Transcript Disease Control Phase

ODRP 726
Patient Diagnosis and Treatment Planning
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Many times the treatment plan will be fairly
uncomplicated
◦ No periodontal disease with poor prognosis for any
teeth
◦ No teeth where restorability is in question
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The finalized treatment plan will contain all
treatment procedures
The dentist is sure that there will only be
minor changes in treatment plan
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Often a patient’s treatment includes much
uncertainty
Patients want to know all that will be involved
in rehabilitating their oral condition
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Too much unpredictability is involved to
finalize overall treatment plan when extensive
problems are involved
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Which teeth are restorable?
Which teeth will need endodontic treatment?
Will periodontal treatment be successful?
Will the patient commit to perio surgery if needed?
Disease
Control 
Phase
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Definitive
Unknown restorability
Phase
 Unknown endo needs
Unknown perio outcomes
Disease control only
 Changes in
Tx Plan
+
 Chances for
Patient
Confusion
Disease
Control 
Phase
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Definitive
Unknown restorability
Phase
 Unknown endo needs
Unknown perio outcomes
All phases can be included
 Changes in Tx
Plan
+
 Chances for
Patient
Confusion
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Design a disease-control-only plan
◦ Improves unpredictability by
 controlling variables such as periodontal disease and
rampant caries
 simplifying the situation by extracting hopeless teeth.
◦ Provisional replacements for missing teeth may be
fabricated for interim esthetics and function
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In some cases design a disease-control
treatment plan plus tentative definitive
treatment plan.
Tentative definitive plan
◦ Discuss the possible treatment outcomes
◦ Important to have a tentative definitive plan to
identify key teeth when tooth supported denture is
considered
◦ A post-treatment assessment is performed at the
end of disease control phase to evaluate:
 Level of disease resolution (Perio re-eval)
 Patient compliance
 Patient desire for further care
◦ Options:
 Maintain the patient at current state
 Design definitive phase treatment plan
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Control active oral disease and infection
Stop occlusal and esthetic deterioration
Manage risk factors
Periodontal therapy, endodontic therapy,
extractions, operative treatment to eradicate
caries
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Particularly valuable when the dentist is
uncertain about:
◦ Disease severity
◦ Outcome of disease control
◦ Patient commitment to treatment
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Some teeth may receive only palliative
treatment – until perio treatment is complete
Patient may enter a holding period and not
proceed to definitive disease
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Consider all reasonable treatment options
Discussion with patient to reach a consensus
on objectives
Dentist helps the patient:
◦ Set achievable treatment goals
◦ Build realistic expectations for treatment outcomes
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Establish clear, specific, quantifiable
standards for success (outcomes measures)
◦ Target plaque score
◦ Target bleeding score
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Specify the factors to be evaluated at the post
treatment assessment
◦ Plaque and bleeding score
◦ Status of periodontal disease and need for surgery
◦ Need for endo/crown
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Delineate the steps to be implemented when
the patient does or does NOT meet the
standards for success
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68 yr old Caucasian female
“Wants a prettier smile
No pain
All teeth are mobile, maxillary Class II and III
Recurrent decay #3 – replace crown
Recurrent decay #12 – place crown
Patient would like to keep as many teeth as
possible
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Should we prepare a comprehensive
treatment plan or just the Disease Control
Phase?
When would it be helpful to treatment plan
only the Disease Control Phase?
◦ Uncertain about disease severity
◦ Uncertain about the outcome of disease control
◦ Uncertain about the patient’s commitment to
treatment
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68 yr old Caucasian female
“Wants a prettier smile”
No pain
All teeth are mobile, maxillary Class II and III
Recurrent decay #3 – replace crown
Recurrent decay #12 – place crown
Patient would like to keep as many teeth as
possible
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What are all the treatment options?
What are realistic expectations for treatment
outcomes?
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What could be quantifiable standards for
success post disease control phase?
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Address the patient’s Chief Complaint as
quickly as possible, insuring that this will not
conflict with the primary goals of the disease
control phase
◦ Example: Patient just had # 8 extracted and has
returned for a comprehensive treatment plan. The
patient has moderate periodontal disease and
multiple Class II cavities.
◦ CC: replace #8 with an implant.
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What would you treat first?
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Sequence by Priority
◦ Treat the most severe and urgent needs first
◦ Example:
 Moderately large asymptomatic cavity on vital tooth
 Amalgam or composite restoration
 Large cavity with asymptomatic necrotic pulp
 Root canal tx and crown
 Grossly decayed, asymptomatic, non-restorable tooth
 Extraction
◦ Which would you treat first?
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Sequence by quadrant or sextant
It is most efficient and productive to restore
all carious teeth in the same area at the same
time
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Integration of periodontal therapy
Should perio therapy always come first in
disease control?
What takes priority over periodontal
treatment?
