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Chapter 3 Patient Goals and Desires: Short-term: Resolution of the chief complaint (relieve pain, repair broken teeth) Long-term: Maintain oral health Keep teeth for a lifetime Stay free from pain Replace teeth for more comfortable eating Extract all teeth and replace with dentures Patient modifiers:

Negative Patient Modifiers Positive Patient Modifiers

Inadequate time for treatment Interest in oral health

Inadequate financial resources Ability to afford treatment- which is dependent on: Patient’s financial resources Level of immediate care necessary Types of procedures proposed Feasibility of postponing care Availability of third party assistance

Fear of dental treatment History of regular dental care

Lack of motivation

Poor oral health

Diet high in refined carbohydrates

Destructive oral habits

Poor general health

Dentist Goals and Desires Remove or arrest dental disease Eliminate pain Determine the correct treatment for each problem Treat the most severe problems first Choose the best material Provide ideal treatment plan for patient Modified treatment plan = balances the patient’s treatment objectives with those of the dentist. Dentist Modifiers

1. The dentist’s level of knowledge and experience 2. Technical Skills 3. Treatment planning philosophy

Key teeth – the important or key teeth that can be salvaged

1. Retaining key teeth improves the prognosis for other teeth or the case as a whole. 2. Serve as abutments for fixed and removable dentures – adds stability to a dental prosthesis 3. Characteristics

a. Periodontally stable b. Favorably positioned in the arch

i. At least canines and one molar c. Have not moved excessively out of position d. Restorable

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Phasing

Textbook phases LLUSD phase

Systemic phase: Evaluation of patient’s health Phase 1: Patient assessment, diagnosis and treatment planning ) includes “Systemic Phase”

Acute phase: resolve symptomatic problems Phase 2: “Acute” problems + periodontal treatment

Disease control phase: control active oral disease Phase 3: “Disease Control” – endodontic therapy, oral surgery, direct restorations

Definitive treatment phase Phase 4: Orthodontic therapy

Phase 5: Single unit restorations, fixed partial dentures, implant placement and restoration

Phase 6: Removable partial dentures, complete dentures

Maintenance phase Phase 7: Treatment complete exam and plans for maintenance

Treatment planning for patient with mild disease. Phase 1: Comprehensive oral evaluation (including health assessment “Systemic”), Perio Diagnosis “Disease Control Phase” and “Definitive Treatment Phase” are combined. Phase 2: Periodontal treatment Phase 3: Restore broken, unesthetic restorations, build-ups as needed, small to moderate caries, root canal

treatment and build-up Phase 4: Orthodontic treatment Phase 5: Crowns, fixed partial dentures, implants Phase 6: Removable partial denture, complete denture Phase 7: Treatment complete exam – plans for Maintenance Phase

Treatment planning for patient with moderate to severe disease. Phase 1: Comprehensive oral evaluation (including health assessment “Systemic”), Perio Diagnosis Disease Control Treatment Plan Phase 2: Treatment of “Acute” problems if present – symptomatic teeth (Acute Phase) Periodontal treatment procedures Phase 3: “Disease Control Phase” procedures – extractions, temporary or permanent direct restorations, root

canal therapy. Phase 7: Treatment complete examination – post-treatment assessment and determination of the next step

1. Poor response to treatment – continue in disease control and no advancement to “Definitive treatment”

2. Good response to treatment – move on to “Definitive Treatment Phase” Definitive Treatment Plan Phase 2: Advanced periodontal therapy Phase 3: Definitive restoration of individual teeth – direct restorations (if temporary restorations were placed) Elective extraction of asymptomatic teeth Elective root canal treatment of asymptomatic teeth (that you wouldn’t treat if the patient will not

move on to complete the definitive treatment plan. Stabilize occlusion Bleaching of teeth Phase 4: Orthodontic treatment Phase 5: Placement of implants Indirect single unit restorations Fixed partial dentures Implant pontics Phase 6: Removable partial dentures, complete dentures Phase 7: Treatment complete exam – post-treatment assessment and development of maintenance plan

(Maintenance Phase)

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Chapter 7: The Disease Control Treatment Plan (The Disease Control Phase of Treatment) Purpose:

