Diagnosis &Treatment Planning in Conservative Dentistry

Presented ByDr.M Arsalan Zubair

M.D.S resident Dow Dental CollegeDow University Of Health Sciences

Patient Assessment

• Chief Complaint Symptoms

• Medical History Communicable Disease,

Allergies or Medications,

Cardiac abnormalities,

Physiologic changes associated with aging

• Dental History

• Magnification

• Photography in Operative dentistry

• Advantages: Easy to use

We can document current esthetic condition of patient

Notice changes in existing pits and fissures

Photographs of treatment of deep carious lesion aid in future diagnosis of tooth

For digital documentation it is easier and cost effective.

• Preparation Of Clinical Examinations Clean, dry, Well illuminated mouth that’s why initial scaling, flossing, tooth

brushing is required

Proper examination instruments

Cotton rolls should be placed

Floss is good for determining over hanging, improper contours and open contacts

Starting from the upper right quadrant with posterior tooth and then moving to maxillary and mandibular arches

Risk assessmentRisk Indicators

• Categorization according to the above factors

• Identify early lesion

• Visual changes

• Tactile sensation

• But explorers are discouraged Why???

Clinical Examination of Caries

• Good for root surface caries

• Radiographs are also good

• Primary Occlusal grooves and Fossa are less prone

• Occlusal fissures and pits are more prone

• Chalkiness or softening or cavitations of tooth structure

• Brown gray discoloration radiating peripherally from pit and fissure

• Carious pits

Causes Developmental defects

Erosion or Abrasion

Occurrence

Occlusal two-third of Facial and lingual surface of tooth

May be on the palatal side of Maxillary tooth

ICDAS(International caries Detectionand Assessment system)

• Histological depth1= 90% in outer enamel & 10% into dentin2=50% inner enamel & 50% into outer one third dentin3=77% dentin4=88% dentin5=100% dentin6=100% dentin into one third of inner dentin

• Proximal surface cariesDiagnosed

Radio graphically

Visually by separating contact

Fiber optic transillumination

• Brown Spots Remineralized lesion less prone

to caries rather more resistant to caries.

• Proximal Surface Caries in

anterior teethDiagnosed

Radio graphically

Visually

Fiber optic transillumination

Probing or explorer

• Cervical Caries White spot early enamel lesion

Dry and wet is distinguishing test

Diagnosed tacitly

• Root surface Caries Root exposure, dietary changes, Systemic disease, Xerostomia

Lesion at C.E.J

Soft and spread laterally around C.E.J

Active lesion is soft and cavitated

Best diagnosed by vertical bite wing radiographs

• New Methods For Diagnosing caries DIAGNOdent

Spectra Camera

Carie ScanPro

• DIAGNOdent device

• Major disadvantage is false positive test

• Spectra Camera

• High energy violet or blue light on tooth surface

• It stimulate porphyrins metabolites which make carious lesion red while enamel appear green

• It has scale 0-5

• Carie Scan PRO Caries detection by alternating current impedance

spectroscopy(ACIST)

Detects early carious lesion

Provide color and numerical scale for severity of caries

Clinical examination Of Amalgam Restorations

• Amalgam blues• Proximal overhangs• Marginal Ditching• Voids• Fracture lines• Lines indicating the interface b/w abutted restorations• Improper anatomic contours• Marginal ridge incompatibility• Improper proximal contacts• Recurrent Caries• Improper occlusal contacts

Clinical Examination Of Tooth colored Restorations

• Proximal Over hangs

• Marginal ditching

• Recurrent caries

• Improper contour

• Marginal Ditching

• Voids

Clinical Examination of Dental implants and Implant Supported

Restorations

• In molars it is difficult to replace three roots with one implant

• Vertical loss of bone support prior to implant placement makes vertical space making crown implant ratio difficult

