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Chapter 3

Patient Goals and Desires:

Resolution of the chief complaint (relieve pain, repair broken teeth)
Maintain oral health
Keep teeth for a lifetime
Stay free from pain
Replace teeth for more comfortable eating
Extract all teeth and replace with dentures
Patient modifiers:
Negative Patient Modifiers
Inadequate time for treatment
Inadequate financial resources

Fear of dental treatment

Lack of motivation
Poor oral health
Diet high in refined carbohydrates
Destructive oral habits
Poor general health

Positive Patient Modifiers

Interest in oral health
Ability to afford treatment- which is dependent on:
Patients financial resources
Level of immediate care necessary
Types of procedures proposed
Feasibility of postponing care
Availability of third party assistance
History of regular dental care

Dentist Goals and Desires

Remove or arrest dental disease
Eliminate pain
Determine the correct treatment for each problem
Treat the most severe problems first
Choose the best material
Provide ideal treatment plan for patient
Modified treatment plan = balances the patients treatment objectives with those of the dentist.
Dentist Modifiers
1. The dentists level of knowledge and experience
2. Technical Skills
3. Treatment planning philosophy
Key teeth the important or key teeth that can be salvaged
1. Retaining key teeth improves the prognosis for other teeth or the case as a whole.
2. Serve as abutments for fixed and removable dentures adds stability to a dental prosthesis
3. Characteristics
a. Periodontally stable
b. Favorably positioned in the arch
i. At least canines and one molar
c. Have not moved excessively out of position
d. Restorable

Textbook phases
Systemic phase: Evaluation of patients health
Acute phase: resolve symptomatic problems
Disease control phase: control active oral disease
Definitive treatment phase

Maintenance phase

LLUSD phase
Phase 1: Patient assessment, diagnosis and treatment
planning ) includes Systemic Phase
Phase 2: Acute problems + periodontal treatment
Phase 3: Disease Control endodontic therapy, oral
surgery, direct restorations
Phase 4: Orthodontic therapy
Phase 5: Single unit restorations, fixed partial dentures,
implant placement and restoration
Phase 6: Removable partial dentures, complete dentures
Phase 7: Treatment complete exam and plans for

Treatment planning for patient with mild disease.

Phase 1:
Comprehensive oral evaluation (including health assessment Systemic), Perio Diagnosis
Disease Control Phase and Definitive Treatment Phase are combined.
Phase 2:
Periodontal treatment
Phase 3:
Restore broken, unesthetic restorations, build-ups as needed, small to moderate caries, root canal
treatment and build-up
Phase 4:
Orthodontic treatment
Phase 5:
Crowns, fixed partial dentures, implants
Phase 6:
Removable partial denture, complete denture
Phase 7:
Treatment complete exam plans for Maintenance Phase

Treatment planning for patient with moderate to severe disease.

Phase 1:
Comprehensive oral evaluation (including health assessment Systemic), Perio Diagnosis
Disease Control Treatment Plan
Phase 2:
Treatment of Acute problems if present symptomatic teeth (Acute Phase)
Periodontal treatment procedures
Phase 3:
Disease Control Phase procedures extractions, temporary or permanent direct restorations, root
canal therapy.
Phase 7:
Treatment complete examination post-treatment assessment and determination of the next step
1. Poor response to treatment continue in disease control and no advancement to Definitive
2. Good response to treatment move on to Definitive Treatment Phase
Definitive Treatment Plan
Phase 2:
Advanced periodontal therapy
Phase 3:
Definitive restoration of individual teeth direct restorations (if temporary restorations were placed)
Elective extraction of asymptomatic teeth
Elective root canal treatment of asymptomatic teeth (that you wouldnt treat if the patient will not
move on to complete the definitive treatment plan.
Stabilize occlusion
Bleaching of teeth
Phase 4:
Orthodontic treatment
Phase 5:
Placement of implants
Indirect single unit restorations
Fixed partial dentures
Implant pontics
Phase 6:
Removable partial dentures, complete dentures
Phase 7:
Treatment complete exam post-treatment assessment and development of maintenance plan
(Maintenance Phase)

