Different ortho: comprehensive, limited
- Age groups for having certain treatments
- Interceptive / Phase 1 / Early / Limited Treatment – Early Mixed Dentition (7-10 years)
- Comprehensive Treatment – Late Mixed Dentition – Permanent Dentition (> 10 years ….)
- Surgical Orthodontics - Orthodontic Component may be started early (growing patient), however the orthognathic surgery is performed when the patient has stopped growing)
- Adjunctive / Minor Tooth Movement/ Limited Treatment – Adults, Goal is to facilitate restorative, periodontal, prosthetic treatment
American orthodontic association: what age do they recommend screening or treatment for ortho
Habits: when should you get the patient off to ortho, what habits require referral to ortho, malocclusions
- Crossbite of anterior teeth
- Crossbite of posterior teeth
- Severe crowding
- Class II /Protrusion
- Class III / Underbite
- Ectopic Eruption
- Abnormal Spacing
- Habits that persist beyond age 4 should be intercepted - thumb sucking, tongue thrusting, ...
Patient who’s young and lost primary teeth, permanent teeth aren’t in, what do you do next?
Treatment: different restorative treatments, patient with edge to edge bite
- What do you do with crowns, veneers, or composites
- Always Phase 1 (restorative, endo and perio) prior to starting active orthodontic treatment.
- IPR + reshaping for triangular shaped tooth w/ black triangles
- Tooth movement -> proximal decay treatment
- Forced eruption -> extraction, implant, restoration
Noncarious cervical tooth loss
- Meth mouth - rampant dark cervical caries in long term methamphetamine/cocaine user
- Non-carious cervical lesions - not always easy to explain.
- Erosion and abrasion can be prevented by patient education in tooth brushing technique and diet.
- •The cleaner the tooth surface the more sensitive.
- •Highest incidence-bicuspids & canines opposite to the dominant hand. Super eruption
- •Acid diet loss of dentin
- •Occlusal forces causing abfraction of tooth structure doubtful
- Lingual erosion from regurgitation of stomach acid bulimia Possible serious eating disorder
Abfractions, habit driven, is it erosion or abrasion
- No evidence supporting occlusion force being the reason.
- Erosion and/or abrasion
Do you restore them if the patient’s sensitive, maybe it’s a plaque trap
- Most do not require restoration, except:
- •Too deep/close to pulp.
- •Too sensitive - poor candidate for topical desensitizer.
- •Too ugly
- •Sometimes need to eliminate undercut if tooth is to serve as removable partial abutment.
- Local anesthesia, isolation
- Minimum preparation, retention on coronal aspect of cavity.
- Etch, bond posterior composite no overhang in furcation. Little or no polishing, do not damage cementum on the root surface
Which factors predict if a patient is at risk for recurrent caries
- caries on lower front teeth
- Old patients with root carries <- dry mouth <- drug, esp polypharmacy
- previous caries
- high sugar diet/snack, sleep time snack without brushing
Enamel white spots, with regards to appearance, how they occur
- When enamel is exposed to caries acids an enamel white spot forms.
- Indicate areas where caries may develop.
- Indicate ongoing caries process .
- smooth surface white spots can ->
- Partial remineralization - less white and smoother; with improved oral hygiene and fluoride treatment.
- progress to probeable caries.
- Active white spot - Rough, soft, under plaque.
- Arrested white spot - Smooth, plaque free
Sensitivity and specificity with regard to radiographs, detection of occlusal caries
- Sensitivity – Probability that a subject with disease tested positive; true pos/(true pos + false neg).
- Specificity – Probability that a subject who is disease free tested negative; true neg/(true neg + false pos)
- Bitewing vs large caries: 90% specificity, 45% sensitivity
different clinical presentations of erosion, abfraction, attrition
- Erosion - cervical lesion on buccal surface; lingual lesion from regurgitation of stomach acid bulimia.
- Abrasion - cervical lesion on buccal surface
- Attrition - from occlusal forces, incisal area of mandibular incisors, cupped lesions on molar cusps in ecstasy abusers.
