Diagnosis in F.P.D

Contents

• Introduction • Effects of tooth loss• Reasons for treating tooth loss• Diagnosis

Diagnosis• Personal habits• Chief complaint• Medical history• Dental history• Examination

General Extra oral Intra oral Occlusal RadiographicVitality tests

Effects of tooth loss

Drift of Neighboring Teeth :Effect depends upon

intercuspation of teeth on either side of space with those of opposing arch

Age and periodontal conditionTooth movements depend

upon position of tooth in arch

1) lower molars tilt mesially2) upper molars tilt mesially and

rotate around palatal root3) the premolars stay upright

and move bodily into any space

Over eruption of opposing teethOver eruption leads to:

1.Loss of bony support for tooth2.Overgrowth of alveolus3.Traumatic occlusion4.Loss of contacts which leads to

food impaction.periodontal breakdown and subgingival caries

Failure to maintain space after tooth extraction can lead to tooth movement unless this is prevented

The teeth may tilt into the space or an opposing tooth may over erupt

Either can result in functional excursions and periodontal destruction

Reasons for treating tooth loss• Esthetics• Function• Pain due to TMJ dysfunction• Speech• Maintenance of dental health

Personal Details • The patient’s name,age,sex,

address, phone number,occupation, and marital and financial status are noted.

• In addition to establishing rapport and developing a basis for the patient to trust the dentist, small and seemingly unimportant personal details often have considerable impact on establishing a correct diagnosis, prognosis, and treatment plan.

Chief Complaint

 This is the reason ,usually a symptom or a cluster of symptoms why the patient seeks treatment

It can be urgent ,such as acute pain ,or gross swelling or minor complaint.

The chief complaint should always be noted and addressed because it is generally the reason why the patient sought care in the first place

All findings are grouped as either symptoms (subjective ,elicited by history and interview as described by the patient)or signs (objective often measurable ,discovered by examination)

SOAP – this acronym often seen in medical and dental notes

S= Subjective (symptoms elicited by patient)

O= Objective (signs discovered by examination)

A= Assessment (analysis of the information- the diagnosis)

P= Plan (what you intend you do about the problem)

Chief complaints usually fall into one of the following four categories

Comfort (pain, sensitivity, swelling)

Function (difficulty in mastication or speech)

 Social (bad taste or odor)Appearance (fractured teeth or

restorations, discoloration)

Lack of Comfort

• If pain is present, its location, character, severity, and frequency should be noted, as well as the first time it occurred, what factors precipitate it (e.g., hot, cold, or sweet things), and any changes in its character .Is it localized or more diffuse in nature ?

Impaired Function

Difficulties in mastication and speech may result from a fractured cusp or missing teeth.It may also indicate a more generalized malocclusion or dysfunction.

 Social

A bad taste or smell often indicates compromised oral hygiene and periodontal disease. Often social pressures prompt the individual to seek care.

Poor Appearance Compromised appearance is a strong motivating factor for patients to seek advice as to whether improvement is possible

Such individuals may have missing or crowded teeth or a tooth or restoration may be fractured.

Their teeth may be unattractively shaped, malpositioned, or discolored, or there may be a developmental defect.

History

Medical History• An accurate and current

general medical history should include any medication the patient is taking as well as all relevant medical conditions. If necessary, the patient’s physician(s) can be contacted for clarification.

The following classification may be helpful: 

I)Conditions affecting the treatment methodology

Any disorders that necessitate the use of antibiotic pre medication

Any use of steroids or anticoagulants, and any previous allergic responses to medication or dental materials

Once these are identified, treatment usually can be modified as part of the comprehensive treatment plan

II)Condition affecting the treatment plan

Previous radiation therapy Hemorrhagic disorders Extremes of age Terminal illness

For instance, the patients who have received radiation treatment may suffer from xerostomia,which is conducive for greater carious activity and hence extremely hostile for cast metal restorations.They are also more susceptibility for infection following injury and delayed healing

Patients with prosthetic valves are on Coumadin ,an anticoagulant.

