Diagnosis and Treatment Planning PDF

2 C. R. G. Torres et al. Learning Objectives not harmful to the patient’s health. Based on the most prob- 1 After completion of this chapter, the reader is competent to: able diagnosis, a treatment plan can be compiled in close col-...

2 C. R. G. Torres et al. Learning Objectives not harmful to the patient’s health. Based on the most prob- 1 After completion of this chapter, the reader is competent to: able diagnosis, a treatment plan can be compiled in close col- 5 Understand the importance of unfolding the patient’s chief laboration with the patient. Planning the clinical complaint procedures is crucial since mistakes both in treatment plan- 5 Use open-ended questions and periodical summaries as ning and in the practical execution of such plan will lead to a communication tools during the medical interview result that is far from the ideal [17, 66]. 5 Apply active listening as a stylistic means to keep patients In modern dentistry, treatment planning should be talking guided by patients’ wishes and demands in the first place. 5 Recognize medical conditions that may interfere with dental Based on patients’ chief complaints and findings of the clini- treatments cal examination, a list of diagnoses is formulated. One by 5 Identify indications of antibiotic prophylaxis in risk patients one, the problems are analyzed regarding options for treat- to prevent bacterial endocarditis ment, each one with their inherent advantages and disadvan- 5 Identify medicinal product interactions and most prevalent tages. The best solution for each problem is chosen and diseases in a patient written in sequence; so, this list of solutions will lead to the 5 Describe challenging conditions when treating elderly treatment plan. patients The process to reach a treatment plan is primarily driven 5 Structure the dental assessment in different sections, i.e., by dental problems presented by the patient. However, com- anamnesis, self-reported complaints, extra- and intraoral prehensive evaluation of the patients’ general health, socio- examination economic status, and individual preferences is mandatory to 5 Highlight the most important criteria when assessing caries reach consent about the most suitable and personalized treat- and non-carious lesions, periodontal and endodontic ment option. conditions Items included on the treatment plan can be classified by 5 Differentiate between pathologic and within biological topics, as endodontic, periodontal, restorative, etc. The list is variation conditions dynamical and can be modified if new problems occur or the 5 Differentiate assessment criteria for different types of patient changes his or her opinion during the course of treat- restorations ment. The treatment for each individual problem has 5 Identify biological risks and discriminate harmful from the objective to reach the idealized final result, in other harmless conditions words, the individually desired oral rehabilitation of the 5 Explain the multifactorial genesis of non-carious lesions and patient. If the proposed treatment for any individual prob- know operative and non-operative treatment options lem conflicts with the proposed general treatment, the indi- 5 Explain conditions that lead to extrinsic and intrinsic staining vidual or general plan has to be modified until it coincides to 5 Reproduce basic knowledge about occlusion concepts and each other. function in general The patients’ interview should usually begin with the 5 Understand the basics of dental esthetics evaluation of the chief complaint and patients’ expectations 5 Identify risk factors that promote the onset or progression of relative to the treatment outcome. Next, a medical and dental oral diseases and calculate the individual caries and peri- history has to be recorded. On the medical history, the pres- odontal risk ence of systemic diseases including allergies and medications 5 Come to a patient-centered personalized treatment plan that affect the patient and more importantly the subsequent according to shared decision-making concepts dental treatment has to be investigated. On the “dental his- 5 Apply ASA classification to categorize patients according tory,” previous treatments should be evaluated as well as the their general state of health degree of success that was obtained. 5 Differentiate stages within the treatment concept and stick Actually, most dental patients are anxious to a certain to them degree. Agitation is usually observed especially during the 5 Create a patient file and know about the importance of first appointment. As dental professionals, we have to know detailed documentation that agitation can lead to speechlessness, and frightened patients tend to forget about what they really want to explain. Therefore, we need to be trained in professional interviewing 1.1 Introduction and how to get to the core of patients’ demands and expecta- tions. Diagnosis describes the process of determination and judg- The objective part of the evaluation begins with the anal- ment of variations from what is normal. Abnormal situ- ysis of the patients’ general aspect followed by the vital signs ations can bring up discomfort, pain, and loss of function checking such as blood pressure among others, an extraoral and may compromise esthetics. Therefore, diagnoses of exam of head and neck region, visually or by touch. Then, the alterations from what is normal in the stomatognathic sys- dentist follows to the intraoral exam, checking the soft tissue, tem is fundamental to execute an efficient dental treatment, gingiva, and tooth structure. The goal of the exam is to distin- aiming the re-establishment of the patient’s health. However, guish the normal from the abnormal, determining which abnormal situations may also be a biological variation and abnormal findings are a problem and require treatment or it Diagnosis and Treatment Planning 3 1 will influence the treatment. The nonclinical part of the exam nificantly longer problem presentations when the doctor is performed by the analysis of radiographies, plaster models initiates the interview with an open-ended question. on articulators, and photographs. Thereby a patient is respected as an autonomous person Nowadays, the clinical approaches should be based on a rather than a passive, confirmative authority. Patients so-called evidence-based clinical practice, on which the cli- should not be interrupted when presenting their chief com- nician guides their decisions related to the patient’s health on plaint but rather be encouraged to provide as much perti- published findings on scientific researches. Therefore, this nent information as possible. approach can be defined as the conscious, explicit, and Active listening is a communication competency that insightful use of the best available scientific evidence when helps health-care professionals to deeply reveal the patients’ taking decisions about the care of the patients. This vision concerns, ideas, and explanations about a given disease. allows the integration among individual clinical quality of In the first step, it is important to present our undivided the dentist, the patient’s preferences, and the best basis found attention to the patient and encourage them to talk. Nodding on scientific researches [17, 43]. and any other open nonverbal communication, including eye contact and an open posture, will help to make the patient feel comfortable and welcome. Telephone calls, ambient 1.2 Subjective Exam noises, or distractions of any other source should be avoided at any time. Just as well, taking notes on a file or in the com- The data from the so-called subjective exam, also called puter may unsettle the patient while talking. In case there is anamnesis, come from the interview with the patient. It an urgent need to do so, we should comment on that before- derives from the Greek words, ana (open) and mnesis hand and explain to the patient that it is inevitable to take (memory). In a medical context, anamnesis means recorda- down notes, but we pay full attention notwithstanding. Active tion, reminiscence, that is, the group of information that is listeners avoid interrupting at all costs. After the patient has part of the clinical history of the patient up to the moment explained the chief complaint, it is wise to rephrase it with of the exam. On this exam, crucial information is gath- our own words to ensure we have fully understood the cen- ered to determine the patient’s desires and the causal fac- tral point. We may encourage the patient to correct or add tors of many oral diseases, as well the safety of dental something whenever appropriate. procedures. Perception of verbal and nonverbal cueing plays a central role when we try to disclose hidden messages from another person. Signal words like “painful,” “expensive,” “time- 1.2.1 Chief Complaint consuming,” etc. might be a hint for worries a patient does not want to unfold straight away. Observing a person’s body The chief complaint is the motive why a patient consults the language will help us to get a vision about their mental and dentist. The answer should be registered on the file, prefera- emotional state. bly using the exact patient’s wording (. Fig. 1.12). During Addressing a patient’s feelings is the third step that in discussion and registration of the chief complaint, the most cases will lead to a trustful and overt doctor-patient patient will notice that his problem was acknowledged. relationship. Potential longer lulls in a conversation may feel Focusing on the chief complaint and paraphrasing it with awkward for both of the interlocutors. It is not wise to bridge our own words ensure that patients would feel correctly that break immediately nor to pose a second question when understood and dentists do not lose sight of the major con- the answer is not given immediately. Allowing pauses is a cerns. Concomitantly it positively affects