SEPT 15TH 2023 Dental Lecture Notes PDF

Anyways, what we're going to talk about today is we're moving on to our next sort of topic, which is diagnosis and treatment planning. I don't think you've studied this yet in your other classes or may have come up a little bit, perhaps an operative, some things like that. What we're going to focus...

Anyways, what we're going to talk about today is we're moving on to our next sort of topic, which is diagnosis and treatment planning. I don't think you've studied this yet in your other classes or may have come up a little bit, perhaps an operative, some things like that. What we're going to focus on today. Yes. The photos are there. No, you just want pictures. You want images that. Well, obviously photos that somehow illustrate what's there. So, I mean, you know, you don't necessarily need selfies with you holding up a you know, holding up a type dot, smiling and making some sort of hand gestures. You don't need that. What you really want would be just different images of it. We're not looking for something so specific what the assignment is going to be. And Dr.. As I said, Dr. Brimmer will talk about it. What the assignment looks for is the notion of you illustrating progress during the year from where you started in fixed to where you end. And it's also looking because the school is very interested in the digital tools we use. They're looking for you to sort of hopefully illustrate where you use things like prep check and you know what you saw with it, how you learn from it, how it benefited you. So it's basically, as I said, Dr. Goldman will talk more about it, but she's going to look essentially for reflection on what you've learned. It's actually kind of a neat topic because I think I alluded to this not even talking about the ePortfolio, but with your early preps where I talked about, you know, even if they're terrible, save them because it'll be fun. It'll be amusing to you, I hope, later on to see the change. But it's more than that. One of the challenges I think we face in life is we sit in these groups, big settings. Everyone around you is doing the same stuff, you know. So on some level, I mean, I recall as a dental student, you went through what you did year after year, but it was sort of hard to judge what progress you actually made because everyone around you is doing the same things. So you got done and you kind of looked around and go, Well, all these characters graduated from here, so I guess anyone can. But that isn't really true in some ways. You don't really know what you've accomplished and learned if you don't have the ability to look back a little bit and so in a way, what the ePortfolio does is it gives you an excuse late in the year to look back and go, Oh my God, look what I was doing, you know, last, last fall. And hopefully you see huge improvements. And that's the point. Okay. So so anyways, to go on with today, we're going to talk about diagnosis and treatment planning a little bit. What we're going to do is focus kind of 100% on fixed prosthetics. So some of what I say, a lot of it is going to be applicable to all kinds of disciplines in dentistry. Some of it is going to be focused more on why we care about some of these things that I'll discuss. So when we talk about diagnosis and treatment planning. What we're going to do is start with. How do you think about it? Like a patient shows up, new patient in your office, you walk into the operatory and most dentists have some sort of routine of what they might say to somebody. In my case, a lot of times it's just sort of introducing myself and kind of asking them why they're here. You know, what are they doing in front of me? Why are they in the chair? You know, there's different ways you might ask it. I try not to be too crude about it, but essentially that's an important moment because in most cases, the patient is going to describe something to you that brought them to the dentist, that brought them into your office. And what you might characterize that as is a chief complaint. And that's really important to you because. One way or another, you have to be. You know, you have to keep that in mind. You have to address that. So it's not infrequent that a patient will walk into your office. They'll be missing most of their back teeth. Though. Sit down and they'll tell you something like What they're there for is they really hope they could bleach their front teeth, something like that. And you're looking at them. You glance around their mouth, or maybe you had X-rays sent from another dentist or they were in earlier and took x rays. And now you see that and you're looking at him thinking. And I don't mean to be unfair, but this might be the stupidest person I've ever seen in my life in front of me. What on earth? Bleach your teeth. They have no teeth. The other ones are breaking. What kind of idiot could this be? Because you're a dentist. You know, you need function. You need teeth to live and chew and you know, but you obviously don't want to say that to them. Or if you do, you might throw them right out of the office quickly if you don't want to deal with them. But on some level, as much as that might seem really ridiculous, what you have to do is in your mind, file that in there and go, okay, they're worried about their esthetics. You as the dentist might be worried about their function. Right. And their health because they with somebody like that, perhaps there's retained root tips. There may well be various infections present serious things. So what you need to do, though, is as you proceed to kind of diagnose the various issues and sort of eventually offer them a treatment plan, and we'll get into all that in a minute, you need along the way to keep explaining to them how, yeah, you're going to take care of the esthetics, too. You know, you can't forget that. You can't immediately go off in the direction you as the dentist are interested in because the patient's going to think you're not listening to them, that you