Professional Documents
Culture Documents
Phasing
Textbook phases
Systemic phase: Evaluation of patients health
Acute phase: resolve symptomatic problems
Disease control phase: control active oral disease
Definitive treatment phase
Maintenance phase
LLUSD phase
Phase 1: Patient assessment, diagnosis and treatment
planning ) includes Systemic Phase
Phase 2: Acute problems + periodontal treatment
Phase 3: Disease Control endodontic therapy, oral
surgery, direct restorations
Phase 4: Orthodontic therapy
Phase 5: Single unit restorations, fixed partial dentures,
implant placement and restoration
Phase 6: Removable partial dentures, complete dentures
Phase 7: Treatment complete exam and plans for
maintenance
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 patients 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 (dont spend a lot of time and money on teeth
that might not be retained)
Sealants on susceptible
pits/fissures
Custom home fluoride
trays
Prescription dentrifice or
fluoride gel
Xylitol products
Tooth resistance
receptivity to
fluoride
Saliva
Remineralization
Bacteria
Antimicrobial
Reduces substrate for
cariogenic bacteria
Less acid-induced
dissolution of tooth
Antimicrobial effect
Remineralized tooth
structure
Remineralization
Eliminates nidus of
infection, improves
cleansibility, arrests
progression of caries
Eliminates sites of
infection
Antimicrobial
Remineralization
Antimicrobial
Does not cause
decrease in pH
Chlorhexidine rinse
MiPaste
Baking soda rinse
Xerostomia
Plaque
Removes
plaque/calculus
Removes plaque
Decreases plaque
accumulation
Eliminates substrate
for cariogenic bacteria
Starves bacteria
Reduces microbial
count
Low buffering
Low pH saliva
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)
Reversible pulpitis
Healthy pulp
Reversible pulpitis
Healthy pulp
Depth of
caries/fracture/
defect
Moderate depth
Pulp
exposure
Periapical
area
Treatment
No
Healthy
Close proximity
to pulp
Healthy
Reversible pulpitis
Healthy Pulp
Yes
Healthy
Irreversible
pulpitis
Necrotic pulp
Asymptomatic
Pulpless tooth
Yes OR
No
Healthy OR
Pathology
present
Pathology
present
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 cant 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
Periodontal therapy
Asymptomatic restorable severe
Asymptomatic non-restorable
Asymptomatic restorable - moderate/mild
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 isnt bothering the patient, but it cant be saved
due to caries, perio
Asymptomatic restorable the tooth isnt bothering the patient, and it can be saved.
Enameloplasty followed by
sealant/flowable resin
Composite Resin
Indications
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
Uncertainty whether caries is in the dentin
Contraindications
Microleakage
Staining
Wear
Technique sensitive vs. amalgam
Difficult to detect caries radiographically
Glass Ionomer
Amalgam
Inlay intracoronal,
indirect
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
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
Composite/porcelain excellent esthetics
Increased resistance to abrasion /occlusal wear compared
to direct-fill composites
More precise contacts/occlusion than direct restoration
Crown - indirect
Indications
Contraindications
C. Cosmetic Dentistry
Treatment
Microabrasion
Contouring teeth
Vital bleaching
Non-vital bleaching
Veneers
Hypersensitive teeth
Thin enamel
Risk of pulpal sensitivity to hot/cold
Tetracycline stain not as responsive
Relapse can occur
Contraindicated when tooth has been
heavily restored
Patient with Class III and end to end bite
Bruxism or pencil chewing
High level technical skill
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
Insufficient mesial-distal tooth replacement width
Inadequate interarch space
Inadequate ridge
Deficient soft tissue contours
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Indications
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
Complete dentures
Contraindications
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
Cost
Required time and effort
Necessity for surgery
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