The perception of the subject of diagnosis varies

Making a Comprehensive Diagnosis in a Comprehensive Care Curriculum Gordon D. Douglass, D.D.S., M.S. Abstract: Comprehensive care models in dental education encourage students to deliver patient-centered care. But to deliver effective comprehensive care, a clinician must first make a comprehensive diagnosis. Students of general dentistry are taught to make one or more diagnoses as defined by the dental specialties, and to direct patient care accordingly. Without a comprehensive diagnosis, patients may receive fragmented, poorly prioritized care that is inappropriate to their overall oral health. This paper presents a simple diagnostic classification that can be used to make a comprehensive diagnosis with which to guide the student of general dentistry in planning comprehensive care. Dr. Douglass is Clinical Professor, Department of Preventive and Restorative Dental Sciences, University of California San Francisco. Direct correspondence to him at Department of Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, CA 94143-0758; 415-476-9118 phone; 415-476-0858 fax; gordond@itsa.ucsf.edu. Key words: comprehensive patient care, oral diagnosis, dental care, classification Submitted for publication 9/24/01; accepted 1/2/02 The perception of the subject of diagnosis varies significantly among dental clinicians. Yet the dictum to which we must subscribe is: proper treatment derives from a proper diagnosis. For many, the word diagnosis is almost entirely associated with oral medicine. For many others, diagnosis is merely a poorly defined word with little meaning which, by convention, must be sandwiched between examination and treatment planning. Frequently being at the point of entry in clinical dentistry, however, a general dentist must have the knowledge and clinical expertise to assess the multitude of conditions and diseases that impact the health of the system of those patients to whom he or she is responsible, make a diagnosis, and create and manage a treatment program that is reflective of that person s phenotype. The general dentist is, in fact, the primary diagnostician of clinical dentistry, and the health (or destruction) of a patient s stomatognathic system will greatly depend on the clinician s diagnostic skills. This paper presents a diagnostic classification system that has been developed at the University of California San Francisco School of Dentistry to teach dental students how to make a comprehensive diagnosis. Diagnosis in Medicine and Dentistry Medicine generally defines diagnosis as the determination of the nature or cause of a disease. However, in medicine, patients frequently see their physician only when they have a problem. In contrast, many dental patients enjoy excellent dental health due to the dental profession s enormous success at promoting dental health. For these patients, the dentist must look beyond problems and make a comprehensive diagnosis. Unfortunately, a comprehensive diagnosis in general dentistry has not been well defined. Considering the complexity of the general dentist s assessments, the more narrow definition as used in medicine, dental specialties, and dental emergencies does not fully suit the needs of the general dentist in providing long-term comprehensive care. Students of general dentistry are taught to make one or more separate diagnoses as defined by the various specialties and then direct the patient s care accordingly. 1,2 The lack of a defined comprehensive diagnosis in general dentistry, and a subsequently sequenced comprehensive care treatment plan, may then result in fragmented care that is directed toward specialty diagnoses, rather than toward the patient s overall dental health. For example, a patient may be referred for scaling and root planing before a high caries-risk problem is addressed, or a patient may be treatment planned for extensive restorative work before addressing the reason for the loss of teeth that is, there is a lack of emphasis on prioritizing. Defining Comprehensive Diagnosis Early in its development, national conferences were held to discuss the concept of comprehensive 414 Journal of Dental Education Volume 66, No. 3