1. To eradicate active disease and infection 2. To arrest occlusal, functional and esthetic deterioration 3. To address, control or eliminate causes and risk factors for future disease

Structuring the Disease Control Treatment Plan

1. Address the patient’s chief concern as quickly as possible 2. Sequence by priority 3. Sequence by quadrant/sextant 4. Integrate periodontal therapy with caries control in the same quadrant/sextant 5. Keep definitive phase options open with minimalist treatment (don’t spend a lot of time and money on teeth

that might not be retained)

Common Disease Control Problems A. Dental Caries

a. Caries Control: Any and all efforts to prevent, arrest, remineralize or restore carious lesions b. Caries Control Protocol: A comprehensive organized plan designed to arrest or remineralize early carious

lesions, to eradicate overt carious lesions, to prevent the formation of new lesions in an individual who has a moderate or high rate of caries formation or is at significant risk for developing caries in the future.

c. Objectives: i. Eliminate the nidi of infection

ii. Reduce the microbial load of pathogenic bacteria d. Strategies

i. Plaque elimination ii. Limit refined carbohydrate and acid exposure

iii. Provide fluoride exposure e. Caries control protocol must address all indicated parts of the caries cycle:

i. Tooth resistance ii. Saliva

iii. Plaque iv. Bacteria

f. Determination of the patient-specific cause of increased caries risk is imperative i. Systemic

ii. Oral home practices iii. Dietary issues iv. Salivary pH

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g. Disease control procedures for caries/caries risk

Item Tooth resistance Saliva Plaque Bacteria

Oral prophylaxis receptivity to fluoride

Removes plaque/calculus

Oral self-care Removes plaque

Pro fluoride gel application

Remineralization Antimicrobial

Reduce frequency/duration of acid/CHO exposure

Reduces substrate for cariogenic bacteria Less acid-induced dissolution of tooth

OTC fluoride toothpaste/rinse

Remineralized tooth structure

Antimicrobial effect

Restore carious lesions Eliminates nidus of infection, improves cleansibility, arrests progression of caries

Sealants on susceptible pits/fissures

Eliminates sites of infection

Custom home fluoride trays

Remineralization Antimicrobial

Prescription dentrifice or fluoride gel

Remineralization Antimicrobial

Xylitol products Does not cause decrease in pH

Decreases plaque accumulation

Eliminates substrate for cariogenic bacteria Starves bacteria

Chlorhexidine rinse Reduces microbial count

MiPaste Low buffering

Baking soda rinse Low pH saliva

Xerostomia Salivary substitutes

B. Periodontal Disease

a. Control and elimination of the important causes and risk factors for periodontal disease i. Local factors

ii. Heredity iii. Systemic factors and immunoinflammatory response iv. Tobacco use v. Deleterious habits

vi. Defective restorations vii. Occlusal trauma

b. Treatment of active periodontal disease i. Initial therapy

1. Oral self-care instructions and determination of specific areas of difficulty for patient 2. Extraction of hopeless teeth 3. Elimination of iatrogenic restorations and open carious lesions contributing to

periodontal diseases 4. Scaling and root planing 5. Limited occlusal adjustment 6. Pharmacotherapy 7. Post-Initial Therapy Evaluation (Perio Re-Eval)

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C. Pulpal and periapical disease a. Conservative procedures

i. Direct or indirect pulp cap b. Endodontic evaluation (vitality testing) for the following:

i. Deep carious lesions ii. Fractured, leaking or missing restorations

iii. Teeth that have had major fractures iv. Possible cracked tooth syndrome v. Large restorations in close proximity to the pulp

vi. Non-carious tooth loss approximating the pulp vii. Periapical lesion

viii. Pain to hot/cold, biting or spontaneous pain ix. Inadequate root canal fillings (short, poor filling)

c. Definitive root canal therapy and definitive restoration (build-up, not crown) OR Extraction d. Pulpal problems and their treatment

Pulp status Depth of caries/fracture/ defect

Pulp exposure

Periapical area

Treatment

Reversible pulpitis Healthy pulp

Moderate depth No Healthy Place direct-fill restoration Place adhesive material as “bandage” over site

Reversible pulpitis Healthy pulp

Close proximity to pulp

Healthy Total caries removal & final form of prep – if pulp exposure, then endodontic therapy or extraction is required – use when tooth requires crown or if it is a KEY tooth. OR Minimal additional caries removal or preparation, avoid pulpal encroachment; OK to leave area of affected dentin and indirect pulp cap. Monitor at specified intervals and endo/extract if irreversible pulpitis or necrosis occurs. Use if tooth would be extracted.