Chapter 7: The Disease Control Treatment Plan (The Disease Control Phase of Treatment)
1. To eradicate active disease and infection
2. To arrest occlusal, functional and esthetic deterioration
3. To address, control or eliminate causes and risk factors for future disease
Structuring the Disease Control Treatment Plan
1. Address the patients chief concern as quickly as possible
2. Sequence by priority
3. Sequence by quadrant/sextant
4. Integrate periodontal therapy with caries control in the same quadrant/sextant
5. Keep definitive phase options open with minimalist treatment (dont spend a lot of time and money on teeth
that might not be retained)

Common Disease Control Problems

A. Dental Caries
a. Caries Control: Any and all efforts to prevent, arrest, remineralize or restore carious lesions
b. Caries Control Protocol: A comprehensive organized plan designed to arrest or remineralize early carious
lesions, to eradicate overt carious lesions, to prevent the formation of new lesions in an individual who
has a moderate or high rate of caries formation or is at significant risk for developing caries in the future.
c. Objectives:
i. Eliminate the nidi of infection
ii. Reduce the microbial load of pathogenic bacteria
d. Strategies
i. Plaque elimination
ii. Limit refined carbohydrate and acid exposure
iii. Provide fluoride exposure
e. Caries control protocol must address all indicated parts of the caries cycle:
i. Tooth resistance
ii. Saliva
iii. Plaque
iv. Bacteria
f. Determination of the patient-specific cause of increased caries risk is imperative
i. Systemic
ii. Oral home practices
iii. Dietary issues
iv. Salivary pH

g. Disease control procedures for caries/caries risk

Oral prophylaxis
Oral self-care
Pro fluoride gel
frequency/duration of
acid/CHO exposure
OTC fluoride
Restore carious lesions

Sealants on susceptible
Custom home fluoride
Prescription dentrifice or
fluoride gel
Xylitol products

Tooth resistance
receptivity to




Reduces substrate for
cariogenic bacteria
Less acid-induced
dissolution of tooth
Antimicrobial effect

Remineralized tooth


Eliminates nidus of
infection, improves
cleansibility, arrests
progression of caries
Eliminates sites of


Does not cause
decrease in pH

Chlorhexidine rinse
Baking soda rinse

Removes plaque

Decreases plaque

Eliminates substrate
for cariogenic bacteria
Starves bacteria
Reduces microbial

Low buffering
Low pH saliva
Salivary substitutes

B. Periodontal Disease
a. Control and elimination of the important causes and risk factors for periodontal disease
i. Local factors
ii. Heredity
iii. Systemic factors and immunoinflammatory response
iv. Tobacco use
v. Deleterious habits
vi. Defective restorations
vii. Occlusal trauma
b. Treatment of active periodontal disease
i. Initial therapy
1. Oral self-care instructions and determination of specific areas of difficulty for patient
2. Extraction of hopeless teeth
3. Elimination of iatrogenic restorations and open carious lesions contributing to
periodontal diseases
4. Scaling and root planing
5. Limited occlusal adjustment
6. Pharmacotherapy
7. Post-Initial Therapy Evaluation (Perio Re-Eval)

C. Pulpal and periapical disease

a. Conservative procedures
i. Direct or indirect pulp cap
b. Endodontic evaluation (vitality testing) for the following:
i. Deep carious lesions
ii. Fractured, leaking or missing restorations
iii. Teeth that have had major fractures
iv. Possible cracked tooth syndrome
v. Large restorations in close proximity to the pulp
vi. Non-carious tooth loss approximating the pulp
vii. Periapical lesion
viii. Pain to hot/cold, biting or spontaneous pain
ix. Inadequate root canal fillings (short, poor filling)
c. Definitive root canal therapy and definitive restoration (build-up, not crown) OR Extraction
d. Pulpal problems and their treatment
Pulp status

