Intermediate Clinical Overview Level II Training

1. Intermediate Clinical OverviewLevel II Training

2. Objective To expand your knowledge of clinical terms, practices, and the reasoning behind why certain procedures are performed, giving you added confidence in assisting your patients.

3. Covered in this course • Why specific treatment is indicated • Reasons for post op complications • Sample narratives • Crown, Bridge, Fixed, and Removable Prosthetics • How procedures are performed • Surfaces of the tooth • Identifying X-Rays • Stages of Periodontal Disease • Conclusion/Quiz

4. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant Fillings Extreme decay can result in the loss of the affected tooth or teeth, potentially preceded by great discomfort, infection and other health problems. A filling material inserted directly into hole in the tooth is used to correct a cavity. The filling is allowed to harden, thus “filling” the hole in the tooth. This not only provides strength and structure to a tooth, it also eliminates the pain of the cavity.

5. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant Crown-fracture Unlike cracks in bones, the cracks in teeth do not repair themselves or heal over. Once a crack has formed it can, and often will, increase in size over time due to repeated exposure to heavy biting forces. In order to avoid any further damage to the tooth, a full coverage crown is indicated.

6. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant Crown- Existing Even with the best oral hygiene, dental crowns are not expected to last more than 10 years for most people. Throughout the course of several years, the dental crown will be exposed to much wear and tear, plaque and bacteria. It may even break. For these reasons, a dentist will recommend replacing your old dental crown with a new one.

7. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant How does Periodontal Disease develop? • If plaque and tartar is left on the teeth, as we mentioned before, it provides the right conditions for bacteria to thrive. The bacteria irritate the gums, which means that they bleed more easily. Most adults have some degree of gum disease. What does Periodontal Disease do? • Gum disease can break down the support (bone) structures of the teeth, so that eventually, they will become loose. The problem is that until it gets quite severe, the person often has no symptoms. Sadly, the damage to the support structures of the teeth is irreversible. The good news is that if gum disease is caught in time, its progression can be halted and improved upon, and that is the key. What happens if nothing is done about it? • If gingivitis not treated and nothing is done about it, the inflammation will work its way down towards the foundations of the tooth causing a “periodontal pocket”. Again, within the confines of the pocket, the conditions are such that the bacteria can cause more damage. How do you control Periodontal Disease? • To stop gum disease from progressing, your dentist may advise periodontal therapy, or deep cleaning. This gets rid of the bacteria in the pocket and provides the necessary conditions for healing to occur.

8. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant What are Occlusal Guards? • Occlusal splints (also called bite splints, bite planes, or night guards) are removable dental appliances carefully molded to fit the upper or lower arches of teeth. What do Occlusal Guards do? • They are used to protect tooth and restoration surfaces, manage mandibular (jaw) dysfunction, and stabilize occlusion or create space prior to restoration procedures. People prone to nocturnal bruxism, or nighttime clenching, should routinely wear occlusal splints at night. What are Occlusal Guards made of? • Occlusal splints are typically made of a heat-cured acrylic resin. How does an Occlusal Guard fit in the patient’s mouth? • They generally cover all the teeth of the upper or lower arch. Occlusal splints are usually used on either the upper or the lower teeth, termed maxillary splints or mandibular splints respectively. Maxillary splints are more common, although various situations favor mandibular splints.

9. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant What does a bridge do? • Dental bridges literally bridge the gap created by one or more missing teeth. crown crown Pontic (gold, alloys, porcelain, or combination) Supported by natural teeth or implants Abutment teeth

10. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant What are Complete Dentures? • Dentures are artificial replacements for your natural teeth. Dentures are needed when you have several unhealthy teeth or no teeth. Dentures will replace your missing and/or unhealthy teeth. Dentures will restore your smile and return some of the chewing power you once had. Basics About Dentures • Dentures are removable. Dentures can replace all of your teeth, or they can just replace a few missing ones. Complete dentures are usually made of an acrylic resin, while partial dentures are made from a combination of acrylic resin and metal. • Dentures will restore your smile and increase your chewing power. • Complete dentures cover your entire jaw and can be used in place of your upper teeth, lower teeth or both. Complete dentures consist of artificial teeth and gums. They rest directly on your gums and are used if you have no remaining natural teeth.

11. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant Partial Denture Partial dentures fit around your remaining, healthy teeth. Partial dentures usually have artificial teeth and gum, connected by a metal framework. Partial dentures are usually held in place by clasps that attach to your natural teeth.

