Patient Assessment, Examination, Diagnosis & Treatment Planning in Operative Dentistry

Y A S S E R A L I A L M O R T A D A A L W A S I F I
B D S , M S C , D D S , P H D
C O P Y R I G H T © 2 0 1 9 , A L W A S I F I , Y . A . A L L R I G H T S R E S E R V E D
DIAGNOSIS & TREATMENT PLANNING
I N O P E R A T I V E D E N T I S T R Y

D I A G N O S I S & T R E A T M E N T P L A N N I N G I N O P E R A T I V E D E N T I S T R Y - C OPYRI GHT © 2 0 1 9 , A L W ASIFI , Y . A .
E X P E C T E D
O U T C O M E S
By the end of this presentation, you are expected to be
able to:
1. Record patient data and realize its importance
2. Record the patient chief complaint and analyze its history
3. Correlate between the medical and dental history and the
proposed treatment plan
4. Correlate between the oral and dental clinical findings and the
proposed treatment plan
5. Properly diagnose dental caries by different techniques
6. Properly diagnose and evaluate existing restorations
7. Design a proper restorative treatment plan
3

PART I: PATIENT ASSESSMENT &
INFORMATION GATHERING
I.A. DEMOGRAPHIC DATA 13
I.B. CHIEF COMPLAINT 19
I.C. MEDICAL HISTORY 22
I.D. DENTAL HISTORY 27
4
C O N T E N T S
Expected Time: 30 Min

PART II: CLINICAL EXAMINATION &
DIAGNOSIS
II.A. EXAMINATION OF DENTAL CARIES
II.A.1. Traditional Techniques
II.A.2. Advanced Caries Detection Aids
II.A.3. Caries Risk Assessment
31
38
127
144
II.B. EXAMINATION OF EXISTING RESTORATION
II.B.1. Amalgam restoration
II.B.2. Tooth Colored Restoration
II.B.3. Indirect Restoration
161
162
183
186
5
C O N T E N T S

PART II: CLINICAL EXAMINATION &
DIAGNOSIS
II.C. EXAMINATION OF OTHER TOOTH DEFECTS 188
II.D. ADJUNCTIVE AIDS FOR EXAMINING TEETH & RESTORATIONS 215
II.E. EXAMINATION OF OCCLUSION 235
II.F. EXAMINATION OF PATIENT IN PAIN 240
II.G. EXAMINATION OF CRACKED TOOTH 245
6
C O N T E N T S

C O N T E N T S
PART III: TREATMENT PLANNING
III.A. PROGNOSIS 253
III.B. TREATMENT PLANNING 257
III.C. INTERDISCIPLINARY CONSIDERATIONS 265
7

INTRODUCTION
8

D I A G N O S I S & T R E A T M E N T P L A N N I N G I N O P E R A T I V E D E N T I S T R Y - C OPYRI GHT © 2 0 1 9 , A L W ASIFI , Y . A . 9
• Diagnosis is the art of identification or
recognition of the patient’s problem
• To achieve proper diagnosis, the operator
should have:
- Interest
- Intuition
- Curiosity
- Patience
- Sense
INTRODUCTION

• Diagnostic procedures includes:
I. Patient assessment & information gathering
II. Clinical examination
INTRODUCTION

I. PATIENT ASSESSMENT &
I N F O R M A T I O N
G A T H E R I N G
11

I. P A T I E N T
ASSESSMENT &
INFORMATION
G A T H E R I N G
• All the collected data from the patient must be registered in the
patient chart which should be uncomplicated, comprehensive,
accessible and up to date
• This chart could be electronic form (softcopy) or paper form
(hardcopy)
• The Chart is then followed by an interview with the patient to
validate the given information and extract any missing data
• The chart is divided into sections deals with:
1. Demographic or personal data
2. Chief complaint (present illness)
3. Medical history (past and present)
4. Dental history (past)

I. P A T I E N T
ASSESSMENT &
INFORMATION
G A T H E R I N G

1. Name:
• Calling the patient in his name adds a more
ethical communication
2. Address:
• Patient from area known by epidemic infections
needs special precautions
• Reflects patient availability and frequency of
treatment appointments
I.A. DEMOGRAPHIC DATA
Epidemic Chart

3. Age:
• Size and approximation of the pulp chamber
• Depth of the cavity and biological principles to
be followed
• Position of the gingival attachment
• Condition of calcified Tooth structure (attrition)
• Selection of restorative material & technique
Aging attrition

4. Gender:
• Certain diseases are related to specific sex, e.g.
gingival enlargement during pregnancy and
menstruation
• Palatal erosive lesions due to regurgitation of
gastric uptake and hyperacidity during
pregnancy
• Selection of restorative material & technique
Palatal erosion

Pregnancy gingivitis Pregnancy gingival polyp

5. Occupation:
• Provides an idea about certain occupational
defects, e.g. notches in anterior teeth of
dressmakers and carpenters
• Degree of interest of the restorative treatment
• The material & technique of choice
Occupational tooth wear

I. P A T I E N T
ASSESSMENT &
INFORMATION
G A T H E R I N G

I.B. CHIEF COMPLAINT
Definition:
• The main problem that drives the patient to
dental clinic
• Should be recorded in patient’s own wards
Complaints that may need restorative
management:
• Food stagnation & impaction
• Cavitation or fracture
• Discoloration
• Sensitivity or pain

I.B. CHIEF COMPLAINT
History of C.C.:
• It helps the clinician to establish location,
nature, quality and urgency of the problem.
• It also encourages the patient to volunteer
additional information that will complete the
verbal picture of the problem
• Ask about:
1. Commencement: when did it/they start?
2. Location: ask the patient to describe or ask
them to point/outline the area with one
finger
3. Type: description of symptoms. Avoid
putting words in the patient’s mouth
4. Incidence: how long ago did the episodes
start?
5. Duration: for how long do they persist?
Frequency? Are they getting better, staying
the same, or deteriorating?
6. Initiating/relieving factors: does anything
make the symptoms worse or better?
• Answers to the above will often provide the
clues to help direct the clinician to the correct
diagnosis

I. P A T I E N T
ASSESSMENT &
INFORMATION
G A T H E R I N G

• Before examination and diagnosis, the patient
completes a standard & comprehensive
medical history form
• The form is the focus of the subsequent patient
interview with the practitioner that helps
identify conditions that could alter, complicate,
or contraindicate proposed dental procedures
I.C. MEDICAL HISTORY

Importance:
• There are no systemic contra-indications to
restorative treatment except those in
uncontrolled diabetes and patient with a recent
history of myocardial infarction, are temporary
contra-indicated due to the L.A., till they will be
controlled
• Some patients may require antibiotic
prophylaxis before starting dental treatment
because of systemic conditions, e.g. prosthetic
valve, history of rheumatic fever, cancer
chemotherapy and / or radiotherapy
• Patients with infectious diseases need special
precautions to prevent cross infection to the
dental staff or to the other patients, e.g.
Hepatitis, Herpes, AIDS, Syphilis, T.B.
• To avoid adverse drug interaction with a
medication that might be prescribed during
treatment
• Some conditions may contra-indicate the use of
certain equipment during treatment e.g. E.P.T.
Such conditions as patient with pace-maker of
the heart
• Some patients are aware of their systemic
condition while others may not