the doctor-patient rhetorical device that can inspire a patient to disclose further relation showing that we listen carefully and really want to information. We should always keep in mind that most get to the core of a patient’s complaint [54, 66]. If the dentist patients feel tense at least which can cause confusion or too quickly interrupts the patient or tries to focus on other short-term oblivion. problems, omitting the discussion of the chief complaints, At the end of medical interview, it is highly recommended patients may question the dentist’s professional competen- to summarize the essential points and ask the patient whether cies. The patient should be encouraged and guided to discuss there is anything they would like to address or which has all the aspects of the problems in that matter including loca- been stated incorrectly. A final summary appears highly pro- tion, duration, and quality of symptoms, as well as any fessional and marks the end or a new phase within the con- related factors. These information are called the history of versation. In longer consultations, intermediate summaries the present illness. will help the professional to structure the interview and high- It is advisable to start the interview with an open-ended light the most relevant points not only to the patient but also question that allows the patient to explain their chief com- to himself or herself. plaints. “How may I help you” and “what can I do for you today?” are very nice opening questions since patients > The chief complaint is the motive why a patient desire opportunities to present concerns in their own consults the dentist. The answer should be registered time. In contrast to closed-ended questions (“I under- on the file, preferably using the exact patient’s stand you have an aching tooth”), patients will provide sig- wording.  4 C. R. G. Torres et al. > It is advisable to start the interview with an > Before planning an oral examination or dental 1 open-ended question that allows the patient to treatments, the general medical history of the patient explain their chief complaints. “How may I help you? ” has to be checked thoroughly; general health and “what can I do for you today?” are very nice problems or medication may influence therapeutic opening questions since patients desire opportunities decisions or the results of dental treatment and may to present concerns in their own time. even threaten the patient’s life. > Patients should not be interrupted when presenting 1.2.2.1 Compulsory Notification of Infectious their chief complaint but rather be encouraged to Diseases provide as much pertinent information as possible. When reviewing the medical history, the dentist may identify > Perception of verbal and nonverbal cueing plays a clinical manifestations of infectious and contagious diseases central role when we try to disclose hidden messages that put the life of a patient at risk or which involve a delay in from another person. dental treatment. It may be that the dentist is the first health professional to identify patients with those diseases. Apart > At the end of medical interview, it is highly from arranging medical consultation followed by medical recommended to summarize the essential points and treatment, the governmental health system has to be notified ask the patient whether there is anything they would of some of these cases, following the rules established by each like to address or which has been stated incorrectly. country. Often, the general health practitioner will take care of the procedures, but the dentist should confirm these actions. The disease control system requires certain infec- tious and contagious diseases to be reported, so that they can 1.2.2 Medical History trace a map with the number of cases within a specific region and check the risk of an epidemic, enabling initiation of pub- Before planning an oral examination or dental treatments, lic health measures, such as vaccination to ameliorate the the general medical history of the patient has to be checked spread of the disease. The list of compulsory notification dis- thoroughly; general health problems or medication may eases is frequently revised and changes according to each influence therapeutic decisions or the results of dental treat- country. ment and may even threaten the patient’s life. Also, dentists have the responsibility of guaranteeing that the dental treat- > When reviewing the medical history, the dentist may ments do not produce systemic consequences by interacting identify clinical manifestations of infectious and with previous diseases or medication intake. Initially, the contagious diseases that put the life of a patient at patient or legal guardian should answer a comprehensive risk, or which involve a delay in dental treatment. questionnaire concerning the patient’s medical history (. Figs. 1.12 and 1.13), preferably in a quiet environment such as the waiting room. Some dental institutions either 1.2.2.2 Systemic Diseases send these forms to the patient or offer an online version to Patients with systemic diseases may require special care, be completed prior to the first appointment. During the visit, especially those with cardiac disorders. Dental procedures the dentist will check the answers and address any open that cause bleeding may allow oral bacteria to penetrate the question directly with the patient. The form helps to bloodstream (bacteremia) and establish themselves on identify conditions that may interfere, complicate, or contra- abnormal or damaged valves, thus increasing the risk of bac- indicate dental procedures. Questionnaires should be terial endocarditis. According to the guidelines, patients with modified according to the specialty of the clinician and the prosthetic cardiac valves or prosthetic material used for car- category of patient (i.e., elderly, children, etc.), and additional diac valve repair, and those with a previous infective endocar- surveys may be added if necessary. Patients or legal guard- ditis, are at high risk of bacterial colonization. Other patients, ians should sign the questionnaires. This information needs who should receive an antibiotic prophylaxis prior to highly to be updated on a regular risk-adapted basis. invasive dental procedures , include those with congenital The clinician may identify infectious and contagious dis- heart diseases involving unrepaired cyanotic defects (includ- eases of compulsory notification, allergies, current and past ing palliative shunts and conduits), completely repaired medication that may interact with drugs prescribed or defects with prosthetic material or devices during the first 6 injected by the dentist, or systemic diseases (i.e., endocardi- months after the procedure, and repaired defects with resid- tis) that may demand preoperative antibiotic treatment. ual defects at or adjacent to the site of the prosthetic patch or A meticulous record of the medical history should avoid life- device. These procedures comprise extractions and peri- threatening incidents and identify conditions that require odontal treatments, probing, scraping, gingival surgeries, medical consultation. In individuals who present with several implants, reimplantation of displaced teeth, and routine den- systemic diseases and take many medications, the dentist tal prophylaxis when bleeding is likely. Patients who have should closely collaborate with a general practitioner to min- taken a combination of fenfluramine and phentermine, as an imize the overall health risk during dental treatment. appetite suppressor to lose weight, are more susceptible to Diagnosis and Treatment Planning 5 1 cardiac valve diseases. Patients that have a joint prosthesis are hypertensive crisis. In such cases, it is recommended to use a also at high risk of developing problems associated with bac- non-adrenergic vasoconstrictor such as felypressin. However, teria, because they may establish themselves up to 2 years its use is contraindicated in pregnant women because it after they have entered the bloodstream. However, in may lead to uterine contractions. The anesthetic substance general administration of prophylactic antibiotics cannot be prilocaine, when used in patients with cardiac arrhythmias recommended prior to dental procedures to prevent pros- who use antiarrhythmic medications such as tocainide, can thetic joint infection , because of the risk of antibiotic increase the toxicity of the antiarrhythmic drugs. Prilocaine resistance; a careful risk-benefit analysis remains necessary. must not be used in patients with anemia or pregnant women Therefore, antibiotic prophylaxis is not indicated for proce- because of the risk of methemoglobinemia. dures that present low bacterial incidence, such as dental res- Retraction cords with adrenaline used as vasoconstric- toration procedures, placement of a rubber dam, local tors have been abandoned due to the availability of better anesthesia, removal of sutures, radiographies, post cementa- alternatives for hemostasis. In addition, use of epineph- tion, installation of prosthesis, impressions, etc.. rine in patients with antidepressants needs to be analyzed with caution due to its potential for interactions. When oral hypoglycemic drugs are swallowed and absorbed, they Tip are released into the bloodstream. Some molecules are free in the blood and produce its therapeutic effects, while the rest Take your time and try to keep the patient’s medical history are bound to plasma proteins. However, nonsteroidal anti- comprehensive and up to date. It might save lives. inflammatories can compete with oral hypoglycemic drugs for these plasmatic bonds, increasing the fraction of free molecules, which may result in hypoglycemia. 