1. Lecture 5: Disease Control Phase
ODRP 726
Patient Diagnosis and Treatment Planning

2. How comprehensive should the treatment plan be?

3. How comprehensive should the treatment plan be?
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
The finalized treatment plan will contain all treatment procedures
The dentist is sure that there will only be minor changes in treatment plan

4. Simple case

5. How comprehensive should the treatment plan be?
Often a patient’s treatment includes much uncertainty
Patients want to know all that will be involved in rehabilitating their oral condition

6. How comprehensive should the treatment plan be?
Too much unpredictability is involved to finalize overall treatment plan when extensive problems are involved
Which teeth are restorable?
Which teeth will need endodontic treatment?
Will periodontal treatment be successful?
Will the patient commit to perio surgery if needed?

7. How comprehensive should the treatment plan be?
Disease
Control 
Phase
Definitive
Phase 
Unknown restorability
Unknown endo needs Unknown perio outcomes
 Changes in Tx Plan +
 Chances for Patient Confusion
Disease control only

8. How comprehensive should the treatment plan be?
Disease
Control 
Phase
Definitive
Phase 
Unknown restorability
Unknown endo needs Unknown perio outcomes
 Changes in Tx Plan +
 Chances for Patient Confusion
All phases can be included

9. Comprehensive Tx Plan? 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

10. Comprehensive Tx Plan?
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

11. Comprehensive Tx Plan?
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

12. Disease Control Goals Control active oral disease and infection
Stop occlusal and esthetic deterioration
Manage risk factors
Periodontal therapy, endodontic therapy, extractions, operative treatment to eradicate caries

13. Disease Control Phase Objectives
Particularly valuable when the dentist is uncertain about:
Disease severity
Outcome of disease control
Patient commitment to treatment
Some teeth may receive only palliative treatment – until perio treatment is complete
Patient may enter a holding period and not proceed to definitive disease

14. Disease Control Phase: Communication
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
Establish clear, specific, quantifiable standards for success (outcomes measures)
Target plaque score
Target bleeding score

15. Disease Control Phase: Communication
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
Delineate the steps to be implemented when the patient does or does NOT meet the standards for success

16. Mrs. S 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

17. Mrs. S

18. Mrs. S

19. Mrs. S
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

20. Let’s review Mrs. S 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

21. Mrs. S

22. Mrs. S

23. Mrs. S What are all the treatment options?
What are realistic expectations for treatment outcomes?

24. Mrs. S
What could be quantifiable standards for success post disease control phase?

25. Sequencing the Disease Control Phase
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.
What would you treat first?

26. Sequencing the Disease Control Phase
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?

27. Sequencing the Disease Control Phase
Sequence by quadrant or sextant
It is most efficient and productive to restore all carious teeth in the same area at the same time

28. Sequencing the Disease Control Phase
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

29. Sequencing the Disease Control Phase
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

30. Sequencing the Disease Control Phase
Minimalist treatment
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

31. Dental Caries Overall management Comprehensive caries diagnosis
Assessment of caries risk
Basic caries intervention protocol for patients with active lesions or those who are at risk for developing new lesions
Supplemental caries intervention protocol to address specific needs of those requiring additional measures or the patient who remains caries active
Maintenance and re-evaluation at appropriate intervals to identify new lesions and re-evaluate the risk for future caries activity

32. Caries Control 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

33. Caries Control Protocol
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
Comprehensive, organized plan designed to:
Arrest or remineralize early carious lesions
Eradicate overt carious lesions
Prevent the formation of new lesions

34. Periodontal Disease The Reality
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

35. Treatment of Active Periodontal Disease
Systemic considerations
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
Lessening the force or intensity

36. Treatment of Active Periodontal Disease
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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37. Treatment of Active Periodontal Disease
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
dental--health.com

38. Treatment of Active Periodontal Disease
Of or related to medical examination or treatment
Elimination of iatrogenic restorations and open carious lesions contributing to periodontal disease – complete BEFORE scaling and root planing
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)
Open margins
Open contacts
Overhangs
Poor contours

39. Treatment of Active Periodontal Disease
Manage other dental problems that contribute to periodontal disease
Acute occlusal trauma from significant occlusal interferences

40. Treatment of Active Periodontal Disease
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.

41. Treatment of Active Periodontal Disease
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

42. Treatment of Active Periodontal Disease
Pharmacotherapy -
Chlorhexidine
Reduces plaque, gingival inflammation and bleeding
Selected conditions
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

43. Treatment of Active Periodontal Disease
Post-Initial Therapy Evaluation (Perio Re-Eval)
6-8 weeks after the completion of SRP
The patient should have effective hygiene program
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

44. Pulpal and Periapical Disease
In the disease control phase there are three options:
Irreversibly compromised tooth
Root canal treatment
Provisional restoration of tooth – usually with foundation restoration (core build-up, post and core)
Initial restorative treatment for conditions, which may if untreated lead to loss of pulp vitality
Decay, fractured teeth, recurrent decay, missing restorations
Opportunity for conservative pulp treatment (direct or indirect pulp capping) with definitive diagnosis following

45. Pulp and Periapical Disease
Thorough evaluation of the tooth and periapical areas (endodontic testing) is important before restoring the tooth
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intelligentdental.com

46. Pulp and Periapical Disease
Healthy Pulp or Reversible Pulpitis
Caries, fracture or defect is of moderate depth and the pulp is not exposed
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

47. Pulp and Periapical Disease
Healthy Pulp and Periapical Area or Reversible Pulpitis
Caries, fracture or defect is in close proximity to the pulp
Two schools of thought
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.

48. Pulp and Periapical Disease
Two schools of thought
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.
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

49. Mechanical pulp exposure
dentalindia.com

50. Carious pulp exposure
dentaljuce.com

51. Which approach is better?
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
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
Sometimes either
Engage the patient in a discussion with benefits and risks involved with each.

52. Pulp and Periapical Disease
Reversible Pulpitis or a Healthy Pulp and Healthy Periapical Area
The pulp is exposed.
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

53. Pulp and Periapical Disease
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.

54. Pulpotomy: only the pulp from the chamber is removed
kokkinosmileclinic.com
“Baby” root canal
contempclindent.org

55. Pulpectomy: all pulp (from chamber and roots) is removed
smilewinnipeg.dentistryonline.com
“Mini root canal”
First step of the root canal procedure
saugusdental.com

56. Pulp and Periapical Disease
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.

57. Single Tooth Restoration in the Disease Control Phase
Tooth (no RCT is necessary)
Direct fill restoration
Tooth – crown required
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
Tooth – compelling esthetic concern
Crown may be placed in disease control phase
Tooth having received root canal treatment
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

58. Supererupted Tooth Extending into Opposing Edentulous Space
Occlusal reduction (without root canal treatment or crown)
Can be done in Disease Control
Allows determination if there will be sensitivity
RCT and Crown Planned
RCT - Disease Control
Core/Build-up in Disease Control
Crown in Definitive Treatment Phase
Crown without RCT
Definitive treatment

59. Impacted Tooth (other than 3rd molar)
Exposure and forced eruption
Begin as early as possible to determine the outcome by the time definitive treatment begins
Extraction
Disease control – so definitive treatment is not delayed
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periodontist.org

60. Questions?