◦ Treatment of deep caries in vital teeth
◦ Symptomatic pulpal problems
◦ Acute oral infections
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Keep definitive phase options open with
minimalist treatment in the disease control
phase.
◦ Key teeth
◦ Other teeth that might be salvageable but
uncertainty if it is feasible or desirable for the
patient to expend the resources to restore them
definitively
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Minimalist treatment
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Provisional restorations rather than crowns
Pulp-capping rather than RCT initiation
Pulpectomy/pulpotomy rather than definitive RCT
Exception: Definitive direct-fill restorations are
preferred over temporary fillings
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Overall management
1. Comprehensive caries diagnosis
2. Assessment of caries risk
3. Basic caries intervention protocol for patients with
active lesions or those who are at risk for
developing new lesions
4. Supplemental caries intervention protocol to
address specific needs of those requiring
additional measures or the patient who remains
caries active
5. Maintenance and re-evaluation at appropriate
intervals to identify new lesions and re-evaluate
the risk for future caries activity
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Individual restoration of cavities
Use of sealants or conservative composite
restorations to prevent, control new or
incipient lesions
Dietary and/or behavioral approaches to
prevent new caries
Use of fluoride and/or MI Paste to strengthen
the tooth
Elimination of plaque
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Caries control protocol is for individuals:
◦ With moderate or high rate of caries formation
◦ Who are at significant risk for developing caries in
the future
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Comprehensive, organized plan designed to:
◦ Arrest or remineralize early carious lesions
◦ Eradicate overt carious lesions
◦ Prevent the formation of new lesions
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Can be stabilized and controlled
May be inactivated for a period of time
In a predisposed patient, the possibility of
reactivation persists
The patient with periodontal disease can be
expected to require some sort of therapy for
as long as they have teeth.
The PATIENT has a great deal to do with how
long they have teeth
Chronic disease
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Systemic considerations
Lessening the force or intensity
◦ Identification and mitigation of diseases,
treatments or medication regimens that might
 Promote periodontal disease
 Delay healing
 Interfere with periodontal therapy
◦ Identification of patients who require antibiotic
prophylaxis
 Risk of endocarditis
 Risk of artificial joint infection
◦ Determination if antibiotics are contraindicated
◦ Obtain physician’s clearance for invasive treatment
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Oral self-care instructions
◦ Demonstration of brushing and flossing techniques
◦ Provide additional oral health care aids and
instruction
◦ Training is imperative
◦ Implementation – can the patient manage the tools
correctly?
◦ Support
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Extraction of hopeless teeth
◦ Severe periodontal disease
◦ Severe decay or fracture
◦ For prosthodontic reasons
 Tooth will not be functional
 Tooth is poorly positioned
◦ Extraction may be delayed
 To preserve appearance
 To prevent collapse of VDO
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Of or related to medical
examination or treatment
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Elimination of iatrogenic restorations
and open carious lesions contributing
to periodontal disease – complete
BEFORE scaling and root planing
Open margins
Open contacts
Overhangs
Poor contours
◦ S & RP will be more effective
◦ Patient’s oral self-care efforts are more
effective
◦ Tissues heal more quickly and completely
◦ The interim evaluation can be complete and
definitive
◦ Determine the cause of sensitivity (pulpal or
dentinal)
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Manage other dental problems that
contribute to periodontal disease
◦ Acute occlusal trauma from significant occlusal
interferences
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Scaling and Root Planing
◦ Is a technically challenging procedure that takes
patience, persistence and skill
◦ IT TAKES TIME
◦ Educate the patient about the challenge of the
procedure and it’s value
◦ If in doubt, use anesthesia
 The patient will be more comfortable and you will be
more comfortable.
 It allows you to do the job more thoroughly than
without it.
