:toc:

include::diagnosis/pulpitis.adoc[]

== Parts involved * teeth * gingiva

= Complaints Findings are signs, symptoms,complaints

Missing Broken Blackish discoloration 1^st stage of dental caries

== Dentition Humans have two sets of teeth in their lifetime. The first set of teeth to be seen in the mouth is the primary or deciduous dentition, which begins to form prenatally at approximately 14 weeks in utero and is completed postnatally at approximately 3 years of age. In the absence of congenital disorders, dental disease, or trauma, the first teeth in this dentition begin to appear in the oral cavity at the mean age of 6 months, and the last emerge at a mean age of 28 ± 4 months. The deciduous dentition remains intact (barring loss from dental caries or trauma) until the child is approximately 6 years of age. At approximately that time, the first succedaneous or permanent teeth begin to emerge into the mouth. The emergence of these teeth begins the transition or mixed dentition period, in which there is a mixture of deciduous and succedaneous teeth present. The transition period lasts from approximately 6 to 12 years of age and ends when all the deciduous teeth have been shed. At that time, the permanent dentition period begins. Thus the transition from the primary dentition to the permanent dentition begins with the emergence of the first permanent molars, shedding of the deciduous incisors, and emergence of the permanent incisors. The mixed dentition period is often a difficult time for the young child because of habits, missing teeth, teeth of different colors and hues, crowding of the teeth, and malposed teeth.

After the shedding of the deciduous canines and molars, emergence of the permanent canines and premolars, and emergence of the second permanent molars, the permanent dentition is completed (including the roots) at approximately 14 to 15 years of age, except for the third molars, which are completed at 18 to 25 years of age. In effect, the duration of the permanent dentition period is 12 or more years. The completed permanent dentition consists of 32 teeth if none is congenitally missing, which may be the case. The development of the

== Dentition Formulae

(di2-dc1-dm2)/(di2-dc1-dm2)×2 = 20 (I2-C1-P2-M3)/(I2-C1-P2-M3)×2 = 32

https://en.m.wikipedia.org/wiki/Dentition

However, a few of the morphologic traits that are used in anthropologic studies 2 are considered in later chapters (e.g., shoveling, Carabelli trait, enamel extensions, peg-shaped incisors). Some anthropologists use di1, di2, dc, dm1, and dm2 notations for the deciduous dentition and I1, I2, C, P1, P2, M1, M2, and M3 for the permanent teeth. These notations are generally limited to anthropologic tables because of keyboard incompatibility.

=== Tooth naming discrepancies M3

=== Eruption sequence whereas anatomically modern humans have the sequence M1 I1 I2 C P3 P4 M2 M3

=== Chronology

== Sequence

== Loss of tooth

== Mixed dentition

== Emergency of permanent

== Identification of tooth

== Tooth numbering System

=== Each

First molar Second molar

=== Universal

=== FDI

= Anatomy of tooth

<<>>

Areas or location Division Into Thirds, Line Angles, and Point Angles

Shapes

Teeth a. Pulpal disease b. Pulpoperiapical disease c. Gingival and periodontal disease

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:TIP: list in descending order of occuring

diagnosis (disease)

Enamel -> dentin -> pulp -> missing

== Disturbances in eruption of teeth . Premature eruption . Eruption sequestrum . Delayed eruption . Multiple unerupted teeth . Retained deciduous teeth . Embedded and impacted teeth . Ankylosed deciduous teeth

== Occlusal malocclusion

angles classification

maximum intercuspation (MI)

Tooth malalignment/ malpositioning Crowding, tipping, drifting, rotation

Marginal ridge discrepancies Proximating marginal ridges at differing levels

Open proximal contacts Proximating teeth not in contact

Extrusion/hypereruption Tooth migrates vertically into space left by missing tooth

Occlusal plane discrepancies Irregular or imbalanced occlusal plane (e.g., reverse Curve of Spee; extrusion of tooth or bone base)

Skeletal malalignment

Reduced vertical dimension of occlusion [VDO]

Primary occlusal trauma

Secondary occlusal trauma

Clenching/bruxism/ parafunction

= Each tooth

over time normal mastication

Pathological Causes (Excessive or Accelerated Wear)

• Bruxism (Teeth Grinding & Clenching) – Most common cause, often stress-related or due to occlusal disharmony

• Malocclusion – Improper bite alignment causing excessive wear on specific teeth

• Parafunctional Habits – Nail-biting, pencil chewing, or pipe smoking

• Dietary Factors – Hard foods, coarse diets, or acidic foods softening enamel

• Occupational Factors – Habitual use of teeth (e.g., tailors cutting threads, musicians holding instruments)

• Salivary Flow Reduction (Xerostomia) – Decreased lubrication accelerates wear

• Genetic Factors – Some individuals have naturally weaker enamel

Consequences * Dentin Hypersensitivity * Pulpitis

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Examination

Methods of clinical examination * Visual- appeared * Tactical - antomy * History - how it formed mechanism * Investigation-

== findings . mobility . recession . pain . TOP . VT . bleeding . size . shape . number . structure . blackish colour . cavitation

== Findings Findings are also together called signs or symptoms or complaints

• Tender on percussion
• Pain

see the anatomy

enamel < dentin < pulp < periapical

= 1.Enamel

// Acquired Pathological enamel // . Attrition . Abrasion . Erosion . Abfraction . White spots . Enamel Fractures . Cracked Tooth Syndrome (CTS) . Non-Carious Cervical Lesions (NCCLs) . Craze line . Enamel spur . Vertical fracture . Deposits on teeth . Dental stains . Dental plaque . Dental calculus . Halitosis . Enamel Hypoplasia . Fluorosis . Turner’s Hypoplasia . Molar-Incisor Hypomineralization (MIH) // Congenital anomalies enamel // // Developmental disturbances in size of teeth . Microdontia . Macrodontia // Developmental disturbances in shape of teeth . Gemination . Fusion . Concrescence . Lobodontia . Globodontia . Dilaceration . Talon cusp . Dens in dente . Dens evaginatus . Enamel pearl . Taurodontism . Supernumerary roots . Congenital Enamel spur // Developmental disturbances in number of teeth . Anodontia . Supernumerary teeth . Predeciduous dentition . Postpermanent dentition // Developmental disturbances in structure of teeth . Amelogenesis imperfecta . Environmental enamel hypoplasia . Dentinogenesis imperfecta . dysplasia . Regional odontodysplasia . Dentin hypocalcification

= 2.pulp . Focal reversible pulpitis . (Chronic hyperplastic pulpitis) . Acute pulpitis . Chronic pulpitis

== 3.Peridontal ligament . Acute apical periodontitis . Chronic apical periodontitis . Apical periodontal cyst . Periapical abscess

// Periodontal diseases . Chronic periodontitis . Aggressive periodontitis . Systemic Periodontitis . Necrotizing diseases of periodontium . Acute necrotizing ulcerative gingivitis . Acute necrotizing ulcerative periodontitis . Abscesses of periodontium . Ginigival abscess . Pericoronal abscess . Periodontitis associated with endodontic lesions . Endodontic-periodontal lesions . Periodontal-endodontic lesions . Combined lesions . Developmental or acquired deformities . Mucogingival deformities . Mucogingival deformities and conditions around teeth . Mucogingival deformities and conditions on edentulous edges Peri-implant diseases Peri-implant mucositis and peri-implantitis

// Gingival diseases 1. Plaque-induced gingival diseases 2. Nonplaque-induced gingival diseases Gingival enlargement Inflammatory gingival enlargement Drug-induced gingival enlargement Enlargement associated with systemic factors Idiopathic gingival enlargement Neoplastic enlargements False enlargements

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== Mechanism (storyline)

B (Non-Progressive Enamel Loss): Mostly pathological but stable. These conditions do not worsen over time unless external factors intervene (e.g., trauma, acid exposure, etc.). Some, like fluorosis or hypoplasia, are developmental rather than progressive diseases.

C (Enamel Level Variations): Developmental anomalies rather than true pathological conditions. They result from defects in enamel or dentin formation but do not necessarily lead to progressive deterioration unless secondary factors (e.g., wear, caries) come into play.

D (Excess Enamel): Developmental anomalies rather than pathological conditions. Extra enamel formations like enamel pearls or talon cusps are structural variations and do not inherently cause disease, though they may lead to complications (e.g., periodontal issues or occlusal problems).

So, in summary:

A → Pathological B → Developmental or pathological (but stable) C → Developmental anomalies D → Developmental anomalies

1 due to only pulpal inflammation only

In enamel conditions, you categorized them into progressive loss, non-progressive loss, variations, and excess, covering different ways enamel can be affected.

However, in pulp, you only have a sequential progression because pulp diseases usually follow a pathophysiological timeline rather than separate categories.

Possible Pulp Categories (Expanding Beyond Just a Sequence):

= . Enamel

A. Progressive Enamel Loss (Worsens over time)

= Enamel Author: Sri Ram Date: {docdate}

== A. Progressive Enamel Loss Worsens over time

• link:diagnosis/caries.adoc[Caries]
• link:diagnosis/attrition.adoc[Attrition]
• link:diagnosis/abrasion.adoc[Abrasion]
• link:diagnosis/erosion.adoc[Erosion]
• link:diagnosis/abfraction.adoc[Abfraction]
• link:diagnosis/cracked_tooth_syndrome.adoc[Cracked Tooth Syndrome (CTS)]
• link:diagnosis/post_eruptive_enamel_breakdown.adoc[Post-eruptive enamel breakdown (PEB)]
• link:diagnosis/hypocalcified_amelogenesis_imperfecta.adoc[Hypocalcified amelogenesis imperfecta]

• Attrition • Fracture • Erosion • Abrasion • Caries • Periodontal disease • Mechanical injury from dental procedures(Abfraction) • Irritation from dental materials from neviil

However, in most cases, pulpitis is primarily caused by caries or trauma, with periodontal diseases playing a secondary role in its development.