Reversible pulpitis Healthy Pulp

Yes Healthy Direct pulp cap and direct restoration IF no large carious exposure or excessive bleeding or pus; preferable if mechanical or small carious pulp exposure with healthy pulp and periapical area. Ongoing monitoring. Use if tooth would be extracted. RCT if tooth will have crown or is a KEY tooth.

Irreversible pulpitis Necrotic pulp

Yes OR No

Healthy OR Pathology present

Definitive pulpal therapy with root canal treatment OR Extraction

Asymptomatic Pulpless tooth

Pathology present

Root canal therapy IF patient is immunocompromised or a restoration is planned for the tooth. If patient is healthy and no treatment is required, re-evaluate at specified intervals for increase in lesion size.

D. Single tooth restoration

a. No root canal therapy required i. Direct-fill restoration

ii. If tooth requires a crown, place a core build-up until definitive treatment plan b. If root canal therapy is required

i. Definitive restoration is required in Disease Control Plan – but NOT crown. Do post or core and build-up only.

ii. Provisional (temporary) crown can also be placed if there is inadequate tooth structure.

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E. Stabilization of dental malalignment, malocclusion, occlusal disharmony – usually in definitive treatment plan. HOWEVER, the following problems can be treated in the Disease Control Treatment Plan

a. Food impaction and periodontal disease from: i. Plunger cusp – recontour cusp

ii. Open contact – direct fill restoration iii. Marginal ridge discrepancy – recontouring of the “high” tooth or replacement of the direct

restoration b. Generalized occlusal trauma

i. Comprehensive occlusal adjustment after periodontal therapy ii. Provisional splinting

c. Localized occlusal trauma i. Individual teeth with gross discrepancies causing aberrant excursive patterns in eccentric jaw

movements causing occlusal trauma 1. Should be eliminated in the disease control treatment plan 2. Selective occlusal adjustment and removal of premature contacts or excursive

movement interferences d. Supraerupted tooth into opposing edentulous space

i. Conservative treatment – occlusal reduction WITHOUT root canal therapy or cast restoration ii. If needed, root canal treatment should take place in disease control treatment plan

iii. Orthodontic intrusion should wait until definitive treatment plan e. Impacted tooth other than a third molar

i. Should be treated in disease control 1. Forced eruption 2. Extraction

f. Decreased vertical dimension of occlusion i. Decision: should bite be opened or not? Should be made in disease control treatment plan

ii. VDO should be opened 1. Patient can’t afford it – treatment should be planned without it 2. Patient can afford it – refer to prosthodontist for reconstruction

F. TMJ Disorders a. Reducing anterior disc displacement

i. Treatment: Avoid re-injury, NSAIDs for pain control, splint therapy b. Nonreducing anterior disc displacement

i. Treatment: Avoid re-injury, NSAIDs for pain, soft diet and voluntary limitation of opening ii. No response – refer

c. Degenerative joint disease – osteoarthritis i. Treatment: NSAIDs for pain, soft diet, splint therapy

d. Myalgia i. NSAIDs, muscle relaxants, antidepressant therapy, splint therapy

G. Replacement of missing tooth or teeth

a. Temporary (provisional) removable partial denture b. Bonding the crown of extracted tooth into the new space

Disease control treatment plan – sequencing

Symptomatic restorable/non-restorable Symptomatic – the tooth is bothering the patient – RCT, extraction, direct restoration Non-restorable (root tips, severe periodontal disease, inadequate biologic width) Severe problem – restorable but we need to stop the disease progression before it starts to bother the patient or require more extensive treatment – D3 caries, missing restoration Asymptomatic non-restorable – the tooth isn’t bothering the patient, but it can’t be saved due to caries, perio Asymptomatic restorable – the tooth isn’t bothering the patient, and it can be saved.

