Non pharmacological

1. Tell show do

• Tell – Explain procedure with age appropriate language
• Show – Demonstrate procedure
• Do – Perform procedure

Communication should be gentle, addressing the child. Use euphemism (eg. call LA “sleeping juice”, rubber dam “umbrella”) and smile. Have positive reinforcement.

2. Behavior modelling – Show other children getting procedures and how they behave

3. Distraction – Music, videos, virtual reality

4. Relaxation therapy – Relaxation exercises to do at home

5. Systemic desensitization – Present the procedure in a graduated fashion to reduce anxiety

6. Hypnosis – Altered state of consciousness to produce desirable behavior

7. Aversive techniques: Must obtain parent consent, informed consent, document indication and duration. Should be legal in country of practice and be used with extreme caution.

• Hand over mouth – and explain in child’s ear. Contraindicated in children below 3 and special health care needs
• Protective stabilization – can cause physical and psychological harm. Active is by dental team, passive is by protective devices
• Voice control – Changing volume, speed or tone of voice to get child’s attention

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Pharmacological

• Nitrous oxide
• Conscious sedation
• General anesthesia

Factors when prescribing

• Safety
• Efficacy
• Affordability
• Availability
• Route of admin
• Frequency

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How to prescribe

1. Formulation of drug: PO, IV, IM, PV, PR

2. Name of drug: Paracetamol, Amoxycillin

3. Dosage: mg, g, avoid decimals

4. Frequency: OD, BD, TDS, Nocte, PRN (state minimum dose interval in PRN)

5. Duration: 5/7, 2/52, 3/12

Eg. PO Augmentin 625mg BD x 5/7

• 1-5 years: 1/4 of adult dose
• 6-12 years: 1/2 of adult dose

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Calculating Drug dosage

The Reference Manual of Pediatric Dentistry – Useful Medications For Oral Conditions

Use the app Dental Drugs (App store, Play store) to quickly refer for prescribing medications, calculating maximum anesthetic dosages or recalling common treatment/emergency protocols in practice

Bilateral bite wing (BBW)

• Patient head straight so occlusal plane is parallel to the floor
• Bite should be normal
• X-ray central beam:
  • Vertical angulation: +10°
  • Horizontal angulation:
    • Premolar BBW: 30° from mid-sagittal plane, aimed at inner canthus of the eye
    • Molar BBW: 60° from mid-sagittal plane, aimed at outer canthus of the eye

Watch video

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Intraoral periapical (IOPA)

• Identification dot on film always placed towards incisal/occlusal surface of teeth and towards midline
• Vertical angulation at occlusal plane is zero, upward is negative and downwards is positive

Maxilla

• Patient head slightly tilted down so occlusal plane is parallel to the floor

Tooth	Vertical film angulation	X-ray central beam aim
Incisors	+45°	Tip of the nose
Canine	+45°	Canine eminence – distal and inferior borders of ala of nose
Premolars	+30°	Perpendicular to pupil of the eye, film is horizontal
Molars	+20°	Perpendicular to outer canthus of the eye, film is horizontal

Mandible

• Patient head slightly tilted up so occlusal plane is parallel to the floor
• Film must touch floor of the mouth

Tooth	Vertical film angulation	X-ray central beam aim
Incisors	-15°	Tip of the chin
Canine	-20°	Perpendicular to ala of nose
Premolars	-10°	Perpendicular to pupil of the eye
Molars	-5°	Perpendicular to outer canthus of the eye

Watch video

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Orthopantomogram (OPG)

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Other radiograph techniques

Intraoral radiographs

Extraoral radiographs:

Download Medicos Dental Material App on:

• App store
• Play store

This app has instruments, their name and use and tray set ups for all dental procedures

Primary teeth

• Sequence of eruption: A-B-D-C-E

Tooth	Arch	Calcification (Weeks in utero)	Crown completion (Months)	Eruption (Months)	Root completion (Years)
A CI	Max Mand	14	1.5 2.5	10 8	1.5
B LI	Max Mand	16	2.5 3	11 13	2 1.5
C C	Max Mand	17	9	19 20	3
D M1	Max Mand	15	6 5.5	16	2
E M2	Max Mand	19 18	11 10	29 27	3

