CHAPTER 3 PART II: DIAGNOSIS & TREATMENT PLANNING

examination for amalgam restorations

Evaluation of existing restorations should be accomplished systematically in a clean, dry, well-lit field.

Clinical evaluation of amalgam restorations requires visual observation, application of tactile sense with the explorer, use of dental loss, interpretation of radiographs, and knowledge of the probabilities that a given condition is sound or at risk for further breakdown.

11 distinct conditions might be encountered when amalgam restorations are evaluated:

voids

fracture lines

amalgam “blues”

amalgam tattoos

marginal ditching

proximal overhangs

recurrent cares lesions

improper proximal contacts

improper occlusal contacts

improper anatomic contours

marginal ridge incompatiblity

lines indicating the interface between abutted amalgam restorations placed at separate times

Examination for Metal Restorations

Indirect metal restorations should be evaluated clinically in the same manner as amalgam restorations.

Any aspect of the restoration that is not satisfactory, that is causing harm to tissue or occlusal function, should be noted and considered for recontouring, repair, or replacement.

examination for Composite and Other Tooth-Colored Restorations

Tooth-colored restorations (direct and indirect) should be evaluated clinically in the same manner as amalgam and cast-metal restorations.

the presence of improper contour or inadequate proximal contact, overhanging margin, recurrent cares, or occlusal interference should be noted and considered for correction.

Corrective procedures include recontouring, polishing, repairing, or replacement of the restoration.

Examination for Dental Implants and Implant-Supported Restorations

•Baseline Radiographs. Essential for determining initial implant bone support levels during restoration.

•Percussion Test. Should produce a clinical sound indicating proper integration of the implant.

Probing Depths: Must align with the thickness of local gingival fissue.

•Gingival Tissue Assessment: Check for inflammation signs like redness, swelling, tenderness, and bleeding on probing.

•Marginal Adaptation: Implant restorations and abutments must allow optimal bofilm removal; deviations should be documented.

•Implant Size: Often smaller than the roots of replaced teeth, necessitating modified cervical contours for restorations.

•Proper Cervical Contours: Critical for reducing food impaction and biofilm accumulation, especially in proximal areas.

•Chronic Inflammation (Pen-implantitis): May result from residual dental cement or biofilm, leading to localized bone loss and affecting long-term implant survival.

•Per-implantitis Etiology: Multifactorial, requiring careful evaluation and management.

examination for localized enamel hypoplasia & hypocalcification

noncavitated white areas on teeth surfaces often result from childhood conditions (fever, trauma, fluorosis).

diagnosed as nonhereditary developmental enamel hypoplasia.

arrested /remineralized incipient caries leave opaque, discolored, and hard surfaces.

intervention is needed only for aesthetic concerns or if the areas are uncleanable.

examination for Erosion and Its Causes

Chemical erosion leads to smooth surface loss, often linked to acidic agents (e.g., sports drinks, vomiting, GERD).

• Document erosion progression via models, photography, or digital scans.

• Saliva flow and buffering capacity affect erosion progression.

Abrasion

Loss of tooth structure from friction with external objects (e.g. hard objects, abrasive substances).

Appears as rounded notches in cervical areas.

abfraction

Wedge-shaped defects in cervical areas from tooth flexure due to heavy occlusal forces.

Etiology is multifactorial and debated.

Attrition

• Mechanical wear from functional /parafunetional movements (e.g., bruxism).

• Excessive attrition leads to visible wear facets or cupped-out areas.

• Stress, airway issues, and sleep apnea are possible contributors.

examination for fractures

early fractures may require dyes/transillumination for detection.

nonfunctional cusps (e.g., mandibular molars, maxillary premolars) are more prone to fracture.

risk factors: extensive restorations, stained fractures, or minimal remaining dentin.

severe fractures often treated with restorations or extractions.

Examination for Dental Anomalies

Variations like dens in dente, microdontia, amelogenesis imperfecta, and dentinogenesis imperfecta may be noted.

Further details require reference to oral pathology resources.

Dental caries

is a multifactorial, transmissible, infectious oral disease caused by the interaction of cariogenic biofilm and fermentable dietary carbohydrates over time

Caries lesions result from the caries process but are not its cause.

Clinical Decision-Making for Caries:

• Diagnostic methods (e.g, visual inspection, radiographs, detection devices) have limitations and are prone to inaccuracies.

• Strong evidence of cavitation or dentin penetration should precede operative treatments.

• A reasonable approach is monitoring and minimally invasive treatment due to the slow progression of caries.

Balancing Risks Across Treatments

• Dental treatments often reduce risks in one area while potentially increasing risks in another.

•Example: Preparing teeth for full-coverage crowns may improve ooclusion or esthetics but increases risk for caries or pulpal pathology.

Prognosis

refers to the prediction of the likely course and outcome of a disease or condition. It also estimates the outcome expected from an intervention, whether preventive or operative.

it can describe the likelihood of recovery and the expected success of a treatment based on factors like functional value, comfort, esthetics, and longevity.

Classification of Prognosis

Good

Fair

Poor

Hopeless

Good prognosis

Favorable outcomes with minor risk factors.

Fair prognosis

Moderate success with potential challenges or risks.

poor prognosis

limited success due to significant barriers or advanced disease

Hopeless prognosis

Minimal to no chance of favorable outcomes

factors influencing prognosis

Risk Factors and Indicators:

• Behavioral and sociodemographic elements.

• Physical, microbiologic, or environmental influences.

• Host-related factors (e.g, systemic health, immune status).

Skill of the Dentist:

• Expertise in diagnosis, treatment planning, and execution plays a crucial role in determining outcomes.

Disease Status at Treatment Onset:

• The severity and progression of the disease directly impact the prognosis.