== B. Non-Progressive Enamel Loss Stable, does not worsen on its own

• link:diagnosis/white_spots.adoc[White spots]
• link:diagnosis/enamel_fractures.adoc[Enamel fractures]
• link:diagnosis/craze_lines.adoc[Craze lines]
• link:diagnosis/non_carious_cervical_lesions.adoc[Non-Carious Cervical Lesions]
• link:diagnosis/turners_hypoplasia.adoc[Turner’s Hypoplasia]
• link:diagnosis/fluorosis.adoc[Fluorosis]
• link:diagnosis/enamel_hypoplasia.adoc[Enamel Hypoplasia]

== C. Enamel Level Variations These conditions affect enamel structure but do not fall into loss or excess

• link:diagnosis/molar_incisor_hypomineralization.adoc[Molar-Incisor Hypomineralization (MIH)]
• link:diagnosis/hypomaturation_defects.adoc[Hypomaturation defects]
• link:diagnosis/pitted_enamel.adoc[Pitted enamel]
• link:diagnosis/dentinogenesis_imperfecta.adoc[Dentinogenesis imperfecta]
• link:diagnosis/dentin_hypocalcification.adoc[Dentin hypocalcification]
• link:diagnosis/regional_odontodysplasia.adoc[Regional odontodysplasia]

== D. Excess Enamel

• link:diagnosis/enamel_pearl.adoc[Enamel pearl]
• link:diagnosis/talon_cusp.adoc[Talon cusp]
• link:diagnosis/dens_evaginatus.adoc[Dens evaginatus]
• link:diagnosis/cusp_of_carabelli.adoc[Cusp of Carabelli]
• link:diagnosis/leongs_premolar.adoc[Leong’s premolar]

== Dentin Dentin Hypersensitivity

= 2.pulp Etiology is (E-1)A

//Reversible Pulp Conditions . Focal Reversible Pulpitis . Pulp Hyperemia(if resistant as in young)

// Irreversible Pulp Conditions . Acute Pulpitis (Severe pain, inflammation) . Chronic Pulpitis (Fibrosis, low-grade pain) . Chronic Hyperplastic Pulpitis (Pulp Polyp)

// Pulp Degeneration (Breakdown Without Infection) . Pulp Calcifications (Pulp Stones) . Internal Resorption . Pulpal Atrophy

//Pulp Necrosis & Infection . Pulp Necrosis (No response to vitality tests) . Pulp Gangrene (Necrosis with bacterial invasion)

= Periapical (Apical) Periodontal Lesions (Primarily Affect PDL)

Yes, Periapical (Apical) Periodontal Lesions follow a sequential progression in most cases. The sequence is as follows:

1️⃣ Apical periodontitis → Initial inflammation of the PDL due to pulpal infection or trauma 2️⃣ Acute apical periodontitis → Sudden, painful inflammation of the PDL with possible pus formation 3️⃣ Chronic apical periodontitis → Long-standing inflammation of the PDL, may form granulomas 4️⃣ Apical periodontal cyst → Chronic infection leads to cyst formation in the PDL 5️⃣ Periapical abscess → Pus accumulation due to bacterial infection, often from chronic apical periodontitis

= 3. Endodontic-Periodontal Lesions (PDL Affected by Endo-Perio Connections)

Periodontitis associated with endodontic lesions Endodontic-periodontal lesions Periodontal-endodontic lesions Combined lesions

When I say "broader periodontal diseases," I mean conditions that affect more than just the periodontal ligament (PDL).

PDL-Specific Conditions (Directly Affecting PDL)

These diseases start in or directly impact the periodontal ligament, often due to infections from the pulp or trauma:

1. Apical periodontitis (Inflammation of PDL at the root tip)
2. Acute apical periodontitis (Sudden, painful inflammation of PDL)
3. Chronic apical periodontitis (Long-term inflammation of PDL)
4. Apical periodontal cyst (Cyst formation in PDL due to chronic infection)
5. Periapical abscess (Pus formation in PDL due to infection)
6. Endodontic-periodontal lesions (Infection spreads between pulp and PDL)

Broader Periodontal Diseases (Affect More Than Just PDL)

These conditions affect not only the PDL but also the gingiva, alveolar bone, and surrounding structures:

1. Chronic periodontitis (Affects PDL + bone + gums) L

2. Aggressive periodontitis (Rapid destruction of PDL + bone)

3. Systemic periodontitis (Caused by systemic diseases, affecting bone & gums too)
4. Necrotizing periodontal diseases (ANUG, ANUP) (Affect gums + bone + PDL)
5. Abscesses of periodontium (gingival abscess, pericoronal abscess) (Localized infections in gum areas)
6. Mucogingival deformities (Affect gum shape & attachment)
7. Peri-implant diseases (mucositis, peri-implantitis) (Affect implants, not natural PDL)

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-> x-axis time and disease

Physiological * aging by over time normal mastication

Pathological Causes (Excessive or Accelerated Wear)

• Bruxism (Teeth Grinding & Clenching) – Most common cause, often stress-related or due to occlusal disharmony

• Malocclusion – Improper bite alignment causing excessive wear on specific teeth

• Parafunctional Habits – Nail-biting, pencil chewing, or pipe smoking

• Dietary Factors – Hard foods, coarse diets, or acidic foods softening enamel

• Occupational Factors – Habitual use of teeth (e.g., tailors cutting threads, musicians holding instruments)

• Salivary Flow Reduction (Xerostomia) – Decreased lubrication accelerates wear

• Genetic Factors – Some individuals have naturally weaker enamel

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= Caries

Dental caries is a multifactorial disease with interplay of three primary factors – the host, the microbial flora, and the substrate – with time as an inevitable fourth factor.

• Time
• Host
• Microbial flora
• Substrate

I.Biofilm II. Tooth habitat III. Diet IV. Saliva

mechanism

= Mechanism // Ongole,cowman, sturdvant's,differential diagnosis

Sturdvant's 3 according types ->4 name at diagnosis sturdvant's -> mechanism cowman sturdvant's-> clinical findings oongle

= clinical features

colour = white spot or brown or black spots probing = catchy roughness or cavity or food pain = no

visual 0 white spots 1 black or brownish 2 cavitated

Tatical 0 catchy rough surface 1 cavitated

ICDAS

0 = sound tooth structure 1 = first visual change in enamel 2 = distinct visual change in enamel 3 = enamel breakdown, no dentine visible 4 = dentinal shadow (not cavitated into dentine) • 5 = distinct cavity with visible dentine 6 = extensive distinct cavity with visible dentine

0 = not sealed 1 = restored • 2 = sealant, partial 3 = sealant, full; tooth-coloured restoration 4 = amalgam restoration 5 = stainless steel restoration • 6 = ceramic, gold, porcelain-fused-to-metal (PFM) crown or veneer 7 = lost or broken restoration 8 = temporary restoration

= Erosion

Dental erosion is defined as irreversible loss of dental hard tissue by a chemical process that does not involve bacteria

= Abrasion

= Hypersentivity senstivity

== apical peridontitis Apical periodontitis is the inflammation of the periodontal ligament around the root apex.

This process may be acute or chronic depending on the virulence of the microorganisms involved, the type and severity of the physical or chemical irritants and host resistance.

// etiology The common causes of apical periodontitis include spread of infection following pulp necrosis, occlusal trauma from a high restoration or biting suddenly on a hard object, inadvertent endodontic procedures such as overinstrumentation,pushing the infected material into the apical portion, or chemical irritation from root canal medicaments.

Patients suffering from acute apical periodontitis usually give the history of previous pulpitis. Thermal change does not induce pain as in pulpitis. Due to the collection of inflammatory edema in the periodontal ligament, the tooth is slightly elevated in its socket and causes tenderness while biting or even to mere touch. The external pressure on the tooth forces the edema fluid against already sensitized nerve endings and results in severe pain. Radiographic appearance is essentially normal at this stage except for a slight widening of periodontal ligament space.

the periapical periodontitis occurs due to the spread of pulpal infection, the tooth should be extracted or endodontic treatment be initiated to drain the exudate.

select the treatment Diagnostic - Clinical Evaluation - Diagnostic Imaging - Diagnostic cytology Preventive - Dental Prophylaxis - Topical Fluoride Treatment (Office Procedure) - Counseling - oral hygiene instructions - Caries prevention - Space Maintenance (Passive Appliances) Restoration - Amalgam Restorations - Resin-Based Composite Restorations — Direct - Gold Foil Restorations - Inlay/Onlay Restorations Endodontic - Pulp Capping - Pulpotomy - Root canal/endodontic therapy - Endodontic Orthograde Retreatment - Apicoectomy/Periradicular Services - periapical currettage - Replantation - Regeneration - Apexification - endo anesthesia

Periodontitics - Gingivectomy/gingivoplasty - Crown lengthening - Osseous surgery - Bone grafting - Splint - Scaling Prosthodontics removable - Complete Dentures - Partial Dentures Implant - Single crown - Fixed partial denture retainers-implant - Surgical Implant Services Prosthodontics fixed - Fixed Partial Denture-Pontics - Fixed Partial Denture Retainers — Inlays/Onlays - Fixed Partial Denture Retainers — Crowns - Fixed Partial Denture Services Maxillofacial surgery - Extractions(Removal of a tooth or teeth) - exodontia - transalveolar - impacted - fractures(trauma) - Corticotomy(A surgical procedure involving cutting of jaw bone) - Alveoloplasty(Smoothing or reshaping of the alveolar ridge) - Vestibuloplasty (Surgical modification of the vestibule) - Excision (Surgical removal of tissue) - Surgical Incision (A deliberate cut or wound made during surgery) - Suturing (Stitching to close a surgical incision or wound) General - Anesthesia(to eliminate pain before surgery) - General anesthesia - Drugs - Services

Nikhil marah, textbook of paediatric dentistry, ch 62 paediatric extraction

These are common indications for tooth extraction. Here's a refined list for clarity:

1. Teeth affected by advanced caries and its sequelae
2. Teeth affected by periodontal disease
3. Extraction of healthy teeth to correct malocclusion
4. Over-retained teeth
5. Trauma to the teeth or jaws causing dislocation (avulsion)
6. Extraction for esthetic reasons
7. Extraction for prosthodontic reasons
8. Impacted and supernumerary teeth
9. Extraction of decayed first or second molars to prevent impaction of third molars
10. Teeth involved in a fracture line
11. Teeth involved in tumors or cysts
12. Tooth as foci of infection
13. Teeth affected by crown, abrasion, attrition, or hypoplasia
14. Teeth affected by pulpal lesions (e.g., pulpitis, pink spot, pulp polyp)
15. Teeth in the area of direct therapeutic irradiation.

These are contraindications to tooth extraction. Here is a refined list for clarity:

1. Presence of acute oral infections such as necrotizing ulcerative gingivitis or herpetic gingival stomatitis
2. Pericoronitis (especially if a difficult surgical procedure involving bone removal is anticipated)
3. Extraction of teeth in previously irradiated areas (allow at least 1 year for maximal recovery of circulation to the bone)
4. Relative systemic contraindications to tooth extraction:
5. Uncontrolled diabetes
6. Acute blood dyscrasias
7. Untreated coagulopathies
8. Adrenal insufficiency
9. General debilitation for any reason
10. Myocardial infarction (wait for a 6-month period)

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Neelima Anil malik,textbook of oral maxillofacial surgery,ch 18 exodontia

Indications for tooth extraction include:

1. Severe Caries (49% of cases): When endodontic treatment is not possible due to technical or economic reasons.
2. Severe Periodontal Disease (41% of cases): When the teeth are not salvageable by periodontal therapy.
3. Severe Attrition, Abrasion, Erosion: Significant wear of teeth that cannot be restored.
4. Acute/Chronic Pulpitis or Pulpal Necrosis: Due to trauma or infection, where the tooth cannot be treated by endodontic methods.
5. Teeth with Necrosed Pulp and Periapical Lesions: Not treatable by endodontic treatment.
6. Over-Retained Deciduous Teeth: Blocking the eruption of permanent teeth.
7. Supernumerary Teeth: Extra teeth that cause issues with normal dental development.
8. Malposed Teeth: Causing constant trauma to soft tissues or prone to caries due to cleaning difficulties.
9. Impacted Teeth: Teeth that are unable to properly erupt through the gum.
10. Tooth in the Fracture Line: Extraction is done if the fractured tooth is a source of infection, has a root fracture, or interferes with fracture reduction or healing.
11. Teeth Involved in Pathology: Such as cysts or tumors.
12. Teeth with Poor Prognosis in Therapeutic Radiation: To prevent osteoradionecrosis or radiation caries prior to radiation therapy for oral malignancies.
13. Teeth with Vertical Fracture or Cracked Tooth Syndrome: A painful condition where extraction is necessary.
14. Prophylactic Extraction: To prevent issues in cases like endocarditis, rheumatic fever, prior to cataract surgery, etc.
15. Orthodontic Treatment Considerations: For therapeutic extractions, malposed teeth, crowding, or serial extractions.
16. Prosthetic Purpose: When teeth interfere with the stability or construction of full or partial dentures.
17. Supraerupted Teeth: Teeth that have vertically extruded due to the absence of an opposing tooth.
18. Teeth Causing Chronic Trauma to Soft Tissues: Such as constant cheek biting or ulceration on the lateral border of the tongue.
19. Orthognathic Surgical Procedures: Upper third molars are extracted in Le Fort I osteotomy, lower third molars in sagittal split osteotomy, and premolars in anterior subapical osteotomy procedures.