Technique:
• Most oral healthcare teams use a formatted
checklist, which should include information
about:
- Cardiac problems or disease / rheumatic
fever / blood pressure
- Respiratory disease / asthma / shortness of
breath
- Diabetes / epilepsy / jaundice / hepatitis
history
- Current / recent past medications
- Allergies
- Bleeding / hemorrhages/ clotting defects
- other illnesses / operations / hospital
admissions
- Pregnancy
- HIV / AIDS / communicable disease risk

Scully and Cawson gave a checklist of medical conditions that should be
reviewed and need special care*:
• Anemia
• Bleeding Disorders
• Cardio-Respiratory Disorder
• Drug treatment & Allergies
• Endocrine Disease
• Fits & Faints
• Gastrointestinal Disorders
• Hospital Admissions
• Infections
• Jaundice
• Kidney Disorders
• Likelihood of pregnancy or
• Pregnancy
• Mental state
• Neurologic problem
* Scully C., 2014. Scully’s Medical Problems in Dentistry. 7th Ed. Elsevier LTD. ISBN: 978–0–7020–5401-3

I. P A T I E N T
ASSESSMENT &
INFORMATION
G A T H E R I N G

Importance:
• Provides an idea about the degree of interest
and satisfaction of the patient to different dental
treatment techniques
• Also it gives an idea about the suspected
unwanted or adverse reactions of the patient
that may occur due to dental treatment
“It is important to understand past experiences
in order to provide optimal care in the future”
I.D. DENTAL HISTORY

II. CLINICAL EXAMINATION
&
D I A G N O S I S
29

II. C L I N I C A L
EXAMINATION &
D I A G N O S I S
• Examination is the process of observing and testing both
normal and abnormal conditions
• Diagnosis is the determination and judgment of variations from
normal

II. C L I N I C A L
EXAMINATION &
D I A G N O S I S

• Finding an accurate method for detecting and
diagnosing any disease has been the goal of
the healing arts since the time of Socrates
• Caries diagnosis implies more than just
detecting lesions
• It is a mental resting place on the way to
treatment decision, it is intimately linked with
the treatment plan to be followed
• Consequently, caries detection - as an
intellectual process - is the determination of the
presence and extent of a caries lesion and the
judgement of its activity is an integral part of
diagnosis
• Diagnosis must include an assessment of
activity because active lesions require active
management (non-operative and operative
treatment), whereas arrested lesions don not
• Early diagnosis of the carious lesion is
important because the carious process can be
modified by preventive treatment so that the
lesion does not progress

H O L D T H I S
T H O U G H T
A goal without a plan is just a wish

All are pits and fissures occlusal caries
But, do you think all should be managed with Black’s Class I cavity preparation?

T A K E A N O T E
Caries detection methods should be
capable of detecting lesions at an early
stage, when progression can be arrested
or reserved, avoiding premature tooth
treatment by restorations

Detection Vs Diagnosis
• Detection: The determination of the presence
and extent of a caries lesion and the judgement
of its activity
• Diagnosis: Carious lesion classification or/and
scoring after correlating the presence, extent
and activity of the carious lesion with all risk
factors including patient attitude and behavior
“Proper diagnosis is the corner stone of
treatment planning and success, and prevention
of recurrence”

II.A. EXAMINATION
OF DENTAL CARIES

• Visual examination has been widely used in
dental clinics for detecting carious lesions on
all surfaces
• Visual detection of carious lesions relies on
the following operator-controlled factors:
1. Using ‘sharp’ eyes and the recommended
use of magnification in the form of dental
loupes
2. Using good illumination from the
overhead dental chair light or a more
focused light from an LED headlight,
usually coupled with the use of
magnification loupes
3. Having clean and dry tooth surfaces to
examine both wet and dry using a 3-1
air/water syringe. If surface debris
(plaque/calculus) is present, this may have
to be removed prior to any dental
examination taking place
4. Using rounded/ball-ended dental
explorers—the use of sharp dental probes
is contraindicated for carious lesion
detection as they can, with injudicious use,
cause cavitation in a previously non-
cavitated lesion
II.A.1. Traditional Techniques – a) Visual examination

5. Teeth separation may be beneficial to
assess the proximal surfaces of adjacent
teeth visually, ideally with magnification.
Wedges or orthodontic separators can be
placed interproximally for a few minutes
prior to the examination of the field, to
gently displace the gingiva apically and
part the teeth slightly through movement
within their periodontal ligament spaces. In
this way, incipient or cavitated lesions may
become more evident
6. Sufficient time allocated for the
examination of all tooth surfaces as well as
the soft tissues and periodontium

Magnification Loupes Magnification Loupes with LED Headlight

(a) An active root caries lesion with overlying plaque deposit in an area of stagnation alongside the margins of a partial denture. The buccal cervical
abrasion cavity has been caused by excessive toothbrushing. (b) A stagnant plaque biofilm present on the proximal root surface, which when
removed (c) reveals an active root caries lesion

(a) A maxillary molar that is apparently caries-free with
saliva obscuring the occlusal fissures. (b) When the saliva is
removed with the 3-1 air/water syringe, an incipient white
spot lesion becomes evident

(a) A smooth surface incipient
white spot lesion (WSL)
associated with the cervical
aspect of a mandibular canine. (b)
A cross-section through an
equivalent buccal cervical WSL
showing the classical ‘inverted
cone’ shape of the non-cavitated
enamel lesion. (c) This lesion has
been probed using a sharp dental
explorer resulting in (d) operator-
induced (iatrogenic) cavitation of
the lesion that should have been
managed non-operatively. The
use of a sharp dental probe to
elicit ‘sticky fissures/surfaces’ is
contraindicated for caries
detection

Orthodontic elastic separators
to separate teeth over the
course of few minutes for a
closer look between teeth
prone to caries lesions

Principle of Visual Examination:
• The earliest detectable changes within tooth
structure affect the micro-porosity of enamel,
which in turn affects the transmission of light
through the enamel
• Next would be color changes within enamel
and dentin followed by defects within the
enamel
• These can all be detected visually with the
clinician’s eyes using direct vision or vision
assisted with a mirror and a standard dental
operatory light
• Decision (absence or presence of a lesion) is
based on subjective interpretation of integrity,
texture, translucency/opacity, location and
color
• Visual examination reveals dental caries by
discoloration or / and cavitation

Caries can be diagnosed clinically by careful inspection:
A. Carious pit on cusp tip
B. Loss of translucency and change in color of occlusal enamel resulting from a carious fissure
C. White chalky appearance or shadow under marginal ridge
D. Incipient smooth-surface caries lesion, or a white spot, has intact surface
E. Smooth-surface caries can appear white or dark, depending on the degree of extrinsic staining
F. Root-surface caries

White Spot Cervical Lesions:
• Chalky white area that appears with dryness &
disappears with wetting indicates active
cervical carious lesion
• This is described as disappearing-
reappearing phenomenon

Limitations of Visual Examination:
• Its subjectivity between different practitioners
specially of early lesions
• International Caries Detection and Assessment
System (ICDAS) was developed at 2002 to aid
visual examination of dental caries with specific
caries index for different degrees of variation
from normal