Reversible pulpitis
Healthy pulp
Reversible pulpitis
Healthy pulp

Depth of
Moderate depth






Place direct-fill restoration

Place adhesive material as bandage over site
Total caries removal & final form of prep if pulp exposure, then
endodontic therapy or extraction is required use when tooth
requires crown or if it is a KEY tooth. OR
Minimal additional caries removal or preparation, avoid pulpal
encroachment; OK to leave area of affected dentin and indirect
pulp cap. Monitor at specified intervals and endo/extract if
irreversible pulpitis or necrosis occurs. Use if tooth would be
Direct pulp cap and direct restoration IF no large carious
exposure or excessive bleeding or pus; preferable if mechanical
or small carious pulp exposure with healthy pulp and periapical
area. Ongoing monitoring. Use if tooth would be extracted.
RCT if tooth will have crown or is a KEY tooth.
Definitive pulpal therapy with root canal treatment OR

Close proximity
to pulp


Reversible pulpitis
Healthy Pulp



Necrotic pulp
Pulpless tooth

Yes OR

Healthy OR

Root canal therapy IF patient is immunocompromised or a

restoration is planned for the tooth. If patient is healthy and no
treatment is required, re-evaluate at specified intervals for
increase in lesion size.

D. Single tooth restoration

a. No root canal therapy required
i. Direct-fill restoration
ii. If tooth requires a crown, place a core build-up until definitive treatment plan
b. If root canal therapy is required
i. Definitive restoration is required in Disease Control Plan but NOT crown. Do post or core and
build-up only.
ii. Provisional (temporary) crown can also be placed if there is inadequate tooth structure.

E. Stabilization of dental malalignment, malocclusion, occlusal disharmony usually in definitive treatment plan.
HOWEVER, the following problems can be treated in the Disease Control Treatment Plan
a. Food impaction and periodontal disease from:
i. Plunger cusp recontour cusp
ii. Open contact direct fill restoration
iii. Marginal ridge discrepancy recontouring of the high tooth or replacement of the direct
b. Generalized occlusal trauma
i. Comprehensive occlusal adjustment after periodontal therapy
ii. Provisional splinting
c. Localized occlusal trauma
i. Individual teeth with gross discrepancies causing aberrant excursive patterns in eccentric jaw
movements causing occlusal trauma
1. Should be eliminated in the disease control treatment plan
2. Selective occlusal adjustment and removal of premature contacts or excursive
movement interferences
d. Supraerupted tooth into opposing edentulous space
i. Conservative treatment occlusal reduction WITHOUT root canal therapy or cast restoration
ii. If needed, root canal treatment should take place in disease control treatment plan
iii. Orthodontic intrusion should wait until definitive treatment plan
e. Impacted tooth other than a third molar
i. Should be treated in disease control
1. Forced eruption
2. Extraction
f. Decreased vertical dimension of occlusion
i. Decision: should bite be opened or not? Should be made in disease control treatment plan
ii. VDO should be opened
1. Patient cant afford it treatment should be planned without it
2. Patient can afford it refer to prosthodontist for reconstruction
F. TMJ Disorders
a. Reducing anterior disc displacement
i. Treatment: Avoid re-injury, NSAIDs for pain control, splint therapy
b. Nonreducing anterior disc displacement
i. Treatment: Avoid re-injury, NSAIDs for pain, soft diet and voluntary limitation of opening
ii. No response refer
c. Degenerative joint disease osteoarthritis
i. Treatment: NSAIDs for pain, soft diet, splint therapy
d. Myalgia
i. NSAIDs, muscle relaxants, antidepressant therapy, splint therapy
G. Replacement of missing tooth or teeth
a. Temporary (provisional) removable partial denture
b. Bonding the crown of extracted tooth into the new space
Disease control treatment plan sequencing
Symptomatic restorable/non-restorable
Periodontal therapy
Asymptomatic restorable severe
Asymptomatic non-restorable
Asymptomatic restorable - moderate/mild

Symptomatic the tooth is bothering the patient RCT, extraction, direct restoration
Non-restorable (root tips, severe periodontal disease, inadequate biologic width)
Severe problem restorable but we need to stop the disease progression before it starts to
bother the patient or require more extensive treatment D3 caries, missing restoration
Asymptomatic non-restorable the tooth isnt bothering the patient, but it cant be saved
due to caries, perio
Asymptomatic restorable the tooth isnt bothering the patient, and it can be saved.