Contraindications for dental extractions include:

Systemic Contraindications: - Cardiovascular issues (e.g., unstable angina, recent myocardial infarction) - Blood disorders (e.g., anemia, leukemia) - Uncontrolled diabetes or hypertension - Severe renal disease - Liver disease (e.g., cirrhosis) - Bleeding disorders - Respiratory issues (e.g., asthma, COPD) - Long-term corticosteroid or immunosuppressive therapy

Physiologic Contraindications: - Pregnancy (particularly in the first and last trimesters) - Menstruation (due to stress and potential for excessive bleeding) - Extreme old age

Absolute Contraindications: - Recently irradiated areas - Recent myocardial infarction - Areas of central hemangioma or AV malformations - Malignant tumor sites

Relative Local Contraindications: - Acute periodontal or gingival infections (e.g., ANUG) - Acute abscesses or cellulitis - Acute pericoronitis

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Exodontia practice,abhay N datakar

Periodontal Disturbances

Periodontal issues are a leading cause of dental extraction in India. The decision to extract a tooth involves evaluating the success of periodontal therapy, the patient's attitude towards preserving the tooth, and economic and time factors. A tooth may need to be extracted if there is more than 40% loss of periodontal support, even if the patient wishes to save it.

Dental Caries

For teeth extensively damaged by caries, extraction may be necessary if conservative treatments fail due to technical reasons or patient non-cooperation. Sharp margins from carious teeth can cause mucosal ulcers, and multiple carious teeth can impair oral hygiene, necessitating their removal.

Pulp Pathology

Extraction is indicated when endodontic therapy is not feasible or if the tooth has pulpal pathology.

Apical Pathology

Teeth unresponsive to conservative measures for apical pathology, due to technical or systemic factors, should be extracted before the pathology worsens and affects adjacent teeth.

Orthodontic Reasons

Teeth may require extraction during orthodontic treatment for: - Therapeutic Extractions: To create space for realigning malposed teeth. - Malposed Teeth: When realignment is difficult. - Serial Extraction: During mixed dentition, to prevent malocclusion and ensure proper eruption of permanent teeth.

Prosthetic Considerations

Extraction of certain teeth may be needed to improve the design and success of partial dentures. However, caution is required when patients request the extraction of remaining teeth for complete dentures to prevent bone atrophy and loss of denture stability.

Impactions

Impacted teeth that cause facial pain, periodontal issues, TMJ problems, cysts, or pathological fractures should be carefully evaluated for extraction.

Supernumerary Teeth

Malpositioned or unerupted supernumerary teeth that cause malocclusion, periodontal issues, facial pain, or esthetic problems should be extracted unless their retention is advantageous.

Tooth in the Line of Fracture

Teeth in the line of fracture should be extracted if they are a source of infection, fractured themselves, or interfere with fracture reduction or healing.

Teeth in Relation to Bony Pathology

Teeth involved in cyst formation, neoplasm, or osteomyelitis should be evaluated for extraction. If there is a chance to guide the tooth to normal occlusion, conservation should be considered.

Root Fragments

Root fragments may remain asymptomatic but can cause issues like recurrent ulceration, bony pathology, or facial pain. Small fragments can be left alone with periodic observation, but larger fragments should be removed, especially in medically compromised patients.

Teeth Prior to Irradiation

Before irradiation for oral carcinomas, only teeth that cannot be maintained in sound condition should be extracted to avoid osteoradionecrosis or radiation caries.

Focal Sepsis

Teeth that appear sound but are foci of infection, as indicated by radiological evaluation, should be extracted, especially if underlying systemic disorders exist.

Esthetics

Teeth may need to be extracted for esthetic reasons, such as for marriage or job opportunities, followed by immediate prosthetic restoration.

Economic Considerations

If economic constraints prevent conservative treatment, extraction may be necessary, with the final decision left to the patient's discretion.

Contraindications

Certain systemic and local factors may contraindicate extraction, either relatively or absolutely. Conditions like uncontrolled diabetes, cardiac problems, leukemia, renal failure, and liver disorders are absolute contraindications. Conditions like controlled diabetes, hypertension, steroid therapy, pregnancy, bleeding disorders, and medically compromised states are relative contraindications that require careful evaluation and management before extraction. Active infections and recently irradiated patients also require special considerations to prevent complications.

CD

indications

• A full arch of missing teeth

• Dental implants that have been deemed inappropriate by patient and/or doctor because of financial constraints, a medically compromised status that contraindicates surgery, or inevitable damage to vital structures such as maxillary sinuses, nerves, and vessels

• Intraoral cancer that has caused a loss of gross intraoral tissue, resulting in an edentulous dental arch; the complete denture prosthesis would then not only replace teeth but also fill in the portion of missing tissue (eg, nasopharynx, hard palate)

Complete deture

Contraindications

The following conditions can affect the prognosis of a com- plete denture: • Pemphigus,an autoimmune disease present with bullae formation,which may be exacerbated. • Patients with partial anodontia will have to go through multiple denture therapies until their growth period ends. • Allergies to acrylic occurs in about 1.3%of patients.Such patients can be treated with a metallic denture base. • Patients with bone necrosis cannot be advised for a com- plete denture treatment until the bone is completely healed. • Patients withtumors involving thejawsand surrounding structures are not recommended with dentures. However, they can undergo denture treatment after complete resolution of the tumor.

Dental history

Existing denture

Extraoral Examination

The patient's head and neck region should be examined for any pathological condition. Facial color,tone, hair color and texture, symmetry and neuromuscular activity are noted.It includes

• facial examination
• examination of muscle
• tone and development
• lip examination
• TMJ examination
• neuromuscular examination

Intraoral Examination - Existing Teeth - Mucosa - Mucosal Displaceability - Saliva - Residual Alveolar Ridge

= FPD

Indications of Fixed Restorations

Tooth-Bounded Edentulous

Regions Generally any unilateral edentulous space bounded by teeth suitable for use as abutments should be restored with a fixed partial denture cemented to one or more abutment teeth at either end. The length of the span and the periodontal support of the abutment teeth will determine the number of abutments required. As mentioned earlier, such a span could be managed with the use of dental implants if deemed feasible and elected by the patient. The fact that implant support does not place additional functional demands on adjacent teeth likely contributes to their preservation, although this has not been universally demonstrated. For conventional fixed prostheses, lack of parallelism of the abutment teeth may be counteracted with copings or locking connectors to provide parallel sectional placement. Sound abutment teeth make possible the use of more conservative retainers, such as partial-veneer crowns, or resinbonded-to-metal restorations, rather than full crowns. The age of the patient, evidence of caries activity, oral hygiene habits, and the soundness of remaining tooth structure must be considered in any decision to use less than full coverage for abutment teeth. Two specific contraindications for the use of unilateral fixed restorations are known. One is a long edentulous span with abutment teeth that would not be able to withstand the trauma of nonaxial occlusal forces. The other is abutment teeth, which exhibit reduced periodontal support due to periodontal disease, which would benefit from cross-arch stabilization. In either situation, a bilateral removable restoration can be used more effectively to replace the missing teeth.

Modification Spaces

A removable partial denture for a Class III arch is better supported and stabilized when a modification area on the opposite side of the arch is present. A fixed partial denture need not be used to restore such an edentulous area because its inclusion may simplify the design of the removable partial denture. However, when a modification space is bound by a lone-standing single-rooted abutment, it is better restored by means of a fixed partial denture. This acts to stabilize the at-risk tooth, and the denture is made less complicated by not having to include other abutment teeth for the support and retention of an additional edentulous space or spaces. When an edentulous space that is a modification of a Class I or Class II arch exists anterior to a lone-standing abutment tooth, this tooth is subjected to trauma by the movements of a distal extension removable partial denture far in excess of its ability to withstand such stresses. The splinting of the lone abutment to the nearest tooth is mandatory. The abutment crowns should be contoured for support and retention of the removable partial denture; in addition, a means of supporting a stabilizing component on the anterior abutment of the fixed partial denture or on the occlusal surface of the pontic usually should be provided.

Anterior Modification Spaces

Usually any missing anterior teeth in a partially edentulous arch, except in a Kennedy Class IV arch in which only anterior teeth are missing, are best replaced by means of a fixed restoration. There are exceptions. Sometimes a better esthetic result is obtainable when the anterior replacements are supplied by a removable partial denture, at other times treatment is simplified by inclusion of an anterior modification space into the removable partial denture (Figure 13-20). This is also true when excessive tissue and bone resorption necessitates placement of the pontics in a fixed partial denture too far palatally for good esthetics or for an acceptable relation with the opposing teeth. However, in most instances, from mechanical and biological standpoints, anterior replacements are best accomplished with fixed restorations. The replacement of missing posterior teeth with a removable partial denture is then made much less complicated and gives more satisfactory results.

Replacement of Unilaterally Missing Molars (Shortened Dental Arch)

Often the decision must be made to replace unilaterally missing molars (Figure 13-21). The decision must balance the impact of the treatment on the remaining oral structures with the potential benefit to the patient long term. To restore the missing molars with a fixed partial denture would require a cantilever prosthesis or the use of dental implants. A cantilever-fixed prosthesis is most applicable if the second molar is to be ignored, then only first molar occlusion need be supplied with the use of a cantilever-type fixed partial denture. Occlusion need be only minimal to maintain occlusal relations between the natural first molar in the one arch and the prosthetic molar in the opposite arch. The cantilevered pontic should be narrow buccolingually and need not occlude with more than one half to two thirds of the opposing tooth. Often such a restoration is the preferred method of treatment. However, at least two abutments should be used to support a cantilevered molar opposed by a natural molar. To replace unilaterally missing molars with a removable partial denture necessitates the use of a distal extension prosthesis. This involves the major connector joining the edentulous side to retentive and stabilizing components located on the non-edentulous side of the arch. Leverage factors are frequently unfavorable, and the retainers used on the non-edentulous side are often unsatisfactory. Two factors important to consider in making the decision to provide a unilateral, distal extension removable partial denture include the opposing teeth and the future effect of the maxillary tuberosity. First, the opposing teeth must be considered if it is considered important to prevent extrusion and migration. This influences replacement of the missing molars far more than any improvement in masticating efficiency that might result. Replacement of missing molars on one side is seldom necessary for reasons of mastication alone. Second, the future effect of a maxillary tuberosity must be considered if concern exists for tuberosity enlargement. Often when left uncovered, the tuberosity increases in size, making future occlusal treatment difficult. However, covering the tuberosity with a removable partial denture base, in combination with the stimulating effect of the intermittent occlusion, helps maintain tuberosity size and position. In such an instance, it may be better to make a removable partial denture with cross-arch stabilization and retention than to leave a maxillary tuberosity uncovered.