- Erosion abrasion - brushing, opposite side of dominant hand.
- Abfractions look like, chops at or below cervical margin, occlusal surfaces, wearing, loss of vertical dimension
Know what the goals of the caries exam and risk assessment are
- To restore to form and function
- Done to benefit patient - will the thing get worse? Is it negatively influencing the patient.
Criteria and factors for successfully endodontically treated teeth
- •Good apical seal
- •No sensitivity to pressure
- •No exudate
- •No fistula
- •No apical sensitivity
- •No inflammation
Strindberg's criteria: what’s considered a success or not, endo needed or not
- stringent radiographic criteria: If the tooth had a radiolucency, it needed a root canal; After RCT, the radiolucency should disappear. If it didn’t disappear, the RCT failed
- Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised
- However, some studies still use Strindberg’s dated criteria.
- The definition of “success” for dental implant studies is often implant survival
- Unlike implants and FPDs, RCTs aim to cure existing disease.
Lazarski: reviewed endo cases and what were the conclusions?
- With endo and implants, things of that nature
- RCT teeth not restored were significantly more likely (>4X) to undergo extraction.
Article by Torabinejad, what the root canal studies measure and show
- RCT studies measure both the healing of existing disease and the occurrence of new disease.
- 97% long term survival rate for either extraction/implant or RCT/restoration. Both better than extraction and bridge (no replacement)
- Evaluated success or failure of dental implant.
Another article: Iqbal, with regards to root canals and implants, what are the survival rates between the two treatment modalities
- survival of single-tooth implants vs. RCT and restored teeth
- 1. Slight favor for implant but overall similar
- 92-97% (4-8yr) for RCT
- 95-99% (2-16yr) for implant
- 2. No significant differences
- More prosthetic complications with implants
- Implants vs. Endodontics: “No difference in the survival rates between the two treatment modalities.”
With regards with restoring a tooth: endo/post/core/crown or grafting and implant, What are the success rates, are they similar, and what other factors do you have to consider
- outcomes are similar with either treatment
- decisions should be based on factors such as
- potential adverse outcomes
- ethical factors
Within these studies, determine what lenient success criteria indicate as opposed to stringent criteria with regard to root canal prognostics
No mobility for implant, bone loss, pocketing, recession, etc are fine.
Stringent radiographic criteria with regards to radiolucency, if the tooth has to be in function, does it have to be asymptomatic to be successful
Evidence of delayed healing: if you have endo and if you still have residual PA radiolucency, is that considered healing?
If you remove all the pathology and disease processes, RCT is successful.
Know the criteria between success of implant survival and root canal, are the criteria the same or different and what is that criteria
He showed us graphs, what’s the estimated age, what age are people living to, and are we having an increase in individuals who are dentate or edentulous
Geriatric is 65 and above, increasing, doubles in 50 yrs
Dental management of elderly population is NO different from treating the general dental population
- Dental Risk Evaluation and Mitigation
- Algorithm designed for Medically Complex Dental Patient
- Answer “No” to four basic questions to reduce your risk of harming a patient
- 1. Risk of bleeding
- 2. Risk of infections
- 3. Risk of adverse drug Reactions
- a. Allergies
- b. Drug interactions
- c. Drug metabolism
- 4. Patient’s ability to tolerate the Dental procedure
Changes in the Aging
- • Occlusal wear continues throughout life
- • Normal wear
- • Pathologic wear
- • Enamel becomes more brittle with age
- • Formation physiologic and reparative secondary dentin
- • Sclerosis of the dentinal tubules
- -> decrease sensitivity to cold, hot sweets and pain
- • Decrease in response to stimuli
- Taste and Smell:
- • Reduces salivary flow (aging, medication)
- - Saliva dissolves tastants and transports them to the taste buds
- Mastication, Speech and Swallowing
- • Oral motor disturbances are the primary aging problem
- - Muscle changes - Progressive atrophy of the masticatory, buccal and labial muscles
- - Changes in strength of the tongue and masticatory muscles
- - Reduced chewing efficiency
- • Changes in swallowing
- - Increase risk of choking, aspiration pneumonia
For geriatric patients, they require special treatments medically and dentally
With regards to the aged population, do you do more prosthetics, are teeth being retained more, or are we going towards implants, crown, bridge
- 60% of old people have teeth
- 96% of Americans 65+ experience dental caries
- dentulism significantly higher for those live in poverty than those at 200% or more of poverty level.