12. Why specific treatment is indicated Fillings Crown-fracture Crown-existing Periodontal Scaling Occlusal Guards Bridge Complete Denture Partial Denture Implant Implant A dental implant is commonly made of titanium, a metal that is well-tolerated by the body, which is placed into the jawbone. It is used to support one or more false teeth. A small attachment at the top of the implant emerges through the gum. Crowns, bridges, or dentures can then be attached to the implant by screws or clips. For people in good general health who have lost a tooth or teeth due to disease, an injury, or some other reason, dental implants are an ideal option. They are so natural-looking; you may forget you ever lost a tooth!

13. Reasons for post op complications Fillings Extractions Temporaries Fillings – Common Problems • Temperature Sensitivity - Due to the depth of the filling? • Chewing Sensitivity - High Occlusion (Hitting High) • Rough Spot - Smooth filling • Sore gums/jaw - Area of injection - Length of time keeping mouth open

14. Reasons for post op complications Fillings Extractions Temporaries Extractions • Pain in jaw - Force used to elevate the tooth places pressure on the jaw muscle • Pain with extraction site - Worst pain usually 3-4 days post treatment - May need to schedule for dry socket

15. Reasons for post op complications Fillings Extractions Temporaries Temporaries Temporary has come off Solution: - Place temp back on if possible to avoid shifting or breaking of natural tooth - Schedule appointment to have recemented Sensitivity Solution: - due to the temporary nature may leak saliva or food onto tooth not uncommon with final crown this will not be a problem. May want to brush with sensitivity toothpaste.

16. Sample Narratives

17. Sample Narratives • Crown due to RCT Tooth #? Had root canal therapy completed. Core buildup (or post and core) and full coverage crown are the required restoration. This is an initial placement. If replacement, date initial crown was placed. Attach PA and intra oral photo.

18. Sample Narratives • Crown due to old filling Tooth #? Had recurrent decay under large existing restoration. Over 65% of coronal tooth structure is missing. Core buildup (or post and core) and full coverage crown are the required restoration. This is an initial placement. – Attach PA and intra oral photo

19. Sample Narratives • Crown due to fracture Tooth #? Has (enter surface here) ____ fracture. Over 65% of coronal tooth structure missing. Core buildup and full coverage crown required. This is an initial placement. - Attach PA and intra oral photo

20. Sample Narratives • Replacing existing crown Tooth #? Has recurrent decay under existing crown (5-10 yrs old) due to defective margins. New core build up ( or post and core) and full coverage crown are the required restoration. This is a replacement crown. - Attach PA and intra oral photo

21. Sample Narratives • Periodontal Scaling Pt has Stage? Perio with all quads having 4-5+mm pockets with chronic inflammation, infection, and bone loss. Pt has heavy amounts of sub gingival calc., gum tissue was very red and inflamed and bleeding heavily while scaling. Charting sent. - Attach perio charting and Xrays (at least 4 BW and pan or fmx)

22. Sample Narratives • Occlusal guards Patient presents with moderate to severe ear on anterior teeth and severe wear on posterior teeth due to nocturnal bruxism. See enclosed intra-oral pictures. - Attach intra oral photos

23. Sample Narratives • Bridge Tooth #? Was non restorable and extracted. Teeth #? And ? Have recurrent decay under existing restoration; over 65% of coronal tooth structure is missing. There are no other missing teeth on the upper arch. Bridge #? X ? Is required to restore arch to function. This is the initial placement. If replacement date original bridge was placed. - FMX or Panorex and intra oral photos

24. Sample Narratives • New Complete Denture Maxillary denture replaces teeth #’s (list teeth numbers), that were extracted on ?. This is the initial placement of the maxillary denture. - Attach pan or FMX

25. Sample Narratives • Replacement Denture/ Partial Existing maxillary denture is ill-fitting and unrestorable. New maxillary denture is required to restore arch to function. This is a replacement. Date existing Partial or Denture was placed. - Attach Panorex or FMX

26. Sample Narratives • New Partial Mandibular partial replaces teeth #s (list teeth numbers) that were non restorable and extracted on ?. This is an initial placement. - Attach Panorex or FMX

27. Crown/Bridge, Fixed, and Removable Prosthetics:Different types Crown/Bridge All Porcelain Porcelain fused to metal Removable Prosthetics All Porcelain Crown Code: 2740 (Example: Bruxzir, Empress, and Procera) • provide the best natural color match than any other crown type • may be more suitable for people with metal allergies • not as strong as porcelain-fused-to-metal crowns • they wear down opposing teeth a little more than metal or resin crowns • good choice for front teeth