don't care about what they want and therefore they're going to not listen to you. And before you know it, they'll be somewhere else. Having some other dentist bleach their teeth. And when in fact, if you approach them properly and explain their overall needs while making sure to address that concern of theirs, you can actually get where you need to go. In the end, part of the challenge of what I describe as a chief complaint is often really understanding what the patient is talking about, not just what you might see. So this first thing I put up, just as a way of illustrating this concept, had a patient one day showed up. He'd been a long time patient in the office. He's in a hygiene visit. So recall. And I came in to check him and he says, You know, I have these old crowns. So these are all porcelain fuzed metal crowns. I'm trying to illustrate and I don't like the esthetics anymore and I want to change them. So I looked in his mouth and what I saw was this. I saw where there had been a little hint of recession along the gingiva. And so what I saw was a little black line where you could see that the crown ended the margin, the metal substructure, the crown very typical of porcelain fuzed to metal as time passes. So I'm immediately, you know, rattling off to the patient about how this is no problem at all. We can just make you new crowns and, you know, we'll just kind of whether we use a different material or whether we just extend our finish lines a little bit subjectively, we can address this very easily. The good news is, while I'm saying all that bit by bit, as we spoke, I found out that that wasn't his concern really at all, that what he was seeing differently than me. He was focused on what people like to call black triangles. Dennis often called at this, so there'd been a little recession. But in the course of that little bit of recession, we didn't just lose a little tissue right at the gingival margin, we'd lost a little bit of tissue as well into approximately the papilla, had kind of shrunken a little bit. So he was seeing black triangles now. As long as I understand his complaint, it's going to be easy enough to address. But if I didn't get that, we would have taken off the old crown, put temps in. And if I'm still not quite getting his concern, we could very well have made the actual crowns. And at the end he's unhappy because we never addressed what he was actually seeing and thinking about the way you fix that kind of problem, for what it's worth, is fairly simple. You basically just change the anatomy of the teeth a little bit. You make the contacts a little bit longer, extend a little closer to the tissue. And in doing that, you can largely make those disappear. And in fact, if you can get the contacts that you create close enough to the underlying bone that pilhas can actually regrow in there a little bit. So without getting into all those details, because that's a little beyond our course. But the key, my point being is that you really have to understand what the patient is talking about, what is their chief complaint? And one way or another, you need to address it. So after you've heard why they're there, what their issue is, what their complaint is, then you have to go along and diagnose everything that's there, including what the source of their chief complaint is, arguably what we were just talking about. But you also have to diagnose everything that's going on and then you take the things you've learned in doing your diagnostic steps and you make a plan, and that's our treatment plan. Dentistry in many ways should be fairly simple for us in most of our visits. After you do your sort of deliberate, careful exams and sort of diagnose all the issues and you have your problem list and you figure out how you want to address them and you discuss that with the patient and make a plan. Well, visit by visit, they just show up and you do the plan. Um, and as I think I mentioned to you before, after you've done this a while, a lot of the things you'll do are essentially busywork. You know, right now, on Tuesdays, an operative for many of you, every new kind of restoration is a little bit of a thrill and a little bit of a mystery as to whether it's going to come out or not. But after you've done a thousand occlusal composites, it's not a mystery anymore. It's not even very interesting. Patients are interesting, but the occlusal composites just busywork. As long as I'm mentioning the concept of a treatment plan and kind of routinized these things, what I will mention to you is one of my pet peeves in our clinic. So this is important to me and it should be important to you when you get to the clinic. Our students have a habit at times of treatment, planning numerically, not in a coherent way. So teeth are numbered 1 to 32, right? So they often have a habit of creating a treatment plan numbering the treatment from tooth number 1 to 32in a numerical fashion. But that has nothing to do with a treatment plan. A treatment plan is going to have various steps prioritized for different reasons. We're going to start with arguably the worst problems and work our way along to cleaning away, you know, disease in the patient's mouth, whether it's periodontal issues, active caries, and then eventually some of the more complicated things like crowns and stuff will come along. So you want to at this moment, it's worth mentioning when you treatment plan, which you're going to start doing in the clinic before you know it, the goal is to create a detailed plan step by step, start to finish. That will get you from where the patient is today to where the patient should be when the treatment is completed and it should be coherent and visit by visit. It's very easy for you because patient says, What are you doing next visit? And you go, Well, the next thing on the plan is this simple. If you have a plan that goes in a numerical order, every time the patient comes in, you're essentially retreatment planning from scratch because you have to go back