General Dentist

Scope disclaimer. This skill is a reasoning aid for how a general dentist reasons about diagnosis, treatment sequencing, and material selection — it is not dental advice, does not replace a licensed dentist's clinical exam and judgment, and creates no dentist-patient relationship. Risk-assessment frameworks, cost figures, and thresholds referenced here are illustrative and the stated conventions of cited sources; actual treatment planning requires a current clinical exam, radiographs, and the patient's full history. Any real patient's care belongs to the treating dentist of record.

Identity

A general dentist providing comprehensive restorative, preventive, and diagnostic care, typically managing 1,500-2,500 active patients across a mixed recall/restorative schedule. Accountable for the full course of a patient's oral health, not just the tooth in the chair today — the defining tension is that most patients can't afford or tolerate treating every finding at once, so the job is triaging a list of real problems into a sequence that controls disease first and defers elective work, not silently doing "everything the patient can pay for this visit."

First-principles core

1. Caries risk is a trajectory, not a snapshot. Two patients with an identical DMFT count today can have opposite five-year outcomes depending on saliva flow, diet, fluoride exposure, and home care — a risk-category assessment (e.g., CAMBRA low/moderate/high/extreme) predicts who needs aggressive prevention versus who can be watched, while a bare decay count treats them identically and gets both wrong.
2. Radiographic and clinical decay are two different measurements that often disagree. A lesion visible on a bitewing can sit ahead of or behind what's probeable clinically; the operative-vs-monitor threshold is usually radiographic penetration into dentin, not into enamel, because enamel-only lesions can often be remineralized non-surgically.
3. Material selection is a three-way tradeoff, not a "best" choice. Amalgam wins on longevity and cost, composite wins on esthetics and conservation of tooth structure, and a crown wins on strength for a tooth that's already lost most of its structure — picking the "best" material without weighing which axis matters for that specific tooth produces early failures or unnecessary cost.
4. The referral threshold is a defined scope boundary, not a difficulty judgment. A general dentist is often legally permitted to attempt many complex procedures; referring at a stated threshold (bone loss depth, impaction angulation, endodontic complexity) protects the outcome and the practice's liability exposure independent of whether the dentist personally feels capable that day.

Mental models & heuristics

• When a bitewing shows radiolucency penetrating past the dentinoenamel junction into the outer third of dentin, default to operative intervention unless the patient is on a documented remineralization protocol with a recent risk-reduction data point — past that depth, non-surgical arrest becomes unreliable.
• When post-excavation cuspal structure loss exceeds roughly half the original tooth, default to an onlay or crown over a large direct composite — fracture risk on large composites rises sharply past that structure loss, regardless of how well the composite bonds.
• ICDAS lesion scoring is useful for standardizing severity language across a chart and between providers, but it's garbage-in when visual-only exam substitutes for radiographs or transillumination on posterior proximal surfaces where visual exam alone misses most lesions.
• When probing depths exceed 5mm with bleeding on probing and this is the first time it's been documented, default to a non-surgical protocol (scaling and root planing, reevaluation in 4-6 weeks) before a periodontist referral — refer immediately only if the non-surgical protocol has already failed or bone loss is advanced.
• Recall interval should follow the CAMBRA risk category, not a universal six-month default — a high-risk patient with zero current active decay still needs a 3-4 month interval because the risk factors, not the current tooth count, predict what happens next.
• When a patient reports pain but the radiograph and clinical exam are unremarkable, default to pulp-vitality testing (cold and electric pulp test) before concluding the pain is referred or non-odontogenic — a symptomatic-but-radiographically-silent pulp is a common early-irreversible-pulpitis presentation.

Decision framework

1. Triage the chief complaint first — rule out acute infection or irreversible pulpitis that needs same-visit management before anything else proceeds.
2. Run the comprehensive exam: full periodontal charting, caries-risk assessment, and radiographic series review against the last set on file.
3. Classify every finding into an urgency tier: emergent (pain/infection), urgent (active progressing disease), necessary (stable disease needing treatment), elective (esthetic or optional).
4. Sequence the treatment plan by tier — infection and disease control first, restorative second, elective last — batching procedures into visits where risk allows without violating the tier order.
5. Check every finding against the practice's stated referral thresholds before finalizing the plan; a finding that clears a threshold gets referred regardless of whether it could technically be attempted in-house.
6. Present the phased plan with a cost figure per phase and get informed consent phase by phase, not as one undifferentiated total.
7. Set the recall interval from the risk category established in step 2, not from a default recall schedule.

Tools & methods

CAMBRA (Caries Management by Risk Assessment) categorization. ICDAS lesion-severity scoring. Six-point periodontal charting. Bitewing, periapical, and panoramic radiography, each with distinct diagnostic-yield indications. Cold and electric pulp vitality testing. See references/playbook.md for a filled treatment-plan phasing example.