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Permanent teeth

• Sequence of eruption:
  • Maxilla: 6-1-2-4-5-3-7-8
  • Mandible: 6-1-2-3-4-5-7-8

Tooth	Arch	Tooth germ appearance (IU)	Beginning of crown calcification	Crown calcification complete	Eruption	Root completion
6 M1	Max Mand	16	At birth	2.5-3 years	6-7 years	9-10 years
1 CI	Max Mand	16	3-4 months	3-4 years	7-8 years 6-7 years	10 years 9 years
2 LI	Max Mand	16	10-12 months 3-4 months	4-5 years	8-9 years 7-8 years	11 years 10 years
3 C	Max Mand	18	4-5 months	6-7 years	11-12 years 9-10 years	13-15 years 12-14 years
4 PM1	Max Mand	20	1.5-2 years	5-6 years	10-11 years	12-13 years
5 PM2	Max Mand	22-24	2-3 years	6-7 years	10-12 years 11-12 years	12-14 year
7 M2	Max Mand	1st year	2.5-3 years	7-8 years	12-15 years 11-13 years	14-16 years
8 M3	Max Mand	3rd year	7-9 years 8-10 years	12-16 years	17-24 years 17-21 years	18-25 years

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Common teeth notation systems:

• FDI World Dental Federation notation
• Universal Numbering System
• Palmer notation

Patient positioning when extracting teeth

• Maxillary teeth: 3 inch below shoulder level of operator and 45 degree chair angulation
• Mandibular teeth: At elbow level of operator and 90 degree chair angulation
• 1st, 2nd and 3rd quadrant: Right front of patient
• 4th quadrant anterior teeth: Right front of patient
• 4th quadrant posterior teeth: Behind right side of patient/ just right side

Tooth extraction forceps and elevators

Click here

Tooth extraction techniques

Elevator techniques

Elevators works on principles of:

1. Wedge
2. Lever
3. Wheel and axle
4. Combination of the above

1. Wedge principle

2. Lever principle

3. Wheel and axle

Post extraction steps

• Ensure complete tooth and root removal and confirm by showing to patient
• Inspect socket and remove sharp bony margins – if present smoothen with a file
• Compress expanded socket with digital pressure
• Apply pressure pack
• Prescribe analgesics if needed

Post op instructions for patient

• Bite on pressure pack for 30-60 minutes
• Swallow saliva normally
• Do not rinse or spit for 24 hours
• Do not stick finger or tongue at extraction site
• Drink water and fluids normally, do not use straw
• Do not eat until the effects of anesthesia go away
• Eat soft and cold diet
• Apply cold compression/ice pack for swelling
• After 24 hours use salt water rinse
• Avoid smoking for 5 days

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Indications

1. Gross caries
2. Tooth injury and tooth cannot be salvaged
3. Tooth in jaw fracture line
4. Impacted tooth
5. Pre-prosthetic preparation
6. Orthodontics
7. Supernumerary teeth
8. Associated pathology
9. Severe periodontal disease
10. Retained deciduous teeth
11. Patient preference/economic constraints
12. Preparation for radiotherapy

Contraindications

Local:

1. History of irradiation in that area
2. Lack of cooperation or consent from patient
3. Lack of proper equipment
4. Lack of adequate skill
5. Severe infections – control infection first

Systemic:

1. Severe metabolic disease – uncontrolled DM, renal disease
2. Hepatic dysfunction – decreased coagulative factors
3. Coagulopathies – hemophilia, platelet disorder
4. History of CVD
5. Leukemia
6. Pregnancy
7. Steroid therapy

NB:

• Avoid extraction during menstruation – risk factor for alveolar osteitis

Complications

a. Complication due to injection technique and anesthetic solution:

• Needle brakage
• Failure to work
• Allergy
• Syncope
• Hematoma if in vessel

b. Complication pre-op

• Lack of cooperation, anxiety
• Poor access – trismus, decreased mouth opening, crowded/malaligned teeth

c. Complications during surgical procedure

• Difficulty in luxation – root dilaceration, curvature, hypercementosis
• Soft tissue injury
• Damage to adjacent teeth
• Fracture of mandible, alveolus or tuberosity
• Fractured instrument – eg. needle
• Tooth/root displacement into maxillary antrum – Caldwell Luc approach to remove
• Loss of extracted tooth or root – stop everything and look for it, can do chest xray
• Nerve injury:
  • Neuropraxia – temporary conduction loss
  • Axonotmesis – axon and myelin sheath damaged but epineurium, perineurium and endoneurium intact
  • Neurotmesis – nerve transection
  • Paresthesia – tingling/prickling sensation
  • Dysesthesia – abnormal sensation
  • Hyperesthesia
  • Hypoesthesia
  • Anesthesia
  • Formation of:
    • Phantom limb syndrome
    • Anesthesia dolorosa – sense of touch diminished but malfunctioning painful sensation left intact in trigeminal nerve

d. Complications after procedure

• Hemorrhage
  • Primary – laceration of artery, surgery done in infected area with granulation tissue
  • Reactionary – occurs few hours after surgery , failure of coagulation
  • Secondary – 7-10 days after surgery, due to infection + partial division of blood vessel
• Alveolar osteitis
• Infection
• Delayed healing
• Pain

Maxillary extraction forceps

Maxillary anterior forceps – Incisors and canines

Maxillary premolar forceps – Premolars

Maxillary molar forceps – Molars

Maxillary cow horn forceps – Molars with extensive loss of coronal structure

Maxillary third molar forceps – Third molars

Maxillary bayonet forceps – Roots

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Mandibular extraction forceps

Mandibular anterior forceps – Incisors and canines

Mandibular premolar forceps – Premolars

Mandibular molar forceps – Molars

Mandibular cow horn forceps – Molars with extensive loss of coronal structure

Mandibular third molars forceps – Third molars

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Elevators

Straight elevator – Luxation of maxillary and mandibular teeth

Coupland elevator – Split multi-rooted teeth and are inserted between the bone and tooth roots and rotated to elevate them out of the sockets

Apexo elevator – Extraction of root pieces

Cross bar elevator – Extraction of mandibular roots

Cryer elevator – Extraction of roots, elevation of upper third molars

Warwick James elevator – Extraction of retained roots, deciduous teeth, maxillary third molars, and teeth with less resistance

Root tip elevator – Removal of apical root tips/fragments of roots

Techniques of administrating LA

1. Inferior alveolar nerve block: Mandibular posterior teeth

Picture

• Between pterygomandibular raphe and coronoid notch (feel with thumb)
• Insert from contralateral side, 1cm above occlusal plane
• Contact bone, withdraw slightly and give LA

2. Mental nerve block: Mandibular anterior teeth

Picture

• Between 1st and 2nd premolar

3. Anterior, middle, posterior superior alveolar nerve block: Maxillary teeth

Picture

• At junction of mucobuccal fold

4. Greater palatine nerve block: Maxillary posterior teeth

Picture

• In front of 1st molar at junction of vertical and horizontal hard palate
• Withdraw after contacting bone

5. Nasopalatine block: Maxillary anterior teeth

Picture

• Insert in incisive papilla

6. Infiltration: Picture

• At mucogingival level

7. Buccal Infiltration: Picture

• Parallel to occlusal plane
• Distal to 2nd molar

8. Intrapapillary: Picture

9. Intraligamentary (supplemental): Picture

10. Intrapulpal (supplemental): Picture

11. Intraosseous (supplemental): Picture

12. Gow-Gates technique: Video

13. Vazirani-Akinosi technique: Video

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Calculating LA dosage

Use the app Dental Drugs (App store, Play store) to quickly refer for prescribing medications, calculating maximum anesthetic dosages or recalling common treatment protocols in practice

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Desirable properties of LA

• Non irritant
• Reversible effect
• Long enough duration for procedure
• Low toxicity
• Fast onset of action
• Potent