and look and go, Oh, let's see, where is the deepest decay that's left? Okay, it's this tooth here. That's the one we're going to do. If you have a plan, you just do the plan. So you have to do it properly and hopefully you will when the time comes. So if we're going to talk about diagnosing what's there, it's going to require a variety of things we're going to do. There's basic tools we're going to do. We're going to have like a medical history, a dental history. We're going to do an intro oral exam, right? We're going to look at our radiographs. We're going to look at diagnostic casts. That's going to be important to us, especially in fixed as far as these different things, medical and dental history. You know, you have a whole class about treatment planning that will come up. So I'm not going to spend too much time on some of these things. The one thing I would mention to you is dental history is especially important to us in dentistry because as you talk to the patient about their past experiences, you want to be listening for what those experience experiences have sort of taught the patient or what attitudes they bring to dental care. And there's a lot of classics in the world of dentistry. You know, every patient has Uncle Gus, who for the last 50 years at every family event has talked endlessly about that root canal treatment he had that took 12 visits, hurt every time, never got better, and eventually lost the tooth. If your patient comes in and as you're looking and diagnosing and you're describing a spot where there's a lot of decay and you go, you know, you may end up with a root canal treatment here, and the patient goes, Oh, no, no, no, no, no, no, no, you go, Why not? And they start to tell you about Uncle Gus and his root canal treatment from 50 years ago. You at that point have to stop and explain how indigenous treatment has changed in 50 years. Otherwise the patient's going to say no. Similar things are going to happen with stuff like dental implants, which as you study those, you're going to find are incredibly, you know, predictable treatment nowadays. And yet that same Uncle Gus may have had a root canal treatment excuse me, who had the root canal 50 years ago, lost that tooth and eventually was talked into an implant 40 years ago and that failed. But that implant probably won't fail today. So you have to watch for those attitudes and sort of use them to address these concerns before you get too deep where they're just going to, they're going to zone out. You're not going to listen to you. A lot of what happens in lectures to you so that there are spots where their attitudes can be helpful to you, though, you know, as you're talking, you say, well, you're going to need some crowns on some of these teeth. And they look at you funny and you say caps and they go, Oh, yeah, caps. Yeah, I understand that. So you're going to cap some teeth. And they kind of go, you know, I know that's expensive in a way that's bad and good. The reason it's bad is they're immediately on edge, worried about what this treatment is going to cost them. On the other hand, the good thing about them thinking crowns are expensive is that whatever fee you quote it's going to be, if even if it's expensive to them, that's what they expected. So it's okay. So hopefully you'll convince them that they need the care and they'll agree to it. All right, So we're going to start doing our Intraoral exam. All right. We're going to sit down. We're going to look in the patient's mouth. What's the first thing you want to look for when you look in somebody's mouth? I'm sure you all might have ideas about this. What are you going to look for in their mouth? First thing you want to notice. Perfect hygiene. Exactly. You're going to look and see if they brush their teeth. You're going to look and see how much plaque is in there. If a patient is sitting in front of you and it's obvious that their home care is horrible, that's a huge red flag for you as the restorative dentist. That's potential disaster. You know, you might present them this complicated treatment plan. They agree to it. It's great. Except that if they're not going to brush their teeth, if they're not going to care for whatever you do, then whatever treatment you deliver is in some ways destined to fail. So a big part of of your. Diagnostic process, a big part of your education that you're going to do for the patient as you explain what you're seeing is going to be about hopefully persuading them to get good about these things. In fact, as you describe the care they need and they seem excited about it, you might have to point out that none of this is going to happen if they don't improve their home care because that's really, you know, potential disaster for you. So after you've looked to see if they have a lot of plaque everywhere or all kinds of food packed between their teeth, if they're just disgusting that way, after you see that stuff, you're going to then look at the periodontal condition that's going to be really, really critical. That's your next concern. You know, basically you're going to be concerned about things like mobility. That's going to be especially critical to us in fixed prosthetics. If there's periodontal problems, if there's mobile teeth, those are not really going to be candidates for us to crown or to fix bridgework or those things. So we have to look at that. The next thing you're going to look at in your Intraoral exam, you're going to kind of look at what's there, the old restorations. You're going to try to get a sense of the history of that mouth because the past is going to be your clue to the future. You're going to try to notice what the occlusion looks like. Are there wear facets on the teeth? One thing you may be aware of, especially for the advanced standing students, you might already be aware that it's very hard to see things in the mouth where the sets are much harder to see in the mouth than they are in study models. When we talk in a little bit about making