care. In Comprehensive Care in Dentistry (1979), Crandell and Bawden report on these national conferences and the struggle to define the subject. 3 In this report, Crandell and Bawden attribute the following definition of comprehensive care (a.k.a. total patient care) to McCracken (1979): Total patient care is the attitudinal concept and system in which patients receive: a complete diagnosis; motivation and education toward prevention with emphasis on, and maintenance of, an optimum state of health; full treatment planning commensurate with the patient s desires, acceptance, and implied understanding of the plan; therapeutic procedures within the medical, psychological, financial, and acceptance limits of the patient; and finally, maintenance of the patient s achieved state of health on a continuing basis. A definition of the complete diagnosis (or comprehensive diagnosis) McCracken refers to must be broad enough to encompass all that the comprehensive care model embodies. A comprehensive diagnosis must weigh and prioritize the diagnoses as defined by dental specialties, and address them in a way that takes into consideration the patient s biological, psychological, and social needs and resources because the patient s oral health whole is more than the sum of its parts. The Comprehensive Diagnosis The general dentist has the unique responsibility to provide an overall assessment of dental health in the absence of specific patient complaints. The experience is like being given only the middle panel of a three-panel comic strip and asked what the two missing panels illustrate. Like the comic strip, the state of a patient s chewing system is a continuum. An ideal continuum would have a patient begin as an edentulous infant, pass through a normal primary dentition, and then live a long life with a healthy, fully functional, complete permanent dentition. The general dentist s role as the primary diagnostician should be to acquire complete examination data, compare the data to an ideal continuum, and then make a comprehensive diagnosis according to a criteriabased classification system. In their book Oral Diagnosis, Kerr, Ash, and Millard 5 state that students should be taught a systematic approach to diagnosis that is simple enough to learn yet so rational as to be difficult to forget. A simple, broadly based system directed toward the general dentist was initially published by Braly 6 in 1972. Braly s classification focused on the need to maintain, modify, or reestablish occlusal stability. The system designated three Case Types (Types I-III) that allowed for rational treatment decisions for restorative care, and it has been used in the University of California San Francisco (UCSF) predoctoral clinics for the last thirty years. Since the introduction of our comprehensive care curriculum, however, the Braly classification system has been modified and expanded for teaching diagnosis to students in general dentistry. Before discussing the UCSF-modified Braly system, let me define the terms to be used. The stomatognathic system is defined as the combination of structures involved in speech, receiving, mastication, and deglutition of food as well as parafunctional actions. 7 Occlusion is defined as the static relationship between the incising or masticating surfaces of the maxillary or mandibular teeth or tooth analogues. 7 Dorland s Medical Dictionary, 23rd edition, defines physiologic as characteristic of or appropriate to an organism s healthy or normal functioning. Within dentistry it has been defined as characteristic of or conforming to the innate function of a tissue or organ. 7 It would seem reasonable, therefore, for us to designate the stomatognathic system physiologic if it is healthy, stable, and functioning within the expected norms, that is, no unexpected tissue degeneration nor pain in associated structures. We have chosen to designate the system as non-physiologic (unhealthy, unstable) if it displays evidence of past or present unexpected degenerative processes. Modification of the Braly system has added three new Case Types (Types A-C). The new Case Types (Tables 1-3) are related to findings for which treatment will not involve the restoration of tooth structure. For example, a Type A patient has a system that is physiologic but presents with soft tissue such as gingivitis, lichen planus, candida infection, etc. For this Case Type no restorative procedure is necessary, and the goal of treatment of the soft tissue is to maintain an otherwise physiologic stomatognathic system. Types B and C are non-physiologic and differ in the severity of the findings. A typical Type B patient might present with occlusal discrepancies causing discomfort in individual teeth or with unexpectedly severe periodontal March 2002 Journal of Dental Education 415

