Oral health assessment, diagnosis and treatment planning
A systematic assessment
Start with the presenting complaint in the patient's or whānau's words, then history: medical conditions, medicines, allergies, previous dental experience, diet and free-sugar frequency, fluoride exposure, oral hygiene, smoking or vaping, and social or access barriers. Examine extra-orally (swelling, lymph nodes, TMJ) and intra-orally (soft tissues, plaque, gingival bleeding, occlusion, caries). Chart both dentitions accurately and use recognised systems - visual/tactile caries detection such as ICDAS, dmft/DMFT counts, and erosion scoring. Request radiographs only when the clinical question justifies them, following selection criteria and ALARA.
Risk drives the plan
Complete a caries risk assessment rather than counting holes. Risk determines recall interval, preventive intensity and whether to treat or monitor. Write a diagnosis, a problem list, a plan that starts with prevention and minimally invasive care, the consent discussion, and a review date.
Worked example
A 7-year-old has white-spot lesions on the upper incisors, plaque along the gingival margin, and reports sweet drinks several times daily. Diagnosis: early childhood caries, active, high risk. Plan: fluoride varnish now, 1000 ppm fluoride toothpaste twice daily with supervised brushing, water and plain milk between meals, dietary goal-setting with the whānau, sealants when first permanent molars are fully erupted, and review in three months.
Traps
Diagnosing from a radiograph alone; charting without a written risk level; planning restorations before prevention; failing to record what was discussed and declined; missing extra-oral signs such as facial swelling.