Periodontal therapy

Asymptomatic restorable – severe

Asymptomatic non-restorable

Asymptomatic restorable - moderate/mild

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Chapter 8: The Definitive Treatment Plan (The Definitive phase of treatment)

A. Advanced Periodontal Therapy a. Periodontal disease and related conditions

i. Periodontitis not responsive to initial therapy ii. Localized infrabony defects

iii. Furcation involvement iv. Root proximity v. Congenital or medication-induced gingival overgrowth

vi. Mucogingival conditions vii. High frenal attachment

viii. Esthetic and architectural defects or problems b. Treatment procedures

i. Periodontal surgery ii. Placement of antimicrobial-impregnated fibers, cords or gels

iii. Bone regenerative and replacement therapy c. Keys to decision making

i. Professional modifiers – what the dentist should evaluate 1. Importance of relevant systemic factors

a. Immunocompromised b. Smoker c. Medications

2. Tooth related issues a. Open contact, poorly contoured restoration b. Importance of the tooth to the overall oral condition

3. Localized periodontal factors 4. Level of patient cooperation 5. Level of oral self-care 6. Prognosis for treatment options

ii. Patient modifiers 1. Healthy lifestyle? 2. Tobacco use 3. Understanding of the importance of proposed treatment 4. Motivation, can the patient be motivated? 5. Patient discomfort related to condition 6. Personal reasons for the patient to have the treatment (esthetics, halitosis) 7. Willing to undergo extraction of hopeless teeth 8. Inconvenience, stress, post-operative discomfort of a surgical procedure 9. Financial resources 10. Willingness to follow through with maintenance

B. Restoring Individual Teeth – see treatment by condition p.192

Treatment Indications Contraindications

Pit and Fissure Sealant Susceptible pits and fissures Restore/resurface shallow incipient lesions Low caries activity, low risk for new caries Tooth can be monitored for loss of sealant

Enameloplasty followed by sealant/flowable resin

Uncertainty whether caries is in the dentin

Composite Resin Excellent color matching characteristics Easy to use

Microleakage Staining Wear Technique sensitive vs. amalgam Difficult to detect caries radiographically

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High caries risk patients

Glass Ionomer Tooth colored Fluoride release Bonds to dentin and enamel Direct fill for large carious lesions High risk caries Difficult to isolate tooth Can be used as temporary restoration

More prone to fracture & wear then composites Limited shades More opaque

Amalgam Replace missing cusps Build-up material for core after RCT Inexpensive Easy to handle Strong, durable Resistant to fracture /marginal leakage Long service life Where operator visibility is compromised or isolation of the tooth is a problem Deep subgingival margins High caries risk patients

Color doesn’t match tooth Additional tooth structure may have to be removed for adequate retention

Inlay – intracoronal, indirect

Composite/porcelain – excellent esthetics Increased resistance to abrasion /occlusal wear compared to direct-fill composites More precise contacts/occlusion than direct restoration

Increased chair time, cost, technical demands

Onlay – indirect, covers one or more cusps

Strengthen tooth weakened by caries, tooth fracture previous large restoration Provides excellent protection against fracture Porcelain onlays – better esthetics More precise contacts/occlusion than direct restoration

Tooth preparation is challenging Two appointments Porcelain more prone to fracture than gold

Crown - indirect Provides protection for the tooth that has been severely compromised by caries or fracture More precise contacts/occlusion than direct restoration PFM & all-porcelain good esthetics Gold provides better margin, less chance of fracture, less tooth removal than PFM/all porcelain Technically easier than onlay

More tooth structure will need to be removed

C. Cosmetic Dentistry

Treatment Indications Contraindications Microabrasion Remove intrinsic enamel discolorations/defects

Conservative, little tooth structure removed

Contouring teeth For fractured, chipped, extruded, overlapped teeth Hypersensitive teeth Thin enamel

Vital bleaching In-office bleaching – more immediate results At-home – 6-8 weeks

Risk of pulpal sensitivity to hot/cold Tetracycline stain not as responsive

Non-vital bleaching Discolored tooth that has had endodontic treatment Relapse can occur

Veneers Improve esthetics by changing color, contour, size of tooth Direct (composite) or indirect (composite or porcelain) More conservative than PFM or full porcelain Porcelain indicated with extreme enamel discoloration, stable in color, strong, resists staining Close diasthemas