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Mechanism of action of LA

LA = Tertiary amine base [B] + Water soluble hydrochloride [B.HCl]

• Injected into tissues
• Base liberated in alkaline pH of tissues

B.HCl + HCO₃ = B + H₂CO₃ + Cl

• Base diffuses through nerve sheath into axoplasm and partially ionizes

B + H⁺ = BH⁺

• Ionized form of BH⁺ enters sodium channel from interior of nerve and combines with a specific receptor in the channel to block sodium influx into the nerve and therefore prevent action potential initiation

BH⁺ + Receptor = Block sodium influx

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Structure of LA

Aromatic group – Intermediate bond (amide/esters)- Tertiary amine

Amides:

• Lignocaine
• Prilocaine – metabolism in liver and lungs. Primary product of metabolism is ortho-Toluidine – associated with methemoglobinemia
• Mepivacaine
• Bupivacaine

Esters:

• Cocaine – Only cocaine causes vasoconstriction
• Procaine – used in case of drug induced arteriospasm. Procaine broken down to PABA – associated with allergic reaction.
• Amethocaine
• Chloroprocaine

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Factors affecting LA action

1. pK_a (physiologic pH): ↓ pK_a leads to faster onset of action as ↑ molecules diffuse through the nerve sheath

2. Lipid solubility: ↑ lipid solubility leads to ↑ potency and therefore block conductions at low concentration

3. Protein binding: ↑ protein binding leads to ↑ duration of action as it firmly attaches to proteins at receptor sites

4. Non nervous tissue diffusibility: ↑ diffusibility leads to slower time of onset

5. Vasodilator activity: ↑ vasodilator activity leads to ↑ blood flow to region and therefore ↑ removal of anesthetic molecules and so ↓ potency and duration

6. Tachyphylaxis: ↑ tolerance when injected repeatedly. Mop up of HCO3, alkaline pH of tissues not sustained

7. Infection: Acidic pH therefore prevent ready formation of free base

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Contents of LA

Local anesthetic agent	Lignocaine HCL	Block nerve conduction
Vasoconstrictor	Epinephrine	– Increase duration by decreasing absorption of LA – Control bleeding – Prevent systemic toxicity
Reducing agent	Sodium metabisulphite	Antioxidant
Preservative	Methylparaben	Bacteriostatic and antioxidant
Isotonic solution	Sodium chloride or Ringer’s solution	–
Fungicide	Thymol	–
Diluting Agent	Distilled water	–
To adjust pH	Sodium hydroxide	–
Nitrogen bubble	1-2mm in diameter	To prevent oxygen from being trapped in the cartridge and potentially destroying the Vasopressor or vasoconstrictor

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Pharmacokinetics of LA

1. Uptake:

• LA causes vasodilation and increased uptake into circulation
• Esters cause more vasodilation
• Procaine used in case of drug induced arteriospasm
• Only cocaine causes vasoconstriction

2. IV of LA:

• May cause increased toxicity/adverse effect
• Used to treat ventricular dysrhythmias
• Local and systemic toxicity effects:

3. Toxicity: Balance between absorption into circulation and rate of elimination from circulation

4. LA crosses blood brain barrier (BBB) and placental barrier

5. Esters metabolized by pseudocholinesterase

• Atypical pseudocholinesterase – cannot metabolize esters – increase toxicity
• Pseudocholinesterase also metabolize succinylcholine – therefore atypical pseudocholinesterase associated with difficult general anesthesia (sleep apnea). Succinylcholine used to cause short term paralysis as part of GA
• Procaine broken down to PABA – associated with allergic reaction

6. Amides metabolized in liver

• Liver perfusion and function important to determine rate of amide elimination
• Liver cirrhosis, hypotension and congestive heart failure – reduce rate of elimination and therefore increase toxicity
• Prilocaine metabolism in liver and lungs. Primary product of metabolism is ortho-Toluidine – associated with methemoglobinemia