1.2.2.3 Medications A patient’s medication may have a broad impact on the sto- 1.2.2.4 Allergies matognathic system or, in the case of polypharmacy, lead to The patient’s reports regarding allergy history and anamnes- substance interactions. Certain drugs are known to change tic allergic reactions must be investigated, especially with the salivary composition or flow rates, increase tissue bleed- regard to previously injected anesthesia. It is well-known that ing, produce lichenoid reactions, lead to gingival hyperpla- many problems related to anesthesia occur because of acci- sia, or change the overall appearance of the soft tissues [54, dental intravascular injection, high dosages, and excessive 66]. The reduction in salivary flow is associated with the pre- use of anesthetic. Some individuals present allergic reactions, scription of over 400 medications, including anticholiner- especially to the preservatives of the injected solution. gics, adrenaline blockers, antipsychotics, antihistamines, Naturally, patients that report allergy problems with local diuretics, and antihypertensives. A reduced salivary flow anesthesia should not receive this type of medication until increases the risk of developing (root) caries, some altera- further investigation has been performed by a specialized tions of the mucosa, an increase in biofilm retention, and doctor. The patient’s opinion should always be trusted until reduced quality of life due to xerostomia [10, 54, 65]. Dentists those additional tests have excluded the risk of allergy. This should recognize the use of medications that increase the risk precaution is necessary, considering that anaphylactic shock for xerostomia and hyposalivation and should initiate corre- can put the patient’s life at risk, requiring immediate treat- sponding treatment concepts. Close communication with ment with basic life support measurements and necessitating the general practitioner and the use of alternative medica- removal to a hospital. tions that have fewer adverse effects on salivary flow may be > Some individuals present allergic reactions, especially helpful, accompanied by treatment of the dry mouth symp- to the preservatives of the injected solution. toms. Tricyclic antidepressants can sensitize patients to epinephrine, a very common vasoconstrictor on local anes- Some patients report latex allergies; in those cases, it is rec- thesia. Antiepileptic agents can predispose to gingival hyper- ommended that the clinician uses vinyl gloves and a rubber plasia in the presence of bacterial biofilm, and antibiotics can dam without latex. Other allergies with relevance to dental reduce the effectiveness of contraceptives. treatments include allergic reaction to restorative materials, There are restrictions on the use of dental anaesthetic solu- such as amalgams or resinous monomers, and will dictate the tions that contains sympathomimetic amine vasoconstrictors choice of dental materials to be used. Some individuals also (i.e., adrenaline, noradrenaline, levonordefrin, phenyleph- present allergy to hydrogen peroxide, which contraindicates rine) in patients having hypertension and serious cardiac bleaching treatments, especially those techniques that are problems, uncontrolled diabetes mellitus, hypothyroidism, available at home. pheochromocytoma, sensitivity to sulfites, use tricyclic anti- depressants, phenothiazine compounds or non-selective beta 1.2.2.5 Older Patients blockers or are crack and cocaine users [4, 54]. Medication Because of the well-known demographic changes, particu- for hypertension that contain propranolol, when associated larly in western countries, the number of older patients that with adrenaline-containing anesthesia, may cause a sud- need to be treated in dental practice will continue to den increase in arterial blood pressure and induce a serious increase over the coming decades. These patients represent a  6 C. R. G. Torres et al. vulnerable and heterogeneous patient group, due to a great 1.2.2.6 Psychological and Social Aspects 1 number of changes related to aging, behavior, diet, and oral During anamnesis, the clinician should analyze the patient’s and systemic health; accordingly, this group requires special expectation and priorities relative to the treatment and his attention. The prevalence of multimorbidity and polyphar- oral health in general. Knowing about a patient’s priority is macy is high and has a negative impact on daily oral hygiene crucial when it comes to treatment decisions. Patient’s expec- capabilities. Neurodegenerative or mental disorders such as tations are highly variable and in the vast majority of cases depression, Alzheimer’s disease, and Parkinson’s diseases not congruent with those of the attending dentist. Accepting play a major role in reduced oral health. Furthermore, that patients have different views than ours leaves the around 50% of individuals over the age of 75 years take at decision-making process much easier and both doctors and least two medications [12, 54], increasing the risk of reduced patients much more satisfied. Therefore, we have to evaluate salivary flow rates and oral diseases. what is important for an individual patient. Esthetics, com- > Because of the well-known demographic changes, fort, time-consumption, monetary aspects, longevity, success particularly in western countries, the number of older rate, and biocompatibility are among the most important patients that need to be treated in dental practice will categories that should be discussed before we start discussing continue to increase over the coming decades. treatment options. Social inequality in many countries leads to diminished > Around 50% of individuals over the age of 75 years access and lower financial means for medical treatment of take at least two medications, increasing the risk of the socially deprived. Caries, however, the most prevalent reduced salivary flow rates and oral diseases. chronic disease worldwide most often affects underprivi- leged members of our society. In order to overcome The aging process in older patients produces physiological this obvious inconsistency, health-care systems should changes that are not pathological. Attrition, erosion, and become aware of this immanent problem and try to make abrasion of enamel reduce its thickness so that it becomes dental health services accessible and affordable for those more mineralized and translucent; the underlying dentin who are in need of it. Overtreatment of people in higher becomes more apparent, resulting in a yellow appearance of socioeconomic positions reflects the flip side of modern the teeth, and the pulpal chamber reduces in size. The chro- health-care systems. mogenic substances from the diet penetrate the enamel’s microcrystalline structure, making it darker. The gum may > Social inequality in many countries leads to diminished become inflamed and friable, associated with gum recession access and lower financial means for medical and consequent exposure of the root. treatment of the socially deprived. The oral alterations associated with malnourishment, immunosuppression, dehydration, smoking, alcohol con- sumption, diseases, medications, and dental problems reduce 1.2.3 Dental History the ability to feel the taste and smell in older patients. The perception of salt and bitterness and the olfactory senses The patients’ dental history comprises the registration of pre- lower with age, while the perception of sweet and sour is vious experiences in terms of dental treatments as well the unchanged. As a result, food becomes less tasty and unappe- current oral problems (chief complaint). Those reports give tizing. Therefore, sugar, fat, and salt are added in an attempt us valuable information about previous and existing prob- to improve the taste. It is crucial to evaluate dietary habits in lems, positive and negative experiences with the dental treat- older patients to identify malnutrition, give suggestions for ment, how often a patient visited the dentist, and the patients’ improvement while lowering the risk for dental diseases at attitude toward past dental treatments. Integration of the the same time. For example, aromatic herbs can improve the information will give us an overall view of a patient’s attitude taste of food in place of sugar and salt. Saliva stimulants, and level of significance about his oral health status. The candy, sugar-free gum with citrus aromas that contain xylitol patient can report problems with specific types of dental pro- or other sugar substituents, and brushing or scraping the cedures, which may be modified, if possible, to allow more tongue can improve the sense of taste, while smoking cessa- comfort [54, 66]. tion can improve the olfactory perception of older people. The patient may not spontaneously give the information Periodontal diseases can progress faster in older patients, that we might need, and it is necessary that the clinician and root caries is the most significant reason for dental loss directs the interrogatory, asking some specific questions in in these patients. Inefficient removal of the biofilm, reduced relation to (thermal) sensitivity or discomfort during chew- salivary flow rates, a diet rich in refined sugar, the presence of ing, if he presents some type of pain; if he has had any trauma fixed or removable prosthetic appliances, abrasion of the on the face, infections, lost or fracture of restorations, tooth cementoenamel junction (CEJ), gingival recession, and bone fractures, and impaction of food in between the teeth; and if loss due to periodontal disease mean that the root surface is he presents difficulties during the hygiene or bleeding when more prone to caries. Accordingly, dental restorations are doing the oral hygiene. It should also be asked whether a hard to perform, satisfactory filing materials are missing, and patient uses dental floss, and how often, asking information the restorations are at a high risk of caries recurrence. about the areas that he cannot pass the dental floss or if the Diagnosis and Treatment Planning 7 1 dental floss rips when passing between the teeth. Additionally, mobility, and it can indicate the presence of infections or it should be asked whether the patient is satisfied with the neoplasia. Muscles should be palpated, searching for rigid oral esthetic, the shape and color of their teeth, or any other or sensitive areas. The mastication muscles can present aspect that he or she may want to point out. In case there is a trigger points that may be related to temporomandibular report of any problem, complementary exams are used to get disorders. The region of the temporomandibular joint to a specific diagnosis [54, 66]. One example of a question- (TMJ) should be palpated, asking the patient to open and naire about the dental history can be seen in. Fig. 1.13 and close the mouth, to verify the presence of pain, clicks, or may be answered by the patient alongside with the medical crepitation. history questionnaire. 