Contraindicated when tooth has been heavily restored Patient with Class III and end to end bite Bruxism or pencil chewing High level technical skill

Porcelain fused to metal All-porcelain

Insufficient tooth structure to support veneer All porcelain is more translucent, lifelike PFM is stronger, less likely to fracture (more likely to fracture than all gold) PFM with working cusps in metal is good for bruxing, clenching PFM requires less tooth reduction than PFM. PFM can have metal margins, better adaptation

All porcelain is more fragile, less likely to fracture in patient with aggressive bite/clenching/bruxing habit. All porcelain requires more extensive tooth reduction than PFM

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D. Elective (nonacute) endodontic problems a. Teeth that have deep or large restorations b. Teeth that have had direct or indirect pulp capping c. Severely broken down tooth, inadequate remaining coronal structure for crown, with prefabricated or

cast post and build-up d. Teeth that will be devitalized in the process of overdenture construction to become overdenture

abutments e. Supererupted teeth that are likely to be devitalized in the process of altering occlusal plane f. Re-treatment of a failing root canal filling

i. When the tooth is symptomatic ii. Clinical or radiographic signs of ongoing or recurrent infection

iii. Systemic health conditions that could result in health risk if left untreated iv. If problems will arise if the tooth is left untreated v. If the tooth requires a new crown or will be an abutment for fixed or removable partial denture

g. Extraction due to failing root canal filling i. Vertical root fractures

ii. Severely debilitated health (ASA IV) iii. Patient unwillingness to re-treat

h. You can wait and see with a failing root canal filling (periapical signs of inflammation & chronic infection) i. Tooth is asymptomatic

ii. Tooth does not require extensive restoration iii. Patient is systemically healthy and not at risk for systemic infection iv. Patient is fully aware of consequences of no treatment v. Re-evaluate at specified intervals

i. Treatment for Nonacute endodontic problems i. Root canal therapy

ii. Root canal therapy re-treat iii. Apical surgery

1. Indicated when conventional root canal therapy has been unsuccessful 2. Canals are calcified 3. Irretrievable cemented post

j. Keys to decision making: i. Remember: Not all teeth should have endodontic therapy (non-functional, 3rd molar)

ii. Is the tooth in a functional position? Is it in occlusion? iii. Can the tooth be restored?

1. How much tooth loss near the level of alveolar bone? Inadequate biologic width? Is crown-lengthening possible? If yes, will it diminish the bone support?

2. Is there caries involvement into the furcation areas? 3. Poor crown: root ratio 4. Poorer prognosis

a. Dilaceration of roots b. Calcified canals c. Poor access for endodontic treatment

iv. Final restoration must be placed as soon as possible to prevent further breakdown of the tooth.

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E. Extractions and Preprosthodontic surgery a. Extractions

i. Indications 1. Hopelessly compromised teeth from restorative or periodontal standpoint 2. Salvageable, but patient does not have the time, financial resources, motivation 3. Tooth would not be satisfactory abutment to support prosthesis 4. To provide space for ortho treatment

ii. Common complications of extractions 1. Bleeding 2. Postoperative pain 3. Dry socket 4. Infection

b. Asymptomatic third molar extraction i. Indications

1. Healthy patient aged 19-25 whose impacted third molars have caused repeated episodes of pericornitis

2. No reasonable prospect for the 3rds to become properly aligned and fully functional and patient wants to stave off future problems

3. Third molars that have poor perio or restorative prognosis and patient is not motivated to retain

4. When the risk of future complications or problems in the presence of the 3rd molars is high (caries, periodontal disease, pericornitis)

ii. Contraindications 1. The possibility of surgical complications is high (paresthesia, fracture, dry socket,

infection) 2. Reasonable probability that it will be needed in the future as an abutment, anchor for

ortho treatment, or to maintain occlusal plane 3. Loss of the third molars will compromise the patient’s occlusion, function, mastication

c. Preprosthodontic surgery – to provide more optimal situation for replacement of teeth. i. Exophytic soft tissue

ii. Bulbous tuberosities iii. Exostoses and tori iv. Ridge augmentation procedures v. Surgical procedures associated with implant placement

1. Bone grafts in site with deficient quality and quantity of bone (4-6 months before implant fixture placement)

2. Sinus floor is in inferior position – sinus floor elevation (sinus lift procedure) – 4-6 months before fixture placement.