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Contraindications of LA

Absolute	LA allergy	Eg. to esters	Give amide
Absolute	Sulfur allergy	Avoid articaine	Give non sulfur containing LA
Absolute	Bisulfite allergy	Avoid LA with vasoconstrictor	Give LA with no vasoconstrictor
Relative	Atypical pseudocholinesterase	Avoid esters	Give amide
Relative	Methemoglobinemia	Avoid articaine and prilocaine	Give other LA
ASA (III-IV)	Significant liver dysfunction	Avoid amides	Give esters judicially
ASA (III-IV)	Significant renal damage	Avoid amides and esters	Give LA judicially
ASA (III-IV)	Significant CVD	Avoid high concentration of vasoconstrictor	Give LA with epinephrine concentration 1:100,000 or 1:200,000
ASA (III-IV)	Clinical hyperthyroidism	Avoid high concentration of vasoconstrictor	Give LA with epinephrine concentration 1:100,000 or 1:200,000

History

Biodata

1. Date
2. File number
3. Full name
4. Age/date of birth
5. Gender
6. Contact
7. Physical address
8. Occupation
9. Name of guardian/parent – for children
10. Source of referral (if referred)

Presenting complaint

In patients own words, what is the problem

History of presenting complaint

• S – Site
• O – Onset
• C – Character (throbbing, continuous, dull, acute, sharp)
• R – Radiation (to head)
• A – Associated symptoms (fever, discharge)
• T – Timing (day or night, after eating)
• E – Exacerbating factors (hot/cold food), Alleviating factors (Pain medications)
• S – Scale (scale of 1-10, rate the pain)

Previous treatments concerning the presenting complaint

Past dental history

• Index visit or
• Previous dental treatments done
  • What they were
  • When
  • Where
  • If extraction done – any complications
  • Tolerance to LA

Dental habits

• How many times do they brush their teeth
• How do they brush
• Which toothpaste
• How often they change their brush
• Any interdental cleaning methods used – floss, toothpicks
• Abnormal habits eg. mouth breathing, lip sucking

Past medical history

• History of chronic illness:
  • CHD/CVS, infective endocarditis
  • Respiratory – asthma, bronchitis
  • GIT – peptic ulcers, diarrhea, vomiting, jaundice, hepatitis, gastritis
  • Diabetes
  • CNS disorders
  • Bleeding disorders – hemophilia, anticoagulant therapy
  • Infectious diseases – TB, HIV, Herpes
  • On any medications – NSAID, corticosteroids, anticoagulants, anticonvulsants
• Previous hospital admission – When, where, why, treatment provided
• Food or drug allergy

Obs and gyn history for females

• Last menstruation date and regularity
• Pregnancy status
• Type of contraceptives used

Family social history

• Alcohol – amount and frequency
• Smoking – amount and frequency
• Drugs
• Family status – parents, siblings, chronic illness in family
• Martial status and children
• Water source – borehole or city council

For pediatric and orthopedic patients

Birth history:

Prenatal:

• Health and nutritional status of mother during pregnancy
• Complications during pregnancy:
  • Infections – rubella, TB, syphilis, UTI
  • Pre-eclampsia
  • Hypertension
  • Diabetes
  • Antepartum bleeding
• Drugs
• X-ray
• Rh incompatibility may result in erythroblastosis fetalis – leading to green blue discoloration of dentition. Picture

Natal:

• Full term or premature
• Mode of delivery – Normal/C-section and why?
• Did the baby cry on birth
• Birth weight
• Breast fed or formula milk given

Postnatal:

• Vaccinated
• Developmental history
• Nocturnal feedings/sweetened milk – predisposes to early childhood caries (read more)
• Brushing habits – frequency, by who, supervised?