1.3.3 Intraoral Exam Tip During the intraoral clinical exam teeth, soft tissues and peri- The more patient-related information you get, the odontal structures are examined. more reliable your diagnosis will be. 1.3.3.1 Evaluation of the Soft Tissues A visual and/or tactile analysis is performed on the cheeks, 1.3 Objective Exam lips, palate, dorsum, and, under the tongue, the vestibule regions, and the tonsils. The presence of ulcer lesions or After anamnesis and subjective examination, a clinician con- nodes, vesicles, or inflammation has to be thoroughly inves- ducts the objective clinical examination. Records obtained tigated. In some cases, the dentist is the first to detect infec- from the subjective exam can help to guide the clinical exam, tious and contagious diseases, as well as neoplasia, that can allowing that the most probable diagnosis is reached. put the patient’s life at risk. Many infectious diseases present The clinical exam consists of the general evaluation of the their first signals inside the oral cavity. Every clinician should patient, outside and inside the mouth, and the esthetic analy- be prepared to diagnose or at least suspect any alterations sis. From the reports of the subjective exams and the changes and direct the patient to a specialized dentist or doctor for found on the objective exam, the clinician will elaborate a further analysis. problem list that needs to be addressed for a complete reha- bilitation of the patient. 1.3.3.2 Periodontal Evaluation A thorough periodontal evaluation is essential for all patients, not only to determine the periodontal situation and its effects 1.3.1 General Aspects and Vital Signals on possible dental restorative treatment plans but also to establish the potential effect of existing or planned restora- As soon as the patient enters the office, his general appear- tions on periodontal health. Also, it is well-known that ance may be observed. He may present as a healthy rather many diseases such as diabetes have an impact on periodon- unremarkable person or present signs of debility, malnutri- titis and should therefore be treated. Visually, a healthy gum tion, malformation, or signals that suggest a congenital syn- is pink and firm, with the attached gingiva presenting the drome. Deficiency on the general self-care, as the lack of aspect of an orange peel; in contrast, inflamed gum is usually personal hygiene, can be associated with the lack of compro- red, soft, swollen, and smooth. The depth of the gingival sul- mise on the maintenance of the oral health. cus must be verified with a probe. In healthy gums, no bleed- Vital parameters, such as blood pressure and heart rate, ing should occur after probing, and the gingival sulcus should may easily be checked during the first or any follow-up be 1–2 mm deep. The presence of calculus and periodontal appointment. Instant blood sugar analysis can indicate the pockets with a sulcus deeper than 3 mm, as is the case with presence of diabetes. Patients presenting signals or symp- inflammatory active pockets associated with bleeding, is an toms of systemic problems should be referred to a general indicator of periodontal disease. The periodontal chart practitioner prior to dental treatment, except in case of an is a schematic representation of the depth of the periodontal emergency. pockets and should be filled out correctly to determine the necessity for periodontal treatment (. Fig. 1.15). The calcu- lation for the gingival bleeding index should be executed and 1.3.2 Extraoral Exam registered on a clinical chart. Surfaces that present bleeding are registered, and their percentage in relation to the total Before any intraoral examination, the head and neck region surfaces that were analyzed is calculated. The involvement of should be checked first. The exam comprises visual assess- bifurcations on the posterior teeth is evaluated, mobility of ment and palpation. Visual aspects can show us sores, teeth as a result of bone loss or excessive occlusal forces; these asymmetries, swollen areas, redness, or fistulas. The palpa- factors should be taken into account when performing risk tion of the submandibular and cervical lymphatic glands assessment for each tooth and when making therapeutic can show swelling of lymph nodes, sore or not, hard or with decisions.  8 C. R. G. Torres et al. > A thorough periodontal evaluation is essential for all Detection of Caries Lesions 1 patients, not only to determine the periodontal situation Caries lesions are clinical symptoms of the disease “caries,” and its effects on possible dental restorative treatment resulting from the unbalance of demineralization and rem- plans but also to establish the potential effect of existing ineralization processes. Early stages impose as subsurface or planned restorations on periodontal health. lesions in the enamel, eventually progressing toward the A radiographic exam may be indicated to analyze bone dentinoenamel junction (DEJ) and later on into the den- topography. Then the presence of gingival recession areas tine. Surface cavitation occurs at a rather late stage as a and regions with a small quantity or lack of attached gum is result of mechanical instability. Caries lesions usually prog- evaluated, which is registered on the clinical chart. Presence ress very slowly in enamel and take up speed past the of biofilm and residues indicates deficiency of oral self-care. DEJ. Detection and diagnosis of caries lesions are a chal- The existence of gingival inflammation impairs dental restor- lenging process. On the occlusal site, a seemingly intact ative procedures, because of the difficulty in obtaining a dry surface can overlay a rather extensive lesion, a phenomenon field, risking the success of the treatment; the disease needs that is referred to as “hidden caries.” Examination of inter- to be controlled and the situation improved before planning proximal sites is challenging as well, because we do not further treatments. have a direct view on the surface. Meticulous cleaning and The presence of dental restorations with an inadequate air-drying prior to visual examination and utilization of a contour can result in periodontal problems. Overcontouring validated caries classification are reported to be sufficient and the resulting overhangs in the proximal area, due to an and accurate. However, bitewing radiographs are excess of restorative material that pours out during applica- extensively used as an adjunct caries detection method. tion, result in inflammation and pain during cleaning by the Bitewing radiographs are highly accurate for cavitated patient (. Fig. 1.5b). Open approximal contacts, particularly proximal lesions and suitable to detect dentinal caries in the posterior region, foster food impaction and increase lesions. Although repeated bitewing radiographs may biofilm accumulation. These conditions may lead to gingi- result in overdiagnosis and hence overtreatment, radio- val inflammation, tooth dislocation, increased mobility and graphs are a suitable method for monitoring interproximal bone loss. In cases of deep caries lesions or necessary non-cavitated lesions that are treated non-operatively or restorative treatment, radiography should be used to estimate microinvasively. the position of the cavity margin, to assess whether there On root surfaces, especially in patients with periodontal will be an invasion of the biological width. Teeth that pockets, lesions can progress fast, affecting the pulp tissue. need restorative treatment, but have a doubtful periodontal Detection of such lesions may be complicated by the pres- prognosis, should be noted on the clinical chart and added ence of the gingival tissue, and here radiography plays a very to the problem list. Until the diagnosis of this particular important role, too. Progression of a caries lesion depends on tooth becomes positive, the restorative treatment should be many variables, for which many detection methods are avail- as minimal as possible, and the treatment plan has to remain able. For detailed information, see 7 Chap. 3. flexible. > Bitewing radiographs are highly accurate for detection 1.3.3.3 Dentition Evaluation of cavitated proximal lesions. They are also a suitable method for monitoring interproximal non-cavitated The dentition is subject to a broad range of alterations, which lesions that are treated non-operatively or can lead to loss of structure, pain, or pulpal symptoms. Others microinvasively. are related to the formation of dental structures, such as ame- logenesis and dentinogenesis, the position of a tooth in the jaw or agenesis. In general, the visual exam should be performed Non-carious Lesions after air-drying the teeth and under good lightening condi- Non-carious lesions result from the loss of dental structure tions. Additional isolation of the area during examination can without the participation of bacterial biofilm. They can be be achieved with cotton rolls and saliva ejectors. However, cot- divided accordingly to its etiology in