disease. The goal of treatment for a Type B is to modify the stomatognathic system to control the destructive processes. Treatment for a Type B patient might include occlusal adjustment, extractions (such as an unopposed super-erupted third molar), or periodontal therapies and home care. Finally, a Type C is non-physiologic but presents with a severely dysfunctional system requiring multidisciplinary evaluation and care. A typical Type C patient might be a patient with maxillomandibular dysfunction requiring combined surgical and orthodontic procedures. The Type C patient should only be treated by a clinician trained Table 1. Diagnosis Type A (non-restorative) MAINTENANCE Phenotype: A chewing system functioning within normal physiologic parameters Treatment goals: To maintain and/or enhance the health of the system No restorative procedures required or necessary Soft or osseous tissue health or disease The TMJ, maximum intercuspation, and eccentric excursive mandibular movements fall within normal limits Physiologic RCP to ICP shift No muscle tenderness No excessive tooth mobility/attrition/abfraction, nor loss of tooth support Stable occlusal contacts Vertical dimension within normal limits for the patient Has had positive working relationships with dental therapists Example: A patient with no restorative needs with soft or hard tissue disease that can be treated without affecting the system detrimentally Table 2. Diagnostic Type B (non-restorative) MODIFICATION Phenotype: A chewing system that is nonphysiologic without signs or symptoms of systemic or neuromuscular Treatment goals: Alteration of conditions with which degenerative processes can be associated No restorative procedures required or necessary No TMD or restricted range of motion Psychosocial issues that can be overcome Example: A patient with an abnormal craniomandibular relationship requiring orthodontics to handle the administrative and therapeutic aspects of multidisciplinary patient management. Case Types I-III (Tables 4-6) are related to findings for which treatment will require dental restorations. These are the patients most frequently seen in the general practice of dentistry. A Type I is defined as a physiologic system functioning within the expected norms. Typical findings for this case type include healthy, uncompromised supporting tissues; occlusal wear appropriate to the age of the patient; pain-free unimpeded movements of the mandible; a physiologic retruded contact position (RCP) to maximum intercuspal position (MIP) shift; and a healthy attitude toward professional dental care. The goal for the Type I is to avoid adversely affecting the stomatognathic system with whatever restorative or preventive (sealants, etc.) procedure is required as a part of routine dental care. Though treatment of a Type I patient may seem easy, the opposite is in fact true. Within the Type I classification are those patients who may require single tooth restorations, and the ability to place even a single restoration in a patient s mouth without affecting the stomatognathic system adversely is exceedingly difficult. Examples of very common simple but potentially destructive procedures include an occlusal sealant that is incompletely bonded Table 3. Diagnostic Type C (non-restorative) RE-ESTABLISHMENT Phenotype: A chewing system that is nonphysiologic with signs and/or symptoms of systemic and/or neuromuscular Treatment goals: Treatment must be directed toward longterm management of a severely dysfunctional system No restorative procedures required or necessary Vertical dimension altered from normal Excessive tooth mobility Abnormal craniomandibular relationship Evidence of TMD (muscle/tmj tenderness/pain/ inflammation) Restricted range of motion Degenerative processes in the TMJ Psychosocial issues requiring multidisciplinary management Example: A patient with a severely abnormal craniomandibular relationship needing nonrestorative multidisciplinary management 416 Journal of Dental Education Volume 66, No. 3

and only later is found to have leaked and caused a severe carious lesion; a small occlusal restoration that does not properly restore interocclusal contact that may ultimately result in the extrusion of an opposing tooth; and the single porcelain on metal crown frequently placed on the first molar of a young patient that with time may cause severe attrition and/or fracture of the opposing first molar. Case Types II and III define a system that is not functioning within the expected norms and is, therefore, termed non-physiologic. Typical findings associated with a non-physiologic system may include unrestored missing teeth; tipped and extruded teeth; limited TMJ function; tissue inflammation; pain; tooth hypermobility; a loss or replacement of tooth structure beyond that expected for the age of the patient (for example, a young patient with extensive caries, multiple root canals, crowns and fixed and removable partial dentures, and/or severe occlusal wear); and a non-physiologic RCP to MIP shift. A non-physiologic shift is defined as one in which a causal relationship with clinical findings such as mobile teeth, tooth fracture, and tooth wear is suspected. Since the Type II is non-physiologic, the goal is to improve conditions. Generally, this means motivating the patient to do those things necessary to manage the processes that are adversely affecting the system. Adverse influences may be related to diet, salivary flow, oral hygiene procedures, bruxing, stress, unrestored missing teeth, or any other condition determined to be detrimental. If the destructive processes can be controlled, the result is a stable, healthy situation that lends itself to routine restorative procedures. A Type III is distinguished from a Type II by the presence of dysfunctional findings that will require long-term multidisciplinary management. Rep- Table 5. Diagnostic Type II (restorative) MODIFICATION Phenotype: A chewing system that is nonphysiologic without signs or symptoms of systemic or neuromuscular Treatment goals: Alteration of conditions with which degenerative processes can be associated Excessive tooth mobility/attrition/abfraction or loss of support Extensive loss of occlusal surfaces due to caries or defective restoration of tooth structure Missing and/or unrestored teeth No TMD or restricted range of motion Psychosocial issues that can be overcome Example: A patient with tipped/extruded/mobile, and/or missing teeth, requiring intra- and inter-arch restorative procedures Table 4. Diagnostic Type I (restorative) MAINTENANCE Phenotype: A chewing system functioning within normal physiologic parameters Treatment goals: Select restorative materials and techniques that will maintain the health of the system The TMJ, maximum intercuspation, and eccentric excursive mandibular movements fall within normal limits Physiologic RCP to ICP shift No muscle tenderness No excessive tooth mobility/attrition/abfraction, not loss of tooth support Stable occlusal contacts Vertical dimension within normal limits for the patient No TMD nor restricted range of motion Isolated periapical lesion Defective pits and fissures Has had positive working relationships with dental therapists Example: A patient needing routine intra-arch operative procedures Table 6. Diagnostic Type III (restorative) RE-ESTABLISHMENT Phenotype: A chewing system that is nonphysiologic with signs and/or symptoms of systemic and/or neuromuscular Treatment goals: Treatment must be directed toward long-term management of a severely dysfunctional system Vertical dimension altered from normal Excessive tooth mobility/attrition Abnormal craniomandibular relationship Evidence of TMD (muscle/tmj tenderness/pain/ inflammation) Restricted range of motion Degenerative processes in the TMJ Psychosocial issues requiring multidisciplinary management Example: A patient with an abnormal craniomandibular relationship needing multidisciplinary management and restorative procedures March 2002 Journal of Dental Education 417

