Diagnostic Records: What to Take and Why

Abstract

As we discussed in the previous chapter, the complete examination is the most important step to a proper diagnosis for your patient. There are many protocols available, but there are no short cuts in gathering all the data needed to provide your patient’s with an accurate, and predictable treatment plan (House MM (1957) The relationship of oral examination to dental diagnosis. J Prosthet Dent 8(2):208–219). A complete examination consists of 12 steps. The first ten steps are dedicated to understanding the functional (occlusion, temporomandibular joints, centric relation, range of motion) and structural (structural and periodontal integrity, dental caries) conditions of your patient’s masticatory system. This information becomes useful in determining if the patient’s masticatory system is either stable or unstable. A masticatory system is stable when temporomandibular joints, masticatory muscles, and teeth are all healthy and do not exhibit any signs of breakdown (see Figs. 5.1 and 5.2). On the other hand, a masticatory system is considered unstable when any combination of the three components exhibits signs of breakdown (see Figs. 5.2 and 5.3). Once you have made the determination that your patient’s masticatory system is “unstable,” it is time to complete the final two steps of the comprehensive examination. The remaining two steps are considered necessary in order to solve structural and functional problems. The process of solving these problems will be discussed later in Chap. 8, and is referred to as diagnostic occlusal treatment assessment (DOTA). The last two steps, 11 and 12, in the comprehensive examination consist of obtaining diagnostic records and digital photographs. This chapter focuses on the relevance of the diagnostic records and digital photography. It is paramount that these diagnostic records be correctly completed with precision and accuracy. Any inaccuracies in the transfer of the information will compromise the predictability of the outcome. Less predictability results in a different outcome for our patients, and often results in a more stressful process for both dentist and patient (Fig. 5.4).

“Tide and Time wait for no man.”

Geoffrey Chaucer, Poet