Download sheet#6,Dr Ahmad Maaita,Doaa Hanandeh

9/7/2014
Diagnosis #6
Doa’a Hanandeh
 Treatment planning : Formulating a logical sequence of treatments designed to restore the
patient’s dentition to good health together with optimal function and appearance with the
minimum necessary intervention. It is not a static , it is a multiphase and dynamic series of
events. We choose the treatment plan for every patient according to the patient’s needs not
our needs. And we should re-evaluate after each phase if we have achieved our objectives or
not.
Your patient may have many problems “pics on slide 3” like : broken teeth, caries,
infections like sinus tract , edentulous spaces, gingiva problems ,… etc. How can I treat
these patients ??
 Development of treatment plan consists of four steps:
1. Problem(s) identification.
2. Decision to recommend intervention . (If I should intervene or not).
3. Identification of treatment alternatives.
{ any problem, have one diagnosis and many methods to treat}
4. Selection of the treatment with patient's involvement
1) We will start with problem(s) Identification (( diagnosis )) :
the patient go to the dentist because he complains from something like pain or esthetic
problem for example. We will start the diagnosis from his chief complaint, he may complain
from many other things.
Then I take the patient’s history >> do the examination to the patient to know its status >> do
special investigation >> reach to the diagnosis.
a) History:
1- Chief complaint :
If the patient has pain >> I should ask him about: the location of pain, the onset, the
severity, is it sharp or dull pain?, how much does it last for? Is it localized?
If the patient have appearance problem >> I should know if he has reasonable expectations
or just he wants to look like one of the celebrities for example..
2- Medical history :
- We should check all the systems >> we have to know if the patient have diabetes,
hypertension, seizures, … etc.
we should know if the patient has been hospitalized recently and why? Does he have a
history of hepatitis ?
- Does he have allergy from penicillin, amoxicillin, rubber latex ? If yes, we shouldn’t use
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these things to avoid the anaphylactic shock, and save the life of the patient.
-What are the medications of him?
3- Dental history :
Is the patient registered with the dentist or not ? “we don’t have this thing in Jordan”
Is he a regular attender ? or there is a long period of time between each 2 visits ?
Does he brush his teeth ? Does he have any dental procedures done recently? Any
extractions? Any adverse reactions to local anesthesia?
4- Social history :
Is he married? Does he live alone ?
Does he have any problems in transportation? So if we put a long treatment plan and the
patient lives in Aqaba for ex. , Is it reasonable to come to Amman many times? Or do all the
treatment in one visit ? Is he committed to this treatment or not?
Is he a smoker? Because part of our job is to advice patients to stop smoking with healthcare
providers .
Is he alcoholic? There is an acceptable certain limit, after this limit it will be excessive and
makes problems.
b) Examination:
1- Extra-oral exam:
- facial symmetry: everyone – for a certain extent- has a symmetric face but of course not
100% symmetric but this is normal. We notice the gross asymmetry. Some of them is
congenital like:
HFM : Hemi Facial Microsomia, condylar hypoplasia.
But it could be due to a tumor, abscess, cellulitis.. etc
- TMJ
- LN: lymph nodes : are they swollen and tender because of infection ? or without
tenderness “and this is worse because it may be a tumor”?
- MOM: Muscles of mastication
- lips: I should notice the lip line >> It may be high lip line or low lip line according to
the gingiva and teeth that the patient shows. So we have to notice the esthetic demand for
each type.
Also we notice if the patient has competent lips or not {competent lips : the lips come
together without an effort from the patient}
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Diagnosis #6
Doa’a Hanandeh
2- Intra-oral exam:
- Soft tissue : lips, tongue, cheeks, sublingual tissue :are they normal or there is ulcer? Is
the texture color normal?
- Teeth charting : there is a chart and we fill it with these thing about each tooth: is there
a fracture, caries, fillings, crowns, partial bridges, partial denture .
- Inspection : we see if there is a gross problem or not ,
palpate the teeth and the buccal and lingual vestibules and notice if there is a tender or
any abnormal thing,
percussion test directly to the periodontal tissue.
- Mobility : Is there a any movement in teeth ? If yes, is the movement for all the teeth
because of periodontal disease? Or for one tooth because of malocclusion or fracture?
- Saliva : It is necessary to test the saliva because it is important in preventing caries by:
* flushing and make the debris not to stick to the tooth structure,
* it acts as a buffer “the most important cause” >> the bacteria produce acids that make
caries, and saliva have a buffering system like the carbonic acid - bicarbonate system.
* Saliva is important in remineralization because it is a reservoir for calcium, phosphate
and other minerals..
* It has antibodies: Immunoglobulins (e.g: IgE).