erosion, abrasion, ton rolls may hinder the view on the soft tissues. All teeth abfraction, and attrition, even though in many cases the ori- should be clean, without residues of bacterial biofilm and gin is multifactorial. extrinsic stains, which might require a previous prophylaxis. The term dental erosion is used to describe the physical Unwaxed dental floss may be passed through all approximal result of a pathologic, chronic localized, and usually painless contact areas. In case the floss rips or tears apart, it indicates a loss of hard tissues that is chemically attacked by acids with- rough surface, excess restorative material, or cavities. out the involvement of bacteria. The acids attacking enamel and later on dentin may be of extrinsic (diet) or Tip intrinsic (reflux) origin. The acids promote loss of structure and softening of the surface layer, which is then worn by the Meticulous examination of periodontal conditions is as friction of the food bolus or brushing, characterizing the ero- fundamental as assessment of the teeth. sive tooth wear (ETW). According to the etiology, the lesions can be classified as extrinsic, intrinsic, or idiopathic Diagnosis and Treatment Planning 9 1 (unknown origin). As an example of extrinsic acidic sources, typical signs. In advanced situations, the morphology may the frequent consumption of sour fruits, low-pH juices or completely transform into concave surfaces. Restorations are sodas, sports drinks, and alcoholic beverages is to be men- not affected and become exposed (. Fig. 1.1b). On smooth tioned. Other sources are the work environment (as indus- surfaces, typical characteristics are surface flattening and an trial acids), pool water, and some medication as effervescent intact rim of enamel along the gingival margin. Concavities tablets of vitamin C (. Fig. 1.1a) may be the cause for dental usually wider than deep can be observed in some cases. erosion. The main characteristic of ETW is the loss of con- tour and natural surface morphology. On occlusal surfaces, > Non-carious lesions result from the loss of dental the flattening of the structures and cupping of the cusps are structure without the participation of bacterial biofilm. a b c d e f. Fig. 1.1 Non-carious lesions. a Dental erosion caused by the very d erosion of the lingual surfaces because of regurgitation of gastric frequent ingestion of lemonade; b erosion resulting from the abusive acid; e abrasion by excessive brushing; f, g abfraction on anterior and ingestion of cola based soda; c erosion on the tip of the cusps on posterior teeth; h, i intense attrition in patient with bruxism patients with gastroesophageal reflux associated with attrition;  10 C. R. G. Torres et al. 1 g h i. Fig. 1.1 (continued) As example of the intrinsic source, gastric acids produce an lem. Some studies suggested that those patients should not erosive challenge during vomiting, constant regurgitation, or brush their teeth immediately after acid exposure, although reflux. The gastric acid has a pH of 1–1.5 and hence is much others did not confirm this recommendation. The tooth- lower than the critical pH for enamel dissolution. Intrinsic brush should have extra soft bristles, and the toothpaste erosive challenges are associated with psychosomatic disor- should contain little abrasive substances. Additionally, ders or psychogenic eating disorders, such as nervous fluoride-containing mouth rinses may be used on a regular anorexia or bulimia. Somatic causes comprise pregnancy, basis. A neutral 2% sodium fluoride gel or 5% fluoride var- alcoholism, treatment for alcoholism and gastrointestinal nish can be applied on dental visits. The use of sugar-free dysfunction, hiatus hernia, peptic and duodenal ulcers, and chewing gums can stimulate salivary flow. Deeply eroded gastroesophageal reflux. Dental erosion due to chronicle lesions might benefit from a mechanical barrier against acid regurgitation often hits the internal region of the arches, cor- attacks by adhesive restorations. Dentin sealants also responding to the track of the regurgitated acid over the dor- seem to be rather resistant against erosive conditions and sum of the tongue, along the palatal surfaces of the maxillary might serve as an intermediary treatment option for exposed teeth and the occlusal sites of the posterior mandibular teeth dentin surfaces. Acidic drinks should not be held in the (. Fig. 1.1c, d). Even though it may affect the occlusal and mouth, especially not being “swished” around the teeth. lingual surfaces of every maxillary tooth, it is confined to the Using a non-plastic straw will minimize the fluids’ contact buccal and occlusal sites of the mandibular premolars and time with the teeth and save our environment at the same molars. Buccal surfaces of maxillary teeth are usually not time. affected, and the posterior teeth are protected by the neutral- > Eliminating or reducing the causative factor, i.e., the izing saliva from the parotid gland. Lingual surfaces of the source of acid, is crucial for patients with erosive mandibular teeth are covered by the tongue and thereby pro- problems. tected from the acidic challenge. Eliminating or reducing the causative factor, i.e., the Abrasion is defined as tooth wear induced by substances or source of acid, is crucial for patients with erosive problems. objects other than food. Tooth brushing is the main etiologi- This can include medical treatment for any intrinsic prob- cal factor of abrasion depending on tools, dentifrices, and Diagnosis and Treatment Planning 11 1 techniques used for the cleaning procedure (. Fig. 1.1e). In esthetically unacceptable for the patient. Further indications addition, the type of material, hardness of the bristles, for restorations may be remaining dentin sensitivity after whether these bristle tips are rounded or not, and their flex- non-operative care, periodontal problems, the use of the ibility have an impact on abrasive wear, as well as abrasivity, tooth as an abutment for prosthesis or due to caries lesions pH, and the quantity of toothpaste used. [7, 54]. Restorative procedures in the cervical part of a tooth Abfraction derives from the Latin word frangere which are demanding, since moisture control and contouring might means to break. It is used to describe the specific wedge- be challenging. The indication should thoroughly be weighed shaped defects in the cervical region, resulting from occlusal against potential disadvantages, especially for periodontal forces applied to the tooth, leading to its flexion (. Fig. 1.1f g, health. g). Parafunctional forces especially during lateral movements Attrition is defined as wear by tooth-to-tooth contact of the mandible expose teeth to intense flexion and shear without the impact of any other substance. It can result from forces, resulting in substance loss in the cervical region, physiological or pathological etiological factors. Physiological which is the weakest part of the tooth. Lesions are located on wear is considered a slow degradation of the dental shape, the CEJ, caused by microfractures on the enamel, growing manifested as a flattening of the tips of the cusps in posterior perpendicularly to the long axis of the affected tooth. The teeth and the incisal curve of the anterior teeth (. Fig. 3.16c, d) resulting damages have the wedge shape and sharp edges. [66, 70]. Characteristic features are opposing wear facets The incisal/occlusal wall generally has sharp cavosurface with sharp margins. When the wearing becomes excessive, it angles, forming a right angle to the external tooth surface. may be related to pathological causes. Excessive attrition is The gingival cavosurface angle are located on the root surface primarily caused by bruxism that will result in facets on the. Apart from dynamic occlusion parameters, the use of opposing teeth (. Fig. 1.1h, i). Since elimination of the para- hard toothbrushes and a horizontal brushing technique are functional habits is very hard to achieve, occlusal acrylic frequently associated with the occurrence of non-carious resin splints are used to prevent the patient from further cervical lesions. tooth wear. The clinician has to identify patients with exces- Differential diagnosis and origin of non-carious cervical sive tooth wear, especially younger individuals. Significant lesions is not always unequivocal. There is a high chance attrition areas that resulted on exposition of dentin and pres- that a lesion’s etiology has more than one origin; however, ent sensibility or discomfort might be considered for restor- some fundamental properties can be observed. Abrasive ative treatment. However, a previous analysis of the occlusion lesions are more frequently on the buccal surfaces and above and the causal factors of the wearing should be carried out the gum, while abfractions can be located partially or com- previously. pletely under the gum. The abrasive lesion is characterized The resulting wear of an antagonistic tooth against a res- by a rather shallow and rounded morphology, whereas toration very much depends on the restorative material used. abfractions have a wedge shape with sharp edges. Abrasions Wear analysis showed that amalgam would cause a slightly usually involve many neighboring teeth, while the abfrac- increased wear to the opponent tooth. Microfilled com- tion can occur in just a single tooth. Abfraction is always posites result in wear similar to the enamel, while hybrid associated to some occlusal interference, while the abrasion composites generate a slightly increased wear compared to is not necessarily accompanied by an occlusal interference. enamel. The microhybrid and nanofilled composites seem to As abrasion intensifies structural loss of a tooth under ero- induce a similar wear than the enamel. Cast gold restorations sive conditions. Erosion and abrasion may be important are usually softer than enamel and amalgam, resulting in less secondary