Clinicians should be cautious when commenting before a thorough examination is completed. With adequate experience, a clinician can often assess preliminary treatment needs during the initial appointment. However, fairly assessing the quality of a previously rendered treatment can be difficult, because the circumstances under which the treatment was rendered are seldom known. When such an assessment is requested for legal proceedings, the patient should be referred to a specialist familiar with the "usual and customary" standard of care.
Periodontal History. The patient's oral hygiene is assessed, and current plaque-control measures are discussed, as are previously received oral hygiene instructions. The frequency of any previous debridements should be recorded, and the dates and nature of any previous periodontal surgery should be noted.
Restorative History. The patient's restorative history may include only simple composite resin or dental amalgam fillings, or it may involve crowns and extensive fixed partial dentures. The age of existing restorations can help establish the prognosis and probable longevity of any future fixed prostheses.
Endodontic History. Patients often forget which teeth have been endodontically treated. These can be readily identified with radiographs. The findings should be reviewed periodically so that periapical health can be monitored and any recurring lesions promptly detected (Fig. 1-6).
Orthodontic History. Occlusal analysis should be an integral part of the assessment of a postortho-dontic dentition. If restorative treatment needs are anticipated, they should be undertaken by the restorative dentist. Occlusal adjustment (reshaping of the occlusal surfaces of the teeth) may be needed to promote long-term positional stability of the teeth and reduce or eliminate parafunctional activ-
ity. On occasion, root resorption (detected on radiographs) (Fig. 1-7) may be attributable to previous orthodontic treatment. As the crown/root ratio is affected, future prosthodontic treatment and its prognosis may also be affected. Restorative treatment can often be simplified by minor tooth movement. When a patient is contemplating orthodontic treatment, considerable time can be saved if minor tooth movement (for restorative reasons) is incorporated from the start. Thus good communication between the restorative dentist and the orthodontist may prove very helpful.
Removable Prosthodontic History. The patient's experiences with removable prostheses must be carefully evaluated. For example, a removable partial denture may not have been worn for a variety of reasons, and the patient may not even have mentioned its existence. Careful questioning and examination will usually elicit discussion concerning any such devices. Listening to the patient's comments about previously unsuccessful removable prostheses can be very helpful in assessing whether future treatment will be more successful.
Oral Surgical History. Information about missing teeth and any complications that may have occurred during tooth removal is obtained. Special evaluation and data collection procedures are necessary for patients who require prosthodontic care subsequent to orthognathic surgery. Before any treatment is undertaken, the prosthodontic component of the proposed treatment should be fully coordinated with the surgical component.
Radiographic History. Previous radiographs may prove helpful in judging the progress of dental disease. They should be obtained if possible, because it is generally better to avoid exposing the patient to unnecessary ionizing radiation. Dental practices will usually forward radiographs or acceptable duplicates promptly upon request. In most instances, however, a current diagnostic radiographic series is essential and should be obtained as part of the examination.
TMJ Dysfunction History. A history of pain or clicking in the temporomandibular joints or neuro-muscular symptoms, such as tenderness to palpation, may be due to TMJ dysfunction, which should normally be treated and resolved before fixed prosthodontic treatment begins. A screening questionnaire will efficiently identify these problems. The patient should be questioned regarding any previous treatment for joint dysfunction (e.g., occlusal devices, medications, biofeedback, or physical therapy exercises).
An examination consists of the clinician's use of sight, touch, and hearing to detect conditions outside the normal range. To avoid mistakes, it is critical to record what is actually observed rather than to make diagnostic comments about the condition. For example, "swelling," "redness," and "bleeding on probing of gingival tissue" should be recorded rather than "gingival inflammation" (which implies a diagnosis).
Thorough examination and data collection are needed for the prospective fixed prosthodontic patient, and the protocol for this effort can be obtained from various textbooks of oral diagnosis.7.8
istory Taking and Clinical Examination GENERAL EXAMINATION
The patient's general appearance, gait, and weight are assessed. Skin color is noted for signs of anemia or jaundice. Vital signs, such as respiration, pulse, temperature, and blood pressure, are measured and recorded. Fixed prosthodontic treatment is often indicated in middle-aged or older patients, who can be at higher risk for cardiovascular disease. Relatively inexpensive cardiac monitoring units are available for in-office use (Fig. 1-8). Patients with vital signs outside normal ranges should be referred for a comprehensive medical evaluation before definitive treatment is initiated.
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