28. Crown/Bridge, Fixed, and Removable Prosthetics:Different types Crown/Bridge All Porcelain Porcelain Fused to Metal Removable Prosthetics Porcelain Fused to Metal Code 2751 (Example: Captek) • Can be color matched to your adjacent teeth (unlike the metallic crowns) • Causes more wearing to the opposing teeth compared with metal or resin crowns • The porcelain portion can also chip or break off. • Except for ceramic crowns, porcelain-fused-to-metal crowns look most like normal teeth. • Sometimes the metal underlying the crown's porcelain can show through as a dark line, especially at the gum line and even more so if your gums recede • Good choice for front or back teeth

29. Crown/Bridge, Fixed, and Removable Prosthetics:Different types Crown/Bridge Removable Prosthetics Complete Denture Immediate Denture Partial Denture Complete Denture Maxillary: Code 5110 Mandibular: Code 5112 • Complete dentures can be either "conventional" or "immediate.“ • Made after the teeth have been removed and the gum tissue has begun to heal • a conventional denture is ready for placement in the mouth about 8 to 12 weeks after the teeth have been removed.

30. Crown/Bridge, Fixed, and Removable Prosthetics:Different types Crown/Bridge Removable Prosthetics Complete Denture Immediate Denture Partial Denture Immediate Denture Maxillary: Code 5130 Reline 5750 Mandibular: Code 5140 Reline 5751 • made in advance and can be positioned as soon as the teeth are removed • the wearer does not have to be without teeth during the healing period • bones and gums shrink over time, especially during the healing period following tooth removal, therefore they require more adjustments to fit properly during the healing process • generally should only be considered a temporary solution until conventional dentures can be made.

31. Crown/Bridge, Fixed, and Removable Prosthetics:Different types Crown/Bridge Removable Prosthetics Complete Denture Immediate Denture Partial Denture Partial Denture Maxillary Partial w/ Metal Base: Code 5213 Mandibular Partial w/ Metal Base: Code 5214 • Consists of replacement teeth attached to a pink or gum-colored plastic base, which is connected by metal framework that holds the denture in place in the mouth • Partial dentures are used when one or more natural teeth remain in the upper or lower jaw • A fixed (permanent) bridge replaces one or more teeth by placing crowns on the teeth on either side of the space and attaching artificial teeth to them. This "bridge" is then cemented into place • A partial denture fills in the spaces created by missing teeth and prevents other teeth from changing position.

32. Crown/Bridge, Fixed, and Removable Prosthetics:Different types Crown/Bridge Removable Prosthetics Complete Denture Immediate Denture Partial Denture Partial Denture Flex Maxillary: Code 5225 Flex Mandibular: Code 5226 (Example: Valplast, and Flexlite) • Comfortable, beautiful, and affordable choice • Does not have to be rigid to be effective • Allows the restoration to adapt to the constant movement and flexibility in your mouth

33. How Procedures Are Performed Fillings Crown/Bridge Prep Fillings – What happens during this visit? • You may be given local anesthesia to numb the area if necessary. • Your dentist will remove decay from the tooth, using hand instruments or a drill. Air abrasion and lasers also can be used to remove decay. A drill, which dentists call a handpiece, uses metal cones called burs to cut through the enamel and remove the decay. Burs come in many shapes and sizes. Your dentist will choose the ones that are right for the size and location of your decay. Why all the different sounds? At first, your dentist will use a high speed drill (the one with the familiar whining sound) to remove the decay and unsupported enamel of the tooth. Once the drill reaches the dentin, or second layer of the tooth, the dentist may use a lower speed drill. That's because dentin is softer than enamel.

34. How Procedures Are Performed Fillings Crown/Bridge Prep Fillings – What happens during this visit?...continued • Once all the decay is removed, your dentist willshape the space to prepare it for the filling. Different types of fillings require different shaping procedures to make sure they will stay in place • Your dentist may put in a base or a linerto protect the tooth's pulp (where the nerves are). The base or liner can be made of composite resin, glass ionomer, zinc oxide and eugenol, or another material. Some of these materials release fluoride to protect the tooth from further decay. • If your dentist is placing a bonded filling, he or she will etch (prepare) the tooth with an acid gel before placing the filling. Etching makes tiny holes in the tooth's enamel surface. This allows the filling to bond tightly to the tooth. Bonded fillings can reduce the risk of leakage or decay under the filling. That's because the etched surface of the tooth and the filling material form a mechanical bond. Bonding is generally done with composite fillings. • Certain types of fillings get hardened by a special light. With these fillings, your dentist will stop several times to shine a bright light on the resin. This cures (hardens) the material and makes it strong. • Finally, after the filling is placed, your dentist will use burs to finish and polish the tooth.