= RPD

Although a removable partial denture should be considered only when a fixed restoration is contraindicated, there are several specific indications for the use of a removable restoration.

Distal Extension Situations

Replacement of missing posterior teeth is often best accomplished with a removable partial denture (see Figure 13-22, B), especially when implant treatment is not feasible for the patient. The exception to this includes situations in which the replacement of missing second (and third) molars is inadvisable or unnecessary, or in which unilateral replacement of a missing first molar can be accomplished by means of a multiple-abutment cantilevered fixed restoration or an implant-supported prosthesis. The most common partially edentulous situations are the Kennedy Class I and Class II. With the latter, an edentulous space on the opposite side of the arch is often conveniently present to aid in required retention and stabilization of the removable partial denture. If no space is present, selected abutment teeth can be modified to accommodate appropriate clasp assemblies, or intracoronal retainers can be used. As stated previously, all other edentulous areas are best replaced with fixed partial dentures.

After Recent Extractions

The replacement of teeth after recent extractions often cannot be accomplished satisfactorily with a fixed restoration. When relining will be required later or when a fixed restoration using natural teeth or implants will be constructed later, a temporary removable partial denture can be used. If an allresin denture is used rather than a cast framework removable partial denture, the immediate cost to the patient is much less, and the resin denture lends itself best to future temporary modifications, including those required after implant placement and before restoration. Tissue changes are inevitable following extractions. Tooth-bounded edentulous areas (as a result of extractions) are best initially restored with removable partial dentures. Relining of a tooth-supported resin denture base is then possible. This is usually done to improve esthetics, oral cleanliness, or patient comfort. Support for such a restoration is supplied by occlusal rests on the abutment teeth at each end of the edentulous space.

Long Span

A long span may be totally tooth-supported if the abutments and the means of transferring the support to the denture are adequate and if the denture framework is rigid. There is little if any difference between the support afforded a removable partial denture and that afforded a fixed restoration by the adjacent abutment teeth. However, in the absence cross-arch stabilization, the torque and leverage on the two abutment teeth would be excessive. Instead, a removable denture that derives retention, support, and stabilization from abutment teeth on the opposite side of the arch is indicated as the logical means of replacing the missing teeth.

Need for Effect of Bilateral Stabilization

In a mouth weakened by periodontal disease, a fixed restoration may jeopardize the future of the involved abutment teeth unless the splinting effect of multiple abutments is used. The removable partial denture, on the other hand, may act as a periodontal splint through its effective cross-arch stabilizing of teeth weakened by periodontal disease. When abutment teeth throughout the arch are properly prepared and restored, the beneficial effect of a removable partial denture can be far greater than that of a unilateral fixed partial denture.

Excessive Loss of Residual Bone

The pontic of a fixed partial denture must be correctly related to the residual ridge and in such a manner that the contact with the mucosa is minimal. Whenever excessive resorption has occurred, teeth supported by a denture base may be arranged in a more acceptable buccolingual position than is possible with a fixed partial denture (Figure 13-22). Unlike a fixed partial denture, the artificial teeth supported by a denture base can be located without regard for the crest of the residual ridge and more nearly in the position of the natural dentition for normal tongue and cheek contacts. This is particularly true of a maxillary denture. Anteriorly, loss of residual bone occurs from the labial aspect. Often the incisive papilla lies at the crest of the residual ridge. Because the central incisors are normally located anterior to this landmark, any other location of artificial central incisors is unnatural. An anterior fixed partial denture made for such a mouth will have pontics contacting the labial aspect of this resorbed ridge and will be too far lingual to provide desirable lip support. Often the only way the incisal edges of the pontics can be made to occlude with the opposing lower anterior teeth is to use a labial inclination that is excessive and unnatural, and both esthetics and lip support suffer. Because the same condition exists with a removable partial denture in which the anterior teeth are abutted on the residual ridge, a labial flange must be used to permit the teeth to be located closer to their natural position. The same method of treatment applies to the replacement of missing mandibular anterior teeth. Sometimes a mandibular anterior fixed partial denture is made six or more units in length, in which the remaining space necessitates leaving out one anterior tooth or using the original number of teeth but with all of them too narrow for esthetics. In either instance, the denture is nearly in a straight line because the pontics follow the form of the resorbed ridge. A removable partial denture will permit the location of the replaced teeth in a favorable relation to the lip and opposing dentition regardless of the shape of the residual ridge. When such a removable prosthesis is made, however, positive support must be obtained from the adjacent abutments.

Unusually Sound Abutment Teeth

Sometimes the reasoning for making a removable restoration is the desire to see sound teeth preserved in their natural state and not prepared for restorations. As mentioned previously, if this decision is made because it is felt that no tooth modification is necessary for removable partial dentures, then the prosthesis will lack tooth-derived stability and support. When this condition exists, the dentist should not hesitate to reshape and modify existing enamel surfaces to provide proximal guiding planes, occlusal rest areas, optimum retentive areas, and surfaces on which nonretentive stabilizing components may be placed. Continued durability of the natural teeth is best ensured if the modifications that optimize prosthesis function are provided. This is due to the fact that such modifications also ensure the most harmonious use of the natural dentition.

Abutments with Guarded Prognoses

If the prognosis of an abutment tooth is questionable or if it becomes unfavorable while under treatment, it might be possible to compensate for its impending loss by a change in denture design. The questionable or condemned tooth or teeth may then be included in the original design and, if subsequently lost, the removable partial denture can be modified or remade (Figure 13-23). Most removable partial denture designs do not lend themselves well to later additions, although this eventuality should be considered in the design of the denture. When the tooth in question will be used as an abutment, every diagnostic aid should be used to determine its prognosis as a prospective abutment. It is usually not as difficult to add a tooth or teeth to a removable partial denture as it is to add a retaining unit when the original abutment is lost and the next adjacent tooth must be used for that purpose. It is sometimes possible to design a removable partial denture so that a single posterior abutment, about which there is some doubt, can be retained and used at one end of the tooth-supported base. Then if the posterior abutment is lost, it could be replaced by adding an extension base to the existing denture framework. Such an original design must include provisions for future indirect retention, flexible clasping of the future abutment, and provisions for establishing tissue support. Anterior abutments that are considered poor risks may not be so freely used because of the problems involved in adding a new abutment retainer when the original one is lost. It is rational that such questionable teeth should be condemned in favor of more suitable abutments, even though the original treatment plan must be modified accordingly.

Basic dental instruments - Mouth mirror - Explorers - Cotton Forceps (Pliers) - Instrument Handles

Enamel-Cutting Instruments - Enamel Hatchet - Enamel Hoe - Straight Chisel - Wedelstaedt Chisel - Binangle Chisel - Angle Former - Gingival Margin Trimmer—Mesial and Distal - Spoon Excavators

Local Anesthetic Syringe/Components and Nitrous Oxide Sedation - Anesthetic Aspirating Syringe - Short Needle - Long Needle - Anesthetic Cartridge - Recapping Device - Computer-Controlled Local Anesthetic Delivery System - Nitrous Oxide and Analgesic Tanks - Nitrous Oxide Nasal Mask - Nitrous Oxide and Oxygen Flowmeters - High-Volume (Velocity) Evacuator (HVE) Tip - Low-Volume (Velocity) Saliva Ejector Tip

Evacuation Devices, Air/Water Syringe Tip, and Dental Unit - Isolite—Illuminated Dental Isolation System - Low-Volume (Velocity) Mandibular Evacuator - High-Volume (Velocity) Surgical Evacuation Tip - Air/Water Syringe with Removable Tip - Self-Contained Water Unit and Waterline Treatment Tablets - Dental Delivery System - Dental Assistant Delivery System - Dental Stools

Dental Handpieces - High-Speed Handpiece - Fiberoptic High-Speed Handpiece - Slow-Speed Motor with Straight Handpiece Attachment - Slow-Speed Motor with Contra-Angle Handpiece Attachment - Prophy Slow-Speed Handpiece/Motor with Disposable - Rechargeable Prophy Slow-Speed Handpiece/Motor- RDH Freedom™ - Disposable Prophy Angle Attachments for Slow-Speed Handpiece/Motor - Prophy Angle Slow-Speed Handpiece/Motor - Electric Handpiece Unit and Handpiece Attachments - Surgical Electrical Handpiece Unit and Handpiece - Air Abrasion Unit and Handpiece Attachment - Air Polisher - Handpiece Maintenance System - Laser Handpiece Unit and Laser Handpiece Attachment - Dental Unit

Burs and Rotary Attachments for Handpieces - Bur - Bur Shanks - Round Bur - Pear-Shaped Bur - Inverted Cone Bur - Straight Fissure Bur—Plain Cut - Tapered Fissure Bur—Plain Cut - Straight Fissure Bur—Crosscut - Tapered Fissure Bur—Crosscut - Finishing Bur - Diamond Bur—Flat-End Taper - Diamond Bur—Flat-End Cylinder - Diamond Bur—Flame - Diamond Bur—Wheel - Mandrel—Snap On - Mandrel—Screw On - Sandpaper Disc with Screw-Type and Snap-On Mandrel - Composite Disc - Rubber Points - Laboratory Bur—Acrylic Bur - Laboratory Bur—Diamond Disc - Magnetic Bur Block with Burs

Dental Dam Instruments - Dental Dam - Dental Dam Stamp - Dental Dam Punch - Dental Dam Forceps - Dental Dam Clamp - Anterior Clamp - Premolar Clamp - Universal Clamp—Maxillary - Universal Clamp—Mandibular - Dental Dam Frame - Preframed Dental Dam

Amalgam Restorative Instruments - Tofflemire/Matrix Band Retainer - Matrix Bands - Matrix Band System - Wooden Wedges - Liner Applicator - Woodson - Amalgamator and Amalgam Capsule - Amalgam Well - Amalgam Carrier - Condenser (Plugger)—Smooth and Serrated - Interproximal Condenser - Burnishers—Football, Ball, and Acorn - T-Ball Burnisher - Beavertail Burnisher - Tanner Carver - Discoid-Cleoid Carver - Hollenback and Half-Hollenback Carvers - Gold Carving Knife - Articulating Paper Holder

Composite Restorative Instruments - Sectional Matrix System - Applicator - Well for Composite Material - Composite Placement Instrument - Composite Burnisher - Curing Light—Battery Operated - Protective Shield for Curing Light - LED and Halogen Radiometers - Finishing Strip