ICDAS (International Caries Detection and
Assessment System):
What is ICDAS:
• ICDAS is a clinical scoring system that is used
to detect and assess dental caries
• It is generated to be used in dental education,
clinical applications, researches and
epidemiological studies
• This scoring system can be used on coronal
surfaces and root surfaces and can be applied
for enamel caries, dentin caries, non-cavitated
and cavitated lesions to detect and assess
these lesions
• ICDAS measures the surface changes and
potential histological depth of carious lesions
by relying on surface characteristics
Aims of ICDAS:
• The aim of planning ICDAS is to gain better
quality information to make decisions about
appropriate diagnosis, prognosis and clinical
management of dental caries at both the
individual and public health levels

Assessment System):
1. ICDAS - I:
• Released in 2002
• 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
• The “D” in ICDAS stands for detection of dental
caries by:
1. Stage of the carious process
2. Topography (pit-and-fissure or smooth
surfaces)
3. Anatomy (crowns versus roots)
4. Restoration or sealant status
• The “A” in ICDAS stands for assessment of the
caries process by:
1. Stage (non-cavitated or cavitated)
2. Activity (active or arrested)

Assessment System):
1. ICDAS - I:
• The caries the visual detection criteria was
determined on a scale of 0 to 6 defines as
Caries Severity Codes
• While caries activity criteria was determined
separately
• Detection criteria of ICDAS – I includes only
primary coronal carious lesions either for pits
and fissures surface lesions or smooth surface
lesions
CODE CRITERIA
0 Sound
1 First visual change in enamel
2 Distinct visual change in enamel
3 Localized enamel breakdown (without clinical
visual signs of dentinal involvement)
4 Underlying dark shadow from dentin
5 Distinct cavity with visible dentin
6 Extensive distinct cavity with visible dentin

Code 0
Sound
Code 1
First visual change
in enamel
Code 3
Localized enamel
breakdown (without
clinical visual signs of
dentinal involvement
Code 4
Underlying dark
shadow from dentin
Code 2
Distinct visual change in
enamel
Code 5
Distinct cavity with
visible dentin
Code 6
Extensive distinct cavity
with visible dentin

Caries activity criteria:
CODE Characteristics of Lesion
Active Lesion Inactive (Arrested) lesion
1, 2 or 3 • Surface of enamel is whitish / yellowish opaque with
loss of luster
• Feels rough when the tip of the probe is moved
• Lesion is in a plaque stagnation area, i.e.: pits &
fissures, near the gingival and approximal surface
below the contact point
• Surface of enamel is whitish, brownish or black
• Enamel may be shiny and feels hard when the tip of
the probe is moved
• For smooth surface lesion is typically located at some
distance from the gingival margin
4 • Probably active
5 or 6 • Cavity feels soft or leathery on gently probing the
dentin
• Cavity may be shiny and feels hard on gently probing
the dentin

Assessment System):
2. ICDAS - II:
• Modified by ICDAS coordinating committee in
2009 which describes both coronal caries and
caries associated with restorations and sealants
(CARS) and root caries
• Criteria are divided into two categories:
1. Coronal caries
2. Root caries
• ICDAS - II system have two-digit coding for
detection criteria of primary coronal caries:
1. The first one is related to the restoration of
teeth and has a coding that ranges from 0
to 9
2. The second digit ranges from 0 to 6 that is
used for coding the caries
• There are minor variations between the visual
signs associated

2. ICDAS – II:
• The first digit is related to the restoration of
teeth and has a coding that ranges from 0 to 9
CODE CRITERIA CODE CRITERIA
0 Not sealed or restored 5 Stainless Steel Crowns
1 Sealant, partial 6 Porcelain or gold or PFM crown or veneer
2 Sealant, Full 7 Lost or broken restoration
3 Tooth Colored Restoration 8 Temporary restoration
4 Amalgam Restoration 9 Missed tooth

2. ICDAS – II:
• Code “9” is used for missing teeth due to one
of the following conditions
90 Implant for other non-carious related reasons 96 Tooth surface cannot be examined: surface
excluded
91 Implant placed due to caries 97 Tooth missing because of caries
92 Pontic placed for reasons other than caries 98 Tooth missing for reasons other than caries
93 Pontic placed for carious reasons 99 Un-erupted tooth

2. ICDAS – II:
• Root caries codes
E • If the root surface cannot be visualized
directly, then it is excluded
1 • There is a demarcated area on the root
surface or at the CEJ that is discolored but
there is no cavitation (loss of anatomical
contour<0.5mm) present
0 • The root surface does not exhibit any
unusual discoloration that distinguishes it
from the surrounding root areas, nor does
it exhibit a surface defect at the
cementoenamel junction or root surface
• The root surface has a natural anatomical
contour
2 • There is a demarcated area on the root
surface or at the CEJ discolored and there
is cavitation (loss of anatomical
contour≥0.5mm) present

2. ICDAS – II:
• Criteria for root caries activity assessment
PARAMETER Characteristics of Lesion
Active Lesion Inactive (Arrested) lesion
COLOR • Yellowish or light brown • Darkly stained
PERCEPTION
ON PROBING
• Soft or leathery texture • Hard texture
APPEARANCE • Matte • Shiny
TEXTURE • Rough surface • Smooth surface
CAVITATION • Cavitated or non-cavitated • Cavitated
LOCATION • Closely adjacent to the crest of the gingival tissues • More distant from the gingival crest

Assessment System):
3. mICDAS:
• A modified ICDAS (mICDAS) carious lesion
scoring system (0–4), linking the clinical
appearance with the equivalent underlying
lesion histology
• This clinical scoring system is useful for
inclusion in the patient’s notes, for monitoring,
and for dento-legal purposes
• mICDAS scores for the visual and histological
lesion appearance correlate with the
radiographic appearance / depth of enamel
and dentine lesions

Assessment System):
3. mICDAS:
• The association between the radiographic
lesion depth (E0–D3) and equivalent
mICDAS scores

mICDAS 1
an incipient white spot lesion
becomes evident with
dryness
mICDAS 3
Small cavity is just detectable within the whitish
opacity/brown discoloration on the occlusal surfaces of
these molars, appearing as a widened fissure and a
cavitated pit, respectively. It can easily be missed clinically
unless the surfaces are clean and vision aided by the use of
magnification
mICDAS 4
Grossly cavitated buccal carious lesions
on LR3 and LR4, with quantities of
stagnant dense plaque deposited on the
exposed dentin
mICDAS 2
The brown, non-cavitated fissures
with underlying grey discoloration
on the occlusal surface of the UL7
are caused by demineralized,
discolored dentin shining through
intact, wet enamel

146(2)http://jada.ada.orgFebruary2015ADA Caries Classification
System

Advances in Visual Examination
Techniques:
1. Magnification:
• Advances in magnification allow practitioners
to observe the finest details with great accuracy
and high resolution
• Magnification can be achieved through intra-
oral cameras via zooming aided with LED light,
or Magnifying loupes utilizing the power of
magnifying lenses that start from 2X up to
Microscopes that can reach magnifications of
20X
MAGNIFICATION RESOLUTION OF EYE
• Unaided vision
• 2X Loupes
• 4X Loupes
• 8X Microscope
• 12X Microscope
• 20X Microscope
• 200 microns – 2mm
• 100 microns – 1 mm
• 50 microns – 0.05 mm
• 25 microns – 0.025 mm
• 16.67 microns – 0.0167 mm
• 10 microns – 0.01 mm
How resolution of human eye increases with magnification
(Ability to differentiate between two lines with that distance
between) - Van-As, 2013

