Diagnosis and Treatment Planning, Including Oral and Maxillofacial Radiology
Diagnosis and treatment planning: the problem list comes first
A defensible plan begins with the chief complaint, but it does not end there. Take a complete medical, dental, and social history; record medications, allergies, bleeding risk, and tobacco use. The extraoral examination screens symmetry, lymph nodes, TMJ, and airway; the intraoral examination covers soft tissue, periodontal charting with probing depths and bleeding points, caries, occlusion, and existing restorations. Radiographs answer specific questions: bitewings for interproximal caries and crestal bone, periapicals for periapical disease and individual roots, panoramic images for a broad survey and third molars, and CBCT when three-dimensional anatomy is genuinely needed.
Radiology traps are common. Panoramic images magnify and distort; they are not for measuring bone loss. Ghost images, burnout, and overlapping structures can mimic pathology. CBCT is not a screening tool and should follow ALARA, with the smallest field of view that answers the question. A radiolucency is not a diagnosis until it is correlated with vitality tests, history, and sometimes biopsy.
Treatment planning is risk-based and sequenced: stabilize pain and infection, control caries and periodontal disease, then restore form and function, and finally address elective esthetics. Write a problem list and let each problem generate options. Obtain informed consent for the plan, alternatives, and risks.
Rule of thumb: if a radiograph does not change a decision, do not take it. Example: a bitewing showing a questionable interproximal radiolucency should be paired with visual-tactile examination and, if needed, a periapical view before drilling.