Thus any procedure which may induce even minor bleeding should be prevented.

Patients who are immunocompromised are more susceptible to opportunistic disease

III)Systemic Conditions with oral manifestations

Periodontitis may be modified by diabetes mellitus, menopause, pregnancy, or the use of anticonvulsant drugs

In case of hiatal hernia, bulimia, or anorexia nervosa, palatal surfaces of teeth may be eroded by regurgitated stomach acid

Certain drugs like anticonvulsants leads to hyperplasia of gingiva

Patients with compromised immunity

•

II)DENTAL HISTORYClinicians should be cautious when commenting before a thorough examination is completed.

Periodontal historyRestorative historyEndodontic historyOrthodontic historyTMJ dysfunction history 

Periodontal History. The patient’s oral hygiene is

assessed Current plaque-control

measuresThe frequency of any previous

debridements should be recorded the dates and nature of any previous periodontal surgery should be noted.

Restorative History may include Only simple composite resin Dental amalgam fillings, It may involve crowns and

extensive fixed partial dentures. The age of existing restorations

can help establish the prognosis and probable longevity of any future fixed prostheses.

Endodontic History. These can be readily

identified with radiographs. The findings should be

reviewed periodically so that periapical health can be monitored and any recurring lesions promptly detected

Orthodontic History. Occlusal analysis should be an

integral part of the assessment of a post orthodontic dentition.

Occlusal adjustment (reshaping of the occlusal surfaces of the teeth) may be needed to promote long-term positional stability of the teeth and reduce or eliminate parafunctional activity.

On occasion, root resorption (detected on radio-graph)may be attributable to previous orthodontic treatment.

As the crown / root ratio is affected, future prosthodontic treatment and its prognosis may be affected

TMJ Dysfunction History. A history of pain Clicking in the

temporomandibular joints Neuro-muscular symptoms such

as tenderness to palpation, may be due to TMJ dysfunction,

Which should be normally be treated and resolved before fixed prosthodontic treatment begins.

Parafunctional habits

Bruxism • Bite Discrepancy• Psychological Triggers • Chemical Triggers

• Intake of “uppers” such as caffeine and amphetamines synergistically enhance the contractions of the jaw muscles

• Hence the use of these drugs can bring about rigorous clenching and grinding

• Certain prescription drugs like the anti-depressant, Zoloft is known to induce Para function.

Diagnosis of Para function

• Much like diagnosis of many other diseases, there are no “litmus tests” for this condition In an acute case

Front to back fracture of the lower molar

2. Morning headaches in the temporal areas.

3. May suffer from stiff neck and shoulders.

4. May find the teeth to be sore, especially upon awakening.

If clenching becomes chronic Abfraction is a condition in which the neck of the tooth is eroded away in a chemical reaction as it flexes under clenching and grinding forces.

As a result of this, the dentinal surface becomes exposed and that area becomes extremely sensitive.

• Sensitive areas on the neck of teethare usually indicative of severe clenching

Excessive wear facets that are flat and shiny on the top of the back teeth, inconsistent with the age of the individual, is a sign of grinding.

Thinning and chipping of the front teeth is another sign of excessive wear from grinding.

Formation of extra bone around the teeth, most commonly on the inside surfaces of the lower premolars.

Previously these bone formations that are called “tori” were thought to be of genetic origin.

Scalloped tongue is a sign of continuous clenchingaccompanied by pressing on the teeth by the tongue.

EXAMINATIONAn examination consists of the

clinician’s use of sight, touch, and hearing to detect conditions outside the normal range.

To avoid mistakes, it is critical to record what is actually observed rather than to make diagnostic comments about the condition.

For example, “swelling,” “redness,” and “bleeding on probing of gingival tissue” should be recorded rather than “gingival inflammation” (which implies a diagnosis).