Habits

• Finger sucking/thumb sucking
• tongue thrusting
• Mouth breathing
• Nail biting – check nails

Diet chart

• 24 hour diet chart
• 7 day diet chart (as investigation)

Family social history

• Name of school
• Class
• Performance in school
• Social or antisocial
• Occupation of parents
• Family history
• Water source

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Clinical examination

General examination

• Anxious or calm
• Build, nourishment – well, poor
• Posture

Vital signs:

• Temperature
• Pulse rate
• Respiratory rate
• Blood pressure

NB: Also measure weight and height for children – to calculate BMI and dosage of LA and drugs

Extra oral examination

• Palpate submental, submandibular and neck lymph nodes
• Facial symmetry – any swellings or asymmetry
• Facial profile
• Scars
• Eyes – jaundice (look down), pallor (look up)
• TMJ movements – clicking or popping sounds, pain, path of closure
• Lips competency
• Hands – examine nails, finger clubbing, cyanosis

Remember it as: J A C C L O W D (Jaundice, anemia, clubbing, cyanosis, lymphadenopathy, oedema, wasting, dehydration)

Intraoral examination

• Oral hygiene status
• Type of dentition: primary, mixed, permanent

Soft tissue examination:

• Gingiva – shape, size, color, bleeding, ulceration, growths, pockets, recession
  • Plaque and gingival score
• Buccal mucosa – color, texture, ulcer, growth, sinus
• Floor of mouth – swellings, ulcer
• Tongue – size, movements, plaque
• Palate – normal, high vault, clefts
• Tonsils – normal, swollen
• Frenal attachments – normal, higher

Hard tissue examination:

• According to quadrants
• Teeth present
• Teeth missing
• DMF
• Palpate, percuss
• Check interproximal caries with floss
• Wear (attrition, abrasion, erosion)
• Discoloration
• Malformation
• Mobility – Millers classification 1950
  • 0 = No detectable mobility
  • 1 = Distinguishable mobility
  • 2 = Horizontal movement > 1mm
  • 3 = Horizontal and vertical movement > 1mm
• Orthodontic assessment
• Fluorosis – TF score for every tooth

Tooth fracture classification

Periodontal assessment

Gingiva:

• Color: Pink, physiologic pigmentation, red, cyanotic
• Size: Mild, moderate, severe inflammed
• Shape: Scalloped, rounded, col – if space between 2 teeth
• Consistency: Firm, flabby
• Texture: Stippling on attached gingiva

Oral hygiene:

• Calculus – presence of supra or subgingival calculus
• Plaque seen with naked eye

Gingival index by Loe and Silness 1963:

• Facial and lingual surface of index teeth: 16, 11, 24 and 36, 31, 44
• Rate:
  • 0 = Normal
  • 1 = minimal inflammation, erythema, no bleeding
  • 2 = Bleed on probing
  • 3 = Spontaneous bleeding
• Find mean score
• GI score:
  • 0-1 = Mild
  • 1-2 = Moderate
  • 2-3 = Severe

Periodontal index by Turesky et al modified Quigley Hein 1970:

Index teeth and disclosing tablet

• 0 = No plaque
• 1 = Flecks at cervical margin
• 2 = Thin continuous band at cervical margin
• 3 = Band wider than 1mm, < 1/3 of crown
• 4 = Plaque < 2/3 of crown
• 5 = Plaque > 2/3 of crown

Furcation involvement – Glickman classification 1953

• Grade 1 – Incipient, pocket formation into furcation fluting, interradicular bone intact
• Grade 2 – Moderate loss of interradicular bone but not through and through
• Grade 3 – Probe goes through and through, orifice occluded by gingival tissue
• Grade 4 – Exposed furcation

Periodontal charting:

• Draw continuous line of free gingival margin – facial and lingual
• Draw interrupted line indicating bone level on facial side
• Record 6 point pocket depth
• Record tooth mobility
• Record missing teeth (X), open contacts(//) and how many mm, overhang restorations (V)
• Calculate clinical attachment loss (CAL): Gingival recession + pocket depth
  • 1-2mm = Mild
  • 3-4mm = Moderate
  • > 5mm = Severe
  • Localized: < 30% of sites
  • Generalized: > 30% of sites

Orthodontic assessment

• A-P: Molar, canine, incisor relationship – Class I, II, III
• Vertical: Open bite, overbite – deep or open
• Transverse:
  • Crossbite anterior or posterior
  • Midlines
  • Crowding or spacing
  • Rotation or displacement
  • Proclination
• Upper and lower arch form – Normal, V shape, square shape