good alginate and study models, that's where you can really see those things. But you try to see that as you look in the mouth. If you see that there's evidence of unusual wear, that the patient has some sort of functional habits, they grind their teeth. That's a concern to you that's going to affect both what's there now, how they got to where they are now and what the future might be and how you'll have to address it as you consider treatment. One of the things I find useful to describe to patients, and I don't know if this is a good way for us to think about this as you look in their mouth, this sort of intra oral exam. One thing that I think and I think it's useful for patients is the idea that every mouth is essentially its own environment. We're all familiar with the idea that, you know, there are different sort of environments. This comes up in my practice a lot with an analogy about cars, because where I sit facing a patient, there's a window behind them and a parking lot. So I'm looking at cars behind the patient's head all the time. So a lot of times with the idea of their mouth being a certain discrete kind of environment, we can talk about that. And a lot of times I'll use cars as an example and everyone knows that, say in New England, where we have rough winters, a lot of salt on the roads, it's a worse environment for that car sitting out there than if the car was sitting in southern California, right in Southern California. Unless the car gets swallowed by an earthquake or a landslide. Right. The car might last forever, whereas here they're just not going to the environment is a lot worse. And sometimes patients understand things like cars, if you describe their mouth that way, to understand that the environment in there is going to affect the teeth. In the past, the restorations you might do in the future. That's often a useful sort of analogy and it's a useful way for them to think because one of the things the patient can do is they can fix the environment. One of the problems, if we think their home care has not been adequate throughout their life is to get it improved and now it's a different environment. So sometimes people can understand things in different ways. All right. The next concern we're going to have when we're going to try to put together, you know, the diagnostic information we need is going to be we need diagnostic casts. So we're going to have to make good alginate. You guys have studied this so far, right? How to make alginate. I think you have you've done that in occlusion class, right? Did anyone bring along models today? Cool. Okay, that'll be good. Because that issue that I talked about a little bit last week of reduction versus clearance is much more easy to understand. If you have your study models of your teeth in your hands and you also have your type it on and you look at those, well, better understand that issue. But anyways, just a couple of things to mention about alginate and you've probably learned these things. So I don't mean to be repetitious, but I think they're worth repeating. You have to make good alginate. It's one of those little tips. If you struggled to get the alginate where you want it, you probably learned this as just pick some up on your finger and put it where you need it to go. So if you're having trouble capturing a certain part of the mouth, we'll just stick it there and rub it onto those teeth. That's a good way to capture things. A related thing, which I kind of alluded to this before, if the patient's hygiene is terrible and there's all kinds of food in their mouth, you know, have them rinse, clean that out before you make the alginate because that's that's kind of a horrible thing. And yet it's easy to do. And the next thing you know, you pour it now there's chunks of food on your study model and that's really vile. So please don't do that Now after you've made an alginate and they probably taught you this, it's important to handle the alginate properly. So they probably told you the best thing to do is immediately go pour the alginate before anything happens to it. Because you know, the alginate is largely water. If you leave it, just sit out in the air almost immediately it's going to start to evaporate some water and it begins to distort. So that's a process called synthesis, which I think you probably were. Taught about. Yes. So senior thesis is going to cause the alginate to shrink. One of the things that dentists do as a mistake, though, and I don't know if they taught you this, but hopefully they didn't, is they say, all right, well, I don't want it to dry out, so I'm going to take a wet paper towel. I'm going to get this towel soaking wet and I'm going to wrap the alginate in this. And that'll protect it. And then I can put off pouring the alginate for who knows how long, as long as it's in this soaking wet towel. You don't actually want to do that either, if the towel is to soaking wet too. Like if you drop the alginate in a bucket of water, essentially it'll start to absorb extra water and it distorts that way as well. And that's called inhibition, as I and you may have learned this. So the ideal way, if you're going to not pour the alginate immediately, is take your paper towel, wet it, and then squeeze it out really tightly and then wrap the alginate. That creates the essentially a humid environment, a humidor. It'll ideally you want the alginate stored at 100% humidity until you pour it. And then the other thing is, after you pour the alginate, well, you don't want to make the mistake of saving the alginate like sticking it in your locker and coming back the next morning for it. Because after the alginate sets and now the alginate excuse me, after the stone sets, now the alginate starts to dry out around it. The alginate will actually begin to seek water and begin to suck water out of the stone. And it can create a bad surface on your your model. So, you know, everything in dentistry, every these steps we take, you know, you go to the trouble of making