disease. A
patient who has stable periodontal health, has
a recent history of no caries lesions, and is at
low risk, may have longer intervals (e.g., 9–12
months) between recall visits. In contrast,
patients at high risk for dental caries or
periodontal problems should be examined
much more frequently (e.g., 3–4 months)
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49. Treatment of
Abrasion, Erosion,
Abfraction, and
Attrition
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50. • Abraded or eroded areas should be considered for
restoration only if one or more of the following is true:
(1) the area is affected by caries,
(2) the defect is sufficiently deep to compromise
structural integrity of the tooth,
(3) intolerable sensitivity exists and is unresponsive to
conservative desensitizing measures,
(4) the defect contributes to a periodontal problem,
(5) the area is to be involved in the design of a
removable partial denture,
(6) the depth of the defect is judged to be close to the
pulp,
(7) the defect is actively progressing, or
(8) the patient desires esthetic improvements.
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51. Treatment of Root-Surface Caries
• Root caries is common in older adults and in
patients following periodontal treatments
• Increases in the number of older patients in
the patient population and tooth retention
have contributed to this growing problem.
Areas with root-surface caries usually should
be restored when clinical or radiographic
evidence of cavitation exists.
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52. • If it is determined that the lesion needs
restoration, it can be restored with tooth-
colored materials or amalgam. Adhesive
materials have enhanced the restorative
treatment of root-surface caries.
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53. Treatment of Root-Surface Sensitivity
• It is not unusual for patients to complain of root-
surface sensitivity, which is an annoying sharp
pain usually associated with gingival recession
and exposed root surfaces.
• The most widely accepted explanation of this
phenomenon is hydrodynamic theory, which
postulates that the pain results from indirect
innervation caused by dentinal fluid movement in
the tubules that stimulates the
mechanoreceptors near the predentinal Areas
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54. • Numerous forms of treatment have been used
to provide relief, such as fluoride varnishes,
oxalate solutions, resin-based adhesives,
sealants, and desensitizing toothpastes that
contain potassium nitrate.
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55. Replacement of Existing Restorations
• Generally, a restoration should not be
replaced unless
(1) it has significant marginal discrepancies,
(2) the tooth is at risk for caries or fracture,
(3) the restoration is an etiologic factor to
adjacent teeth or tissue.
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56. • Indications for replacing restorations include the
following:
(1) marginal void
(2) poor proximal contour or a gingival overhang;
(3) a marginal ridge discrepancy;
(4) over-contouring of a facial or lingual surface;
(5) poor proximal contact;
(6) recurrent caries and
(7) ditching deeper than 0.5 mm of the occlusal
amalgam margin.
By itself, the presence of shallow ditching around an
amalgam restoration is not an indication for
replacement.
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57. Indications for replacing tooth-colored
restorations include:
(1) improper contours that cannot be repaired
(2) large voids
(3) deep marginal staining,
(4) recurrent caries, and
(5) unacceptable esthetics.
• Restorations that have only light marginal
staining and are deemed noncarious can be
corrected by a shallow, narrow, marginal repair
restoration.
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58. Treatment Considerations
for Older Patients
• Older individuals used dental services
infrequently because most were edentulous,
had limited financial resources, and delayed
unmet dental needs until they became
symptomatic.
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59. • individuals are living with increasingly more
complex medical, mental, emotional, and
social conditions that affect their ability to care
for their dentition and periodontium. These
conditions must be considered when planning
dental treatments for them
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60. • Clear and effective communication is crucial.
Because many older adults have hearing loss, the
dentist must speak more distinctly and at a higher
volume.
• Patients with memory loss appreciate written
summaries and instructions that assist them in
remembering details of the visit and planned
treatment when they leave the dental office. The
use of large simple fonts in written
communications is particularly helpful to patients
with diminished visual acuity.
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61. Thank You 
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