Fixed Prosthodontics Restorative Instruments - Facebow - Shade Guides/Digital Color Imaging - Gingival Retraction Cord Instrument - Crown and Bridge Scissors - Contouring Pliers - Provisional Crown–Removing Forceps - CAD/CAM Machine - CAD/CA Milling Machine - Wooden Bite Stick - Trial Crown Remover

Endodontic Instruments - Vitalometer/Pulp Tester - Endodontic Long-Shank Spoon Excavator - Endodontic Explorer - Endodontic Locking Forceps (Pliers) - Broach - Endodontic File—K Type - Endodontic File—Hedstrom - Reamer - Endodontic Stoppers - Endodontic Stand - Endodontic Millimeter Ruler - Electronic Apex Locator - Gates Glidden Bur or Drill - Endodontic Irrigating Syringe - Sterile Absorbent Paper Points - Gutta-Percha - Lentulo Spiral - Gutta-Percha Warming Unit - Endodontic Spreader - Endodontic Plugger - Glick Instrument - Peso File - Micro Retro Amalgam Carrier - Micro Retro Mouth Mirror

Hygiene Instruments - Universal Curettes (Curets) - Universal Curettes (Curet) - Langer Universal Curettes - Area-Specific Curettes—Anterior - Area-Specific Curettes—Posterior - Extended Area-Specific Curettes—Anterior - Extended Area-Specific Curettes—Posterior - Mini Extended Area-Specific Curettes—Anterior - Mini Extended Area-Specific Curettes—Posterior - Implant Scaler - Straight Sickle Scaler - Curved Sickle Scaler - Micro Mini-Five Area-Specific Curette - Magnetostrictive Power Scaler - Ultrasonic Scaler Instrument Tip—Supragingival - Ultrasonic Scaler Instrument Tip—Subgingival - Ultrasonic Scaler Instrument Tip—Furcation - Ultrasonic Scaler Instrument Tip—Universal - Sharpening Stones - Battery-Operated Sharpening Device

Preventive and Sealant Instruments and Whitening Trays - Disposables - Fluoride Trays—Disposable - Vacuum Former - Custom-Fitted Whitening Tray - Scissors—Short Blade - DIAGNOdent - Spectra Fluorescence Caries Detection Aid System

Orthodontic Instruments - Elastic Separators - Elastic Separating Pliers - Steel Spring Separators/Brass Wire Separators - Orthodontic Band with Tubing and Hook - Band Pusher - Band Pusher or Plugger with Scaler - Band Seater—Bite Stick - Orthodontic Bracket - Bracket Placement Card - Posterior Bracket Placement Pliers - Anterior Bracket Placement Pliers - Orthodontic (Shure) Scaler - Arch Wire - How (or Howe) Pliers - Weingart Utility Pliers - Arch-Bending Pliers - Tweed Loop-Forming Pliers (Jarabak Pliers) - Three-Prong Pliers - Bird Beak Pliers - Distal End-Cutting Pliers - Ligatures Ties - Ligature-Tying (Coon) Pliers - Orthodontic Hemostat - Ligature/Wire Cutters - Ligature Director - Bracket Placement Card for Damon Self-Ligating Brackets with Self-Ligating Instrument - Self-Ligating Brackets with Self-Ligating Instrument - Lip Retractors - Posterior Band Remover - Bracket Remover - Adhesive-Removing Pliers - Invisalign and CEREC Omnicam - Temporary Anchorage Device (TAD) - Orthodontic Tooth Separating

Universal Surgical Instruments - Mouth Prop - Mouth Gag - Scalpel Handle with Blades - Scalpel Blade Remover - Tissue Scissors - Tissue Forceps - Hemostat - Periosteal Elevator - Surgical Curette - Tongue and Cheek Retractor - Surgical Needle Holder - Suture Needle and Sutures - Suture Scissors

Periodontal Instruments and Periodontal Surgical Instruments - Periodontal Probes - Furcation Probe - Hoe Scaler—Mesial/Distal and Buccal/Lingual - Back-Action Hoe - Periodontal Knife—Kidney Shaped - Interdental Knife—Spear Point - Interdental File

Oral Surgery Extraction Instruments - Straight Elevator - Luxating Elevator - Periotomes - Root Elevators - T-Bar Elevators - Root-Tip Elevators - Root-Tip Picks - Rongeurs - Bone File - Surgical Chisel - Surgical Mallet - Universal Maxillary Forceps No. 10S - Universal Mandibular Forceps No. 16 - Mandibular Forceps No. 17 - Maxillary Right Forceps No. 88R - Maxillary Left Forceps No. 88L - Maxillary Universal Forceps—Cryer 150 - Mandibular Universal Forceps—Cryer 151 - Mandibular Anterior Forceps - Maxillary Root Forceps - Mandibular Root Forceps - Implant System - Implant

Sterilization and Protective Equipment - Protective Gown - Protective Mask - Protective Glasses/Loupes - Examination Gloves - Overgloves - Nitrile Utility Gloves - Cassette - Color-Coding System for Instruments - Parts Box for Sterilization - Cassette Wrap - Sterilization Pouches - Indicator Tape and Dispensing Unit - Biological Monitors for Sterilizers - Sterilization Spore Check—In Office - Sharps Container - Ultrasonic Cleaning Unit - Sterilizer—Autoclave (Saturated Steam) - Statim G4 Cassette Autoclave - Sterilizer—Dry Heat (Static Air) - Sterilizer—Dry Heat (Rapid Heat Transfer)

Dental Materials Equipment - Flexible Rubber Bowl - Flexible Alginate (Irreversible Hydrocolloid) Spatula - Disposable Plastic Perforated Full Arch Impression Trays - Metal Perforated Full Arch Impression Trays - Disposable Plastic Perforated Quadrant and Anterior - Alginator - Triple Tray (Disposable) - Mixing Gun for Dental Impression Material - Automixer - Bite Registration Tray - Reversible Hydrocolloid Unit - Reversible Hydrocolloid Water-Cooled Impression Trays - Laboratory Spatula - Vibrator for Laboratory - Vacuum Mixing Unit - Laboratory Knife - Model Trimmer - Flexible Mixing Spatula - Paper Mixing Pads

Dental Imaging and Diagnostic Equipment - Intraoral Dental Film - Intraoral Dental Film—Various Sizes - Package of Dental Film - Bite-Wing Tabs - Film Holder—Periapical (EeZee-Grip) - Film Holders—Periapical - Film Holders—XCP - Lead Aprons - Radiation Monitoring Device - Dental X-Ray Unit - Manual Developing Unit - Film Rack - Safelight - Automatic Film Processor - Parts of Automatic Film Processor - View Luminator - Film Duplicator - Intraoral Sensors for Digital Images - Holder for Digital Sensor (EeZee-Grip) - One Ring and Arm Positioning System - Rinn XCP Holders for Digital Sensors - Digital Intraoral X-Ray Unit - Portable X-Ray Unit - SCANX Digital Imaging System - Extraoral X-Rays—Cephalometric and Panoramic - Digital Panoramic/Cephalometric Imaging Unit - Cone-Beam Three-Dimensional (3D) Imaging System - Enhanced Oral Assessment System—VELscope Vx

Vital Signs and Beyond - Stethoscope - Aneroid Blood Pressure Cuff—Sphygmomanometer - Automatic Blood Pressure Monitor - Electrocardiogram (EKG) Machine - Pulse Oximeter - Capnograph - Automated External Defibrillator (AED)

First step

Evaluation

oral medicine also known as case history

Diagnostic imaging

Oral radiology to verification

Restoration

Restoration is conservative dentistry

If we choose patient for complete denture

Choose Next steps stages in it

Radiology is a part of evaluation

No visit= 0 layer starts with complaint evaluation and choose

Preventive Restoration(dental caries teeth without pulp) Endodontics(teeth involving pulp) Periodontitics(gums) Prosthodontics(teeth missing) Orthodontics(malocclusion) Maxillofacial surgery(bone)

1 visit =1 layer starts with full evaluation and choose

Multiple visit = 2 layer starts with limited evaluation and do step

last visit = complaint evaluation and do services

Surgery Starts with Local anaesthesia

= Perio

NONSURGICAL TREATMENT

Phase I Periodontal Therapy

Plaque Biofilm Control for the Periodontal Patient Breath Malodor Scaling and Root Planing Sonic and Ultrasonic Instrumentation and Irrigation Systemic Anti-infective Antibiotic Therapy for Periodontal Diseases Locally Delivered, Controlled-Release Antimicrobials Host Modulation Occlusal Evaluation and Therapy Orthodontics: Interdisciplinary Periodontal and Implant Therapy Periodontal-restorative Interrelationships

Sugrical Treatment

Phase II Periodontal Therapy

Treatment of Gingival Enlargement Resective Osseous Surgery Periodontal Regeneration and Reconstructive Surgery Furcation: Involvement and Treatment Periodontal Plastic and Aesthetic Surgery - Techniques to Increase Attached Gingiva - Techniques to Deepen the Vestibule - Techniques to Remove the Frenum - Techniques to Improve Aesthetics

Phases II Periodontal Therapy basics (Periodontal and Peri-Implant Surgical Anatomy,General Principles of Periodontal Surgery ,

Fundamentals of Periodontal Surgery) Incisions - Horizontal Incisions - Straight and Scalloped Incisions - External Bevel and Internal Bevel Incisions - Crevicular, Crestal, and Submarginal Incisions - Vertical Incisions Papilla Management Flap Elevation Flap Coaptation Flap Closure - Ligation - Interdental Ligation - Sling Ligation - Horizontal Mattress Suture - Continuous, Independent Sling Suture - Anchor Suture - Closed-Anchor Suture - Periosteal Suture

Gingival Surgery - Gingivectomy - Gingival Curettage

Gingivoplasty Flap Surgery

Periodontal flaps are used in surgical periodontal therapy to accomplish the following: 1. Access for root instrumentation 2. Gingival resection 3. Osseous resection 4. Periodontal regeneration

five different flap techniques (1) the modified Widman flap (2) the undisplaced flap, (3) the apically displaced flap, (4) the papilla preservation flap (5)the distal terminal molar flap.