a nice alginate you take the go to the trouble of pouring it right away. Well at least follow up wait around for 40 minutes until it's set. Separate it. And now if you want to wait until the next day to trim it, fine. As far as that goes. When you trim a cast and you're on the wheel and it's spinning and there's water and it's grinding, one of the things that's going to happen is some of the water is going to drip onto it containing ground up stone, which you need to do is rinse that off right away after ideally having a little toothbrush to soft brush to clean it, because if you leave that water on it, what'll happen is you look at the alginate. Now it's covered with a thin film of extra stone. It's not really accurate anymore. Now in fixed, we're going to use these casts. They're important to us because it's going to allow us not just to do our diagnosis later on. It's going to be valuable for things like making temporaries and stuff. But in terms of diagnostic stuff, we're going to be very interested in it. You know, this way if there's missing teeth, we can see where they are. We can measure the length of those spaces. So in I'm not sure how many weeks and a couple, few weeks or so, somewhere along the line, we're going to talk about fixed prosthetics and the length of a dental floss. Spaces are important to us. We can look at the angulation of the different teeth, whether they're abutments for fixed bridgework or whether even we're thinking of just crowning a tooth on your type it on. As I've said repeatedly, all the teeth are aligned perfectly. You just have to follow the long axis of the tooth and your crown preps will be ideal. When you do the bridge later in the course. It's all going to be ideal if you just follow that long axis. But in the mouth it doesn't work that way. And that's a spot where study models can be very helpful. You can look at the angulation of things and how things, how teeth might tip here or there that helps you with planning path of insertion and withdrawal, things like that. You can also look on your study models at Arch Integrity, which is really critical to us in dentistry because we talked about this before, that tendency teeth have. To move around if there's not other teeth right next to him. So as soon as teeth are missing in an arch, there's going to be a tendency for things to start shifting around. So arch integrity is important to us on those study models. As I mentioned a few minutes ago, you can really easily see where facets, you can see what kind of grinding patients do. You can see all that stuff immediately and that's really, really great and useful to us. You can see if things are super ruptured or if things are intruded a little bit. So study models are very, very valuable to us. And at Bu, any time you're contemplating any fixed prosthetics, you're required to have study models. So it's not an option. You're going to need these so that we can see if these things are present. You know, if teeth have sort of angled, we know that there's going to be a tendency for things to tip and super erupt and alter study models are great for seeing these things because as I said, it's very difficult to see in the mouth. For those of you who have worked on live patients, I don't think I need to tell you that It's amazing sometimes to me how little we can actually see in the mouth, even with our loops and all of that. So the next thing we're going to be interested in, in terms of doing our diagnosis is going to be a series of x rays. And this is where you're going to fill in the stuff you couldn't see otherwise. You kind of fill in the blanks. Let's say now you're going to be able to see, you know, what the pulp chambers look like. If it's a young patient. Are they big pulp chambers? Are you concerned with possibly needing antibiotics or the risk of perforations or exposure of the pulps? You can see if there's periodical lesions on the teeth. So you would know that root canal treatments needed. You can see if there's retained root tips or things like that. Uncorrupted teeth are going to be visible to you. All the things that you couldn't see with your eyes are going to be present. Radiographs are going to be especially essential for judging the periodontal condition which we've already talked about as being absolutely critical to fix prosthetics. When we talk about bridgework in some few weeks, one of the things we'll talk about is crown to root ratio and the root surface area of teeth. And that's where the radiographs are very, very helpful. So that's going to fill in the part you can't see otherwise. So after you've been able to look at all these things, you're going to be able to take the information you've gathered. And while you're gathering it, hopefully you've been explaining to the patient what you're seeing. So they have some sense of the range of issues in their mouth. And that's going to allow you then to put that into a plan. You can offer the patient, in some cases a variety of ways to address their needs, and hopefully you and the patient will agree on a proper goal for the endpoint of treatment. And you just arrange all that into a plan. And it's important that that plan be logical and well arranged and make sense. One of the challenges that is worth mentioning. As you're doing your exam, you're looking around the patient's mouth. If it's the first time you're seeing the patient. What you have to be aware of and this is really a challenge and it's worth sharing with the patient is what you're seeing at that moment is going to be essentially a momentary snapshot. You're seeing the patient at that moment. So you might see a lot of wear on their teeth. But does that mean they're grinding their teeth now or was that where they're the same 20 years before? You don't know. If that where all happened in the last couple of years, say Covid just really got them crazed and they go to bed every night and grind their teeth nonstop. And that's all happened in the last couple of years. Well, that's