• Peri-implantitis

• Occlusion is difficult to maintain due to lack of cushioning

• Restoration should confined in the middle with no deflections

Clinical examination of Additional Defects

• Non hereditary hypo calcified areas of enamel

• Chemical erosion

• Idiopathic Erosion

• Abrasion

• Attrition

• Fracture

• Craze line

• Dental anomalies…

Radiographic Examination of Teethand Restorations

• Indications of Radiographs

• Proximal caries, overhang, poorly contoured restorations

• Pulpal abnormalities

• Periapical changes in peridontium

• Impacted tooth or congenital abnormality

• False positive and negative diagnosis

Guide lines for Prescribing Dental Radiographs For Dentate Adults

New Patients

• Recall Patient

• Clinically caries present or High risk

• No Clinically Caries or No Risk Factors

• Periodontal disease

Adjunctive Aids in diagnosis of teeth and Restorations

• Percussion• Palpation• Vitality Test Hot test Cold test Electric pulp tester Test Cavity

• Study Cast

Examination Of Occlusion• Signs of enamel cracks, occlusal trauma• Potential effect of restoration on occlusion• Class of occlusion• Over jet• Over bite• Midline shifts• Position of malposed teeth, super erupted, spacing• Dynamic occlusion should be evaluated• Relation should also be assessed in centric relation• Canine guidance or group function exist• Presence and amount of anterior guidance• Non working side contacts• Abnormal wear should be checked• Plunger cusp

Review Of PeridontiumClinical Examination• Gingival color,shape,texture• Depth of sulcus• Instrument used for measuring depth• Six locations• Normal sulcus depth• Involvement of furcation• Gingival recession• Mobility• Plaque presence• Proper contoured restorations

Radiographic Examination

• Bitewing are good for assessing bone level

• What is Biologic width?

• Normal value?

• What will happen if restoration encroach biologic width?

• What method is done to avoid these condition?

Treatment Planning• General Consideration

• Sequencing

• Interdisciplinary Consideration Endodontic

Periodontics

Orthodontics

Oral Surgery

Fixed and Removable prosthodontics

• Indications for Operative Treatment

• Preventive treatment

• Restoration of incipient lesion

• Treatment Of Abrasion, Erosion and Attrition

• Root surface Sensitivity

• Repairing of Restoration

• Replacement of Restorations

• Indication of Amalgam Restoration

• Indication of Direct Composites

• Indication of Indirect tooth Color restoration

• Geriatric Patient

Sequencing

Inter-disciplinary Consideration in Operative treatment

• Pulpal or periapical Pathology

• Endodontic ally treated tooth show no evidence of healing,

• Inadequate fill

• Fill exposed to oral fluids

• Precede operative treatment

• Poor periodontal prognosis=no extensive restoration

• Good health = Before or after

• Surgical procedure indicated= before permanent restorations

• Biological width: Crown lengthening ( 6 week after surgery)

• Extrusion

• Realignment

• Impacted, Unerupted

• Grossly carious tooth should be extracted especially 2nd molars whose has to receive cast restoration are damaged due to removal of 3rd

molars

• Core buildup can be done from amalgam or composite

• Preparation for receiving clasp, rests in removable prosthesis

Treatment Of Abrasion, Erosion, Abfraction and Attrition

Considered for restoration only• Area is affected by caries

• Defect is sufficiently deep compromise structural integrity of tooth

• Intolerable sensitivity

• Defect continue to peridontal problem

• Area is to be involved in design of partial denture

• Involving the pulp

• Actively progressing

• Desire for esthetic improvement

Treatment of root surface caries

• Arrested lesion not need to be restored until for aesthetic purposes

• Active lesion can be restored by tooth color restorations

Treatment of root surface sensitivity• Fluoride varnishes• Oxalate solutions• Resin based adhesives• Desensitizing tooth paste contain Potassium nitrate• Restorative treatment

Replacement of Existing restoration

Non tooth color restoration• Marginal void• Gingival overhang• Marginal ridge

discrepancy• Over contouring of facial

and lingual surface• Poor proximal Contact• Recurrent Caries• Ditching deeper than

0.5mm

Tooth color restoration• Improper contour that

cannot be repaired• Large voids• Deep marginal staining• Recurrent caries• Unacceptable aesthetics