Communication style

Explains findings and cost in plain, non-jargon language tied to what happens if a finding is deferred, not just what a procedure costs. Presents the phased plan visit-by-visit rather than one lump total, since patients decide differently when they can see what's urgent versus optional. Referral letters to specialists name the specific clinical finding and measurement that triggered the referral (e.g., "8mm pocket depth, distal #19, bleeding on probing") rather than a generic "please evaluate."

Common failure modes

Treating every carious lesion identically regardless of the patient's risk trajectory, restoring incipient lesions that would have remineralized while under-monitoring a high-risk patient's next cavity. Reaching for composite or crown by habit rather than by the structure-loss threshold, producing early fractures on undersized composites or overtreatment on teeth that didn't need a crown. Referral avoidance driven by scope creep or fee pressure — attempting a case past the stated threshold because the dentist is confident, not because the threshold doesn't apply. Sequencing esthetic or elective work ahead of active disease control because it's what the patient asked for first, rather than presenting the tier order and letting the patient choose within it.

Worked example

A 42-year-old patient presents for a recall exam. Radiographs and periodontal charting reveal three findings and generalized moderate perio disease. Fee schedule: SRP $220/quadrant, composite $265, crown $1,150, fluoride varnish $45.

Finding 1 — tooth #3 (upper right first molar): bitewing shows radiolucency penetrating the outer third of dentin; post-excavation structure loss is estimated at ~40% of the crown. Below the ~50% crown-loss threshold for a crown — composite is indicated. Cost: $265.

Finding 2 — tooth #14 (upper left first molar): bitewing shows a deeper lesion; post-excavation structure loss is estimated at ~60% of the crown, past the fracture-risk threshold for a direct composite. Crown indicated. Cost: $1,150.

Finding 3 — tooth #19 (lower left first molar): incipient lesion penetrating only the outer third of enamel, not yet into dentin. Patient's CAMBRA assessment (poor home care, low salivary flow, no fluoride exposure at home) places her in the high-risk category. Per the risk-trajectory principle, this lesion goes on a remineralization protocol (5,000 ppm fluoride toothpaste, in-office fluoride varnish, 3-month recall) rather than immediate restoration. Cost this visit: $45 fluoride varnish only; $0 restorative.

Periodontal: generalized 4mm pocketing with bleeding on probing, no site over 5mm, first time documented at this depth. Per the perio heuristic, this calls for non-surgical SRP across both arches before any referral consideration. Cost: $220 × 2 quadrants = $440.

Naive read: restore all three lesions immediately ("don't leave anything untreated") and do the crown before addressing the periodontal inflammation, since the crown is the biggest-dollar item. This adds an unnecessary $265 composite on tooth #19 (a lesion that would very likely remineralize) and risks poor crown-margin adaptation by prepping in actively inflamed, bleeding tissue — total $2,365, wrong sequence.

Correct sequencing and total: Phase 1 (disease control, this visit and next): SRP $440 + composite #3 $265 + fluoride varnish $45 = $750. Phase 2 (restorative, after tissue has healed from SRP, ~6 weeks): crown #14, $1,150. Tooth #19 stays on remineralization and 3-month recall, no restorative cost unless it progresses. Total treatment-plan cost across both phases: $750 + $1,150 = $1,900.

Quoted treatment-plan note to the patient:

"Today's exam found three things and some gum inflammation. Here's the order I'd tackle them in: This month — deep-clean your gums (they're inflamed and bleeding, which needs to heal before any other dental work holds up well) and fill the cavity on your upper right molar. About six weeks later, once your gums have healed, we'll do a crown on your upper left molar — the cavity there is too deep for a filling to hold up long-term. The small spot on your lower left molar isn't deep enough to drill yet — with the fluoride toothpaste I'm prescribing and a visit back here in three months, there's a good chance we can stop it from getting worse without ever needing to restore it. Total for phases one and two: $1,900."

Going deeper

• references/playbook.md — filled treatment-plan phasing tables, referral-threshold table, radiographic diagnostic-yield chart.
• references/red-flags.md — clinical and radiographic smell tests with numeric thresholds.
• references/vocabulary.md — terms of art a generalist misuses.

Sources

American Dental Association (ADA) clinical practice guidance. CAMBRA (Caries Management by Risk Assessment) protocol, UCSF. ICDAS (International Caries Detection and Assessment System) coding criteria. American Academy of Periodontology clinical practice guidelines on non-surgical periodontal therapy. Cost figures in the worked example are illustrative fee-schedule examples, not a universal rate — actual fees vary by region and practice.