factors on the progression of lesions induced by wear of the antagonistic tooth. Feldspar ceramics produce the abfraction. It is important to control the etiological fac- extensive antagonistic tooth wear; however, modern dental tors of non-carious cervical lesions, because restorations ceramics are significantly less abrasive. will be subjected to the same factors that initially caused the It is not rare to have patients complaining of sensibility lesion. on the root surface, characterized by an acute pain, gener- ally associated with a gingival recession and exposition of > Differential diagnosis and origin of non-carious the cementum or dentin. The most accepted theory to cervical lesions is not always unequivocal. explain this phenomenon is called the hydrodynamic the- Depending on the size, location, and presence of sensitivity, ory, claiming that pain results from the movement of fluids treatment of non-carious (cervical) lesions particularly con- inside the dentinal tubules, stimulating the mechanical sists of controlling the etiological factors. Additionally, this receptors within the pulp tissue. Fluid movements may causal therapy can be flanked by the use of desensitizers or be initiated by thermal changes, air-drying, osmotic pres- ultimately the restorations of these lesions. The restorations sure, or mechanical contact. Any treatment that reduces should be placed when the lesion is active, and non-operative this movement of fluids closing the tubules partially or treatment is not capable to arrest the lesion. A restoration can completely can help to reduce the sensitivity. Further be advantageous when the structural tooth integrity is com- details relative to dentine sensitivity can be obtained in promised, there is a risk of pulp exposure, or the defect is 7 Chap. 18.  12 C. R. G. Torres et al. Tip granulated food. The patient is usually capable to localize 1 the cracked tooth. Cracked teeth mostly respond to vital- The clinical management of non-carious cervical ity tests and can present sensitivity when eating cold, hot, lesions should always include elimination or reduction sweet, or acidic food. Usually no alterations can be seen of the causative factors rather than just restoring the radiographically; teeth are either clinically intact or defect. restored. Diagnosis is performed with a device that allows placing pressure on each cusp separately or by removing the restoration and inspecting the cavity wall. Dye can be Pulpal Diseases applied into the cavity in attempt to visualize a potential crack. For more details about the cracked tooth syndrome, Unhindered progression of a caries lesion may lead to see 7 Chap. 18. pulpal symptoms which manifest as pain and at a later stage can turn into pulpal inflammation and necrosis. > Cracking of a tooth as a result of mechanical overload Patients with pulpal diseases consult the dentist because oftentimes cannot be visually detected, originating a they suffer from pain. Non-symptomatic necrosis of the painful process called “cracked tooth syndrome.” pulp is frequently overseen or incidentally detected on a radiograph. Partial removal of the pulp (pulpotomy) can be Complete tooth fractures can be due to trauma or progres- a sufficient therapy for reversible forms of pulpitis or expo- sion of a crack. It should be verified which tissues are sure of the pulp during caries excavation. Irreversible involved, as the fractures may be having affected the enamel, pulpal inflammation and pulpal necrosis however require enamel/dentin, enamel/dentin/pulp, or enamel/dentin/pulp/ endodontic treatment of the entire root canal system. periodontal tissues. Fractures that involve only the enamel or Pulpal diagnosis is primarily based on reported symptoms, the enamel and the dentin can usually be treated with resto- the reaction to thermal and percussion tests and ultimately rations. Fractures involving the pulp may need an appropri- radiographic examination. Conducting pulp sensitivity ate endodontic treatment. Preserving vitality of the pulpal testing on each tooth is not recommended. However, teeth tissue is preferred whenever feasible and particularly in cases with a symptomatic history, questionable periapical radio- with incomplete root formation. Fractures involving peri- graphic findings, or those considered for restoration might odontal structures, including infrabony defects, may need be tested for signs of pulpal vitality. It is embarrassing for surgical crown lengthening or an orthodontic extrusion both clinician and patient to discover that a recently therapy prior to restoration. Root fractures may occur as a restored tooth had a necrotic pulp before the treatment and side effect of endodontic treatment or due to trauma. Detec- becomes symptomatic after it. A more detailed tion and treatment of such fractures is challenging, and these description about diagnosis of the pulpal alterations can be cases are often called hopeless. Multidisciplinary approaches found in 7 Chap. 9. in terms of combined orthodontic, surgical, and restorative treatment can lead to complete rehabilitation of complicated Dental Integrity and Fractures crown-root fractures.. Figure 1.2a–d shows examples of When submitted to occlusal load, dental cusps tend to cracks and fractures in anterior and posterior teeth. For undergo deflection, which is strongly increased when a details, see 7 Chap. 14. restoration is present. The greater the amount of sub- stance loss, the bigger the cuspal deflection will be. The Shape and Position Abnormalities quantity of movement depends on the intensity of the Teeth can present deviations in shape or size. Such alterations force acting on the tooth. The force is determined by the can have genetic origins, such as conical teeth, dens in dente, muscular strength of the individual and correlates with and microdontia or can be related to infectious diseases dur- parafunctional activities such as bruxism, clenching, and ing odontogenesis period, such as congenital syphilis that grinding. Under the influence of repetitive loads, cusps results in in screwdriver-shaped incisors (Hutchinson inci- suffer fatigue and may happen to fracture, losing that por- sor) or mulberry molars. Disproportion between tooth size tion of the dental structure. Cracking of a tooth as a result and size of the jaw can result in crowding or dental gaps of mechanical overload oftentimes cannot be visually called diastema. Gaps are usually closed with orthodontic detected, originating a painful process called “cracked procedures. In some cases, remaining gaps particularly in the tooth syndrome”. When cracked teeth are submitted anterior region can be corrected with direct or indirect resto- to masticatory or occlusal loads, the crack line opens, rations. Transposition or ectopic eruption describes the phe- resulting in movement of the dentinal fluid. According to nomenon when teeth do not erupt at their predetermined hydrodynamic theory, this movement can cause pain. position within the jaw. Missing teeth may occur due to Patients generally report acute and sharp pain, upon load- agenesis or avulsion, bearing the potential risk of adjacent ing and unloading forces, usually when chewing hard or tooth migration (. Fig. 1.3a–i). Diagnosis and Treatment Planning 13 1 a b c d. Fig. 1.2 Dental fractures. a, b Cracks and fractures on the anterior teeth; c, d cracks and fractures on posterior teeth a b c d. Fig. 1.3 Abnormalities on the shape and position. a Diastemas incisor; d, e dens in dente; f anodonty of the lateral incisors; g left maxillary between anterior teeth; b cone-shaped right lateral maxillary incisor; c canine positioned in place of the lateral incisor; h hypoplasia of the enamel transposition of the maxillary canine on the place of the right lateral on the incisal third of the anterior teeth; i imperfect amelogenesis  14 C. R. G. Torres et al. 1 e f g h i. Fig. 1.3 (continued) Color Changes the enamel surface. For example, staining can be observed Most patients are unsatisfied with their tooth color and feel after regular coffee or tea consumption and tobacco smoking, esthetically impaired. Consequently, the desire for tooth whit- due to ingestion of iron-containing vitamin compounds or ening is among the most often heard demands when assessing from chromogenic bacteria in the biofilm (. Fig. 1.4a). Some the patients’ chief complaints. Color changes can be of extrin- substances capable to cause extrinsic discoloration can also sic or intrinsic origin. Extrinsic staining is frequently caused penetrate to some extent into the tooth, resulting in a mostly by food and beverages, where chromogenic agents attach to yellowish appearance. Intrinsic staining occurs when chro- Diagnosis and Treatment Planning 15 1 mophores are incorporated into the hard tissues during tooth In cases where tooth whitening is not sufficient to fulfill development or caused by conditions acquired later in life, the patients’ need, veneers may be an option to enhance the such as endodontic treatment, dental trauma, or caries. In anterior teeth esthetics, a procedure described in 7 Chap. 17. most cases application of an oxidant bleaching agent is the > Most patients are unsatisfied with their tooth color and therapy of choice, like hydrogen peroxide or carbamide per- feel esthetically impaired. Consequently, the desire for oxide, diffusing into the enamel and dentin and breaking the tooth whitening is among the most often heard chromophores, leaving the tooth with a significantly lighter demands when assessing the patients’ chief complaints. appearance. Tooth whitening can be performed at the dental office or at home, in a single visit or over a longer period. Some people have naturally darker teeth than others do. Peroxide concentrations vary considerably among products Intrinsic color changes can be caused by problems during and are strictly limited in several countries. tooth