resentative of Type III patients are those with TMD requiring a multidisciplinary dental/medical management, patients with complex perio/prosthodontic needs, and patients with dental and emotional disorders. Restorative procedures for the Type III patient should only be treated by a clinician trained and willing to accept the administrative, restorative, and interpersonal responsibilities necessary to manage the multidisciplinary care of this patient. We recognize the stomatognathic system does not function in isolation, and is broadly influenced by psychosocial/cultural factors. Psychological factors include such things as an ability to understand and clearly articulate dental concerns and desires; an ability to give written or verbal consent to treatment; an ability to comply with long-term oral health maintenance; a healthy body image; a history of positive working relationships with dental therapists; a healthy and hardy attitude toward change; and a trust of dental therapists to act in their best interests. Social/cultural factors may include an ability to accept care; a clear understanding of who makes the decisions; financial resources sufficient to allow treatment options; access to dental care; oral health as a priority; and an ability to clearly articulate ethnic and cultural attitudes about dental care. As with any untoward finding, psychosocial/ cultural factors vary in the extent to which they may influence a diagnosis. For example, a patient with a severe somatoform disorder (that is, obsessive concern for a part of the body) related to the appearance of the anterior teeth may cause a diagnosis of a Type I (requiring minor cosmetic procedures) to be a Type III (requiring psychological evaluation and management). Psychosocial factors are indicated in the UCSF system as either inconsequential, able to be overcome, or severe requiring multidisciplinary management. Discussion When the original Braly system was introduced at UCSF thirty years ago, it was limited to restorative dentistry. The modified system presented here is more recent. Its introduction has met with the usual resistance to change and has yet to be universally accepted by UCSF faculty, although progress continues to be made. An advantage to any universal classification system is its usefulness in communicating across disciplines and specialties. At the UCSF predoctoral clinics, all patients who arrive at the school are seen by predoctoral students. At this New Patient Visit, a consultation involving discussion between student and faculty leads to triaging. The preliminary use of the simple classification system presented here helps make a tentative diagnosis and direct patients to the proper level of care in either the predoctoral or postdoctoral programs. Once the patient is assigned to a student and a complete baseline examination with all of the necessary specialty consultations is completed, three simple questions enable the assigned student and faculty mentor to arrive at a proper comprehensive diagnosis (Table 7). The first and most important question is: is the patient s stomatognathic system physiologic? Second, will restorative procedures be necessary to correct the non-physiologic condition? Third, will the solution require multidisciplinary management? A wellinformed assessment is the foundation of the system. The baseline examination is the comprehensive source of that information, so it must be thorough and complete. The advantage of the UCSF system in teaching comprehensive patient care is the increased emphasis placed on the diagnosis prior to undertaking treatment planning procedures. We believe that when the baseline and comprehensive diagnosis are emphasized, there is a greater likelihood of the treatment planned appropriately addressing the needs of the patient. Conclusion Comprehensive patient care in dental education has shifted the curricular emphasis from studentcentered care to patient-centered care. To deliver effective comprehensive care, it is necessary to address the biological, psychological, and social needs of the patient. Students of comprehensive care must, therefore, make a comprehensive diagnosis upon which to base treatment. A simple system to enable and teach students to make a comprehensive diagnosis has been developed for use in the comprehensive care curriculum at the University of California San Francisco School of Dentistry. This paper presents a simple diagnostic classification used to teach comprehensive diagnosis as a part of our comprehensive patient care curriculum. 418 Journal of Dental Education Volume 66, No. 3

Table 7. Steps in a comprehensive diagnosis March 2002 Journal of Dental Education 419

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