Magnifying Loupes
Intra Oral Camera

Dental Microscope

2. Transillumination:
• It is accomplished by placing a mirror or light
source on the lingual side of the anterior teeth
and directing light through the teeth
• Proximal surface caries, if other than incipient,
shows up as a dark area along the marginal
ridge when light is directed through the tooth

2. Transillumination:
a) Fiber-Optic Transillumination Device (FOTI)
• can be used for this method where light is
presented through a small aperture in the form
of a dental handpiece that shines through the
tooth surface showing carious defect
b) Digital Imaging Fiber-Optic
Transillumination Device (DIFOTI)
• The digital version of the previous device

a) Fibro Optic Trans Illumination
(FOTI)
• Fiber Optic Trans-Illumination (FOTI) as a caries
detection technique is based on the fact that
carious enamel has a lower index of light
transmission than sound enamel
• The light is absorbed more when the
demineralization process disrupts the
crystalline structure of enamel and dentin
• In essence this gives that area a more darkened
appearance
• This method of caries detection uses a light
source, preferably bright, to illuminate the
tooth, caries or demineralised areas in dentin
or enamel show up as darkened areas with this
technique
• This effect can be achieved with a fiber-optic
illuminator, which is readily available at the
handpiece coupler of the dental operatory and
has been used for detection of approximal and
occlusal caries

a) Fibro Optic Trans Illumination
(FOTI)
• Posterior approximal caries can be diagnosed
with the light probe positioned on the gingivae
below the cervical margin of the tooth,
whereby the light passes through the tooth
structures and approximal decay produces a
dark shadow on the occlusal surface
• Although this device has the advantage that
the examination is done with an operating light
source already available in general practice, it
is only useful for approximal and occlusal
lesions
• Its sensitivity and specificity are not sufficient
for detection of very early caries
• Besides, it is not quantitative and therefore not
useful as a caries monitor over time

b) Digital Imaging Fibro Optic Trans
Illumination (DIFOTI)
• This is a digitized and computed version of the
FOTI
• While FOTI was designed for detection of
approximal and occlusal caries, digital imaging
fiber-optic transillumination DIFOTI is used for
detection of both incipient and frank caries in
all tooth surfaces
• DIFOTI can also be used to detect fractures,
cracks, and secondary caries around
restorations
• DIFOTI uses white light to trans illuminate each
tooth and to instantly create high-resolution
digital images of the tooth
• It is based on the principle that carious tooth
tissue scatters and absorbs more light than
surrounding healthy tissue
• Decay near the imaged surface appears as a
darker area against the more translucent
brighter background of surrounding healthy
anatomy

• A single fiber-optics illuminator in the
mouthpiece delivers light to one of the tooth’s
surfaces
• As this light travels through layers of enamel
and dentin, it scatters in all directions toward
the nonilluminated surface usually the opposite
surface
• The light is then directed through the
mouthpiece to a miniature electronic charge
coupled device CCD camera in the handpiece
• The camera digitally images the light emerging
from either the smooth surface opposite the
illuminated surface or the occlusal surface
• Decay near the imaged surface appears as a
darker area against the more translucent
brighter background of surrounding healthy
anatomy

• These images are displayed on a computer
monitor in real time and stored on the hard
drive for easy retrieval for comparative review
of images over time
• Image acquisition is controlled with software
and a foot pedal
• Images of the teeth can be viewed by both the
clinician and patient, and therefore can be
used for patient education and motivation
• The average mineral loss of the tooth structure
can be determined via analyzing the recorded
image and assessment of the optical thickness
difference of the tooth structure
• So, it is considered as a qualitative &
quantitative diagnostic method for the lost
tooth structure

II.A. EXAMINATION
OF DENTAL CARIES

II.A.1. Traditional Techniques – b) Tactile examination
“A sharp explorer should be used with some
pressure and if a very slight pull (tug back
action) is required to remove it, the pit should be
marked for restoration even if there are no signs
of decay.”
• This is a quote from G.V. Black’s book
“Operative Dentistry” published in 1924
regarding detection of caries occurring in pits
and fissures of occlusal surfaces where the
developmental lobes of the posterior teeth fail
to coalesce
• Tactile examination based on examining
surface texture and discontinuity
• Catching with sharp dental explorer may
indicate carious lesion of occlusal pits or / and
fissures
• Catching with cow-horn sharp explorer or
threading of un-waxed dental floss may
indicate proximal carious lesions

MARCO POLO CHRISTOPHER
COLUMBUS
PEDRO ALVARES
CABRAL
FERDINAND
MAGELLAN
NEIL
ARMSTRONG
THE MOST FAMOUS WORLD EXPLORERS
NO. 23

• Traditional probing with a sharp explorer has
come into question as the ultimate determinant
of caries activity
• The exclusive use of a “catch” by the sharp
explorer to diagnose caries in pit and fissure
sites should be discontinued and clinicians are
being called upon to use “sharp eyes and a
blunt explorer”
• Also non-cavitated lesions can become
cavitated simply through pressure from the
explorer during the typical examination
• Thus, penetration by a sharp explorer can
actually cause cavitation in areas that are re-
mineralizing or could be re-mineralized
• An explorer can also transfer cariogenic
bacteria from one tooth surface to another
87

LEFT: Overview of a probed occlusal fissure system with initial carious lesion. RIGHT: Note the distinct probing marks at the
fissure wall of the magnified area (arrows)

LEFT: Bottom of the fissure system with an initial carious lesion. The probing mark (1) ends in a distinct enamel break-off (2) on
the opposite side of the fissure slope (arrows). RIGHT: Slope of a deep initial carious fissure with enamel breakoffs (arrows).

LEFT: Impression with surface defect of the dental probe located in porous, initial carious enamel of a fissure wall. RIGHT:
Occlusal pit whose sides were compressed congruent with the dental probe (arrows).

Occlusal pit with probing marks of an initial carious
lesion with interruption of the surface continuity (arrows)

LEFT: Initial carious fissure with extensive enamel break-offs (arrows) with exposure of enamel prisms. RIGHT: Probing marks (1)
and enamel break-offs (2) in initial carious enamel at the bottom of the fissure.