Types of Examination

Emergency examinationScreening examinationComprehensive examination

Techniques of examination

InspectionPalpationPercussionAuscultationOlfaction

ExaminationGeneral Extra oral Intra oral

General ExaminationThe patient’s general

appearance, gait, and weight are assessed.

Skin color is noted for signs of anemia or jaundice.

Vital signs, such as respiration, pulse, temperature, and blood pressure, are measured and recorded.

Fixed prosthodontic treatment is often indicated in middle-aged or older patients, who can be at higher risk for cardiovascular disease.

Patients with vital signs outside normal ranges should be referred for a comprehensive medical evaluation before definitive treatment is initiated.

Extra oral Examination

Facial symmetry.

Cervical lymph nodes are palpated

Temporomandibular Joints

Tenderness, or pain on movement, is noted and can be indicative of inflammatory changes in the retrodiscal tissues, which are highly vascular and innervated.

Tmj ,pg 57TMJ can be

located by palpating bilaterally just anterior to the auricular tragi while having the patient open and close.

This permits a comparison between relative timing of left and right condylar movements.

If there is evidence of significant asynchronous movement or TMJ dysfunction, a systematic sequence for comprehensive muscle palpation should be followed as described by Solberg and Krogh-Poulsen and Olsson.

Each palpation site is given a numerical score based on the patient’s response.

If neuromuscular or TMJ treatment is initiated, the examiner can then re palpate the same sites periodically to assess the response to treatment

A maximum mandibular opening resulting in less than 35mm of interincisal movement is considered to be restricted, because the average opening is greater than 50mm.

Similarly, any midline deviation on opening and or closing is recorded.

The maximum

lateral movements of the patient can be measured (normal is about 12mm)

Muscles of Mastication. Palpated for signs of

tenderness. Palpation is best accomplished

bilaterally and simultaneously. This allows the patient to

compare and report any differences between the left and right sides.

Light pressure should be used (the amount of pressure one can tolerate when gently pushing on one’s closed eyelid without feeling discomfort is a good comparative measure),

If any difference is reported between the left and right sides, the patient is asked to classify the discomfort as mild, moderate, or severe

Lips The patient is observed for

tooth visibility during normal and exaggerated smiling.

This can be critical in fixed prosthodontic treatment planning, especially for margin placement of certain metal ceramic crowns.

Some patients show only their maxillary teeth during smiling.

More than 25% do not show the gingival third of the maxillary central incisors during an exaggerated smile

The extent of the smile will depend on the length and mobility of the upper lip and the length of the alveolar process.

When the patient laughs, the jaws open slightly and a dark space is often visible between the maxillary and mandibular teeth This has been called the negative space.

Missing teeth, diastemas, and fractured or poorly restored teeth will disrupt the harmony of the negative space and often require correction

• Lips are inspected ,palpated bimanually and bilaterally then reflected to reveal labial mucosa

INTRAORAL EXAMINATIONThe intraoral examination can

reveal considerable information concerning the condition of the soft tissues, teeth, and supporting structures.

The tongue, floor of the mouth, vestibule, cheeks, and hard and soft palates are examined, and any abnormalities are noted.

Buccal mucosa including the parotid duct and typical linea alba.

The tongue presents a wide range of normal in a its size shape and surface texture.

The dorsum should be examined and palpated till the circumvallate papilla.retraction of the tongue is necessary in order to visualize the area,which represents a relative high incidence of oral malignancy

The ventral aspect is appreciated for the lingual frenum ,typical varicosities and submandibular salivary glands

Floor of the mouth is palpated bimanually with an opposing thumb or finger braced under the chin,appreciating the salivary glands and muscular floor of the mouth

Residual Ridge Contour• An ideally shaped ridge has a

smooth regular surface of attached gingiva

• Its height and width should allow placement of a pontic that appears to emerge from the ridge .

