BDS,MSc (Comm.Dent),DDPH RCS(England) Patient recall guidelines & Treatment Phase- Comprehensive Treatment planning -2 Recall intervals for scale and polish treatments the prescription and timing of dental radiographs Intervals between examinations that are not routine dental recall, that is intervals between examinations relating to ongoing courses of treatment Emergency dental interventions or intervals between episodes of specialist care DENTAL RECALL GUIDELINES: Nice guideline UK , Clinical guideline 19,2004 This guideline does not cover: The recommended interval between en oral health reviews should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease. This assessment should integrate the evidence presented in this guideline with the clinical judgement and expertise of the dental team, and should be discussed with the patient. During an oral health review, the dental team (led by the dentist) should ensure that comprehensive histories are taken, examinations are conducted and initial preventive advice is given. This will allow the dental team and the patient (and/or his or her parent, guardian or carer to discuss,where appropriate: The effects of oral hygiene, diet, fluoride use, tobacco and alcohol on oral health The risk factors that may influence the patients oral health, and their implications for deciding the appropriate recall interval The outcome of previous care episodes and the suitability of previously recommended intervals The patients ability or desire to visit the dentist at the recommended interval The financial costs to the patient of having the oral health review and any subsequent treatments The interval before the next oral health review should be chosen, either at the end of an oral health review if no further treatment is indicated, or on completion of a specific treatment journey. The recommended shortest and longest intervals between oral health reviews are as follows: The shortest interval between oral health reviews for all patients should be 3 months. The longest interval between oral health reviews for patients younger than 18 years should be 12 months. The longest interval between oral health reviews for patients aged 18 years & older should be 24 months For practical reasons, the patient should be assigned a recall interval of 3, 6, 9 or 12 months if he or she is younger than 18 years old, or 3, 6, 9, 12, 15,18, 21 or 24 months if he or she is aged 18 years or older. The dentist should discuss the recommended recall interval with the patient and record this interval, and the patients agreement or disagreement with it, in the current record- keeping system. The recall interval should be reviewed again at the next oral health review, to learn from the patients responses to the oral care provided and the health outcomes achieved. This feedback and the findings of the oral health review should be used to adjust the next recall interval chosen. Patients should be informed that their recommended call interval may vary over time. 222 RESTORATIVE TREATMENT: Initial treatment: Control etiology: Eg:Dental Caries Advice on diet Oral hygeine Use of Fluorides Oral prophylaxis Dietary advice: Should be personal, practical & positive Adopt less cariogenic diet - Eat less sugar & eat sugar less often Reduce consumption of sugars & fats Increase consumption of fiber rich starchy foods. Fresh fruit & vegetables Meals provide a better nutritional balance than snacks, hence good eating/slash drinking at meal times avoiding between meal snacking is healthy Use of intense sweeteners Eg: Saccharin & aspartime are non cariogenic, but to be used with caution due to the effect on the gastrointestinal system. Chewing gums- sugar free chewing gums (Xylitlol) simulates saliva & thus increases salivary buffers & enhances wash out of sugar. Carbonated beverage have a 2-3 PH & can cause marked loss of tooth structure via erosion. Detersive food stuffs like carrots & apples etc. are of little or benefit in removal of plaque Effective plaque removal is dependent on tooth brushing only Diet & Dental caries: Pre-requsite for dental caries is a carbohydrate form that can be metobolised by oral bacteria. Classification of sugars: Intrinsic sugars: Sugars forming an integral part of certain unprocessed food stuffs. Called intrinsic because they are enclosed within a cell Found in whole fruits & vegetable, mainly as fructose, sucrose & glucose. Contd. Extrinsic Sugars: Found in food outside the cellular structure Further classifies as: Milk extrinsic sugars- In milk & milk containing products mainly lactose. This is of low cariogenicity Non Milk extrinsic sugars: found in confectioneries, soft drinks, biscuits & cakes. Includes sucrose, fructose & glucose. These have the greatest cariogenic potential Factors influencing the cariogenicity of food: Consistency: Sticky retensive foods are more cariogenic than liquid non retensive forms Frequency of consumption: Snacking or grazing results in lower PH, where net outflow of calcium & phosphate ions from tooth surface occurs from prolonged period