For many patients exposing radiographs is uncomfortable. Certain steps must be taken to minimize patient discomfort and maximize patient co-operation.

• Always set the timer before film placement so the patient does not have to wait with the film in his/her mouth while you adjust the exposure time.

• First start with the anterior films. These films are the least likely to induce gag reflex in the patient. This also helps the patient to get used to the technique and increases patient co-operation.

• Use cotton rolls and edge-ease to increase comfort during radiographic procedures.

• Skillful placement of the film reduces patient gagging. However, if it is a problem ask the patient to take deep breaths through his/her nose while you place the film. Any kind of distraction, like talking, asking patient to count their breaths, will reduce the gag reflux.

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These statements should reflect the impression one can get from interpreting the radiographs not from knowledge gleaned from the clinical examination. Address every phase of treatment that is planned. For example:

  • Periodontal
    • Generalized bone loss
    • Isolated angular bone loss
    • Healthy, intact crestal bone
  • Restorative
    • Isolated caries and/or failing restorations
    • Moderate, partially controlled caries rate
    • Rampant, uncontrolled caries rate
  • Endodontic
    • Very deep caries approaching the pulp
    • Periapical radiolucency
  • Prosthodontic
    • Multiple missing teeth

  • Soft Tissue Outlines
  • Bone: Non-Dental
    • Anatomical Features (where significant)
      • e.g. close sinus approximation, tori, foramina
    • Pathology (note if present)
      • e.g. radiolucencies or radiopacities
  • Bone Surrounding Tooth
    • Crestal Lamina Dura
      • Normal–continuous and well-defined smooth
      • Altered–fuzzy, roughened, notched
    • Percentage Bone Loss (if present)
      • Mild: crestal change only with little to no change in bone level
      • Moderate: about 10% to 33% bone loss
      • Severe: greater than 33% bone loss
    • Pattern of Bone Loss (if present)
      • Horizontal: crest, parallels C.E.J.’s
      • Vertical (= angular): crest not parallel to CEJ’s
    • Periodontal Ligament Space
      • Normal, Widened, or Obliterated
    • Radicular Lamina Dura
      • Normal, Thickened, or Absent
    • Interdental Trabeculations
      • Normal, Increased in Density, Decreased in Density
    • Periapical Area (note if changes present)
      • Normal, Widened Ligament Space, Periapical area of Pathology, Radiopacities
    • Furcation Areas
      • Normal, Widened Periodontal Ligament Space, obvious evidence of Rarefaction
  • Teeth
    • Crown
      • e.g. caries, defective restoration, calculus, enamel aberrations
    • Crown-Root Ratio
      • e.g. favorable or unfavorable
    • Root Form
      • e.g. long roots, short roots, conical roots, dilaceration
    • Root Form Relating to Multirooted Teeth (if furcation is involved)
      • e.g. roots fused, convergent or divergent
      • e.g. furcation in coronal, middle or apical 1/3 of root
    • Close root approximation (if present interdentally)
    • Apex (note if changes present)
      • e.g. blunted roots, root resorption, root fracture, hypercementosis
    • Pulp (note if changes present)
      • e.g. obliterated, pulp stones, internal resorption

Diagnosis is defined as the “art of distinguishing one disease from another.” Diagnostic procedures in endodontics encompass a review of the medical and dental histories, clinical and radiographic examinations, and a battery of diagnostic tests. In order to interrelate the findings of these diagnostic procedures with an appropriate treatment modality, a classification system, which allows for the systematic grouping of endodontic pathoses on the basis of the diagnostic findings must be established. In addition, this classification system should use clinical terms that are suggestive of the disease process and serve as a means of communication between dental practitioners.

PULPAL DIAGNOSIS

A tooth with a noninflamed pulp is asymptomatic and gives a positive response when stimulated with the electric pulp tester (EPT). This normal tooth will also respond positively when thermal tested with heat or cold. However, the response is mild and goes away immediately after the stimulus is removed. In addition, percussion will cause no discomfort and the radiograph will reveal no pulpal or periradicular pathosis. As a result of caries, restorative procedures, or trauma, the normal pulp may become inflamed and present itself clinically as either a reversible or irreversible pulpitis.

Reversible Pulpitis

A review of the dental history reveals that the patient is experiencing an intermittent, exaggerated response to a stimulus such as cold or hot. However, the discomfort does not linger after the stimulus is removed. The following diagnostic findings are present: clinical and radiographic exams – restoration and/or caries associated with the involved tooth and the periodontal ligament (PDL) space is WNL; EPT – positive response; thermal tests – nonlingering, exaggerated response to cold and/or hot; percussion – no unusual sensitivity. If the etiology of the inflammation is identified and corrected, the pulp will return to a normal state and the symptoms will disappear. However, if the inflammation continues, localized areas of tissue necrosis will occur which can progress to an irreversible pulpitis.

Irreversible Pulpitis

Irreversible pulpitis may be either symptomatic or asymptomatic. With symptomatic irreversible pulpitis, the patient presents with spontaneous pain and/or an exaggerated response to hot or cold, which lingers when the stimulus is removed. Because the pulp does not contain proprioceptive nerve fibers, patients will have a difficult time localizing the origin of their pain. Thus, referred pain should be considered during the diagnostic workup. The following diagnostic findings are present: clinical and radiographic exams – extensive restoration and/or caries may be associated with the involved tooth, and the PDL space may/may not be widened; EPT – positive response; thermal tests – exaggerated response which lingers after the stimulus is removed; percussion – may/may not elicit a painful response. In some cases of irreversible pulpitis, cold actually alleviates the pain, and the patient might present with a glass of ice water. This finding should then be used as a diagnostic test to determine the etiology of the pain. If the inflammatory exudate causing the increase intrapulpal pressure and resultant moderate to severe pain escapes from the surrounding dentin via a carious exposure or loss of restoration, the irreversible pulpitis may become asymptomatic. In addition, internal resportion and hyperplastic pulpitis (pulp polyp) are examples of asymptomatic irreversible pulpitis.