formation. Excess of fluoride intake can result in hypo- a b c d e f. Fig. 1.4 Color changes of tooth structure. a Extrinsic staining due to trauma and intrusion of the deciduous teeth; g, h darkening of tooth to smoking; b dental fluorosis; c, d amelogenesis imperfecta; e staining 22 by pulp calcification after the orthodontic traction. i Darkening of due to ingestion of tetracycline; f hypomineralization on enamel due the tooth 11 due to pulpal necrosis after trauma at the region  16 C. R. G. Torres et al.. Fig. 1.4 (continued) 1 g h i mineralization during enamel formation, resulting in whit- It should be noted that in cases where dental bleaching is ish areas of enamel, up to a surface with porosities or pits included in the treatment plan, it should precede any restor- in the more severe situations (. Fig. 1.4b). This side effect ative procedure on anterior teeth. A washout phase of mini- of a chronic fluoride overdose during tooth formation is mum 2 weeks should be observed after the bleaching, to called dental fluorosis. Different in origin, amelogenesis and allow the color stabilization and peroxide release from inside dentinogenesis imperfecta result in great esthetic problems, the tooth structure. Besides, the patient should be informed which may require extensive operative care (. Fig. 1.4c, d). that restorations and existing prosthetic appliances will not When ingested during odontogenesis, tetracycline, an be bleached and probably need to be replaced afterward. antibiotic widely used in the past, deposits itself inside the dental structure and results in horizontal striped pattern Tip (. Fig. 1.4e). > Excess of fluoride intake can result in hypominer- Most patients are dissatisfied with their tooth color. alization during enamel formation, resulting in whitish Therefore, whitening procedures should be part of the areas of enamel up to a surface with porosities or pits portfolio of modern dentists. in the more severe situations. Trauma or infection in deciduous teeth can result in hypo- Analysis of Existing Restorations mineralization or hypoplasia in the following permanent The decision whether to keep or to replace an existing resto- teeth (. Fig. 1.4f). Trauma or orthodontic movements can ration is a demanding process in everyday routine. result in dystrophic calcification of the pulpal tissue, also pro- Overtreatment, in terms of random or premature replace- moting dental darkening (. Fig. 1.4g, h). In other cases, ment of an existing restoration, would invariably result in an trauma can lead to pulpal necrosis, which decomposition unnecessary removal of the tooth structure, including the products darken the crown (. Fig. 1.4i). As mentioned above, risk of accidental pulp exposure. Re-dentistry, i.e., replace- aging as a natural process results in darkening of teeth because ment of restorations, is reported to be the dentist main duty of a higher degree of dentin mineralization and the enamel. The diagnostic process and decision tree in favor or becoming thinner and more translucent at the same time. against restoration replacement should be primarily based on Diagnosis and Treatment Planning 17 1 health risks for the patient and always be a result of a shared The margins of the restorations may be examined with an decision-making process. From an ethical point of view, exploratory probe, moved perpendicularly to the interface it is inacceptable that clinicians take decisions for their tooth restoration. It should be moved from the restoration patients and even worse without providing any justification. toward the dental surface and the other way round, working Therefore, transparent findings and diagnoses as well as along the whole margin. In case the explorer gets stuck patients’ preferences should be the basis in the decision-mak- from the tooth toward the restoration, there is an excess of ing this process. restorative material, which can be removed by finishing and polishing (. Fig. 1.5c). In case it gets stuck from the restora- > The decision whether to keep or to renew an existing tion toward the tooth, there is a lack of material. It should be restoration is a demanding process in everyday evaluated whether these margins are accessible to oral routine. Overtreatment in terms of random or hygiene and whether dentin is exposed. The latter may be an premature replacement of an existing restoration unfavorable condition and be considered for either repair or would invariably result in an unnecessary removal of replacement of the restoration. the tooth structure, including the risk of accidental When the probe gets stuck both ways, there is a ditch on pulp exposure. the interface. Marginal ditching is a result of wear or fractures, either in amalgam or in the enamel, mostly due to > Transparent findings and diagnoses as well as patients’ improper cavity preparation (. Fig. 1.5d, e). The presence of preferences should be the basis in the decision-making marginal ditching does not necessarily implicate the presence this process. or an increased risk for developing a caries lesion. Clinical assessment of restorations should be carried out Corrosion products of amalgam may seal the interface and under dry and well-illuminated conditions, isolated with cot- keep the restoration intact for a long time. Ditches going deep ton rolls and saliva ejectors. The clinician first may visually into the interface, with or without dentin exposure, may inspect the restoration, followed by a tactile examination increase the risk of biofilm accumulation and secondary car- with an exploratory probe and probably the use of dental ies. It should be weighed out whether marginal sealing, repair, floss. Bitewing radiographs can yield additional information or entire replacement of this restoration would increase tooth in particular areas that cannot be assessed clinically. longevity and enhance the patients’ quality of life. For evaluation of amalgam restorations, many conditions The occlusal surface of a restoration is examined thor- should be observed, such as transparency through the enamel, oughly for fracture lines (. Fig. 1.5f). Fractures mostly occur marginal integrity, fracture lines, improper anatomic shape in the isthmus region, between the occlusal and proximal (overcontour, undercontour, proximal overhangs, inappro- boxes or where the cavity is rather shallow or irregular, caus- priate height of the marginal ridge relative to the adjacent ing the restorative to fracture. In general, fractures mostly tooth, and inadequate interproximal contacts), recurrent car- result from an incorrect cavity preparation. In cases where ies, inadequate occlusal contact, undesirable surface rough- restorations have been repaired, the junction between the old ness, and violation of the biological width [54, 66]. and new amalgam can be visible, similar to a fracture line. In Facial walls of proximal boxes of the Class II preparations other situations, parts of the fractured restoration have been happen to be very thin in many cases and not supported by lost (. Fig. 1.5g, h). In some cases, the restoration is still in dentin. Due to enamel translucency, shining through place, but the remaining tooth structure fractures (. Fig. 1.5i). amalgam restorations may impair the esthetics. However, This usually happens when the remaining tooth structure is this does not necessarily indicate that the restoration needs too fragile and likely to fracture under occlusal load. to be replaced, unless it is among the patient’s chief complaint The restoration should mimic the individual anatomical (. Fig. 1.5a). When there is no apparent marginal degra- shape of the intact tooth structure, to allow optimal esthetics dation, the discoloration appears gray or blueish. However, and function. Therefore, height and volume of the restored when the discolored area is yellow or brownish, and it seems cusps will guarantee adequate chewing efficiency avoiding to have communication with the cavosurface margin, pres- extrusion of the antagonist (. Fig. 1.5j). Location of the ence of a caries lesion in the interface is likely, indicating a height of curvature on the buccal and lingual surfaces is also health risk for the patient. Consequently, replacement of this very important because it deflects the food bolus, so that the restoration should be discussed with the patient. passing food may stimulate the gingival tissues. Restorations Proximal overhangs, because of inadequate use of the with under or overcontour on the buccal and lingual surfaces matrix and wedge system during restoration, create condi- can result in gingival lesions. Undercontouring may tions favorable for biofilm adhesion and niches that are dif- cause food impaction over the gingival tissue, resulting in ficult to access during oral hygiene (. Fig. 1.5b). Diagnosis of gingival inflammation or recession in the worst case. such overhangs is usually performed with radiographs and Overcontouring deflects food from gingiva and results in the use of an exploratory probe or dental floss. The clinician understimulation of the supporting tissues, promoting the can try to remove the excess of restorative material with a deposit of biofilm in the cervical region and gingival inflam- steel abrasive strip or with an oscillating diamond-coated file mation. (EVA system) in a handpiece (. Fig. 4.36). However, in most The marginal ridge of a restoration should be adjusted to cases, replacement of the restoration may be necessary. the height of the adjacent tooth, creating adequate occlusal  18 C. R. G. Torres et al. embrasures that allow the passage of food toward the buccal > The proximal contact area of Class II restorations should 1 and lingual surfaces. Adequate marginal ridges allow proper be located in the occlusal third of the proximal surface, contact of the opposing tooth in an occlusion of 2:1. Marginal with an occlusal embrasure to allow the insertion of ridges of neighboring