of time. 333 Oral Hygeine Refer Previous lecture on oral hygeine & plaque control: Fluorides: Series of systematic reviews published by the cochrane library have concluded that children who brush their teeth at least one a day with fluoridated tooth paste will have less tooth decay. Has a caries prevention action when delivered in vehicles other than tooth paste also. Fluoride Mode of action Systemic Pre-eruptive effect: Fluoride ions are incorporated into the enamel structure in the form of fluor appetite during the period of tooth formation Topical -post eruptive effect: Fluoride is either incorporated into the crystal lattice or by binding to crystal surface. Calcium Fluoride at the tooth surface not only reduces the solubility of the appetite but also encourages re-mineralisation Fluoride causes decrease acid production by cariogenic bacteria Topical effect at the tooth surface, post eruption is more effective than systemic effect Pain history: Essential in diagnosing pulpal pain Pain quality : Sharpness - Sharp pain can indicate, exposed dentinal tubules & fractured cusp Dullness - May indicate pulpal hyperemia Throbbing pain Particularly if constant may indicate an irreversible pulpitis Duration: Short pain- Few seconds, can indicate reversible pulpitis but may also indicate pain of non dental origin. Eg: Trigeminal neuralgia Constant pain- Often indicates irreversible pulpitis or one of its sequelae Stimuli: Reaction to heat Irreversible pulpitis reacts to heat but not cold Reaction to cold - Reversible pulpitis Reaction to pressure- May indicate periapical or periodontal abcess. Release of pressure- may indicate a cracked cusp Reaction to sweet stimuli- Reversible pulpitis or exposed dentin Time of Pain: Pain pattern day & night is important. Pulpal pain is often worse at night Conclusion: A pain history gives the dentist a guide as to the source of pulpal pain. It does not produce a diagnosis on its own 444 Site & radiation: History indicates primary site of pain & where it radiates. Pain in teeth adjacent to the tooth the patient suspect as the cause of pain or the opposing arch is common. Referred pain from non dental causes- Eg: Sinusitis Pain localisation in difficult in low grade reversible pulpitis & in children Pulpal Diseases: Reversible pulpitis: Symptoms: Pain of short duration as response to Hot, cold & sweet Relieved by analgesics Poor pain localisation Irreversible pulpitis: Pain of long duration Throbbing, dull in nature Worse with hot stimuli Better localisation of pain Not always relieved by analgesics Periapical periodontitis: Symptoms: Dull, throbbing constant pain Frequently keeps patient awake Can localize pain to particular tooth Tender to chew Poor relief from analgesics Stabilisation Phase: Extract unrestorable teeth Restore by simple means- Intra coronal restorations. Amalgam composite restorations etc. Simple endodontic treatment to key teeth Stablisation phase restore by simple means Removal of carious tissue Minimize pulpal and /or periodontal damage Cavity should be prepared such that the restorative material to be used can restore function & appearance of the tooth, & is retained in the tooth Fundamental guiding principle of cavity preparation, is that the preparation should only be as large as the carious lesion. However follow the basic steps in the preparation of cavities, like outline form, resistance & retension form, management of remaining caries, enamel margin finishing & cavity toilet. Simple endodontic treatment for offending tooth: Indirect pulp capping- Should be used for all cavities where it is considered there may be a micro exposure or where removing further remnants of caries is likely to cause classic pulpal exposure A layer of Calcium hydroxide (setting) is placed over the dentine closest to the micro exposure. This is reinforced by a structural lining. 555 2. Direct Pulp capping: An exposed vital pulp may be pulp capped. This is less sucessful than indirect pulp capping but most likely to succeed in circumstances where: pulpal exposure is small (less than 1-2 mm) pulp is free of salivary contamination carious exposure is not present tooth was symptom free prior to cavity preparation Patient is young (Better pulpal blood supply) Reassess Response to treatment Assess patients motivation Oral hygiene Diet Reasess problem teeth Reasess treatment plan in poorly motivated patient, complex treatment will inevitably fail due to poor oral hygeine In some patients no further treatment is required Definitive treatment: Premolar Molar Endodontic treatment Endodontic retreatment Post-core restorations Crown & Bridge Removable prosthesis Implants CONCLUSION: In the formulation & carrying out of treatment: Keep treatment as simple as possible Construct treatment plan where there is scope to reassess & change plan Know your own professional limitations Know your patients limitations When planning restorative treatment, the dentist should take into account not just the teeth but the individual patients total oral health & general health needs 29