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Investigations

• Radiological – describing a x-ray:
  • Name and age of patient
  • Date when the x-ray was taken
  • Quality
  • Teeth present
  • Dental age and why
  • Radiolucent/radiopaque lesions
• Microbiological
• Histopathological
• Study model
• Diet chart
• Plaque score
• BMI

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Diagnosis

• Summarize findings: eg. A 5 year old African male with early childhood caries, dentoalveolar abscess secondary to extensive decay on 55, irreversible pulpitis 85 and 75, and occlusal caries on 54, 64, 84, 74

• For periodontal diagnosis: Severity – extent – diagnosis, eg:
  • Mild – localized – chronic periodontitis
  • Moderate – generalized – plaque induced gingivitis secondary to orthodontic treatment and mouth breathing

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Prognosis for periodontology

1. Excellent prognosis:

• No bone loss
• Excellent gingival condition
• Good patient co-operation
• No systemic/environmental factors

2. Good prognosis:

• Adequate remaining bone support
• Adequate control of etiologic factors and maintainable dentition
• Adequate patient co-operation
• No systemic/environmental factors or well controlled

3. Fair prognosis:

• Less than adequate bone support
• Some tooth mobility
• Grade 1 furcation
• Adequate maintenance possible
• Acceptable patient co-operation
• Presence of limited systemic/environmental factors

4. Poor prognosis:

• Moderate-advanced bone loss
• Tooth mobility
• Grade 1 or 2 furcation involvement
• Doubtful patient co-operation
• Presence of systemic/environmental factors

5. Questionable prognosis:

• Advanced bone loss
• Tooth mobility
• Grade 2 or 3 furcation involvement
• Inaccessible areas
• Systemic/environmental factors

6. Hopeless prognosis:

• Advanced bone loss
• Extraction indicated
• Non maintainable areas
• Uncontrolled systemic/environmental factors

NB: Factors affecting prognosis:

• Diagnosis: Disease severity, plaque and calculus
• Systemic factors: DM, puberty, genetic
• Occlusal factors
• Prosthetic and restorative factors: Caries, teeth vitality, abutment selection, subgingival restorations, fixed or removable prosthesis
• Patient factors: Compliance, co-operation, attitude
• Environmental factors: Smoking, alcohol. bruxism

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Treatment objectives

1. To control infection and relieve pain and discomfort
2. To modify attitude to dental care, and behavior to dental treatment
3. To improve oral hygiene
4. To restore integrity and function of the dentition
5. To achieve cariostasis
6. To improve esthetics and correct malocclusion
7. To maintain a healthy oral cavity
8. Diet planning

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Treatment planning

1. Oral hygiene instruction (OHI)
2. Emergency phase: Systemic diseases, infections
3. Etiological phase: Plaque and calculus
4. Restorative phase: Filling, RCT, Prosthetic replacement
5. Maintenance phase: Recall and review

Periodontal treatment planning

1. Preliminary phase: Systemic disease, infections, OHI
2. Etiological phase: FMS, root planing, fluoride treatment, cavity prep and filling
3. Surgical phase: Disimpaction, gingivectomy, implants, open flap debridement, GTR, furcationplasty
4. Restorative phase: Crown, bridge, crown for implant
5. Supportive periodontal therapy/maintenance phase: Review after 2 weeks
   • High risk – recall every 3 months
   • Moderate risk – recall every 6 months
   • Low risk – recall every year

Pediatric treatment planning

1. Systemic phase – Stabilize chronic illness before dental treatment
2. Emergency phase – Antimicrobials
3. Preventive phase – OHI, behavior management, fluoride application, diet counselling, pit and fissure sealants
4. Preparatory phase – Oral prophylaxis, caries control if multiple lesions, preventive orthodontic consultation
5. Corrective phase – Restorations, prosthetic replacement, extractions, Interceptive orthodontic consultation
6. Maintenance phase – Recall and review, 3-6 months

• Significance of oral prophylaxis:
  • Introduction to dental environment/behavior management
  • Oral hygiene education
  • Uncover carious lesion covered in plaque
  • Healthy gingiva