teeth at a different height may cause dental floss and a tightness to avoid food impaction. food impaction, resulting in gingival inflammation. The restored proximal surfaces should present a natural Furthermore, the patient may face difficulties when using convex contour, to guarantee the formation of a perfect dental floss. The proximal contact area of Class II resto- contact area with the convex surface of the adjacent tooth. rations should be located in the occlusal third of the proximal However, when a proximal carious cavitation remains surface, with an occlusal embrasure to allow the insertion of unrestored, adjacent teeth might show the tendency to drift dental floss and a tightness to avoid food impaction. a b c d e f. Fig. 1.5 Analysis of the amalgam restorations. a Visualization of degradation exposing the dentin; f fracture line. g, h Fracture in the the amalgam by translucency; b cervical overhang (arrow); c excess on restoration body; i fracture of the remaining cusp; j mesiolingual cusp the margins of the proximal restorations (arrow); d marginal degrada- in amalgam with inadequate height; k inadequate proximal contour; tion being checked with an exploratory probe; e intense marginal l restoration with open proximal contact Diagnosis and Treatment Planning 19 1 g h i j k l. Fig. 1.5 (continued) into the open cavity (. Fig. 6.21a, b and. Fig. 1.5k). Restor- excessive force applied during flossing. In situations ative treatment without previous orthodontic treatment where repair of the restoration will not be the solution, the most likely results in a concave contact area, which is unac- total replacement would be necessary. The interproximal ceptable for reasons outlined above. Therefore, orthodontic contacts are best evaluated with waxed dental floss, explor- movement of these teeth, for instance, with the help of ing its resistance when passing through the contact area, separation rubbers, is needed before a final restoration is and using a dental mirror in many angulations, keeping it placed. on the lingual position and observing the teeth from the Open interproximal contacts may foster food impaction buccal aspect, reflecting the light to the contact region, so resulting in discomfort, increased biofilm deposit, and that the clinician can see whether there is space in-between hence gingival inflammation and tooth migration the teeth. For that, the contact area should be dry and free of (. Fig. 1.5l). On the other hand, the contact point should saliva. Creating an anatomic contact point is an impor- not be too tight, in order to avoid the shredding and impac- tant quality factor of a restoration and should be paid par- tion of dental floss fibers or periodontal trauma induced by ticular attention.  20 C. R. G. Torres et al. Tip unsatisfactory color match because of extrinsic staining or 1 degradation, but also due to color mismatch of the compos- Creating an anatomic contact point is an important ite or inadequate translucency (. Fig. 1.6a). In regular hybrid quality factor of a restoration and should be paid composite materials, wear of the organic matrix exposes the particular attention. filler particles, resulting in a dull appearance of the restora- tion (. Fig. 1.6b, c). Usually surface repolishing is sufficient to bring back the lost gloss. However, depending on the Many restorations show some defects in relation to the ana- patients’ diet, consumption of staining substances or tobacco tomic shape, but they provide adequate clinical function and smoking, there might be a tendency toward superficial stain- do not require replacement. When considering the replace- ing of the restoration. Color mismatch per se is not a bio- ment of an existing restoration, it is crucial whether this res- logical hazard; therefore, it is solely incumbent upon the toration has caused damage or is likely to be a risk for the patient whether they feel impaired or not. Change in color patients’ health. may also be the result of the degradation of the polymeric The presence of recurrent caries on marginal areas is matrix, usually an indication for restoration replacement detected visually and/radiographically. It is common to find (. Fig. 1.6d–f). secondary caries lesions in regions where marginal gaps Marginal staining is an indicator that there are marginal occur in gingival walls, and those indicate replacement. gaps at the tooth restoration interface associated with micro- Lesions on the buccal or lingual walls are generally not leakage. These can be superficial and not influence the esthet- detectable in radiographic images due to superposition of the ics, or intense, extending deep into the interface. Most radiopaque restorations. For details about diagnosis of caries superficial stains can be eliminated by repolishing, while the lesions, see 7 Chap. 3. deeper ones might need repair or even replacement of the Occlusal contacts of a restoration are evaluated to restoration (. Fig. 1.6g, h). The presence of a marginal stain determine whether they are serving its chewing function, does not always indicate the need for replacement, unless without causing a symptomatic or pathogenic occlusion. In there is an esthetic impairment that cannot be solved by pol- the absence of gingival inflammation, a traumatic occlu- ishing or when a secondary caries lesion is present sion does not trigger bone loss. However, in the presence of (. Fig. 1.6i). Opaque areas, along the cavity margins, and a periodontal disease, the traumatic occlusion may inten- underlying dark shadows may indicate a carious process sify progression of the disease and bone resorption. underneath the restoration alongside the cavity walls. Usually Restorations with traumatic occlusal contacts should be these lesions are active because the ecosystem is nearly sealed adjusted or replaced. On the other hand, restorations with- and inaccessible to oral hygiene. Progression therefore can- out occlusal contact may foster overeruption of the antago- not be controlled, which is potentially detrimental for the nistic tooth. hard tissues and tooth vitality. Bacterial growth has been The desirable surface roughness of a restoration should shown to progress faster under composite resin restorations be similar to the intact tooth surface, giving the patient com- than under amalgam and glass ionomer. However, mar- fort and preserving gingival health. Rough areas, next to the ginal gap size needs to pass a threshold of approximately gingival margin, promote an increased biofilm deposit and 200 μm to allow sufficient fluid exchange for bacterial sur- should be repolished. On damaged restorations, polishing vival under the restoration. may not be efficient, and replacement is supposedly the best Requirements of the anatomical shape, including contact solution. Restorations with gingival margins violating the points, marginal ridges, and shaping of buccal and lingual biological width are associated with gingival inflammation surfaces that were earlier described, also apply for composite and bone resorption. Surgical crown lengthening is indicated and indirect restorations. (. Fig. 1.6j–l). when the cervical restoration margin invades the connective The esthetic assessment of a restoration performed by a tissues. dental professional may differ from the patient’s perspec- Cast metallic restorations should essentially be evaluated tive. As we strive to establish a collaborative partnership the same way as amalgam restorations. However, they hardly with our patients and oblige ourselves to respect patients’ suffer from external degradation, and the main problems autonomy, it is self-evident that patients exclusively decide happen in the marginal region. Other than amalgam that whether they suffer from esthetic impairment of a restora- tend to fracture when extended secondary caries is present, tion or not. What seems perfect in the eyes of a profes- they do not present any visual signals unless the restoration is sional does not necessarily reflect the individual’s displaced. perception and vice versa. If the patient voices dissatisfac- Direct tooth-colored composite restorations and indirect tion, the dentist should evaluate quantifiable medical rea- ceramic or composite restorations should be assessed analo- sons and whether there is a chance of improvement and gously. Other than metallic restorations, color match is a how this can be achieved. First, the reasons why restora- quality parameter here. It is highly appreciated to have resto- tions have an unfavorable esthetic result should be deter- rations not clearly discernable as such that perfectly blend mined. Probably the reason for an esthetic failure is not into the natural dentition. Some restorations present an the restoration itself but the shade or discoloration of the Diagnosis and Treatment Planning 21 1 remaining tooth. In this case, replacement may lead to a risks and side effects, for instance, additional preparation restoration with the same unsatisfactory result. In case a of the tooth may lead to pulpal symptoms or even an acci- restoration is medically impeccable from the dentist’s but dental pulp exposition. unpleasant from the patient’s perspective, we have to per- ceive patients’ concerns notwithstanding. When we intend > What seems perfect in the eyes of a professional does to replace a restoration because of mere esthetic matters, not necessarily reflect the individual’s perception and the clinician needs to inform the patient in detail about vice versa. a b c d e f. Fig. 1.6 Defects on composite restorations. a Improper restora- marginal sealing; i deep marginal staining with a darkened aspect tions by the lack of the color match; b large class IV restorations under the restoration; j restoration with inadequate color/translucence performed on the central incisors with hybrid composite at the 6th match and anatomic shape; k overhang of restorative material year recall, with sati