• Loss of residual ridge contour may lead to unaesthetic open embrasure(BLACK TRIANGLES),Food impaction and percolation of saliva during speech

Siebert has classified residual ridge deformities into three

• Class I defects – labiolingually loss of tissue with normal ridge height

• Class II defects – Loss of ridge with normal ridge width

• Class III defects –a combination of loss in both dimensions

Periodontal Examination

A periodontal examination should provide information regarding Oral hygiene of the patientThe response of the host

tissues, The degree of irreversible

damage.

Because long-term periodontal health is essential to successful Fixed Prosthodontics existing periodontal disease must be corrected before any definitive prosthodontic treatment is undertaken.

Gingiva The gingiva should be lightly

dried before examination so that moisture does not obscure subtle changes or detail.

Color, texture, size, contour, consistency and position are noted and recorded.

The gingiva is then carefully palpated to express any exudate or pus that may be present in the sulcular area.

 

Healthy gingiva is pink, stippled, and firmly bound to the underlying connective tissue.

The gingival margin is knife-edged, and sharply pointed papillae fill the interproximal spaces.

The width of attached gingiva can be assessed by

• Periodontal probe • Injecting anesthetic solution

 In this examination the probe is

inserted essentially parallel to the tooth and is “walked” circumferentially through the sulcus in firm but gentle steps, determining the measurement when the probe is in contact with the apical portion of the sulcus

Thus any sudden change in the attachment level can be detected

• Ramifications of a biologic width violation if a restorative margin is placed within the zone of the attachment.

Probing depths (usually six per

tooth ) are recorded on a periodontal chart which also contains other data pertinent to the periodontal examination

Tooth mobility or malpositionOpen or deficient contact areas Inconsistent marginal ridge heightsMissing or impacted teeth Areas of inadequate attached

keratinized gingivaGingival recessionFurcation involvements

• Mandibular third molars frequently (30-60%) do not have attached gingiva around distal segment

• A Prospective abutment that does not have attached tissue is a poor candidate to receive a crown.

• Depth from the attachment to the level of the margin is greater than 3 mm.

• Two options were available to appropriately manage treatment: 1) place the original margins half the depth of the sulcus; 2) perform a gingivectomy.

• At six weeks after the gingivectomy and preparation of the teeth

• A 4-year recall photograph after placement of the final restorations

Dental ChartingDental cariesRestorationsWear facets(indicative of sliding

contact sustained over time and thus may indicate Para functional activity)

AbrasionsFracturesMalformations Erosions.

•

Before proceeding with the restorations an ANALYSIS of the occlusion is done and examined for:

Any TMJ Pain, muscle spasm.Ease or Difficulty with which

the various excursions can be made voluntarily by the patient.

Any occlusal interference.

Mobility of teeth during excursion of the mandible with the teeth in contact.

Presence, angle and smoothness of any slide from Retruded Contact Position to InterCuspation Position

The type of lateral guidance.

Presence of any contact on the non- working side.

Location, extent and cause of any faceting of teeth to be restored.

Degree of stability of the occlusion.

Overerupted or tilted teeth interfering with the occlusion.

• Occlusal assessment of restorations.

• Very thin articulating paper is required such GHM which has marking ink only one side thus keeping it as thin as possible.

• The marking ink is transferred from the paper to the tooth and at any point of contact ,provided the teeth are dry

• Special tweezers are available for easier handling

• Helps in determining where premature contacts exist in centric occlusion.

• It is worthwhile while trying – in of any restoration, to establish which occlusal contacts exist between the patients teeth when restoration is out of the mouth.

• If these contacts are memorized and the marks removed they should be repeatable with the restoration in place.

General Alignment The teeth are evaluated for

crowding, rotation, supra-eruption, spacing, malocclusion, and vertical and horizontal overlap.

Teeth adjacent to edentulous spaces often have shifted position slightly.

Small amounts of tooth movement can significantly affect fixed prosthodontic treatment.

Tipped teeth will affect tooth preparation design or in severe cases, may result in a need for minor tooth movement before restorative treatment.

Supra-erupted teeth are often overlooked clinically but will often complicate fixed partial denture design and fabrication.