Chapter 8: The Definitive Treatment Plan (The Definitive phase of treatment)

A. Advanced Periodontal Therapy
a. Periodontal disease and related conditions
i. Periodontitis not responsive to initial therapy
ii. Localized infrabony defects
iii. Furcation involvement
iv. Root proximity
v. Congenital or medication-induced gingival overgrowth
vi. Mucogingival conditions
vii. High frenal attachment
viii. Esthetic and architectural defects or problems
b. Treatment procedures
i. Periodontal surgery
ii. Placement of antimicrobial-impregnated fibers, cords or gels
iii. Bone regenerative and replacement therapy
c. Keys to decision making
i. Professional modifiers what the dentist should evaluate
1. Importance of relevant systemic factors
a. Immunocompromised
b. Smoker
c. Medications
2. Tooth related issues
a. Open contact, poorly contoured restoration
b. Importance of the tooth to the overall oral condition
3. Localized periodontal factors
4. Level of patient cooperation
5. Level of oral self-care
6. Prognosis for treatment options
ii. Patient modifiers
1. Healthy lifestyle?
2. Tobacco use
3. Understanding of the importance of proposed treatment
4. Motivation, can the patient be motivated?
5. Patient discomfort related to condition
6. Personal reasons for the patient to have the treatment (esthetics, halitosis)
7. Willing to undergo extraction of hopeless teeth
8. Inconvenience, stress, post-operative discomfort of a surgical procedure
9. Financial resources
10. Willingness to follow through with maintenance
B. Restoring Individual Teeth see treatment by condition p.192
Pit and Fissure Sealant

Enameloplasty followed by
sealant/flowable resin
Composite Resin

Susceptible pits and fissures
Restore/resurface shallow incipient lesions
Low caries activity, low risk for new caries
Tooth can be monitored for loss of sealant
Uncertainty whether caries is in the dentin


Excellent color matching characteristics

Easy to use

Technique sensitive vs. amalgam
Difficult to detect caries radiographically

Glass Ionomer


Inlay intracoronal,

Tooth colored
Fluoride release
Bonds to dentin and enamel
Direct fill for large carious lesions
High risk caries
Difficult to isolate tooth
Can be used as temporary restoration
Replace missing cusps
Build-up material for core after RCT
Easy to handle
Strong, durable
Resistant to fracture /marginal leakage
Long service life
Where operator visibility is compromised or isolation of
the tooth is a problem
Deep subgingival margins
High caries risk patients
Composite/porcelain excellent esthetics
Increased resistance to abrasion /occlusal wear compared
to direct-fill composites
More precise contacts/occlusion than direct restoration

High caries risk patients

More prone to fracture & wear then
Limited shades
More opaque

Color doesnt match tooth

Additional tooth structure may have to be
removed for adequate retention

Increased chair time, cost, technical


Onlay indirect, covers one

or more cusps

Strengthen tooth weakened by caries, tooth fracture

previous large restoration
Provides excellent protection against fracture
Porcelain onlays better esthetics
More precise contacts/occlusion than direct restoration

Tooth preparation is challenging

Two appointments
Porcelain more prone to fracture than gold

Crown - indirect

Provides protection for the tooth that has been severely

compromised by caries or fracture
More precise contacts/occlusion than direct restoration
PFM & all-porcelain good esthetics
Gold provides better margin, less chance of fracture, less
tooth removal than PFM/all porcelain
Technically easier than onlay

More tooth structure will need to be




C. Cosmetic Dentistry
Contouring teeth
Vital bleaching
Non-vital bleaching

Porcelain fused to metal


Remove intrinsic enamel discolorations/defects

Conservative, little tooth structure removed
For fractured, chipped, extruded, overlapped teeth
In-office bleaching more immediate results
At-home 6-8 weeks
Discolored tooth that has had endodontic treatment
Improve esthetics by changing color, contour, size of tooth
Direct (composite) or indirect (composite or porcelain)
More conservative than PFM or full porcelain
Porcelain indicated with extreme enamel discoloration,
stable in color, strong, resists staining
Close diasthemas
Insufficient tooth structure to support veneer
All porcelain is more translucent, lifelike
PFM is stronger, less likely to fracture (more likely to
fracture than all gold)
PFM with working cusps in metal is good for bruxing,
PFM requires less tooth reduction than PFM.
PFM can have metal margins, better adaptation