• Most of Cariologist and Epidemiologist
recommended the evaluation of the presence
of discontinuities in enamel or micro-
cavitations by using the WHO/PSR probe,
which is ball-ended with a sphere presenting
0.5 mm in the extremity, allowing this kind of
evaluation
94

II.A. EXAMINATION
OF DENTAL CARIES

• Radiology described in 1923 as “the most
revolutionary aid in dental diagnosis which has
come into general application during the
present decade,”
• Traditionally, the first level of technology
beyond the basic eyes of the examiner has
been bitewing radiography
• The use of a bitewing radiography as an
adjunct to the clinical examination could permit
more sensitive detection of proximal and
occlusal caries lesions in dentin and a better
estimation of the lesion depth than the visual
inspection performed alone
• Bitewing projection is the most appropriate
radiographic technique for caries detection
• This technique requires a film-holder with a
wing for the patient to bite
II.A.1. Traditional Techniques – c) Radiographic examination

ABDUL BARI SALEH AL JUHANI
Dent 37 – Taibah University - KSA

• Carious lesions are detectable radiographically
when there has been enough demineralization
to allow it to be differentiate from normal
• They are valuable in detecting proximal caries
which may go undetected during clinical
examination
• On average they have around 50% to 70%
sensitivity in detecting carious lesions
40% demineralization is required for definitive
decision on caries

• Radiographic examinations include:
1. Bitewing radiographs
2. Periapical (PA) radiographs using
paralleling technique
3. Ortho Panto Gram (OPG) – Panoramic
Tomography
• Radiographs can detect:
1. Proximal caries (appear as “triangular”
radiolucency that has its apex toward the
DEJ)
2. Moderate to deep occlusal caries can be
seen as radiolucency in the dentin
3. Defective aspects of restorations: e.g.
Improper contour, overhangs, and
recurrent caries gingival to restorations
4. Pulpal abnormalities such as pulp stones
and internal resorption may be identified
5. Periapical radiographs are helpful in
diagnosing periapical abscesses, dental
granulomas or cysts
6. Impacted third molars and supernumerary
teeth may also be discovered

• Radiographic notation system of dental
caries:
- E0: no enamel lesion
- E1: enamel lesion without cavitation
- E2: cavitated enamel
- D1: demineralization in the outer half of
dentin
- D2: demineralization in the inner half of
dentin
- D3: cavitated dentin lesion

1. Pits & Fissure Caries
a) Incipient occlusal lesions:
• Not very effective
• Caries starts on the walls of the pits & fissures
and tends to spread perpendicular to the DEJ
• Only detectable change is a fine gray shadow
at the DEJ

b) Moderate occlusal lesions:
• First to induce specific changes helping in a
definitive diagnosis
• Broad based, thin radiolucent zone in dentin
with minimal or no changes in enamel
• Presence of a band of increased opacity
between the lesion and the pulp chamber due
to calcification within primary dentin
• This feature is not seen in buccal caries

c) Severe occlusal lesions:
• Readily observed both clinically and
radiographically
• Appear as large cavities in the crowns of the
teeth
• However pulp exposure cannot be determined

2. Proximal Caries
• Density along the proximal surface is high
which does not permit the detection of loss of
small amounts of mineral content
a) Incipient Proximal lesions:
• Commonly seen in the caries-susceptible zone
• Presents as a notch on the outer surface not
involving more than half of enamel
• Diagnosis can be missed, best viewed under a
magnifying glass

2. Proximal Caries
b) Moderate Proximal lesions:
• Involve more than outer half of enamel but do
not extend into DEJ
• May have one of type of appearance:
- 67% - triangle with broad base towards
outer surface
- 16% - a diffuse radiolucent image
- 17% - combination of both

2. Proximal Caries
c) Advanced Proximal lesions:
• Radiolucent triangular cone invading into the
dentin
• In addition, it spreads along the DEJ and
subsequently into dentin
• This forms a 2nd cone with base at DEJ
• Does not involve more than half of dentin
• In some cases, lesions penetrated into dentin
may appear not to have penetrated enamel

2. Proximal Caries
d) Severe Proximal lesions:
• Penetrating more than half of dentin
• Narrow path through enamel, an expanded
radiolucency at DEJ, with a progress towards
pulp
• Lesions may or may not appear to involve pulp
• Undermined enamel fractures under
masticatory load leaving a large cavity

3. Facial & Lingual Caries
• They start as round lesions and enlarge to
become elliptical or semilunar
• Presence of well defined non-carious enamel
around radiolucency
• When superimposed on DEJ, they may mimic
occlusal caries
• Clinical examination helps in definitive
diagnosis

4. Root Caries
• Also called cemental caries with an incidence
of 40%- 70% of the aged population
• Buccal, lingual, proximal
• Usually it is a lesion of dentin associated with
recession
• Ill-defined, saucer-like radiolucency

5. Recurrent Caries
• Occurs immediately next to restorations
• Radiolucency depends on amount of
demineralization and extent of restoration
• Mesio/disto-gingival and occlusal margins-
clearly seen
• Difficult to be detected under
- Facial / lingual restorations-difficult to
detect
- Materials like Ca(OH), composite & silicate
cements

6. Other Radiographic Shadow
a) Radiolucent Cervical Burn Out:
• Evident at the neck of tooth well demarcated
above by enamel cap & below by alveolar
bone level
• It is triangular in shape being less apparent at
the center of tooth
• Good alveolar bone height will enhance
cervical burn-out
b) Radiopaque Zone Beneath Amalgam:
• Tin & zinc ions are released into underlying
dentin

Advances in Radiographic Examination
Techniques:
1. Digital Radiography:
• In digital radiography, the image instead of
being captured on film, it is captured on a
sensor through which the digital X-ray is
transmitted to the computer where it can be
checked, manipulated and stored
• Advantages of digital radiography:
1. Easy & quick
2. Minimal exposure time to x-rays
3. No darkroom & processing solution (avoid
processing errors)
4. Manipulation of image (adjusting contrast,
brightness, size, measurements...etc.)
5. Storing and exchange information with the
other dentists

• Example of digital radiography systems:
Digora Image Plate System
• It is a modification of the digital intraoral
radiography
• The radiographic information is captured on a
phosphorus storage screen or re-usable image
plate which is placed in a scanning unit running
by laser beam and connected to personal
computer
• The tooth image is then transmitted to the
computer
• The software is highly sensitive that allows to
differentiate between 1024 gray levels (Human
eye could only differentiate as maximum as 30
gray hues)
• This enables the operator to distinguish the
earliest changes in tooth structure

• Advantages of Digora system:
1. Accurate radiograph with minimal exposure
time and dose
2. The ability to generate a scale plot of the
lesion boundaries
3. Estimate the depth of penetration
4. Estimate the progress of the lesion
5. The filing system allows accurate follow up
of the case
• Disadvantages of Digora system:
1. Any alteration or modification of the image
will affect the results and follow up of the
case
2. Deterioration of the radiographic plate by
time

Digora System

2. Radio-Visio-Graphy (RVG) Systems:
• Using a highly radio-sensitive metal sensor
instead of the re-usable plates, that is directly
connected to the computer unit (CPU)
• It neglects the use of the digital scanning as the
image is captured directly to the computer
• The software enables zooming, rotation,
cutting, editing and printing
• Recent versions allow the transfer of the image
to a video compatible system
• Advantages:
1. Accurate radiograph with minimal exposure
time and dose by 90%
2. The ability to generate a scale plot of the
lesion boundaries
3. The image could be zoomed, rotated and
cut
4. Further processing of the image is available
5. Filing system that allows follow up
• Disadvantages:
1. The high initial coast
2. Complex operating software compared to
conventional radiograph