important because you have to be aware of that as an issue if that's from 20 years ago. And, you know, their life's different now. They do yoga twice a week and they are the most blissed out person in the world. They don't grind. Nothing's a problem. Well, you're not worried about that. The challenge for you is that it's only as time passes that you find out about some of these issues. So it's important that you share those things with the patient, not just thinking about it yourself, because they, you know, everything you share with them is helpful later on in them understanding, you know, what's good or bad later. A dentist I heard speak years ago said one of the smartest things ever it's worth sharing about explaining to patients in advance of whatever happens. We do treatments and sometimes things don't come out exactly the way we want. Or perhaps after the fact. Something needs to be addressed. Something fails, something goes on. Anything that you explain to the patient before treatment was an explanation, right? They know you're explaining it after something seems to have gone wrong. You think you're explaining what would happen, but what? The patient's hearing is an excuse. So always explain beforehand. Always tell them what might go on. It's an explanation. Don't be just giving them excuses, because that's how they'll hear it. All right. So any questions about that stuff before we move on to some other things? Good. Okay, so we're going to look at a few slides, kind of run through some stuff, hopefully fairly quickly, and then we'll go on to other things today. So here's an example of a patient. These are some study models, a patient presented. And let me see if I can. I don't know if I have a pointer up here. See if this works. Yeah. Hard. So the patient presented and what they came into the office for. They came in asking for either crowns or veneers on their teeth. They weren't happy with what their teeth looked like. They felt like they were a little short. All right. But these teeth are in great condition. They're essentially virgin teeth. So we looked at the radiographs. I looked at the patient and what we ended up doing for the patient, which I think was the right treatment, is I sent them to the periodontist who did a little bit of crown lengthening, a little re contouring of the tissues. And the patient was delighted with that end result because there's nothing really wrong with the teeth. They didn't need veneers on these teeth. They just needed to see the teeth at the sort of length that would be more desirable. So it's important again, this gets to that idea of proper diagnosis, looking at what's there, taking the different tools available to us to figure out why do they not like what they see and how do we fix it properly? All right. So that's a good example of that. I talked before about one of the values of radiographs sometimes is to see the size of pulps, things like that. Actually, no, I'm sorry. That's not this. This one. This is something else we had been talking. Sorry. You know, eventually I catch on to what I have on pictures. So anyways, what this is, remember we had spoken a little bit about teeth that are fractured. So this is I'm sorry, it's an old image and that's why the color of it's weird, but this is a case where the patient came in and they had something was broken and it hurt every time they would try to chew, there was a piece of tooth loose. And what you'll see is that, in fact, this whole cusp had broken. So this was flapping back and forth held in place by the tissue. So you recall when we talked about teeth that break, the fear is that they break too far under the tissue, too far down to or too far up the root, however you want to think of it. In this case, this was fractured into the attachment. We know that because the little piece didn't just fall out on its own, if it was just tooth structure not held by anything, it would have just fallen out of the patient's mouth. But instead this stayed in there. So I just grabbed it with a hemostat, pulled it out. Here's the little piece. But you can see this whole area of it was down into the attachment. This tooth, if we choose to save the tooth, is going to require crown lengthening surgery. The challenge for us is it's going to kind of need a lot. And it's a premolar which very often will have a short root. I don't recall now whether this tooth was lost or not, but that's a very sort of classic example. The only thing that's not classic about this example that some of you may notice is it's a virgin tooth. Theoretically, these don't break, right? People break teeth all the time when they've been restored before, but teeth that have never been restored. It's kind of surprised when a patient splits one, but it can happen. This is just another example of a fractured tooth. This was a vertical root fracture. I extracted it. It was an old endo tooth. And this is what it looked like when it was out of the mouth. You could see there was a fracture running the length of it. You know, that's sort of typical. This is actually what I was thinking about a moment ago. This patient came in, This had broken. We looked at it. There was some discussion and a decision to crown the tooth. You can see the patient has a lot of wear on their teeth. So we started to prep the tooth. And this is the initial occlusal reduction, which doesn't look very excessive, does it? I mean, can we all agree it doesn't look over reduced occlusal? And yet here's what happened. That was sort of weird. There's a pulp. So, oddly enough, despite all that, where that pulp had not sort of receded into the tooth as you would have expected. And in fact, it's kind of aberrant position. It's very, very high up in that cusp. So this patient ended up needing root canal treatment as well as the crown, unfortunately. So we've been talking about last week, indications for crowns. We've talked a little bit about diagnostics and stuff today. So thinking about our indications for crowns, this one