Hypersensitive teeth
Thin enamel
Risk of pulpal sensitivity to hot/cold
Tetracycline stain not as responsive
Relapse can occur
Contraindicated when tooth has been
heavily restored
Patient with Class III and end to end bite
Bruxism or pencil chewing
High level technical skill

All porcelain is more fragile, less likely to

fracture in patient with aggressive
bite/clenching/bruxing habit.
All porcelain requires more extensive tooth
reduction than PFM

D. Elective (nonacute) endodontic problems

a. Teeth that have deep or large restorations
b. Teeth that have had direct or indirect pulp capping
c. Severely broken down tooth, inadequate remaining coronal structure for crown, with prefabricated or
cast post and build-up
d. Teeth that will be devitalized in the process of overdenture construction to become overdenture
e. Supererupted teeth that are likely to be devitalized in the process of altering occlusal plane
f. Re-treatment of a failing root canal filling
i. When the tooth is symptomatic
ii. Clinical or radiographic signs of ongoing or recurrent infection
iii. Systemic health conditions that could result in health risk if left untreated
iv. If problems will arise if the tooth is left untreated
v. If the tooth requires a new crown or will be an abutment for fixed or removable partial denture
g. Extraction due to failing root canal filling
i. Vertical root fractures
ii. Severely debilitated health (ASA IV)
iii. Patient unwillingness to re-treat
h. You can wait and see with a failing root canal filling (periapical signs of inflammation & chronic infection)
i. Tooth is asymptomatic
ii. Tooth does not require extensive restoration
iii. Patient is systemically healthy and not at risk for systemic infection
iv. Patient is fully aware of consequences of no treatment
v. Re-evaluate at specified intervals
i. Treatment for Nonacute endodontic problems
i. Root canal therapy
ii. Root canal therapy re-treat
iii. Apical surgery
1. Indicated when conventional root canal therapy has been unsuccessful
2. Canals are calcified
3. Irretrievable cemented post
j. Keys to decision making:
i. Remember: Not all teeth should have endodontic therapy (non-functional, 3rd molar)
ii. Is the tooth in a functional position? Is it in occlusion?
iii. Can the tooth be restored?
1. How much tooth loss near the level of alveolar bone? Inadequate biologic width? Is
crown-lengthening possible? If yes, will it diminish the bone support?
2. Is there caries involvement into the furcation areas?
3. Poor crown: root ratio
4. Poorer prognosis
a. Dilaceration of roots
b. Calcified canals
c. Poor access for endodontic treatment
iv. Final restoration must be placed as soon as possible to prevent further breakdown of the tooth.

E. Extractions and Preprosthodontic surgery

a. Extractions
i. Indications
1. Hopelessly compromised teeth from restorative or periodontal standpoint
2. Salvageable, but patient does not have the time, financial resources, motivation
3. Tooth would not be satisfactory abutment to support prosthesis
4. To provide space for ortho treatment
ii. Common complications of extractions
1. Bleeding
2. Postoperative pain
3. Dry socket
4. Infection
b. Asymptomatic third molar extraction
i. Indications
1. Healthy patient aged 19-25 whose impacted third molars have caused repeated
episodes of pericornitis
2. No reasonable prospect for the 3rds to become properly aligned and fully functional and
patient wants to stave off future problems
3. Third molars that have poor perio or restorative prognosis and patient is not motivated
to retain
4. When the risk of future complications or problems in the presence of the 3rd molars is
high (caries, periodontal disease, pericornitis)
ii. Contraindications
1. The possibility of surgical complications is high (paresthesia, fracture, dry socket,
2. Reasonable probability that it will be needed in the future as an abutment, anchor for
ortho treatment, or to maintain occlusal plane
3. Loss of the third molars will compromise the patients occlusion, function, mastication
c. Preprosthodontic surgery to provide more optimal situation for replacement of teeth.
i. Exophytic soft tissue
ii. Bulbous tuberosities
iii. Exostoses and tori
iv. Ridge augmentation procedures
v. Surgical procedures associated with implant placement
1. Bone grafts in site with deficient quality and quantity of bone (4-6 months before
implant fixture placement)
2. Sinus floor is in inferior position sinus floor elevation (sinus lift procedure) 4-6
months before fixture placement.
F. Replacing missing teeth
a. Required information
i. Which teeth are missing?
ii. Have the adjacent or opposing teeth moved out of position? If so, how? (important for implant
or FPD)
1. Supererupted opposing tooth decreases the O-G space
2. Tipped, rotated, drifted adjacent teeth affect the M-D space available
iii. Width and height of bony ridge (Important for implant)
1. Implants need 9-10 mm of space mesiodistally (M-D)
2. Implants need 6-7 mm of bone facial-lingually (F-L)
3. Implants need 7 mm of occlusal gingival (O-G) space for the crown
4. If there is moderate to severe bone loss a bone graft is needed
5. If there is inadequate maxillary ridge due to pneumatization of the ridge, a sinus lift
procedure is needed

