Dental Records

     Making records of a patient could include: radiographs (full mouth series, panorex and/or cephalometric), study models, head and neck exam, and a clinical exam (including charting of decayed, missing, and filled teeth, and prosthetics; malpositioned wisdom teeth, full periodontal charting and occlusal analysis, including potential orthodontic needs).

     If a patient presents for a first visit seeking a check-up, then a set of x-rays (not “radiographs”), head and neck exam and complete clinical exam would be indicated.

     If, however, a patient presents with a broken filling around tooth #14 as their chief complaint then only obtain the records necessary to make a proper diagnosis for this area.

     I believe it is a common mistake among students to be so overly thorough at first that after several visits the patient may still not have their chief complaint, the reason the came in the first place, properly addressed and treated. I am not suggesting to hurriedly treat the patient’s chief complaint and miss an important part of a diagnosis either. A master clinician understands the importance of timing in patient care.

Dental Diagnosis

     Diagnosis is the specific description of the presenting dental problem.

     I divide all dental disease into three categories: cavities (not “decay”), gum problems (not “periodontal disease”) and bite problems (not “occlusal discrepancy”). I then decide their short term (not “acute”) or long term (not “chronic”) nature. All diagnosis may be simply categorized:

     You may need to stretch the above definitions on occasion. For example, a periapical lesion in a non-vital tooth which is associated with trauma (not decay) could defy categorization but I would still list it under cavities since most non-vital teeth are associated with decay.

     After properly reviewing the past medical and dental history, radiographs and clinical data you may then make a diagnosis regarding the chief complaint. You should keep in mind the bigger picture of the overall clinical problem as you focus on the chief complaint.

     In the actual patient record I prefer to record my dental diagnostic notes, and to some degree the chosen treatment plan, graphically. The long list of written dental notes in a typical dental school record are not easily grasped visually. This can obscure the bigger picture of diagnosis and treatment planning.

     On a blank piece of paper I will draw a plus sign so that I can represent the four quadrants of the mouth. I then use Palmer notation which is a tooth numbering system that starts from the central incisors (#1) and goes back to the wisdom teeth (#8). With this system tooth number 11 using standard notation would be described as the upper left #3. It would be draw on the diagram below as 3 in the upper right corner since you are looking at the patient’s face in this diagram. If you get used to making your diagnostic notes with your own visual notes you will ultimately find it much easier to plan treatment.

Treatment Planning in Dentistry

     Treatment planning involves offering multiple treatment options based upon a specific diagnosis from ideal dentistry on down, usually varying based upon complexity, fee and treatment time. Figuring out multiple treatment plans may initially seem complex and confusing for students. However, once one understands the complexity, treatment planning can actually become quite easy and fun. To create a treatment plan all one need do is modify your diagnosis by the patient’s chief complaint. You then need to decide if you will treat just the specific chief complaint or the bigger picture.

     For example, if a patient presents with a severely broken upper premolar you could suggest to try to restore the tooth with amalgam, bonding, extract it or perform root canal therapy and fabricate a crown. The choice may not only hinge on the specific tooth in question but the surrounding dentition. The big picture of where comprehensive care will lead in this case might sway the dental student to ultimately recommending one course of treatment over another. What is the condition of the surrounding dentition. Are there other more strategically important teeth in need of more critical care in which the patient should ultimately make a greater investment of emotions, time and money?

     There is usually not just one way to treat a patient. It is possible to treat the same dental problem several different acceptable ways. What is acceptable? First, do no harm.  Second, give the patient what they want if possible. Third, keep in mind the ultimate comprehensive care of the patient and how this may modify initial treatment.