Periodontal Microsurgery

= Treatment Plan Sequencing/Phasing

Proper sequencing is a crucial component of a successful treatment plan. Certain treatments must follow others in a logical order, whereas other treatments may or must occur concurrently and require coordination. Complex treatment plans often are sequenced in phases, including I. urgent phase, II. control phase, III. re-evaluation phase, IV. definitive phase, and V. maintenance phase (that includes reassessment and recare). For most patients, the first three phases are accomplished simultaneously. Generally, the principle of ‘greatest need’ guides the order in which treatment is sequenced. This principle suggests that what the patient needs most is performed first – with pain, bleeding, and swelling at the beginning of the treatment plan and elective esthetic procedures at the end. The process of treatment planning requires that the dentist develop an ever-increasing, comprehensive knowledge of dental disease management in the context of individualized patient care. Study of textbooks devoted to this discipline is indicated.34 Urgent phase The urgent phase of care begins with a thorough review of the patient’s medical history and current condition. A patient presenting with swelling, pain, bleeding, or infection should have these problems managed as soon as possible, before initiation of subsequent phases. Control phase A control phase is appropriate when the patient presents with multiple pressing problems and extensive active disease or when the prognosis is unclear. The goals of this phase are to remove aetiologic factors, eliminate the ecologic niches of pathogens, and stabilize the patient’s dental health. These goals are accomplished by I. removal of active disease such that inflammation may resolve, II. correction of conditions that prevent or limit hygiene efforts, III. elimination of potential causes of disease, and IV. initiation of preventive activities. Examples of control phase treatment include extractions, endodontics, periodontal debridement and scaling, occlusal adjustment, caries arrest and/or removal, replacement or repair of defective restorations such as those with gingival overhangs, and use of caries control measures, as discussed in Chapter 2. The dentist should develop a plan for the management and prevention of dental caries as part of the control phase. After the patient’s caries status and caries risk have been determined, chemical, surgical, behavioural, mechanical, and dietary techniques may be used to improve host resistance and alter the oral flora.34 Chapter | 3 | Chapter 2 presents a detailed discussion of caries diagnosis, prevention, treatment, and control. Re-evaluation phase The re-evaluation phase allows time between the control and definitive phases for resolution of inflammation and healing. Initial treatment and pulpal responses are reevaluated during this phase as the relative effectiveness of control phase treatment may influence and modify the definitive phase treatment plan. This phase is used to reinforce home care habits and assess motivation for further treatment. Patients with an overall low-risk profile, who only require minor alterations in diet, behaviours, and exposure to remineralization agents, may not require a formal control phase/re-evaluation phase process. The treatment plan for these patients may start with a plan to definitively address immediate concerns while simultaneously implementing minor changes and reinforcing habits consistent with dental health. Definitive phase The patient enters the definitive phase of treatment only after the dentist reassesses initial efforts to control disease and, with the patient, determines the need for further care. This phase may include endodontic, periodontal, orthodontic, and surgical procedures. The patient’s active disease must be under control, and preventive efforts habitually established, before fixed or removable prosthodontic treatment. This phase is discussed in more detail in the section on interdisciplinary considerations in operative treatment planning. Maintenance (re-assessment and recare) phase The maintenance phase includes regular reassessment (synonyms include re-evaluation, periodic examinations) that may reveal the need for adjustments to prevent future breakdown, provide an opportunity to reinforce home care, and plan recare treatment steps where disease has returned. Examinations for reassessment most frequently occur as part of strategically planned (recall) appointments for biofilm removal (dental prophylaxis). The frequency of re-evaluation examinations depends, in large part, on the patient’s risk for dental disease. A patient with a low-risk profile may have longer intervals (e.g. 9–12 months) between recall visits. In contrast, patients at high-risk profile should be recalled and examined much more frequently (e.g. 3–4 months).

= Restoration

Restoration - amalgam - composite - porcelain - metallic

Restoration

To fill missing part of teeth

Indication

• Dental caries
• Fracture
• wasting diseases
• Esthetics

Amalgam restoration

indication

I.Restoration of carious or fractured posterior teeth as Class I and Class II restorations II. Replacement of failed posterior restorations III. As a foundation restoration IV. As a caries control restoration V. Due to its strength and ease of use, amalgam may be used (not commonly though) for restoring large ­defects

Contraindication

I.Amalgams are contraindicated in patients who are allergic to alloy components. II. The use of amalgam in more prominent esthetic areas of the mouth may represent a relative contraindication. These areas include anterior teeth and, in some patients, premolars and molars. III. Amalgam should not be used when composite resin would offer more conservation of tooth structure and equal clinical performance.

Advantages

I.Ease of use II. High compressive strength III. Excellent wear resistance IV. Favourable long-term clinical research results V. Lower cost than for composite restorations

Disadvantages

I.Non-insulating II. Nonesthetic III. Less conservative tooth preparation than for composite restorations (more removal of tooth structure during tooth preparation) IV. More difficult tooth preparation than for composite restorations.Initial marginal leakage.

Steps

Complex amalgam restorations

Indications

Complex amalgams may be used as follows: I. Definitive (final) restorations Usually a weakened tooth is best restored with a properly designed indirect (usually cast) restoration that prevents tooth fracture caused by mastication forces (Chapter 23). In selected cases, amalgam preparations that improve the resistance form of a tooth may be designed (Fig. 14.2). When conventional retention features are not adequate because of insufficient remaining tooth structure, the retention form may be enhanced by using auxiliary features such as slots and pins. The type of retention features needed depends on the amount of tooth structure remaining and the tooth being restored. As more tooth structure is lost, more auxiliary retention is required. Slots and pins provide additional resistance and retention form to the tooth when remaining vertical walls are inadequate. II. Foundation restoration Although complex amalgam restorations are used occasionally as an alternative to indirect restorations, particularly due to cost savings, they are often used as foundations for full-coverage restorations. Abutment teeth for fixed prostheses may use a complex restoration as a foundation (Fig. 14.3). III. Control restorations in teeth that have a questionable pulpal or periodontal prognosis

A tooth with a severe caries lesion that may require endodontic therapy or crown lengthening or that has an uncertain periodontal prognosis is often treated initially with a control restoration. A control restoration helps i. protect the pulp from the oral cavity (i.e. fluids, thermal stresses, pH changes, bacteria); ii. provide an anatomic contour that is consistent with gingival health; iii. facilitate control of acidogenic biofilm and resultant caries risk; and iv. provide some resistance against tooth fracture (or propagation of an existing fracture). (See Chapter 2 for caries-control rationale and techniques.) Mesioocclusodistolingual (MODL) complex amalgam in a maxillary first molar. The status and prognosis of the tooth determine the size, number and placement of retention features. Larger restorations generally require more retention. The size, number and location of retention features demand greater care in smaller teeth. Carelessness may increase the risk of pulpal irritation or exposure. IV. Interim restoration Complex amalgam restorations are sometimes indicated as interim restorations for teeth that require elaborate occlusal alterations, ranging from vertical dimension changes to correcting occlusal plane discrepancies. When cost of indirect restorations is a major factor for the patient, the complex direct amalgam restoration may be an appropriate treatment option, provided that adequate resistance and retention forms are included (Fig. 14.4).2,3 For some older patients and/or those who are debilitated, complex amalgam restoration may be the treatment preferred over the more expensive and time-consuming indirect restoration.

Contraindications

I. if the tooth cannot be restored properly with direct restoration because of anatomic or functional considerations (or both); II.if the area to be restored has esthetic importance for the patient.

Advantages

Conservation of Tooth Structure The preparation for a complex amalgam restoration is usually more conservative than the preparation for an indirect restoration.

Appointment Time The complex restoration may be completed in one appointment. An indirect restoration generally requires at least two appointments unless it is done using a chairside computer-aided design/computer-assisted manufacturing (CAD/CAM) system.

Resistance and Retention Forms Amalgam restorations with cusp coverage significantly increase the fracture resistance of weakened teeth compared with amalgam restorations without cusp coverage.4 Resistance and retention forms may be significantly increased by the use of slots and pins (discussed in subsequent sections).

Reduced Cost The complex amalgam restoration may be utilized to reinforce and stabilize compromised posterior teeth at a much reduced cost to the patient. It may serve as a definitive final restoration or an intermediate-term restoration with a long-term goal of indirect, more costly restoration and protection of the tooth.

Disadvantages

Tooth Anatomy Proper contours and occlusal contacts and anatomy are sometimes difficult to achieve with large, complex restorations.

Resistance Form Resistance form is more difficult to develop with a complex amalgam as compared to the preparation of a tooth for a cusp-covering onlay (skirting axial line angles of the tooth or a full crown. The complex amalgam restoration does not protect the tooth from fracture as effectively as a full-coverage indirect restoration.

Composite restoration

Indications

The indications for direct composites are: I.Class I, II, III, IV, V and VI restorations. II. Foundations and core buildups. III. Sealants and preventive resin restorations (conservative composite restorations). IV. Esthetic enhancement procedures: i. Partial veneers ii. Full veneers iii. Tooth contour modifications iv.Diastema closures V. Temporary or provisional restorations VI. Periodontal splinting. VII. Luting of indirect esthetic restorations (when used in flowable form, or when heated to increase flow). The primary contraindications for use of direct composites relate to: I. Inability to obtain adequate isolation. II.Occlusal considerations related to wear and fracture of the composite material. III. Extension of the restoration on root surface. IV. Operator factors.

The following are advantages of composite restorations: I.Esthetics II.Conservative tooth preparation (less extension, minimum depth not necessary, mechanical retention usually not necessary) III. Low thermal conductivity IV. Universal use V. Adhesion to the tooth VI. Repairability.

Disadvantages

I.May have poor marginal and internal cavity adaptation, usually occurring on root surfaces as a result of polymerization shrinkage stresses or improper insertion of the composite. II. May exhibit marginal deterioration over time in areas where no marginal enamel is available for bonding. III. Are more difficult and time consuming to place, and more costly (compared with amalgam restorations) because bonding usually requires multiple steps; insertion is more difficult; establishing proximal contacts, axial contours, embrasures and occlusal contacts may be more difficult and finishing and polishing procedures are more difficult. IV. Are more technique sensitive because the operating site must be appropriately isolated, incremental placement technique must be used for most materials and proper adhesive technique is absolutely mandatory. V. May exhibit greater occlusal wear in areas of high occlusal stress or when all of the tooth’s occlusal contacts are on the composite material.

Veener

Class II Cast Metal Restorations

Types

At present, four distinct groups of alloys are in use for cast restorations: I.Traditional high-gold alloys (ADA specification No. 5) II. Low-gold alloys III. Palladium–silver alloys IV. Base metal alloys (most commonly used).

indications

Large Restorations I.When proximal surface caries is extensive, the cast metal inlay is an alternative to amalgam or composite when the higher strength of a casting alloy is needed. II. The cast metal onlay is often an excellent alternative to a crown for teeth that have been greatly weakened by caries or by large, failing restorations but where the facial and lingual tooth surfaces are relatively unaffected by disease or injury.

Superior Contact and Contour The indirect procedure used to develop the cast restoration allows more control of contours and contacts (proximal and occlusal).

Endodontically Treated Teeth A molar or premolar with endodontic treatment can be restored with a cast metal onlay, provided that the onlay has been thoughtfully designed to distribute occlusal loads in such a manner as to reduce the chance of tooth fracture

Dental Rehabilitation with Cast Metal Alloys When cast metal restorations have been used to restore adjacent or opposing teeth, the continued use of the same material may be considered to eliminate electrical and corrosive activity that sometimes occurs between dissimilar metals in the mouth, particularly when they come in contact with each other.

Posterior Diastema Closure and Occlusal Plane Correction I.The cast inlay or onlay is indicated when extension of the mesiodistal dimension of the tooth is necessary to form a contact with an adjacent tooth. II.Cast onlays also can be used to correct the occlusal plane of a slightly tilted tooth. Removable Prosthodontic Abutment

Teeth that are to serve as abutments for a removable partial denture can be restored with a cast metal restoration. The major advantages of a cast restoration are as follows I.The superior physical properties of the cast metal alloy allow it to better withstand the forces imparted by the partial denture. II.The rest seats, guiding planes and other aspects of contour relating to the partial denture are better controlled when the indirect technique is used

Endodontically Treated Teeth A molar or premolar with treatment root canal filling can be restored with a cast metal onlay, provided that the onlay has been thoughtfully designed to distribute occlusal loads in such a manner as to reduce the chance of tooth fracture.