35. How Procedures Are Performed Fillings Crown/Bridge Prep Crown/Bridge Prep Preparing a tooth for a crown usually requires two dentist visits, the first step involves examining and preparing the tooth, the second visit involves placement of the permanent crown. First visit: Examining and preparing the tooth • Your dentist may take a few X-rays to check the roots of the tooth receiving the crown and surrounding bone. If the tooth has extensive decay or if there is a risk of infection or injury to the tooth's pulp, a root canal treatment may first be performed. • Your dentist will anesthetize (numb) your tooth and the gum tissue around the tooth. • The tooth receiving the crown is filed down along the chewing surface and sides to make room for the crown. The amount removed depends on the type of crown used (for instance, all-metal crowns are thinner, requiring less tooth structure removal than all-porcelain or porcelain-fused-to-metal ones). • If a large area of the tooth is missing (due to decay or damage), your dentist will use filling material to "build up" the tooth to support the crown.

36. How Procedures Are Performed Fillings Crown/Bridge Prep Crown/Bridge Prep Alternative methods

37. How Procedures Are Performed Fillings Crown/Bridge Prep First visit: Examining and preparing the tooth…continued • Your dentist will use impression paste or putty to make an impression of the tooth to receive the crown. Impressions of the teeth above and below the tooth to receive the dental crown will also be made to make sure that the crown will not affect your bite. • The impressions are sent to a dental laboratory where the crown will be manufactured. • The crown is usually returned to your dentist's office in 2 to 3 weeks. If your crown is made of porcelain, your dentist will also select the shade that most closely matches the color of the neighboring teeth. • During this first office visit your dentist will make a temporary crown to cover and protect the prepared tooth while the crown is being made. Temporary crowns usually are made of acrylic and are held in place using a temporary cement.

38. How Procedures Are Performed Second visit: Receiving the Permanent Crown • Your dentist will remove your temporary crown and check the fit and color of the permanent crown. • If everything is acceptable, a local anesthetic may be used to numb the tooth . • The new crown is permanently cemented in place. Fillings Crown/Bridge Prep

39. Identifying X-Rays

40. Identifying X-Rays Panorex Wisdom teeth Wisdom teeth Is one X-ray that provides a full picture of your whole mouth- complete upper and lower jaw; sinuses and jaw joint. It is not as specific as the other X-rays because its purpose is to show the general condition of all the teeth. It is used to help view- general tooth development; trauma; jaw joint pain; wisdom teeth and certain abnormalities. It will give a broad view but does not provide the fine detail that Bite-Wings or P.A.s provide. This X-ray is to be taken every 5-7 years  

41. Identifying X-Rays Periapical nerve crown root Are used to provide images of the entire tooth from crown to root tip. They are utilized to display the root, cysts, abscesses, etc. that are involved with toothaches. We can use them to also check bone level around teeth and to evaluate bone loss that is caused by periodontal disease. They can also be used to assess existing dental work. These X-rays give fine details that are extremely important in diagnosis. It is taken only when necessary to aid in diagnosis of a particular condition.

42. Identifying X-Rays Bitewings : Are a type of X-rays that allow us to obtain view of specific teeth. They show the crowns and part of the root of 2 or 3 your teeth and the immediate surrounding bone level. They are called Bite-Wing because the X-ray film holder provides a surface for you to bite down on in order to hold the X-ray securely in place.       They are used to help detect cavities in between the teeth; bone loss to evaluate periodontal conditions and to determine the quality of previous dental restorations (i.e. filling). It is recommended to take these yearly if you are in good dental health.

43. Identifying X-Rays Amalgam/Composite Restorations Amalgam Amalgam Composite Amalgam

44. Identifying X-Rays Root Canal

45. Identifying X-Rays Crown Root canal & crown Crown only

46. Identifying X-Rays Decay abscess

47. Identifying X-Rays Implants Implant supported bridge Implant supported denture

48. Identifying X-Rays Bone loss and Calculus Bone loss Bone loss calculus

49. Periodontal Disease: The Basics • Separate issue from caries or “tooth decay” and caused by the infection of different pathogens • Lack of proper and thorough oral hygiene will promote the disease process • Between 75% and 95% of all adults have the disease • The Hygienist inserts a probe into the crevice or periodontal pocket to measure the pocket depth • The redder the gum tissue at the neck of the tooth the more severe (indicates inflammation)

50. Stages of Periodontal Disease