6. Be sure that the mandibular canal and mental foramen are not in the area where the
implant is to go there should be at least 2 mm of space between these structures and
where the implant is to be placed.
iv. What is the status of adjacent teeth (Important for FPD)
1. Periodontal, dental restorations/pathology, pulp status, oral hygiene
2. Crown root ratio
3. How much space is available for the replacement? For FPD 4-5 mm of O-G space is
v. Risks if the tooth is not replaced
1. Supraeruption/tipping of opposing teeth leading to increased risk for caries/perio
2. Decreased oral function
3. Loss of vertical dimension of occlusion
4. Collapse of remaining dentition
vi. Solutions to problems with implants
Inadequate bone density or volume
Insufficient mesial-distal tooth replacement width
Inadequate interarch space
Inadequate ridge
Deficient soft tissue contours

bone graft procedure

orthodontic treatment
orthodontic treatment, tuberosity reduction, open
ridge augmentation procedure
Periodontal surgery


Replacement of Missing Teeth See Table 8-6

Implant supported single crown

Improved function
Preservation of remaining teeth and bone
Increased stability and longevity of the
Realistic/esthetic appearance
Easier for the patient to clean and maintain

Implant supported FPD

Fewer pontics, more retentive units

Implants + natural tooth FPD requires
telescoping copings on natural abutments
Fixed metal-ceramic minimal bone loss
and minimal missing soft tissue contours
More stable and retentive than
conventional CD
Less food entrapment, no need for relines,
rebases or denture adjustment
Greater longevity
Functions more like natural teeth
Edentulous patient with severe bone
Facial esthetics enhanced by the labial
Removal at night facilitates cleaning
Fewer implants required less expensive
Replacement teeth are fixed in place
Provides a stable and natural-appearing
alternative to a removable prosthesis
Good esthetics, function, preservation of
arch form
Patients who are not good candidates for
Sufficient abutment support
Prime indication: Patient whose abutment
teeth are heavily restored
Provides a certain level of esthetics and
Cost/tooth replaced with RPD decreases
with more teeth replaced with an RPD
(compared to implant or fixed partial
Prime indication: multiple missing
Easy to fabricate and repair
Provide a level of esthetics and function
acceptable to many patients
Overdenture abutments (usually canines
treated with RCT and attachment) help with

Implant supported Fixed

complete denture

Implant supported overdenture

Fixed partial denture

Removable partial denture

Complete dentures

Length of healing period
One or more surgical procedures
Two step procedure:
8 weeks from extraction to implant placed
3 months following implant placement
Immediate placement after extraction
Eliminates 8 week healing period
Immediate loading after appliance placement
Eliminates 3 month healing period

Required time and effort
Necessity for surgery

Removable prosthesis which attaches to the

Requires more vertical height than
conventional denture or implanted retained
fixed complete denture
More difficult to keep plaque free
Abutment teeth may be compromised
Span too long
Insufficient abutment support
Requires full crown coverage of abutments

Must be removed for cleaning

Esthetics compromised due to clasps
Abutment teeth are at risk for
caries/periodontal disease
Significantly reduced function when compared
with natural teeth, FPD or implant-retained

Lack of denture retention

Loss of chewing ability
Retained overdenture abutments are
vulnerable to caries/periodontal disease