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Scaling and Root Planing
◦ It is better to perform a thorough scaling and root
planing on a smaller area than to scale a larger area
superficially – you will usually have to come back
and rescale
◦ When patients are late, do not try to provide the
entire procedure scheduled
 Rewards the patient for being late
 Very frustrating to do an optimal job in a sub-optimal
amount of time
◦ Sometimes you can’t get all the calculus without a
surgical flap
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Pharmacotherapy ◦ Chlorhexidine
 Reduces plaque, gingival inflammation and bleeding
 Selected conditions
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Acute conditions – acute necrotizing ulcerative gingivitis
Disabled patients with difficulty with OHC
Immunocompromising conditions
Severely debilitating systemic disease
Overt residual gingival inflammation and bleeding after
scaling and root planing
◦ Systemic antibiotic therapy
◦ Site-specific antibiotics
 When a few isolated deep pockets have been unresponsive to
initial S and RP
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Post-Initial Therapy Evaluation (Perio Re-Eval)
◦ 6-8 weeks after the completion of SRP
 The patient should have effective hygiene program
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Review the health history
Complete re-evaluate of the gingival condition
Compare with the pre-treatment evaluation
Determine the effectiveness of treatment
Develop plan for future periodontal therapy
 Interval until maintenance visit
 Perio surgery
 Should definitive treatment phase begin
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In the disease control phase there are three
options:
1. Irreversibly compromised tooth
• Root canal treatment
• Provisional restoration of tooth – usually with
foundation restoration (core build-up, post and core)
2. Initial restorative treatment for conditions, which
may if untreated lead to loss of pulp vitality
• Decay, fractured teeth, recurrent decay, missing
restorations
3. Opportunity for conservative pulp treatment
(direct or indirect pulp capping) with definitive
diagnosis following
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Thorough evaluation of the tooth and
periapical areas (endodontic testing) is
important before restoring the tooth
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Healthy Pulp or Reversible Pulpitis
◦ Caries, fracture or defect is of moderate depth and
the pulp is not exposed
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Treatments
◦ Direct-fill restoration
 Base or liner is usually not warrented
◦ Adhesive material (glass-ionomer cement or resin
hybrid) can be used as “bandage”
 When time does not permit permanent restoration
 Allows confirmation of pulp health
 Necessitates future visit to for final restoration
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Healthy Pulp and Periapical Area or Reversible
Pulpitis
◦ Caries, fracture or defect is in close proximity to the
pulp
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Two schools of thought
1. Total caries removal and final form preparation. If
the pulp is encountered in this process, extraction
or root canal treatment are recommended.
 Compromised pulp =  likelihood of necrosis
 Force the issue – do RCT
 Better sooner than later – calcified canals less likely and
outcome more predictable.
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Two schools of thought
2. Additional caries removal and preparation should
be minimal and should avoid areas where pulpal
encroachment is likely, even if affected dentin
remains between the indirect pulp capping
material and the pulp.
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The pulp has a reasonable likelihood of survival
Indirect pulp cap has generally favorable prognosis
If successful, root canal therapy or extraction is avoided
If unsuccessful, root canal therapy can still be attempted,
although with slightly poorer prognosis
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Sometimes go for the RCT
◦ Key tooth is involved and the overall prognosis
depends on it’s retention
◦ It is imperative to do the root canal, if needed,
before restoration of the tooth
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Sometimes use the pulp-cap
◦ Patient is unwilling or unable to accept root canal
treatment if necessary, and the tooth would have to
be extracted
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Sometimes either
◦ Engage the patient in a discussion with benefits and
risks involved with each.
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Reversible Pulpitis or a Healthy Pulp and Healthy
Periapical Area
◦ The pulp is exposed.
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Treatment options
◦ Direct pulp cap is indicated:
 Small mechanical pulp exposures
 Tooth with healthy pulp and periapical area
 Tooth is treatment planned for direct fill intracoronal
restoration
 Larger mechanical or carious pulp exposure
 Patient cannot decide on a path of treatment
 Tooth is to be extracted at a future date
 Establish time frame and emphasize future problems
◦ Informed consent if very important
◦ The tooth should be monitored indefinitely
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Irreversible Pulpitis or Necrotic Pulp
◦ Definitive treatment is required!
 Extraction or root canal therapy
 Pulp capping is contraindicated
 Pulpotomy or Partial pulpectomy should ONLY be
considered if the doctor cannot execute a complete
pulpectomy or extraction.
 The patient must understand that this is NOT definitive
treatment.
kokkinosmileclinic.com
“Baby” root canal
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“Mini root canal”
First step of the root
canal procedure
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Patient DECLINES
treatment for
Asymptomatic Apical
Periodontitis, Cyst or
Granuloma
◦ If the patient is
immunocompromised,
allowing chronic apical
infection to persist is
inappropriate and
unacceptable
◦ If the patient has normal
host response, it is
appropriate to re-evaluate
the lesion at specified
periods to determine if the
lesion increases in size.
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Tooth (no RCT is necessary)
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Tooth – crown required
◦ Direct fill restoration
◦ Core or crown build-up (direct-fill material) is placed in the
Disease Control Phase, the crown in Definitive Phase
 Substructure for the crown
 Interim (temporary) restoration
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Tooth – compelling esthetic concern
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Tooth having received root canal treatment
◦ Crown may be placed in disease control phase
◦ An effective seal between oral cavity and root canal filling is
required
◦ Direct-fill core/build-up is placed
◦ Provisional post and core
◦ Definitive post and core
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Occlusal reduction (without root canal
treatment or crown)
◦ Can be done in Disease Control
◦ Allows determination if there will be sensitivity
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RCT and Crown Planned
◦ RCT - Disease Control
◦ Core/Build-up in Disease Control
◦ Crown in Definitive Treatment Phase
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Crown without RCT
◦ Definitive treatment
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Exposure and forced eruption
◦ Begin as early as possible to determine the outcome
by the time definitive treatment begins
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Extraction
◦ Disease control – so definitive treatment is not
delayed
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