F. Replacing missing teeth a. Required information

i. Which teeth are missing? ii. Have the adjacent or opposing teeth moved out of position? If so, how? (important for implant

or FPD) 1. Supererupted opposing tooth decreases the O-G space 2. Tipped, rotated, drifted adjacent teeth affect the M-D space available

iii. Width and height of bony ridge (Important for implant) 1. Implants need 9-10 mm of space mesiodistally (M-D) 2. Implants need 6-7 mm of bone facial-lingually (F-L) 3. Implants need 7 mm of occlusal gingival (O-G) space for the crown 4. If there is moderate to severe bone loss a bone graft is needed 5. If there is inadequate maxillary ridge due to pneumatization of the ridge, a sinus lift

procedure is needed

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6. Be sure that the mandibular canal and mental foramen are not in the area where the implant is to go – there should be at least 2 mm of space between these structures and where the implant is to be placed.

iv. What is the status of adjacent teeth (Important for FPD) 1. Periodontal, dental restorations/pathology, pulp status, oral hygiene 2. Crown root ratio 3. How much space is available for the replacement? For FPD 4-5 mm of O-G space is

needed v. Risks if the tooth is not replaced

1. Supraeruption/tipping of opposing teeth – leading to increased risk for caries/perio disease

2. Decreased oral function 3. Loss of vertical dimension of occlusion 4. Collapse of remaining dentition

vi. Solutions to problems with implants

Inadequate bone density or volume bone graft procedure

Insufficient mesial-distal tooth replacement width orthodontic treatment

Inadequate interarch space orthodontic treatment, tuberosity reduction, open VDO

Inadequate ridge ridge augmentation procedure

Deficient soft tissue contours Periodontal surgery

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Replacement of Missing Teeth See Table 8-6 Treatment Indications Contraindications

Implant supported single crown Improved function Preservation of remaining teeth and bone Increased stability and longevity of the prosthesis Realistic/esthetic appearance Easier for the patient to clean and maintain

Cost Length of healing period One or more surgical procedures Two step procedure: 8 weeks from extraction to implant placed 3 months following implant placement Immediate placement after extraction Eliminates 8 week healing period Immediate loading after appliance placement Eliminates 3 month healing period

Implant supported FPD Fewer pontics, more retentive units Implants + natural tooth FPD requires telescoping copings on natural abutments

Implant supported Fixed complete denture

Fixed metal-ceramic – minimal bone loss and minimal missing soft tissue contours More stable and retentive than conventional CD Less food entrapment, no need for relines, rebases or denture adjustment Greater longevity Functions more like natural teeth

Cost Required time and effort Necessity for surgery

Implant supported overdenture Edentulous patient with severe bone resorption. Facial esthetics enhanced by the labial flanges Removal at night facilitates cleaning Fewer implants required – less expensive

Removable prosthesis which attaches to the implants Requires more vertical height than conventional denture or implanted retained fixed complete denture

Fixed partial denture Replacement teeth are fixed in place Provides a stable and natural-appearing alternative to a removable prosthesis Good esthetics, function, preservation of arch form Patients who are not good candidates for implants Sufficient abutment support Prime indication: Patient whose abutment teeth are heavily restored

More difficult to keep plaque free Abutment teeth may be compromised Span too long Insufficient abutment support Requires full crown coverage of abutments

Removable partial denture Inexpensive Stable Provides a certain level of esthetics and function Cost/tooth replaced with RPD decreases with more teeth replaced with an RPD (compared to implant or fixed partial denture) Prime indication: multiple missing teeth/arch

Must be removed for cleaning Esthetics compromised due to clasps Abutment teeth are at risk for caries/periodontal disease Significantly reduced function when compared with natural teeth, FPD or implant-retained prosthesis

Complete dentures Econonomical Easy to fabricate and repair Provide a level of esthetics and function acceptable to many patients Overdenture abutments (usually canines treated with RCT and attachment) help with retention

Lack of denture retention Loss of chewing ability Retained overdenture abutments are vulnerable to caries/periodontal disease