Contraindications

High Caries Rate Facial and lingual (especially lingual) smooth-surface caries indicates a high caries activity that should be brought under control before expensive cast metal restorations are used. Young Patients With younger patients, direct restorative materials (e.g. composite or amalgam) are indicated, unless the tooth is severely broken or endodontically treated. An indirect procedure in a young patient has the following disadvantages: I. Treatment requires longer and more numerous appointments II. Access is more difficult III. Clinical crowns are shorter with larger pulp chambers IV. Younger patients may neglect oral hygiene, resulting in additional caries.

Esthetics The dentist must consider the esthetic impact (display of metal) of the cast metal restoration. This factor usually limits the use of cast metal restorations to tooth surfaces that are invisible at a conversational distance. Composite and porcelain restorations are alternatives in esthetically sensitive areas.

Small Restorations Amalgam and composites are the materials of choice for smaller restorations. Cast metal inlays are rarely done in small class I and II restorations.

Advantages

Strength The inherent strength of dental casting alloys allows them to restore large damaged or missing areas and be used in ways that protect the tooth from future fracture injury. Biocompatibility As previously mentioned, high-gold dental casting alloys are unreactive in the oral environment. This biocompatibility can be helpful for many patients who have allergies or sensitivities to other restorative materials. Low Wear Although individual casting alloys vary in their wear resistance, castings are able to withstand occlusal loads with minimal changes. This is especially important in large restorations that restore a large percentage of occlusal contacts. Control of Contours and Contacts Through the use of the indirect technique, the dentist has great control over contours and contacts. This control becomes especially important when the restoration is larger and more complex.

Disadvantages

Number of Appointments and Higher Chair Time The cast inlay or onlay requires at least two appointments and much more time than a direct restoration, such as amalgam or composite.

Temporary Restorations Patients must have temporary restorations between the preparation and delivery appointments. Temporaries occasionally loosen or break, requiring additional visits. Cost In some instances, cost to the patient becomes a major consideration in the decision to restore teeth with cast metal restorations. The cost of materials, laboratory bills and the time involved make indirect cast restorations more expensive than direct restorations. Technique Sensitivity Every step of the indirect procedure requires diligence and attention to detail. Errors at any part of the long, multistep process tend to be compounded, resulting in less than ideal fits. Splitting Forces Small inlays may produce a wedging effect on facial or lingual tooth structure and increase the potential for splitting the tooth. Onlays do not have this disadvantage.

Direct Gold Restorations

Types

Gold foil Powdered Goal

Indications

I. Class I direct gold restorations are one option for the treatment of small carious lesions in pits and fissures of most posterior teeth and the lingual surfaces of anterior teeth. II. Direct gold also is indicated for treatment of small, cavitated Class V carious lesions or for the restoration, when indicated, of abraded, eroded or abfraction areas on the facial surfaces of teeth (although access to the molars is a limiting factor). III. Class III direct gold restorations can be used on the proximal surfaces of anterior teeth where the lesions are small enough to be treated with esthetically pleasing results. IV. Class II direct gold restorations are an option for restoration of small cavitated proximal surface carious lesions in posterior teeth in which marginal ridges are not subjected to heavy occlusal forces (e.g. the mesial or distal surfaces of mandibular first premolars and the mesial surface of some maxillary premolars). Class VI direct gold restorations may be used on the incisal edges or cusp tips. VI. A defective margin of an otherwise acceptable cast gold restoration also may be repaired with direct gold.

Contraindications

Direct gold restorations are contraindicated in some patients whose teeth have: I. Very large pulp chambers II. Severely periodontally weakened teeth with questionable prognosis III. Patients for whom economics is a severely limiting factor IV. In handicapped patients who are unable to sit for the long dental appointments required for this procedure V. Root canal-filled teeth are generally not restored with direct gold.

Treatment by Replacement of Existing Restorations Indications for replacing restorations include the following: I. marginal void(s), especially in the gingival one-third, that cannot be repaired and predispose to caries formation; II. poor proximal contour or a gingival overhang that contributes to periodontal breakdown; III. a marginal ridge discrepancy that contributes to food impaction; IV. overcontouring of a facial or lingual surface resulting in biofilm accumulation gingival to the height of contour and resultant inflammation of gingiva overprotected from the cleansing action of food bolus or toothbrush; V. poor proximal contact that is either open or improper in location or size, resulting in interproximal food impaction and inflammation of impacted gingival papilla; VI. recurrent caries that cannot be treated adequately by a repair restoration; and VII. superficial marginal gap formation (ditching) deeper than 0.5 mm that predisposes to caries.38 Indications for replacing tooth-coloured restorations include: I. improper contours that cannot be repaired, II. large voids, III. deep marginal staining, IV. recurrent caries, V. unacceptable esthetics.

Resin-bonded Splints and Bridges

Conservative bridges - natural tooth ponitic - denture tooth ponitic - porcelain metal fused ponitic - all porcelain ponitic

Class III and V Amalgam Restorations

indications

Few indications exist for a class III amalgam restoration. It is generally reserved for the distal surface of maxillary and mandibular canines if (i) the preparation is extensive with only minimal facial involvement, (ii) the gingival margin primarily involves cementum or (iii) moisture control is difficult. For esthetic reasons, amalgam rarely is indicated for the proximal surfaces of incisors and the mesial surface of canines. Class V amalgam restorations may be used anywhere in the mouth. As with class III amalgam restorations, they are generally reserved for non-esthetic areas, for areas where access and visibility are limited and where moisture control is difficult and for areas that are significantly deep gingivally. Because of limited access and visibility, many class V restorations are difficult and present special problems during the preparation and restorative procedures. One measure of clinical success of cervical amalgam restorations is the length of time the restoration serves without failing (Online Fig. 26.3). Properly placed class V amalgams have the potential to be clinically acceptable for many years. Some cervical amalgam restorations show evidence of failure, however, even after a short period. Inattention to tooth preparation principles, improper manipulation of the restorative material and moisture contamination contribute to early failure. Extended service depends on the operator’s care in following accepted treatment techniques and proper care by the patient. Amalgam may be used on partial denture abutment teeth because amalgam resists wear as clasps move over the restoration. Contours prepared in the restoration to retentive areas for the clasp tips may be achieved relatively easily and maintained when an amalgam restoration is used. Occasionally, amalgam is preferred when the caries lesion extends gingivally enough that a mucoperiosteal flap must be reflected for adequate access and visibility (Online Fig. 26.4). Proper surgical procedures must be followed, including sterile technique, careful soft tissue management and complete debridement of the surgical and operative site before closure.

Contraindications

Class III and V amalgam restorations usually are contraindicated in esthetically important areas because many patients object to metal restorations that are visible (Online Fig. 26.5). Generally, class V amalgams placed on the facial surface of mandibular canines, premolars and molars are not readily visible. Amalgams placed on maxillary premolars and first molars may be visible. The patient’s esthetic demands should be considered when planning treatment.

Advantages

Amalgam restorations are stronger than other class III and V direct restorations. In addition, they are generally easier to place and may be less expensive to the patient. Because of its metallic colour, amalgam is easily distinguished from the surrounding tooth structure. Amalgam restorations are usually easier to finish and polish without damage to the adjacent surfaces.

Disadvantages

The primary disadvantage of class III and V amalgam restorations is that they are metallic and unesthetic. In addition, the preparation for an amalgam restoration typically requires 90-degree cavosurface margins and specific axial depths that allow incorporation of secondary retentive features. These features result in a less conservative preparation than that required for most esthetic restorative materials.

radiograph

Clinical situations for which radiographs may be indicated include but are not limited to: I. Positive historical findings - I. Previous periodontal or endodontic treatment - - ii.History of pain or trauma - iii. Familial history of dental anomalies - iv. Post-operative evaluation of healing - v. Remineralization monitoring - vi. Presence of implants or evaluation for implant placement II. Positive clinical symptoms/signs - i. Clinical evidence of periodontal disease - ii. Large or deep restorations - iii. Deep carious lesions - iv. Malposed or clinically impacted teeth - v. Swelling vi. Evidence of dental/facial trauma - vii. Mobility of teeth - viii. Sinus tract (‘fistula’) - ix. Clinically suspected sinus pathology - x. Growth abnormalities - xi. Oral involvement in known or suspected systemic disease - xii. Positive neurologic findings in the head and neck - xiii. Evidence of foreign objects - xiv. Pain and/or dysfunction of the temporomandibular joint and/or muscles of mastication - xv. Facial asymmetry - xvi. Abutment teeth for fixed or removable partial prosthesis - xvii. Unexplained bleeding - xviii. Unexplained sensitivity of teeth - xix. Unusual eruption, spacing, or migration of teeth - xx. Unusual tooth morphology, calcification, or colour - xxi. Unexplained absence of teeth - xxii. Clinical erosion

Factors increasing risk for caries may include but are not limited to: I.High level of caries experience or demineralization II. History of recurrent caries III. High titers of cariogenic bacteria IV. Existing restoration(s) of poor quality V. Poor oral hygiene VI. Inadequate fluoride exposure VII. Prolonged nursing (bottle or breast) VIII. Frequent high sucrose content in diet IX. Poor family dental health X. Developmental or acquired enamel defects XI. Developmental or acquired disability XII. Xerostomia XIII. Genetic abnormality of teeth XIV. Many multi-surface restorations XV. Chemotherapy/radiation therapy XVI. Eating disorders XVII. Drug/alcohol abuse XVIII. Irregular dental care (From American Dental Association, US Food and Drug Administration: the selection of patients for dental radiograph examinations. Available on www.ada.org. Document created November 2004)

Limitations of radiographs Dental radiographs should always be interpreted cautiously. The dental radiograph is a two-dimensional image of a three-dimensional mass. • A facial or lingual lesion (or radiolucent tooth-coloured restoration) may be radiographically superimposed over the proximal area, mimicking a proximal caries lesion (false positive). • The general finding that approximately 25% mineral loss has to occur before a radiolucency begins to appear on a radiograph means that a caries lesion may be present and not detected (false negative). • Misdiagnosis may occur when cervical burnout (the radiographic picture of the normal structure and contour of the cervical third of the crown) mimics a caries lesion. • Finally, although a caries lesion may be more extensive clinically than it appears radiographically, it is estimated that over half of radiographically detected proximal lesions (in the outer half of dentine) are likely to be non-cavitated and treatable with remineralization measures