What are the factors that are involved in increased caries rate in the elderly
Certain medications: what is the impact of increased medication use on oral health
Drugs with Strong Anticholinergic (M3) properties causing Hyposalivation
OHAT: oral health assessment tool, what’s the purpose of that, what’s it used for?
- Nursing home - long term care
- For oral health screening
What are the risks and ramifications of hyposalivation and xerostomia
- • Xerostomia
- • Dental caries - Root caries
- • Candidiasis
- • Halitosis
- • Fissured tongue
- • Burning tongue
- • Mucositis, Mucosal ulcers
- • Burning, dry lips
- • Demineralization of the tooth surfaces
- • Difficulty with chewing, swallowing and speech
- • Loss of taste, Altered taste
- • Difficulty wearing dentures
What are examples of barriers to communication and understanding treatment planning with older patients?
- • Hearing Impairment
- • Aphasia, Nonverbal
- • Difficulty understanding
- • Mental status/Dementia
- - Consent to treatment
- - Legal guardianship
Know what the Stephan curve is about
- ● Any plaque pH above 5.5 is the good part and below that is cariogenic
- ● Within 5 seconds of sugar exposure, you'll enter the carious zone, takes some time to return to safe zone
Recognize the categories of medications and what impact they have on the oral environment. 4-5 categories, what impact they have on salivary flow, oral environment. Emphasize the different categories rather than the individual drugs
What factors affect bone loss
- Tooth loss*: COMPRESSIVE (cause bone loss) VS TENSILE (strengthen the bone) FORCES
- Aggressive alveoloplasty
- Systemic diseases (osteoporosis, nutritional deficiencies, renal diseases…)
- Parafunctional habits
If teeth are removed, alveoloplasty, surgery, what’s the rate of bone resorption over time
- First year: 10 X
- After: 1 mm / y
- Mandible 4X maxilla
- Areas of muscle attachments are preserved
Functional cosmetic effects of bone loss, what happens to the face
- Pattern of ridge resorption: Good width/height -> Thin and pointed -> Flattens to basal bone -> Concavity of basal bone
- Often knife-edged
- - Anterior: crest drifts posteriorly and upward
- - Posterior: crest drifts inward and upward
- - Palate becomes ultimately flat
- - Downward and outward
- - Pseudo-widening of the mandible
- Functional effects:
- - Decrease of facial height
- - Overclosed appearance
- - Angular cheilitis
- - Decrease alveolar support for denture/implants
- - Ill fitting dentures
- - Soft tissue encroachment
- COSMETIC CONCERNS
- - Unsupported lips
- - Poor upper vermillion show
- - Increased lower lip vermillion show
- - Loss of nasolabial folds
- - Obtuse nasolabial fold
- - Chin ptosis
Tuberosity reduction: different factors, what’s required, complications that might occur
- Doesn't heal due to systemic issues
- Soft bone, none cortical, easy to remove
Surgical removal of palatal torus and the purpose of a surgical stent
- Remove if undercuts exist or history of ulceration
- When big, split first then crack piece by piece
- Risk of nasal cavity perforation
Why do you use the stent and what’s the purpose? Are there going to be complications with the soft tissue after excision and does a surgical stent help?
- Support the soft tissue, not to develop hematoma, soft tissue dehisence.
Does it guide how much reduction you have to do?