2. Radio-Visio-Graphy (RVG) Systems:

3. Computer Aided radiographic
Systems:
• Computer aided radiographic method utilizes
software that can assess and record lesions’
size
• These systems integrated artificial intelligent
software (Logicon Caries Detection Software)
to diagnose and evaluate carious lesions
• They work with the aid of a unique histologic
database, allowing graphic visualization of the
size and progression of the lesion

4. Subtraction Radiology:
• Digital radiographs offers a number of
opportunities for image enhancement,
processing and manipulation
• One of the most promising technologies in this
regard is that of radiographic subtraction which
has been extensively evaluated for both the
detection of caries and also the assessment of
bone loss in periodontal studies
• The basic premise of subtraction radiology is
that two radiographs of the same object can be
compared using their pixel values
• If the images have been taken using either a
geometry stabilising system (i.e. a bitewing
holder) or software has been employed to
register the images together, then any
differences in the pixel values must be due to
change in the object
• The value of the pixels from the first object are
subtracted from the second image

4. Subtraction Radiology:
• If there is no change, the resultant pixel will be
scored 0; any value that is not 0 must be
attributable to either the onset or progression
of demineralisation, or regression
• Subtraction images therefore emphasise this
change and the sensitivity is increased
• It is clear from this description that the
radiographs must be perfectly, or as close to
perfect as possible, aligned
• Any discrepancies in alignment would result in
pixels being incorrectly represented as change

Example of subtraction of two bitewing
radiographs (a) Radiograph showing
proximal lesion on mesial surface of first
molar, (b) follow up radiograph taken 12
months later, (c) the area of difference
between the two firms are shown as
black, i.e. in this=s case the proximal
lesion has become more radiolucent and
hence has progressed

II.A. EXAMINATION
OF DENTAL CARIES

II.A.1. Traditional Techniques – d) Limitations
Limitations of Traditional Techniques
1. There is great difference between mirror and
explorer findings and histological findings
2. Forceful exploring may create cavitation in
early enamel demineralization
3. False diagnosis results from catching of deep
non carious fissure of parallel side walls
4. Even radiographically, early lesions in enamel
can not be detected
5. Radiograph show only dentinal lesions in the
time of nearly approaching the pulp

II.A.1. Traditional Techniques – d) Limitations
Special Pitfalls of Radiographs
1. Two-dimensional view of three-dimensional
object
2. Radiographic depth of a lesion is often less
than actual depth
3. Overlapping of proximal surfaces on a
radiograph
4. Occlusal (incipient) caries of enamel difficult
to detect
5. Dental anomalies like hypoplastic pits mimic
proximal caries
6. Cervical burnout often confused with root
caries

II.A. EXAMINATION
OF DENTAL CARIES

• It is based on the fact that sound enamel is a
good insulator, while the carious enamel is
porous and filled with fluids and ions from
saliva, so it becomes a good conductor
• The electronic detector can measure
quantitatively any change in enamel electrical
conductivity
• This means that slight drop in the enamel
resistance values indicates the presence of
early demineralization
• Examples:
1. Vanguard Electronic Caries Detector:
where electrical conductivity is expressed
numerically on a scale from 0 to 9
2. Caries Meter L: The Caries Meter L uses
coloured lights to indicate caries extent
(Green-sound, Yellow-enamel caries,
Orange-dentinal caries and Red-caries
reaching the pulp)
3. Electronic Caries Monitor (ECM): measure
the ‘bulk resistance’ of tooth tissue
4. CarieScan: involves the passing of an
insensitive level of electrical current
through the tooth to identify the presence
and location of the decay
II.A.2. Advanced Caries Detection Aids – a) Electronic Caries Detector

II.A.2. Advanced Caries Detection Aids – a) Electronic Caries Detector
Electronic Caries Monitor (ECM) CarieScan

II.A. EXAMINATION
OF DENTAL CARIES

• Caries indicator dyes are non-specific protein
dyes that stain the organic matrix of less
mineralized dentin, including normal
circumpulpal dentin and sound dentin in the
area of the DEJ
• It is a diagnostic aid for detecting occlusal
caries
• The dye is purported to stain only infected
tissue and is advocated for a “painless” caries
removal technique without local anaesthetic
• The technique is laborious, as it is guided by
staining, involves multiple dye application-and-
removal repetitions and requires the use of a
slow- speed bur
II.A.2. Advanced Caries Detection Aids – b) Caries Detection Dye

II.A.2. Advanced Caries Detection Aids – b) Caries Detection Dye
Caries Detection Dye (CDD)

II.A. EXAMINATION
OF DENTAL CARIES

Principles of laser / light-induced
fluorescence:
• Fluorescence is a phenomenon by which the
wavelength of the emitted light is changed to
larger wavelength upon reflectance
• The intensity of fluorescent light is proportional
to the amount of material that causes
fluorescence
• The difference between fluorescence of sound
tooth tissue and that of caries can be made
visibly by quantitative laser
• These tools for example:
1. DIAGNOdent (Argon laser fluorescence)
2. Quantitative laser/Light fluorescence (QLF)
II.A.2. Advanced Caries Detection Aids – c) Laser Fluorescence

1. DIAGNOdent:
• This technique is used to quantify the mineral
loss in carious lesions
• The lesion is subjected to argon laser and will
emit fluorescence which is different in healthy
compared to carious structures
• The initial mineral loss of non-cavitated enamel
and dentin lesions on buccal, lingual and
occlusal surfaces as well as bacterial activity
could be measured
• Red argon laser light is transported through
fiber bundle to tip of a hand piece placed
against the tooth surface
• The laser light penetrate the tooth, difference
in fluorescence between sound and
demineralized enamel as well as fluorescence
of bacterial metabolites are recorded by the
device giving quantitative record of the
existing decay with audible sounds

1. DIAGNOdent:
• The intensity of fluorescence is displayed as a
number ranging from 0-99 indicating the size
and depth of the carious lesion
• 0 indicates minimum fluorescence while 99
indicates maximum fluorescence
• The result reading should be compared with
reading of healthy tooth:
- A reading of 10-20 indicates some enamel
softening so should be monitored
- A reading of 21-99 indicates a definite area
of decay requiring a filling
• The device is available in a classic design and a
newer Pen design

1. DIAGNOdent:

2. Quantitative Light-induced
Fluorescence (QLF):
• Quantitative light-induced fluorescence (QLF),
which is based on auto-fluorescence of teeth
which allows for detection of early carious
lesions
• The teeth are illuminated with high intensity
blue light, the resultant auto-fluorescence of
enamel is detected by an intraoral camera
which produces a fluorescent image
• The emitted fluorescence has a direct
relationship with the mineral content of the
enamel
• The difference between the fluorescence of
sound tooth tissues and that of a caries lesion
can be made visible by the quantitative light-
induced fluorescence method that yields a
quantitative caries diagnosis

2. Quantitative Light-induced
Fluorescence (QLF):
• The intensity of the tooth image at a
demineralised area is darker than the sound
area
• The software of QLF systems can process the
image to provide user quantitative parameters
such as lesion area, lesion depth, and lesion
volume
• These parameters can detect and differentiate
the lesions at very early stages, and make the
QLF system more sensitive to changes of caries
over time
• QLF uses a blue light (488 nm) to illuminate the
tooth, which normally fluorescence a green
colour
• Teeth should be dried before its application
• However it cannot differentiate between decay
and hypoplasia; has inability to detect or
monitor interproximal lesions and is limited to
measurement of enamel lesions of at most
several hundred micro-meters depth