• Example: Severe caries, even with risk factor modifications, may still result in a poor long-term outlook for affected teeth.

Comprehensive Risk Profile:

A detailed understanding of the patient's medical and dental health, including all risk factors, is essential in establishing an accurate prognosis

patient and clinician collaboration

open communication ensures the patient understands.

• The current conditions affecting their oral health.

• Their specific risk profile.

• The associated prognoses for potential treatment options.

by working together, the patient and dentist can

• Identify feasible treatment options.

• Establish a tailored treatment plan that aligns with the patient's health needs and expectations.

holistic approach

include systemic and oral health factors when evaluating prognosis

realistic outcomes

set expectations based on the disease's progression, patient compliance, and potential for recovery

Team Effort

A collaborative approach increases the likelihood of achieving a favorable prognosis and long-term dental health.

Treatment planning

begins with a comprehensive patient assessment, examination, and diagnosis to identify dental problems, risk factors, and prognosis

Clinicians must prioritize minimizing harm, evaluate evidence-based options, and consider non intervention or referrals if necessary

Decisions on surgical or nonsurgical approaches depend on the condition of the tooth or restoration, balancing risks and benefits.

dynamic and patient-centered, balancing immediate needs, long-term goals, and the collaboration between patient and dentist to ensure effective and sustainable oral health care.

Treatment alternatives may include:

monitoring

remineralization

recontouring

repair

restorative procedures

based on current standards

patient-specific factors

treatment phases

urgent phase

control phase

reevaluation phase

definitive phase

maintenance phase

urgent phase

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

is essential for patients with multiple problems, active disease, or unclear prognosis, aiming to remove etiologic factors, preventive activities, and correct hygiene conditions.

reevaluation phase

a crucial stage between control and definitive phases, involving reevaluating initial treatment, reinforcing home care habits, and assessing motivation for further treatment

low-risk patients may not require a formal control phase, but treatment plans may focus on immediate concerns, minor changes, and maintaining dental health habits

definitive phase

The patient enters this phase of treatment after the dentist assesses initial disease control efforts and determines need for further care

Maintenance (Reassessment and Recare) Phase

involves regular reassessment examinations to identify adjustments, reinforce home care, and plan recare treatment.

These examinations are often part of recall appointments for bioilm removal, with frequency depending on the patient's risk for dental disease.

Interdisciplinary Considerations

endodontics

periodontics

orthodontics

prosthodontics & implants

endodontics

teeth requiring large restorations should undergo pulpal evaluation, with necessary endodontic treatments completed before restorations.

periodontics

Periodontal therapy precedes operative care for optimal conditions. Surgical procedures like crown-lengthening are often needed before final restorations.

orthodontics

Caries lesions are addressed before orthodontic treatment, which requires intensive prevention of caries and periodontal issues.

Management of Non-cavitated lesions:

Prefer remineralization therapies requiring patient compliance.

Management of Root caries:

Differentiate active from arrested lesions, prioritize prevention and consider restorations only when necessary.

Management of Abrasion, erosion, attrition

Restore areas only if structural integrity, sensitivity, or esthetics are compromised.

Management of Abrasion, erosion, attrition

Restore areas only if structural integrity, sensitivity, or esthetics are compromised.

Treatment of Root-Surface Sensitivity

often linked to gingival recession and exposed dentin, is commonly explained by the hydrodynamic theory, where rapid fluid movement in dentinal tubules causes pain.

Treatments focus on reducing fluid shifts, such as using: fluoride varnishes, oxalate solutions, glutaraldehyde / HEMA-based desensitizers, and resin adhesives. If nonsurgical treatments fail, restorative procedures may be necessary.

Treatment by Repair and Recontour of Existing Retoration

Amalgam, composite, or indirect restorations can often be repaired instead of fully replaced

This helps prevent further tooth damage

Treatment by Replacement of Existing Retoration

Indications for replacement include recurrent caries, poor fit, or gingival inflammation

Tooth-colored restorations may require replacement due to improper contours, voids, or aesthetics.

Resurfacing or amalgam restorations can be effective in high caries risk patients, and superficial marginal aesthetics can be corrected

Restoration Types

amalgam

Composite and Other Tooth-Colored Restorations

Indirect Cast-Metal Restorations

Indirect Tooth-Colored Restorations

amalgam

Still a reliable material, especially for high caries-risk patients, though concerns about mercury exist

Composite and Other Tooth-Colored Restorations

Used for anterior and posterior teeth, they require careful application to ensure durability.

High caries risk patients may face more recurrent decay with composites than with amalgams.

Indirect Cast-Metal Restorations

Gold alloys remain reliable for restoring compromised teeth in high-stress areas.

are a reliable, predictable option for high-stress areas, covering and reinforcing cusps without removing healthy tooth structure, allowing control of contours and anatomic shapes.

indirect tooth-colored restorations

zirconia-based indirect tooth-colored restorations, using PFM materials

—offering esthetics and durability

—proven successful in restoring individual teeth and edentulous areas

Aesthetic Concerns

Conservative treatments, such as selective recontouring, bleaching, and microabrasion, address aesthetic issues without extensive procedures.

Advances in composite restorations also enable tooth recontouring and addition for better appearance.

Considerations for Older Patients

Older adults face unique challenges in dental care due to medical, social, and financial factors.

Common issues include taste and smell impairments, medical conditions, medication effects, and limited ability to care for their teeth.

Treatments for older adults should focus on maintaining oral health, managing polypharmacy effects, and ensuring cost-effective care.

Prevention is essential, with adapted oral hygiene tools and techniques recommended for individuals with physical limitations.

Treatment Plan Approval

Informed consent is vital for effective dental treatment planning.

Patients should be educated about their conditions, available treatment options, risks, and costs, including proactive conservative treatments when appropriate.