Regarding bone reconstruction and grafting, know the difference between onlay grafts and horizontal grafts
Onlay graft is better for horizontal defects
What areas of the mandible can be harvested for grafting
Ramus, symphysis, border.
other areas that can be harvested for grafting
Anterior iliac crest, Rib
when a sinus graft isn’t necessary
need 7mm+ bone
Someone comes in for a denture, regarding height and width, minimal attached mucosa and shallow vestibule: what’s your recommendation for treatment?
- bone graft, vertical bone osteogenesis
With different anatomic sites in the mandible, which sites undergo the most or least areas of resorption. Some areas resorb more, some resorb less
Which types of malocclusions or relations are going to be due to severely resorbed ridges, both maxillary and mandibular
Recognize when alveoloplasty is necessary in conjunction with extractions or not in conjunction with extractions
If you do alveoloplasty with or without extractions, maybe someone didn’t remove the tori nearby or sharp edges
Maybe you need to remove tori, need to remove 2 undercuts on either side of the RPD or else you don’t have path of draw
If you have excess bone, you need to create some VDO for the denture
Extruded tuberosity: you need to do reduction to create the space
Recognize the different types of bone: I, II, III, IV, where they appear in the mouth
- Type I: Anterior Mandible; mostly compact cortical bone; Minimal trabecular spaces, the densest type of bone; Initial bone to implant interface is approximately 80% with a threaded implant
- Type II: Posterior Mandible; Good thickness of bone at
- superior and inferior borders; More trabecular quality of
- bone in the center of mandible; Initial bone to implant
- interface is approximately 70% with a threaded implant; Approximate healing time is 4 - 6 months based on amount
- of cortical bone engaged
- Type III: Anterior Maxilla; Less crestal bone than Type 1 or 2; Remaining bone is quite trabecular; Initial bone to implant
- interface is approximately 50% with a threaded implant; Approximate healing time is 6 months
- Type IV: Posterior Maxilla; Minimal crestal bone, majority is trabecular; Remaining bone is quite trabecular; Initial bone to implant interface is approximately 25% with a threaded implant; Approximate healing time is 6 - 8 months; Avoid cantilevers and consider 1 implant for each tooth replaced.
Recognize the indications for subperiosteal vs transosteal implants
- subperiosteal: below the periosteum and sits on the bone. for edentulous people.
- transosteal: aka mandibular staple. from the inferior border of the mandible through the alveolus. only used for mandible.
Recognize what implant dentistry is and what the components are
- “Implant Dentistry is Restorative Discipline with a Surgical Component”
- Requires a team approach with a multidisciplinary treatment plan.
Recognize what type of impact oral bisphosphonates vs IV bisphosphonates have on implant dentistry and placement
- IV Bisphosphonates: Absolute Medical Contraindications
- Oral Bisphosphonates: Relative Medical Contraindications; small percentage develops medical osteonecrosis.
Periodontal biotypes, thick vs thin, impact on implants
- Thin: Greater tendency for gingival recession, scar formation and/or papillae blunting; Increased chance for metal show through gingiva
- Thick: Less tendency for gingival recession, scar formation and/or loss of papillae
Implant placement: what determines the length and width that you select
- ● The height of the bone, amount of bone vertically, determines the length of the implant; Also take into consideration the vital structures, the mental nerve/foramen and maxillary sinus
- ● Ridge Width determines the maximum diameter of an
- implant placed in that site; 1 mm or more of bone surrounding the implant
- ● Length determines the maximum diameter and the number of implants placed in that site
Recognize what the anterior-posterior spread is and its effect on the number of implants placed
- ● The AP spread: if you draw a line in the anterior and the distal of the posterior, that distance is the AP spread. The greater the AP spread, the greater the stability of the prosthesis.
- ● The greater the AP spread, the more you can cantilever off the terminal implant
With regards to implants, when do you use a surgical guide and when is a metal framework indicated
- ● Surgical guides are our blueprint that allow us to place implants where they belong relative to the final prosthesis
What’s the distance you want to maintain inter-implant and why do you want to maintain that space?
