Examination, Diagnosis and Treatment Planning the Assessment of Clinical Quality

General Guidelines
The overall quality of dental health care rendered to patients will in the long run be governed by the thoroughness of the initial examination, diagnosis and sequence of treatment planning. For example, a well-carved and highly polished restoration placed within a tooth of questionable periodontal integrity, or a fixed prosthodontic appliance used in the same situation, would raise questions as to the practitioner’s diagnostic judgment.

In evaluating a patient for comprehensive dental care, it is advisable to follow a definite sequence in effecting an acceptable examination, diagnosis and treatment plan.

1. Securing and evaluating a medical history to identify predisposing conditions that may affect treatment or patient management.

2. Securing and evaluating a dental history, including the chief complaint or reason for visit.

3. Inspecting the extraoral head and neck tissues.

4. Inspecting the intraoral hard and soft tissues.

5. Making the necessary radiographic examination.

6. Making impressions for diagnostic models where indicated.

7. Determining from an evaluation of all of the above examination criteria the proper sequence of treatment to be rendered.

8. Discussing with the patient the recommended treatment, alternative treatments and their limitations, fees involved and methods of payment.

The need for periodic radiographic examination as a tool for proper diagnosis and treatment, as well as a preventive aid, is an accepted philosophy. The following guidelines for the proper use of these examinations should be adhered to:

1. Initial Examination:
   Radiographs that are sufficiently current and of diagnostic quality to allow for proper evaluation and interpretation of the oral status.

2. Recall:

   1. At the appropriate interval, as indicated by the patient’s general oral condition and the judgment of the attending dentist, posterior bite-wing plus anterior periapical radiographs may be included in the examination.

   2. Full-mouth radiographic survey should not be taken more often than every three years in the absence of specific indications for more frequent radiographs.

Properly exposed and developed radiographs should exhibit the following characteristics:

1. Sufficient density and contrast to differentiate the various structures of the teeth, the periodontal ligaments, the supporting bone and normal anatomic landmarks.

2. The entire root arid surrounding bone in periapical radiographs.

3. Minimum distortion of image and lack of overlapping images.

Radiographs should be retained as part of the patient’s records so they can be reviewed serially. The amount of radiation exposure to the patients and dental personnel should be minimized by the use of accepted methods of radiation protection.

Quality Evaluation Criteria

ITEM	RATING AND EXPLANATION
MEDICAL AND DENTAL HISTORY	ACCEPTABLE	NOT ACCEPTABLE
	Recorded on chart with notation of periodic updating. Any significant history noted in a conspicuous way on patient’s records (e.g., drug allergy, rheumatic heart, heart disease, etc.). Consultation with patient’s physician when indicated by information elicited in history.	No medical and past dental history taken or recorded. No evidence of updating. No evidence of consultation with patient’s physician where such consultation is indicated.
INSPECTION OF EXTRAORAL HEAD  AND NECK TISSUES	Recorded with notations of periodic updating at recall examinations (e.g., swellings, lymphadenopathy, skin texture, etc.).	Not recorded. No evidence of updating.
INSPECTION OF  INTRAORAL HARD AND SOFT TISSUES	Recorded in systematic manner (e.g., lips, cheeks, tongue, floor of mouth, throat, hard and soft palates, gingiva; teeth: mobility, pocket formation, restorations satisfactory and unsatisfactory, caries, etc.)	Not recorded. No evidence of updating
RADIOGRAPHIC EXAMINATION	I. All areas of proposed treatment visible on radiographs. 2. Radiographs within a satisfactory range of density and contrast. 3. Root apices visible on periapical films. 4. Crown image not overlapped on bite-wings.	1. Proposed treatment areas not visible. 2. Poor film contrast and/or density. 3. Apices of teeth not visible on periapicals. 4. Crown image overlapped on bite- wings. 5. Excessive elongation or foreshortening.
DIAGNOSIS	A specific diagnosis recorded.	No diagnosis recorded.
TREATMENT PLANNING	In general, the following is a suggested sequence: 1. Relief of pain and non-elective surgery. 2. Elimination of infection, 3. Discussion with patient of the possible causes of any disease so that when treatment is instituted elimination of these causes will effect a more lasting result. 4. Thorough prophylaxis. 5. Treatment of caries. 6. Periodontal treatment and elective surgery. 7. Prosthodontic replacements. 8. Placement of patient on recall.	Inappropriate sequence of diagnosis and treatment planning (e.g., construction of a final prosthesis without first removing all caries).
PATIENT CONSULTATION	1. Adequate documentation of the review of the treatment plan; alternative treatment (if any), limitations of treatment, fees for services and payment methods discussed fully with patient. 2. Referral to other health care providers should be made and documented when warranted.	Patient has not been informed of treatment alternatives