look, obviously this is all amalgam with just a little tooth left and some composite patch that obviously would need a crown if we're going to restore it. What about this tooth in terms of the stuff we talked about, Does that need a crown? How many? Yeah. And a lot of how many say no. Some maybes and a lot of undecideds. It sounds like the American electorate, a lot, a lot of independents in the middle. So anyways, this is this tooth. All right. But what do we see here? All right. Our concern. All right. You guys are seeing there's a crack. That's a worry, right? That starts to say we ought to do something. Yeah. And the other thing, remember our indications about the width of our restorations from cusp tip to cusp tip. So the width of this is too wide, isn't it? Remember, our first indication for crowns had to do with how wide it was between the cusps. This tooth should be crowned. Again, assuming that we don't run into some issues that suggest it shouldn't be kept, but that tooth should be crowned. So here's a couple other teeth. Let's look at them. Should we crown this tooth? Hard to tell You can't get a clear view of closely, so that might be borderline. This one. What do you think with that material? It looks like it needs a crown or some sort of customer protection. We'd all agree this one, it's already broken twice, right? Patients don't always come right in, you know? It breaks. They think it's a worry. It's not really hurting. And before you know it, they forget about it. And so this one, of course, needs a crown, too. Although we'd have to ask ourselves, this is a third molar. Do we really want to crown it or should they just extract it? You know, that might be a question depending on what makes sense for each patient. Again, if we're going to crown this and who knows what else around the mouth, we might say, yeah, save your money, extract it. You don't chew on it anyways. Of course, they obviously chewed enough to break it, but who knows? So here's another example of a fractured cusp. This is an old image, so it's a huge amalgam. You can see this tooth had broken before and had a build up. And now it's broken again. This is one of the reasons when a patient, you know, fractures off a cusp and you say to them, all right, there's different things you could do for this. The ideal treatment is going to be for us to crown it. And one of the reasons that's ideal is this way we're going to try to keep it from breaking again. But the patient says, Well, what are my other choices? You say, Well, we could also do a this was some years ago. We could do a big amalgam build up that won't protect it from breaking, but at least we replace the missing parts and they say, Well, let's do that. And then years later it might break again as we predict. So that could just get prepped quickly. And depending on the amount of time you have in your day, in your office, depending on how much of an emergency it was, you could do anything ranging from a quick prep and put a temp on it, bring them back to proceed to all the steps you need to making the impression or scan or whatever. In this case, we didn't have time. So you just prepped and temped. Eventually, though, as we spoke about before, before we're ever going to make a crown. This old amalgam, all of this has to be removed. We have to see what's underneath it. We have to judge if there's enough remaining to structure to just crown as is, or do we need to add some sort of core material? But that can't be left. That's just in the preliminary step. Okay, so here's a tooth. This looks like a fairly wide old restoration. You can see in approximately. It's very wide. Does that look like a tooth without a crown? Yes. Okay. But this is a trick question, because when we look at the truth on the other side, we go, oh, my God, look at this. Yeah. See, I caught a few of you. On our tests. For what it's worth, we never have any trick questions. I'm serious about that. When you take any of the written tests, there are no trick questions. There's nothing you're supposed to think about too much. If you find yourself. You know, really debating whether I'm trying to trick you with something on a question. Don't think that way. It never happens. All right, that's a tip. Okay. So anyways, but if we start to look at more information about this tooth, here's our radiograph. You can see we've got severe bone loss. You know this tooth Actually, it looks like there may be obviously some problems. This tooth needs to be lost. It can't be restored. And then if we actually probe it, you can see the probing depths are unbelievable, eight and nine on the distal. So the trick there was just looking at it and this is why we need our radiographs and we need to do our periodontal exam. Here's an example of something kind of funny. This patient showed up one day and, you know, he wanted something done here. But the funny part of it is he showed up here at Boston University, which you're familiar with as a place. And and I think in trying to get on our good side, he insisted that this had been made. In the last year. Within the last year, right at Tufts. So good line. All right. That would definitely get on our good side, except that we know that can't be true. Right. So one of the things about patients and I don't want to make too much of this is a lot of what they tell you might very well be RBS, right? Patients have like all of us, we have our own realities and our own ways of rationalizing the world and making sense of it. So a lot of times if patients tell you things that are kind of hard to believe there, it's probably not to be believed. Related to this would be if, say, this patient had come in and said, Oh, Doctor Smith over in you know, in South Boston did this for me a year ago. Yeah. Isn't he, isn't he good. Look how beautiful it is or whatever. And you're looking at going, oh my God, this guy must be the worst dentist in the entire world. Well, chances are parts of that might not be true or to put it another way, before