Clinical operative procedures a step-by-step guide

7.1.1 Cavity/restoration classification 7.1.2 Restoration procedures 7.2 Fissure sealant - illustrated 7.3 Preventive resin restoration (PRR), type 3 DBA (enamel pre-etch) - illustrated 7.4 Posterior occlusal composite restoration (Class I)-illustrated 7.5 Posterior proximal adhesive restoration (Class II) 7.5.1 Type 3 DBA (enamel pre-etch)-illustrated 7.5.2 Type 2 DBA,'moist bonding'-illustrated 7.6 Buccal cervical resin co 7.6 Buccal cervical resin composite restorations (Class V), type 2 DBA - illustrated 7.7 Anterior proximal adhesive restoration (Class III), type 2 DBA - illustrated 7.8 Anterior incisal edge/labial composite veneer (Class IV), type 3 DBA (enamel pre-etch) - illustrated 7.9 Large posterior amalgam restoration (bonded) illustrated 7.10 'Nayyar core' restoration 7.11 Direct fibre-post/composite core restoration 7.12 Dentine bonding agents - step-by-step practical guide 7.13 Checking the final restoration 7.14 Patient instructions 8. Recall, maintenance, and repair 140 8.1 Introduction 8.2 Restoration failure 8.2.1 Aetiology 8.2.2 Restorative material used 8.2.3 How may restoration outcome be assessed? 8.2.4 How long should restorations last? 8.3 Tooth failure 8.4 Monitoring the patient/course of the disease 8.4.1 Recall assessment and frequency 8.4.2 Points to consider (especially for a previously high caries risk patient) 8.4.3 Monitoring toothwear 8.5 Repairing/replacing restorations 8.5.1 Dental amalgam 8.5.2 Composites/GIC 8.6 Answers to self-test questions

Amalgam Restorations (Including Polishing)

Resin-Based Composite Restorations — Direct

Gold Foil Restorations

Inlay/Onlay Restorations

= Prognosis Levels of clinical treatment significants;prognosis - level 1 => miracle cures - level 2 => small treatment large benifits - level 3 => benifit but intangible effects ex AIDS,RCT - level 4 => small benifit but more intangible effects

Prognosis is the term used to describe the prediction of the probable course and outcome of a disease or condition

Good prognosis: Control of etiologic factors and adequate periodontal support ensure the tooth will be easy to maintain by the patient and clinician.

Fair prognosis: Approximately 25% attachment loss or grade I furcation invasion (location and depth allow proper maintenance with good patient compliance).

Poor prognosis: 50% attachment loss, grade II furcation invasion (location and depth make maintenance possible but difficult).

Questionable prognosis: >50% attachment loss, poor crown-to-root ratio, poor root form, grade II furcation invasion (location and depth make access difficult) or grade III furcation invasion; mobility no. 2 or no. 3; root proximity.

Hopeless prognosis: Inadequate attachment to maintain health, comfort, and function.

I.Cell A of the table contains the cases that the test identifies as being positive (or diseased) that actually are positive (i.e. confirmed by the ‘gold standard’). These cases are termed true positives. II. Cell B contains all cases for which a positive finding from the diagnostic test is present, but where the actual condition is negative. Therefore, this cell denotes false positives. III. Cell C includes the cases identified by the diagnostic test as not being diseased, but actually are diseased, as determined by the ‘gold standard’. Findings in this cell are termed false negatives. IV. Cell D, includes true negatives, where the diagnostic test accurately identifies non-diseased cases that are truly negative as confirmed by the ‘gold standard’. A perfect diagnostic test would result in all cases being assigned to cells A or D with no false positives (cell B) or false negatives (cell C).

= Examination

age sex Medical history General examination

Extraoral

Head Face - facial form - facial symmetry - facial profile - facial height - muscle tone - muscle development - complexion Lip - nasolabial - philtrum - lip step - lip mobility - lip contact - lip support - lip length - lip health - lip type - Interlabial distance - Incisor exposure - Lip trap - Mentallabial sulucus - Mentalis activitiy - Chin position and prominence TMJ Lymph node Visual treatment objective FMPA

Facial Form

A. Frontal: - Bilateral Symmetry: - Symmetry - Asymmetry

B. Profile: - Straight - Concave - Convex - Protrusive

1) Maxilla: - Normal - Protrusive - Retrusive

2) Mandible: - Normal - Protrusive - Retrusive

C. Vertical: - Face: - Normal - Short - Long

D. Lips: 1) Together in Centric Occlusion when relaxed 2) Apart in Centric Occlusion when relaxed 3) Gummy Smile

Dentition

A. Stage of Dentition: - Primary - Mixed (Early) - Mixed (Late) - Permanent

B. Number of Erupted Adult Teeth: - Incisors: __U, __L - Canines: __U, __L - Premolars: __U, __L - Molars: __U, __L

C. Periodontal Status: - (All adults must have recent periodontal probings) - Abnormal Frenum - Gingival Recession

D. Endodontics:

E. Restorative Status: - Caries - Prosthetic Restorations

Anteroposterior

A. Angle Classification: - Class I - Class II Division 1 - Class II Division 2 - Class III

B. Molar Relationship: - Right Molar: __ - Right Canine: __ - Left Canine: __ - Left Molar: __ - (Choices: II, SI [Super I], I, E, ml) - Edge to Edge - Anterior Crossbite - Incisor Overjet: __mm

Vertical

A. Posterior Openbite: - __mm

B. Overbite: - __%

C. Anterior Openbite: - __mm

Transverse

A. Dental Midlines to Face: - Upper: __mm - Lower: __mm

B. Posterior Crossbite: - Unilateral - Bilateral

C. Intermolar Width Difference: - __mm

D. Scissors Bite

E. Asymmetry in Dental Arches

F. Functional Shifts on Closure: - Anteroposterior - Transverse

Premature Loss of Deciduous Teeth:

Tooth Size/Arch Size: - Excess Space - Adequate Space - Crowding

Radiographic Analysis: - Supernumerary Teeth - Missing Tooth - Impacted Teeth - Root Resorption - Root Dilaceration - Periapical Pathology - Alveolar Bone Height - Other

prosthodontics

• missing

periodontics

• Periodontal pockets
• Alveolar Bone Loss
• Furcation Invasion
• Periodontal Abscess
• Periodontal Abscess and Gingival Abscess
• Periodontal Abscess and Periapical Abscess
• Dental Stains
• Hypersensitivity
• Proximal Contact Relations
• Tooth Mobility
• Trauma From Occlusion
• Pathologic Migration of the Teeth
• Sensitivity to Percussion
• Dentition With the Jaws Closed
• Functional Occlusal Relationships
• recession

Endodontics

• Clinically Normal Pulp
• Chronic Reversible Pulpitis
• Acute Reversible Pulpitis
• Chronic Irreversible Pulpitis
• Acute Irreversible Pulpitis
• Pulp Necrobiosis
• Pulp Necrosis with Infection
• Pulpless, Infected RCS

Tooth fracture Pathological tooth resorption Endodontic Abscesses/Cellulitis, Cysts, and Flare-ups

conservative

• proximal surface caries
• smooth surface caries
• root surface caries
• Amalgam Restorations
• indirect metal restoration
• composite restoration
• implants
• enamel hypoplasia
• imperfecta
• fracture
• attrition -abrasion

Orthodontics

1. Alignment (spacing, crowding)
2. Profile (convex, straight, concave)
3. Transverse deviation ( crossbites)
4. Sagittal deviation (Angle class)
5. Vertical deviation (deep bite, open bite)
6. Transsagittal deviation (combination of crossbite and Angle class)
7. Sagittovertical deviation (combination of Angle class and deep bite or open bite
8. Verticotransverse deviation (combination of deep bite or open bite with crossbite)
9. Transsagittovertical deviation (combination of problems in three planes of space)

maxillo

Exodontia - transalveolar - impacted - sugrical Endodontics

TMJ - affliction - ankylosis - myosfacial pain dysfunction syndrome

Trauma - middle third - mid facial - mandibule fractures - condylar mandibular fractures

Salivary gland Medical emergency - shock and hemorrhage - cardiopulmonary resuction

• tooth mobility
• furcation involvement
• gingival margin (mm),
• probing depth (mm)
• notes.

The degree of the furcation is charted using a circle. - an open circle (degree 1) - a semicircle (degree 2) - a filled in circle (degree 3)

The blue shaded area representing periodontal pockets will be created automatically when the red line which represents the gingival margin and the blue line which represents the attachment level (bottom of the periodontal pocket) are defined

• gingival margin(red)
• probing depth(blue)

• Therefore,Probing Depth (mm) – Gingival Margin (mm) = Attachment Level (mm) For healthy gums attachment = 0 mm For pockets = 7-2 = >4 mm For recession= 2 -4 =< -2 mm

• Six sites per tooth and thier angulation

• furcation involvement

  • Furcations of all molars and first premolars of the upper jaw should be assessed with a furcation probe. The horizontal component of probing is graded (0 - 3) according to the following criteria (Hamp et al., 1975):
  • Grade 0 = Furcation not detectable
  • Grade 1 = Furcation detectable, with a horizontal component of probing ≤3mm
  • Grade 2 = Furcation detectable, with a horizontal component of probing >3mm
  • Grade 3 = Furcation is opened through and through

• Tooth mobility

  • Tooth mobility should be determined using two single-ended instruments and assessed according to the following criteria (Miller, 1950):
    • Grade 0 = Normal (physiologic) tooth mobility
    • Grade 1 = detectable mobility (up to 1mm horizontally)
    • Grade 2 = detectable mobility (more than 1mm horizontally)
    • Grade 3 = detectable vertical tooth mobility

• bleeding on probing

• plaque
• calculus
• debris

Normal

types (i) amalgam ‘blues’, (ii) proximal overhangs, (iii) marginal ditching, (iv) voids, (v) fracture lines, (vi) lines indicating the interface between abutted amalgam restorations placed at separate times, (vii) improper anatomic contours, (viii) marginal ridge incompatibility, (ix) improper proximal contacts, (x) improper occlusal contacts, and (xi) recurrent caries lesions

Examination (features/conformation)

Treatment plan

Treatment

A diagnostic norm is a standard that helps to determine the extent to which a patient deviates from normal. An objective norm is a norm based on a measurement technique that is repeatable, reliable, and based on scientific method. A biometric norm is an objective norm derived from the measurement of a biologic variable in a random sample of persons who are considered normal

Normal = Diagnositic norm = diagnostic

History taking is two types Ask Cross examination

parameters

0 = absent 1 = present (symptomatic) 2 = severe (unsymtopic) 3 = very severe(signs)

Only Pain,TOP,VT are parameters for pulp and Periapical diseases

Pain 0 = absent 1 = present 2 = absent but present as in history

TOP 0 = absent 1 = present 2 = absent but present as feel different

VT 0 = absent 1 = present 2 = sinus opening

Any tooth with decay we check these. But decay

TYPE Subopacity Cavitation Grossly decayed Root stemps

If subopacity and cavitation are Pain,TOP,VT = 0 then caries = restoration

If subopacity and cavitation are pain,TOP,VT >0 = root canal

Grossly decayed and rootstemps= extraction

Then why you need to diagnose grossly decayed and rootstemps? Pain,TOP,VT =0 = treatment no need Pain,TOP,VT >0 = treatment needed

Pain,TOP,VT = 0 is Pain+TOP+VT= 0 Correct version

Caries is brown colour and depth and

Caries(brown Caries have brown,cavity

If cavity then catchy probe.

Decay or Attrition or abrasion or causes pulpitis