QLF

Example of QLF images. (a) White light image of early buccal caries affecting the maxillary teeth, (b) QLF image taken at the same time as (a), note
the improved detection of lesions as a result of the increased contrast between sound and demineralized enamel, (c) 6 months after the institution of
oral hygiene program, the lesions have resolved

II.A. EXAMINATION
OF DENTAL CARIES

• The caries risk assessment is an important part
of this overall process of patient care
• The clinician must gather all appropriate data
from both the interview with the patient and
the clinical examination for caries detection to
formulate an individualized caries risk
assessment
• Part of the caries risk assessment identifies the
causative factors
• According to ICCMS (International Caries
Classification and Management System) caries
risk factors are classified into two groups:
1. Patient level caries risk factors
2. Intra-oral level caries risk factors

1. Patient Level Caries Risk Factors:
• Head and neck radiation
• Dry mouth (conditions, medications /
recreational drugs / self report)
• Inadequate oral hygiene practices
• Deficient exposure to topical fluoride
• High frequency/ amount of sugary drinks/
snacks
• Symptomatic-driven dental attendance
• Socio-economic status/ health access barriers
• For children: high caries experience of mothers
or caregivers

2. Intra-Oral Level Caries Risk Factors:
• Hypo-salivation/Gross indicators of dry
mouth
• PUFA (Exposed Pulp, Ulceration, Fistula,
Absess) – Dental sepsis
• Caries experience and active lesions
• Thick plaque: evidence of sticky biofilm in
plaque stagnation areas
• Appliances, restorations and other causes of
increased biofilm retention
• Exposed root surfaces

CAMBRA:
What is CAMBRA?
• CAMBRA is an acronym for Caries
Management by Risk Assessment
• It describes a preventative form of dentistry in
which patients are categorized by their relative
risk for developing dental caries, based on risk
factors including diet, oral
hygiene, fluoride regiment, and past oral
health history
Principle of CAMBRA:
• CAMBRA system was developed as an
evidence-based approach to the prevention,
reversal, and treatment of patients with dental
caries
• The emphasis is on the whole disease process
and employs the caries balance method, taking
account of all factors that contribute to the
development of dental caries (attacking
factors) and all factors that research has shown
to be protective from dental caries (defense
factors)

The balance amongst
disease indicators, risk
factors and protective
factors determines whether
dental caries progresses,
halts, or reverses

CAMBRA:
Data of CAMBRA:
• The CAMBRA system provides a more in-depth
assessment tool as a key element of the overall
approach and takes account of “4”major
domains:
a) Caries disease indicators:
1. Socio-economic status
2. Developmental problems
3. Presence of lesions or restorations placed
within the previous 3 years
b) Caries risk factors:
1. Visible accumulations of plaque and
quantitative assessment of Streptococcus
mutans and Lactobacilli
2. Frequent snacking
3. Saliva flow and salivary modifying factors
4. Fissure anatomy
5. Root surface exposure
6. Presence of appliances

CAMBRA:
Data of CAMBRA:
c) Caries protective factors:
1. Systemic and topical fluoride sources
2. adequate saliva flow
3. Xylitol in the diet
4. Use of calcium and phosphate paste or
chlorhexidine
d) Clinical examination:
1. Presence of white spots
2. Decalcifications
3. Restorations
4. Plaque deposits
• The tool assigns patients to low, moderate,
high, or extreme risk and offers two formats,
one for patients aged 0-5 years, and one for 6
years onward

CAMBRA:
Analysis of CAMBRA:
• In addition to counting the “yes” checks as
described above, the following three modifiers
apply:
a) High and extreme risk:
- One or more disease indicators signals at
least high risk
- If there is also hyposalivation, the patient is
at extreme risk
- Even if there are no positive disease
indicators the patient can still be at high risk
if the risk factors definitively outweigh the
protective factors
b) Low risk:
- If there are no disease indicators, very few or
no risk factors and the protective factors
prevail, the patient is at low risk
- Usually this is obvious

CAMBRA:
Analysis of CAMBRA:
• In addition to counting the “yes” checks as
c) Moderate risk:
- If the patient is not obviously at high or
extreme risk and there is doubt about low
risk, then the patient should be allocated to
moderate risk and followed carefully, with
additional chemical therapy added
- An example would be a patient who had a
root canal as a result of caries four years ago
and has no new clinical caries lesions, but
has exposed tooth roots and only uses a
fluoride toothpaste once a day

II. C L I N I C A L
EXAMINATION &
D I A G N O S I S

II.B. EXAMINATION
O F E X I S T I N G
R E S T O R A T I O N

• Any existing amalgam restoration should be
checked for:
1. Amalgam Blues or/and Tattoos
2. Fracture Lines
3. Marginal Ditching
4. Voids
5. Overhangs
6. Improper Anatomical Contour
7. Improper Proximal Contact
8. Improper Occlusal Contact
9. Marginal Ridge Incompatibility
10.Recurrent Caries
II.B.1. Amalgam Restoration

1. AMALGAM BLUES OR/AND TATTOOS:
• These are discolored areas are often seen
through the enamel in teeth that have amalgam
restorations, as a result of:
1. Leaching of corrosive products of amalgam
into the dentinal tubules or from
2. The underlying amalgam as seen through
translucent enamel with no dentin support
such as in undermined cusps, marginal
ridges, and regions adjacent to proximal
margins
• When other aspects of the restoration are
sound, amalgam blues do not indicate caries,
do not warrant classifying the restoration as
defective and do not require treatment
• However, treatment may be considered for
elective improvement of esthetics or for areas
under heavy stress that may require a cusp
capping restoration to prevent possible tooth
fracture
• Sometimes, corrosive products of amalgam
could be entrapped within the gingival tissues
and known as “Amalgam Tattoo”

Amalgam Blues Amalgam Tattoo Amalgam Tattoo
Amalgam Blues

2. FRACTURE LINES:
• Using careful visual and tactile clinical
examination techniques, careful examination
should be done to locate fracture line of
amalgam restoration
• A line that occurs in the isthmus region of the
restoration generally indicates fracture and
thus a defective restoration that needs
replacing

3. MARGINAL DITCHING:
• Marginal degradation, ditching, fracture or
crevicing refers to breakage of a thin edge of a
restoration creating an irregular V-shaped
crevice at tooth / restoration interface
• Diagnosis of marginal ditch is either visual or
tactile (by dropping of probe in an opening
when crossing the margin of the restoration)
• Treatment:
1. Shallow ditch (Less than 0.5 mm deep):
does not necessitate repair/replacement as
subsequent self-sealing property of
amalgam can resolve the problem, just
needs follow up
2. Deep Ditch; could be too deep to clean or
jeopardize the integrity of the restoration
therefore the restoration is considered
defective and needs replacement

4. VOIDS:
• Voids are usually localized and caused by
improper condensation of amalgam
• Voids on the margin cause marginal ditching
• Management of voids is determined by its size
and location:
1. if the void is at least 0.3 mm deep and is
located in the gingival one third of the
tooth crown, the restoration is judged
defective and should be repaired or
replaced
2. Accessible small voids in other areas where
the enamel is thicker may be corrected by
re-contouring or repairing with small
restorations