RADIOGRAPHIC EXAMINATIONRadiographs provide essential

information to supplement the clinical examination.

Detailed knowledge of The extent of bone support The root number and

morphologyPeriodontal condition of toothPeriapical pathology Retained rootsCariesRestorations.

Types of radiographs

Intraoral films- standard periapical films,bite wing, occlusal films

Extra oral films- Panoramic films,,Computed tomography,arthography,Magnetic resonance imaging ,Lateral cephalometric films,Bone scans.

TESTING FOR VITALITY

Before any restorative treatment, pulpal health must be assessed.

• Pulp testing is often performed using and electric pulp tester

• A tooth with a porcelain jacket crown presents obvious difficulties for electric pulp testing due to non conductivity of porcelain

If such a tooth is suspected to be non vital and the matter cannot be resolved with the aid of the radiograph ,it may be necessary to cut a small access hole through the cingulum area to the dentine.

If the tooth proves vital this can be filled with composite

If it proves to be non vital then the access hole serves necessary root canal treatment.

Response to cold stimulus can a simple method of determining vitality.

A small pellet of cotton wool is soaked in highly volatile ethyl chloride.

Articulated Diagnostic castsThey must be accurate

reproductions of maxillary and mandibular arches.

Articulated diagnostic casts can provide a great deal of information for diagnosing problems and arriving at a treatment plan.

They allow an unobstructed view of edentulous spaces and accurate assessment of span length as well as occlusogingival dimension

The length of the abutment can be accurately gauged to determine which preparation will provide adequate retention and resistance.

The true inclination of abutment teeth will also become evident,so problems in a common path of insertion can be anticipated.

Further analysis of occlusion can be conducted

Occlusal discrepancies Discrepancies in occlusal planeTeeth that have supra erupted

can be spotted A thorough evaluation of wear

facets, their number size and location

DIFFERENTIAL DIAGNOSISWhen the history and

examination are completed, a differential diagnosis is made.

The practitioner should determine the most likely causes of the observed condition(s) and record them in order of probability.

A definitive diagnosis can usually be developed after such supporting evidence has been assembled.

A typical diagnosis will condense the information obtained during the clinical history taking and examination.

PROGNOSISThe prognosis is an estimation

of the likely course of a disease.

It can be difficult to make, but its importance to patient understanding and successful treatment planning must nevertheless be recognized.

The prognosis of dental disorders, is influenced by general factors(age of the patient, lowered resistance of the oral environment ) and local factors(forces applied to a given tooth, access for oral hygiene measures).

For example, a young person with periodontal disease will have a more guarded prognosis than an older person with the same disease experience.

In the younger person, the disease has followed a more virulent course because of the generally less-developed systemic resistance; these facts should be reflected in treatment planning

Fixed prostheses function in a hostile environment: the moist oral environment is subject to constant changes in temperature and acidity and considerable load fluctuation.

A comprehensive clinical examination helps identify the likely prognosis.

All facts and observations are first considered individually and then correlated appropriately.

General Factors. The overall caries rate of the

patient’s dentition indicates future risk to the patient if the condition is left untreated.

Systemic problems analyzed in the context of the patient’s age and overall health provide important information

Other important factors in determining overall prognosis are the history and success of previous dental treatments.

If a patient’s previous dental care has been successful over a period of many years, a better prognosis can be anticipated than when apparently properly fabricated prostheses fail or become dislodged within a few years of initial placement.

Local Factors. The observed vertical overlap of

the anterior teeth has a direct impact on the load distributed in the dentition and thus can have an impact on the prognosis.

Impactions adjacent to a molar that will be crowned may pose a serious threat in a younger individual in whom additional growth can be anticipated., but it may be of lesser concern in an older individual.

Individual tooth mobility, root angulation, root morphology, crown-to-root ratios, and many other variables all have an impact on the overall fixed prosthodontic prognosis.

Conclusion

Diagnosis is a summation of the observed problems and their underlying etiologies.

Also, the overall outcome and prognosis may be adversely affected.