- compromised blood supply and reduced bone -> peri-implantitis -> domino effect; cantilever.
- 1.5-2mm between implant and natural tooth.
When would a cone beam/CT beam be used? Do you have to do this for multiple implants, single implants, what are the indications for using or not using it?
What would you see radiographically?
- 1. Caries but not to what extent or will caries physically invade the pulp.
- 2. Apical Pathology
- 3. Previous Endodontic Treated Teeth.
- 4. Poor Restorations and Crowns but not whether restorable
- 5. Intact Crowns and Restorations
- 6. Anatomy. Who's going to do it.
- Can't tell Is the tooth vital(alive)
Know the responses of vital and normal teeth
For example, on the table, can you go to SAP before SIP?
- You have to go from SIP to SAP, and those are the questions that he’ll ask
- Therefore, false, you can’t go straight to SAP and that’s an example
- AIP: can you diagnose it from the radiograph?
- Not from pulp test, but radiographically, can you do it?
- CAA (chronic apical abscess) and AAP: what are the radiographic appearances of both?
- For reversible pulpitis, recognize the signs and symptoms and vitality tests
- You have a specific diagnosis and what’s the treatment: do you do endo, extraction, sedative restoration?
- If you compare a normal tooth with a necrotic one, how do the periapical tissues look radiographically and what are the symptoms between both or are they the same?
- What factors are involved in a pulpal inflammatory condition: caries, trauma, or occlusion?
- Comparing pain and periapical pathology
- Is pain always present with PP?
- Same with caries, does that always cause pulpal insult?
- Really know what the tests indicate
- Maybe the tests aren’t accurate, multiple canals, calcifications, traumatized teeth won’t be vital sometimes
- Necrotic tooth is more black as opposed to yellow brown (may be calcific metamorphosis, trauma to the tooth and the pulp canal calcifies, tooth may or may not test vital, can be seen in young people, can be due to restorations too to re-establish the thermal boundary)
Endo teeth and vertical fractures, Which teeth or tooth is most commonly affected?
What are different behavior management techniques and when should you do it
Voice control, papoose (a physical restraint for the child, he didn’t mention that in lecture, but it’s a baby management technique)
What are the indications for a stainless steel crown
- Use for multisurface decay or pulpotomy of primary teeth: start with composite or amalgam and then use a stainless steel crown to restore.
- Do it all in one visit without impression or lab.
- They hold the space and protect the tooth, but aren’t aesthetic.
Best preventative technique for newly erupted permanent teeth, molars predominantly
What’s behavior shaping in children, what does it include
- Management tools, tell show do, voice control, physical restraint, compliments, choices
- 1. Tell the patient what you plan to do at the beginning of the appointment
- 2. Tell the patient why it is necessary to do this procedure
- 3. Explain what you are going to do using substitute words
- 4. Tell……….Show……….Do….
- 5. Reinforce child’s behavior
- 6. Do not make a big deal of minor inappropriate behavior
With regards to parents, special care, handicapped, medically impaired children, should they be allowed in clinic?
- For autism, deaf patients, developmental disabilities, parents help you
What factors are involved in dealing with difficult behavior in pediatric dental patients
Know about open ended questions
- Pros: Develop trust, are perceived as less threatening, allow an unrestrained or free response
- Cons: Can be time-consuming, may result in unnecessary information
What the acronym NURSE stands for and BAGEL
- Emotion-handling skills (N U R S)
- Naming, labeling (e.g. "You sound sad.")
- Understanding, legitimating (e.g. "I can sure understand why . . .")
- Respecting, praising (e.g. "You have been through a lot.")
- Supporting, partnership (e.g. "I am here to help you any way I can.")
- B: body posture
- A: accessing cues
- G: gesture
- E: eye movements
- L: language patterns
Recognize what the stages, I, II, III involve
- I: T1N0M0
- II: T2N0M0
- III: T3 or N1, M0
- IV: M1, M0N2/3 or M0N0/1T4