- Periodontal examination: for screening purposes we divide the mouth into 6 sextants,
and we give a score according to bleeding upon probing, presence of plaque retentive
factors and pockets depths. (we will take it in details later on).
c) Special investigation:
- Sensibility (vitality) testing :
It's an important tool to check whether teeth are vital or not and in order to reproduce
patients' symptoms (i.e.: if the patient complains from pain to cold drinks, then a cold test
can be very helpful to show which tooth is causing it).
If the tooth is vital and asymptomatic but cavitated >> it needs conservative treatment
(filling).
if the tooth is non vital and there is periradicular problems >> it needs root canal
treatment then indirect restoration.
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Doa’a Hanandeh
- Biopsies : “ecisional and incisional biopsies”.
- Radiography: the most frequently used is the peri-apical radiograph.
If the patient didn’t visit a dentist for a long time, we do a full mouth x-ray, which
consists of 14 peri-apical radiograph & 4 bite wings radiograph.
Nowadays we can also use OPG , (panorama, or DPT) , occlusal x-rays,
in ortho : cephalometric x-rays
and also CBCT (cone beam computed tomography) : 3 dimensions image so more detail
information
d) Occlusion registration:
- Study casts: it gives an overview to the patient’s problems, explain to the patient the
intended treatment, .
when we imagine the final outcome, we send it to the lab to wax up the study cast > so
we can predict the final outcome on the cast before we start working on the patients’
teeth.
-
Bite registration: how the patients’ teeth occlude together..i.e: To register the
relationship between the maxilla and mandible. It can be done using: wax rims, fast
setting silicone or bite blocks.
-
Face-bow registration:
after taking the relationship between the maxilla and mandible by the bite registration,
we use the face-bow to take the relationship between the occlusal plane and the
condyles. Most of the patients have a horizontal occlusal plane but not all of them
(refer to the pic in slide 9), so using the face-bow is very important.
(slide 11).
Study casts >> wax up to see if there is space to the teeth >> decide if increase the occlusal
vertical dimension or not.
After we diagnose the patients ‘problems, we move to the next step which is :
2) Treatment options :
* If the patient has edentulous space, what are the options?
- Do nothing (if the patient isn’t bothered.
- Removable denture , which is the easiest way and most conservative.
- fixed Bridges.
- Implants.
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Diagnosis #6
Doa’a Hanandeh
* We decide which option to use according to many things like:
- Cost.
- Patient’s motivation.
- Oral hygiene .
- Age.
- Systemic health.
After we discuss the treatment options we put the treatment plan & a time table..
3- Treatment plan sequencing “we have 6 phases”:
I- Management of the emergency situation :
** Relief of symptoms: If the patient has severe pain and he can’t sleep at night, you
have to relieve the pain at the beginning. Don’t start by advising him to stop smoking or
brush his teeth because he will not listen to you. The same thing in abscess which is
associated to fever and malaise, you have to relieve the symptoms first.
** Management of trauma : If you have a patient who has avulsion or lateral luxation
(refer to the pics in slide 14).
** Appearance: If a patient has decemented crown or fractured tooth and he wants his
teeth to be treated quickly , he doesn’t care about any other problem like gingivitis at that
time.
II- Dealing with incidental findings:
After I deal with the emergency situation, I may find things like in the pics in (slide 15):
** this ulcer has all the features of the malignant ulcer ( It resulted in bone exposure,
rolled margins & it looks very nasty). So, I have to refer it to oral medicine specialist
because If it is at stage one and I wait till I finish my treatment it may become at stage 3..
( Unilateral palatal lump (pic): could be a tumor of a salivary gland)
** diagnosis of systemic diseases like the pic in the slides, it is a red raw beefy tongue
(typical of pernicious anemia) . In the other pic the teeth are eroded on the palatal side
“there is intact enamel and dentine is eroded because enamel is more resistance to acids”
> The patient may suffer from anorexia, bulimia or gastroesophageal reflux disease.
** Potentially infectious diseases : The pic shows hairy leukoplakia on the lateral border
of the tongue. The other pic shows Kaposi sarcoma.The patient may be HIV-positiveand
the dentist may be the first person to detect that. You have to deal with these things
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before gingivitis and caries because they are much more important.
III- Stabilization and prevention (control) phase
ongoing diseases like caries and gingivitis are progressive ( if not treated they become
worse). The same thing periodontal diseases like gingivitis > if not treated it may become
worse (periodontitis) .
What should I do?
** Improve the oral hygiene habits. : this is the first thing we have to do in this phase by
giving the patient instructions about how to clean his teeth, the Technique, what tooth
paste to use, what tooth brush to use.
** Diet analysis and advice : When we eat, the intra-oral bacteria (aciduric bacteria)
ferment carbohydrates and produce acids. This leads to the intra-oral pH level to drop. If
it drops below a certain level, demineralization of enamel and dentine start. If
demineralization exceeds re-mineralization caries will progress and eventually cavitation
occurs.
The critical pH level below which demineralization starts was found to be 5.5 according
to Stephan's curve.