Amalgam Voids
Amalgam Voids

5. OVERHANGS:
• Overhangs, specially proximal ones, possess an
obstacle for proper oral hygiene and cause
food impaction, sever inflammation of adjacent
soft tissue and a potential thread for caries
process in adjacent tooth
• This defect often needs restoration
replacement
• Amalgam overhangs could be diagnosed:
1. Visually if it is a buccal, lingual or occlusal
overhang
2. Tactile using explorer for buccal, lingual,
occlusal or proximal overhangs or dental
floss that shows threading if passed
proximally for proximal overhangs
3. Radiographic; using bitewing views for
proximal overhangs

Proximal overhangs vs Non-proximal overhangs. (A & B) Proximal Overhangs, (C & D) Non-Proximal Overhangs
A CB D

6. IMPROPER ANATOMICAL CONTOUR:
• Amalgam restorations should duplicate the
normal anatomical contours of the teeth
• Restoration that impinge on the soft tissue,
have inadequate embrasure form and proximal
contact, or prevent the use of dental floss
should be classified as defective restoration
• It should be correctly recontoured or replaced
to maintain proper periodontal health
• As over-contoured proximal as well as facial
and lingual surfaces can impinge on the soft
tissue or act as a plaque trap

7. IMPROPER PROXIMAL CONTACT:
• The proximal contact area of an amalgam
restoration against the adjacent tooth should
be evaluated with dental floss or visually by
reflecting light from mouth mirror into the
interproximal region at contact level
• If the contact is “open” (i.e., adjacent proximal
surfaces are not touching) and is associated
with poor interproximal tissue health and food
impaction, the restoration should be classified
as defective and replaced
• Both open and tight contact will result in
gingival and periodontal problems
• Over restoration of proximal contact with extra
tight contact between teeth may result in
recorded degree of mobility of both restored
and neighboring tooth
• Such teeth will be tender to percussion test
• Inadequate embrasure form and proximal
contact that prevent the use of dental floss
should be classified as failed restoration
• It should be correctly recontoured or replaced
to maintain proper periodontal health

Proximal contact reformulation with amalgam restoration. (A & B) open
proximal contact, (C & D) Over tight proximal contact, (E & F) proper
proximal contact reformulation with proper location and contouring
embrasures
A
C
B
D
E F

8. IMPROPER OCCLUSAL CONTACT:
• Improper occlusal contact may induce
destructive effect on the restoration and tooth
(periodontal support) due to exaggerated
forces
• Premature occlusal contacts appear on
amalgam as shiny spots on the surface or
detected using occlusal marking (articulating)
papers
• Correction of occlusal contacts in centric and
eccentric occlusion should be meticulously
done either by adjustments or replacement

9. MARGINAL RIDGE INCOMPATIBILITY:
• 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.
• Both ridges should be approximately at the
same level and with correct occlusal embrasure
form and proper proximal contact
• If the marginal ridges are not compatible and
are associated with poor tissue health, food
impaction, or the inability of the patient to floss,
the restoration is defective and should be
recontoured or replaced

10. RECURRENT CARIES:
• Recurrent caries occurs at the marginal area of
the restoration is detected visually, tactile and
radiographically or with one or more of the
recent methods
• Detection of recurrent caries indicates
replacement of the restoration

II.B. EXAMINATION
O F E X I S T I N G

• Tooth-colored restorations should be
evaluated clinically in the same manner as
amalgam and cast restorations
• If there is improper contour or proximal
contact, an overhanging proximal margin,
recurrent caries or a condition that impairs
cleaning, the restoration is considered
defective
• Corrective procedures include recontouring,
polishing, repairing or replacing
• 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 displacing and the patient is
unhappy with the appearance, the restoration
should be judged defective
• Sometimes the staining is superficial and can
be removed by resurfacing.
• Discoloration should be observed whether
marginal, surface or bulk type of discoloration
II.B.2. Tooth-Colored Restoration

Discoloration of composite
resin restorations. (A & B) Bulk
discoloration, (C) Surface
discoloration, (D) Marginal
Discoloration
A C
DB

II.B. EXAMINATION
O F E X I S T I N G

• Both indirect metallic and indirect tooth-
colored restorations should be evaluated
clinically in the same manner as amalgam
restorations
• If any aspect of the restoration is not
satisfactory or is causing tissue harm, it should
be classified as defective and considered for
replacement
• Indirect tooth-colored restoration should be
inspected for discoloration the same as direct
tooth-colored restorations
• All indirect inlays should be checked for
stability and retention
II.B.3. Indirect Restoration

II. C L I N I C A L
EXAMINATION &
D I A G N O S I S

1. DEVELOPMENTAL DEFECTS:
• As teeth develop and form, they are at risk of
developing defects that manifest clinically after
tooth eruption, often affecting tooth size/
shape/number or the quality/quantity of the
mineralized tissues themselves
• These affected teeth can pose an aesthetic
problem and may also be more prone to the
ravages of tooth wear and/or carious attack
• These defects must be detected and diagnosed
from the intra-oral dental examination and
careful history taking, especially of childhood or
maternal illnesses or trauma to the deciduous
dentition
II.C. EXAMINATION OF OTHER TOOTH DEFECTS

CATEGORY DEFECTS CATEGORY DEFECTS
a) ACQUIRED: 1. Enamel hypoplasia
2. Molar–incisor
hypomineralization
3. Intrinsic dental fluorosis
4. Intrinsic tetracycline stain
a) HEREDITARY:
(Genetic, Familial
History)
1. Hypodontia (oligodontia)
2. Amelogenesis imperfecta
3. Dentinogenesis imperfecta

CATEGORY DEFECTS ETIOLOGY CLINICAL APPEARANCE
a) ACQUIRED: 1. Enamel hypoplasia • Ameloblast damage (systemic
childhood infectious diseases,
trauma/infection to deciduous
predecessor)
• Hypoplastic: ↓ matrix, normal
maturation
• Pitted, thin enamel of normal
hardness
• Hypomineralized: normal matrix, ↓
mineralization
• Opaque, chalky-white, ?softened
enamel
• Systemic cause • Defined areas, bands on all teeth
developing at time of illness

Different grades and
shapes of Enamel
Hypoplasia

CATEGORY DEFECTS ETIOLOGY CLINICAL APPEARANCE
a) ACQUIRED: 2. Molar-Incisor
Hypomineralization
• Systemic illness (high fever,
respiratory illness) from 0 to 2 years
affecting occlusal surfaces of the first
molars and possibly maxillary incisors
• Hypomineralized
• May follow orthodontic treatment
• White-yellow or yellow-brown
opacities, easily chipped, ↑ sensitivity
(exposed dentine, plaque stagnation)

Enamel Hypomineralization: (A) Molar hypomineralization, (B) Incisor hypomineralization and (C) Hypomineralization following
orthodontic treatment
A CB

Patient Assessment, Examination, Diagnosis & Treatment Planning in Operative Dentistry

Patient Assessment, Examination, Diagnosis & Treatment Planning in Operative Dentistry

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