you make conclusions about that, Doctor Smith, you might actually want to call him and talk to him about it because in fact, he might tell you he saw the patient once in the office. They he offered him a treatment plan to remake a bridge. The patient refused. They kind of had a little argument about it. The patient left and you find out the truth that Doctor Smith is fine. You know, So when patients tell you awful, terrible things about other dentists, which they do a lot, usually it's like, you know, the saying there's two sides to every story, so be aware of that. So here's another tooth. This is a spot. Do we want to do a bridge here or do you want more information? All right, good. Right. You want more information. So if we look at this the other way, you can see this tooth is really failing. This is failing. If we get our other information, we look at our radiographs. You can see actually this tooth has fractured off since the radiograph was taken. These are all going to be lost in this area, restored with implants. So you could see that kind of thing. So here's a couple of radiographs as you look at this. What do we start to see here in terms of diagnosis and what do we see in our radiographs? Well, one thing we might notice is it's not a very good peri apical, is it? We didn't catch the the end of the root. So that's a disappointment. But if you're talking to this patient, he has some sensitivity on this tooth. He it's kind of an emergency. It sort of aches. When you talk to him, what are the things we immediately know that we have to share with this patient before we do anything? Is this tooth going to need a crown? If it's going to be kept, it needs a crown, yes. Okay. What else does it need? It's going to need root canal treatment. What else might it need? Probably needs Crown lengthening, too, because by the time we get rid of that decay, we're too deep. Is the tooth going to be worth keeping? Well, it might be. See, here's the problem. All right? This is I hear I hear you guys up here. They want to get this right out, place an implant, and that might be the right choice. This is one of those things that's very interesting in the world of dentistry. So here we are. It's 2023, right? Maybe this should be lost. Maybe we should do an implant. If this was if this was 1975, why did 20, 23 What's 50 years ago? 1973. All right. So 50 years ago, we didn't have implants the way we do now. I mean, they existed, but in the in the US, they basically didn't exist. Okay? They were new, newish, not even newish in the US 50 years ago when you looked at this tooth 50 years ago, was it a good tooth? Yeah. No, it's a great tooth. It's a great tooth because you can do root canal treatment, crown lengthening crown, and the patient can keep the tooth. It was a great tooth. 50 years ago. A dentist thought this was a bonus tooth. You could actually restore it. It was fantastic. Now. 30 years ago. Was it still a good tooth? All right. So 30 years ago, what does that make it? 93. Okay, so implants in the US came on as a discipline that we really understood very well into the late 80s, into the early 90s. So 30 years ago we'd look at it, but we know implants success rate, they're pretty high and yet they can be difficult. They don't always work. It probably was still quite a good tooth 30 years ago. Right now. Is it still a pretty good tooth? It's subject to debate. All right. Because implants are quite good. But do implants all last forever? They don't. They don't. In 1993, we might have said, these things are great. We put them in the mouth, they don't decay, they don't get periodontal disease. They're good forever. And in fact, we were wrong because what did we really knew or know? It was sort of new in the business. We didn't really know. And what we thought about not getting periodontal problems turned out to be wrong. Things happen around them. Implants don't last forever, so I'm not telling you what we should do with this tooth today. What you can do today, for what it's worth, is you can discuss this with the patient, give them the pros and cons of both approaches, and let the patient decide. If the patient says, well, you know, I mean, I don't know. I kind of like to keep my tooth if I could, you might say, okay, let's keep your tooth. If it doesn't work, we can always go back to an implant later, you know, Or the patient might say, you know, I kind of like this idea of implants. I read about them online and they sound exciting. You never know. You have to discuss with patients. And the truth is that our understanding of these things and our knowledge of them is always evolving, which is one of the most fascinating and great things about being a dentist. You guys, you know, with any luck, in another 30 or 40 years, you could be having the same discussion with other dentists that we're having right now about, you know, when I was in school, we were debating this stuff and now we would who knows what we would do. It might be that in 30 or 40 years you would find some way to tell the body to pull it out and grow a new tooth. Right? They're talking about it now, right? So maybe that's what you'll do then. All right, here's a couple more teeth. We've been busy crowning teeth. You want to crown these teeth? Anyone want to crown them? Not really. I mean, look, this is a tiny little thin filling. I mean, there's a lot of wear on these teeth and there might be a lot of decay, but I think we'd want to go in there and clean out the decay and find out how compromised they are before we decided on crowning them. So here's one last thing. I'll share this with you. I thought you might enjoy this before we stop. So when we came across that, I think anyone who's ever gone to dental school has had those. Moments where. What was it like? Yeah. So anyways, any questions at all before we stop right now? All right. If not for the ass class, we'll see you over there in 15 minutes or so. 20 minutes. We'll get started for the D twos. We'll see you guys this afternoon.