Diet analysis: What we do is telling the patient to register everything he eats for 3 days (
typically 2 week days & 1 weekend day!) : he should register: when he eats, the amount
>> then we sit together and highlight excessive sugary drinks and food, excessive acids,
the frequency :the more times I eat, the worse to teeth because every time the ph will
drop again below 5.5 and demineralization happens.
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Diagnosis #6
Doa’a Hanandeh
** Fluoride supplement : Does he drink fluoridated water or not? Does the tooth paste
has fluoride? Does he need fluoride applications like varnish or not?
** Extraction of teeth with poor prognosis : we extract any non-restorable (hopeless)
tooth like fractured tooth, a tooth with root caries, sub gingival caries.
** Periodontal debridement: scaling and polishing (removing the plaque and calculus).
** Caries control : by excavating the carious lesions . we don’t restore caries at this stage
, we just temporize them . The best way for this is using glass ionomer because it
releases fluoride which helps in caries control .
** Replacement/repair of defective restorations : the defective fillings and defective
crown margins act as plaque retentive factors. Managing these margins and restorations
helps achieving a good plaque control.
** Occlusal adjustment- correction of occlusal trauma
IV- Re-evaluation phase :
actually it is not a real phase, but it is important because we have to check (before I start
the irreversible treatment) if we improved the patient’s oral health and whether we
achieved the objectives of the stabilization phase.
It's a holding phase - the time between the control and definitive phases.
Allows for resolution of inflammation and time for healing
To re-assess and reinforce the following:
** Home care habits.
** Motivation for further treatment.
** Initial treatment and pulpal responses.
V- Definitive treatment phase :
.
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Doa’a Hanandeh
It is a multi-disciplinary approach following stabilization of the patient’s condition , and
it is a teamwork between all the specialists.
** First, we have to Approve and design the final prosthesis
** Periodontics: eg: Crown lengthening (to make it enough to retain a restoration),
implant placement…etc
** Endodontics: RCTs and apical surgery.
** Orthodontics: sometimes we need to align tooth to tooth. Sometimes we need
intrusion or extrusion if we don’t have enough space.
** Oral surgery : If we have a ridge with a sever undercut for example, and we can’t put
the denture on it >> we do the corrective surgery at this phase.
** Occlusal management: we have to decide if the restoration will be in the
RCP (retruded contact position) or ICP (inter cuspal position) . conformative approach:
is to conform to the existing occlusion and only make minor modification(s). Sometimes
the existing occlusion is not favourable or does not allow the placement of the intended
prostheses. In this case we re-organize the occlusion. The only predictable and
reproducible maxillary-mandibular relationship in this case is the RCP.
sometimes we decide to change OVD the ( occlusal vertical dimension)
** Prosthodontics: definitive direct and indirect restorations : fillings, crowns & dentures
VI- Maintenance phase
Finally, we have to maintain what we achieved . So we need to:
** reinforce the oral hygiene habits.
** Regular review appointments every 6 months to check if he still maintain a good oral
health.
** Regular periodontal debridement ( regular scale and polish) every 6-12 months.
** Radiographic follow-up : for the patients with high caries rate every 3-6 months.
for the adult patients with low caries rate > once every 2 years.
Also we should follow up the root canals:
We do the first radiographic x-ray after one year, because radiographic changes take
time. If we do a follow up x-ray in less than a year, this considers over exposure .
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Diagnosis #6
Doa’a Hanandeh
 There are many factors that affect the treatment plan: 1) Patient factors . 2) Dentist factors.
1) patient factors :
- Patient preferences: I cannot always do the patient’s preferences. Sometimes they are
not suitable .
- Motivation.
- Systemic health: Ex. If the patient has epilepsy , we try to avoid removable appliances
.
also patient’s with osteoporosis: These patients are now treated with bisphosphonate
: a drug that blocks the action of osteoclasts which are important in healing . So, after
any surgical intervention, bony healing is delayed which puts the patient at risk of
developing bone necrosis (Bisphosphonate-related osseonecrosis) . We try to avoid
surgeries and extraction with these patients .
-
Emotional status.
-
Financial capabilities.
2) Dentist factors:
- Dentist’s knowledge .
- Experience and training : a matter of time.
- Laboratory support : If there is a good technician or not.
- Dentist-Patient compatibility : good patient.
- Availability of specialists .
- Functional, esthetic and technical demand.
 Treatment plan approval: Informed consent has become an integral part of
modern day dental practice . ( It is a contract between the dentist and patient)
It is important to:
a) Provide the patient with the necessary information about the alternative therapies available
to manage their oral conditions .
b) Protect the dentist from mal-practice allegations.
 The consent form should include :
1- Diagnosis of the condition
2- Treatment options available
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Doa’a Hanandeh
3- The advantages and disadvantages of each treatment option ( Pros and cons + associated
risks).
4- The proposed procedure (s)
5- Cost.
GOOD LUCK