Pulpal Necrosis

A circumferential spread of the inflammation will eventually result in either partial or total necrosis of the pulp tissue. If it is partial, the tooth may exhibit some of the signs and symptoms of irreversible pulpitis. Teeth with total pulpal necrosis are usually asymptomatic unless the periradicular area is involved.

PERIRADICULAR DIAGNOSIS

Eventually, the pulpal inflammation will spread through the apical foramen into the periradicular tissue. In fact, periradicular inflammation usually occurs before total necrosis of the pulp has taken place. The response in the periradicular area may be symptomatic (acute) or asymptomatic (chronic).

Acute Periradicular Periodontitis (APP)

Acute periradicular periodontitis may be either primary or secondary. Primary APP is due to an extension of the pulpal disease into the periradicular area or occlusal trauma, while secondary APP is iatrogenic in origin; e.g. overextension of endodontic instruments or obturating materials. In either case, the patient presents with a tooth, which is extremely tender to occlusion or pressure. If resulting from an extension of the pulpal lesion, the tooth may also exhibit the signs and symptoms of irreversible pulpitis. The one diagnostic sign, which is pathognomonic of a tooth with APP, is an extreme response to percussion. In addition, the periradicular area may be tender to palpation.

Acute Periradicular Abscess (APA)

If large numbers of bacteria from the infected pulp tissue gain entry into the periradicular tissue and the patient’s immune system is not able to combat the invasion, the patient will present with the signs and symptoms of an acute periradicular abscess. Clinically, the patient presents with swelling and mild to severe pain. Depending on the relationship of the apices of the involved tooth to the muscular attachments, the swelling may be localized to the vestibule or extend into a facial space. In addition, the patient may exhibit systemic manifestations such as fever, chills, lymphadenopathy, headache and nausea. Since the reaction to the infection occurs very quickly, the involved tooth may/may not show radiographic evidence of a widened PDL space. However, in most cases, the tooth will elicit a positive response to percussion, and the periradicular area will be tender to palpation.

Chronic Periradicular Periodontitis (CPP)

If the immune system is able to combat the influx o bacteria, a low-grade long-standing lesion forms in the periradicular area. As long as the irritants keep emanating from the root canal system, the soft tissue lesion keeps expanding at the expense of the surrounding bone. Clinically, the CPP is asymptomatic and is detected only radiographically by a small or large periradicular radiolucency, which is either well circumscribed or diffuse. Thus, this lesion is often detected during a routine examination, and the patient is surprised that it is present. Histologically, a CPP takes the form of a granuloma or cyst; a diagnosis which can be made only microscopically not radiographically.

Chronic Suppurative Periodontitis (CSP)

If the periradicular lesion establishes drainage by breaking through the cortical plate into the oral cavity, a diagnosis of chronic suppurative periodontitis is made. Clinically, the patient presents with a sinus tract, which can be traced with a gutta-percha point to determine its source radiographically. The patient is usually asymptomatic because the sinus tract allows for drainage of any purulent exudate forming in the periradicular area. The radiographic exam usually reveals a periradicular radiolucency associated with the involved tooth, while the”vitality”, percussion and palpation tests render no response.

Phoenix Abscess

A phoenix abscess is an acute exacerbation of a chronic periradicular periodontitis resulting from an increase in the virulence of the bacteria in the lesion and/or a decrease in the patient’s resistance. The patient exhibits the same signs and symptoms of an acute periradicular abscess except the radiographic exam reveals a periradicular radiolucency associated with the involved tooth.

Chronic Periradicular Periodontitis with Symptoms

Radiographically, this pathosis is the same as CPP; a radiolucent lesion is present. However, instead of being asymptomatic, the patient presents with symptoms such as pain to biting or pressure. It is imperative that these cases receive timely endodontic therapy because they have the potential of evolving into a phoenix abscess.

Summary

Before initiating endodontic therapy, it is imperative that the clinician determines the etiology of the patient’s chief complaint. In order to do this, a thorough diagnostic workup must be performed and both a pulpal and periradicular diagnosis made and entered into the patient’s treatment record. This clinical update presented a classification system of these diagnoses.


Procedure described in Endo book p. 397

  • Inflamed & diseased tissue removed to the level of healthy tissue.
  • Bleeding within normal limits and easily controlled, indicates Px.
  • Not possible to determine if all diseased tissue removed.
  • Absence of symptoms does not indicate absence of disease.
  • Calcific metamorphosis is a common occurrence (not pathosis) may make RCT, if needed, more difficult.

Dental Implants

06Sep07

IMPLANT RESTORATIONS

 

An implant case can be used to substitute for one of the RPD units of the 4 current required for graduation in the Section of Removable Prosthodontics.  The following patient treatments qualify for substitution.

 

1.               Designing and participating in fabrication of a tissue bar used to retain a complete denture.

 

2.               Designing and participating in the fabrication of a single tooth implant crown (i.e., making impressions, diagnostic wax ups, surgical templates, pouring casts and mounting records, etc.)

 

3.               Fabricating an RPD where implant(s) is (are) used as overdenture abutments.

 

4.               Designing and participating in the fabrication of an implant supported fixed partial denture (i.e., making master impressions, pouring and mounting casts, delivery follow-up etc.)

 

5.               All implant cases need to be approved and supervised by Dr. Kumar Shah in order for students to get one RPD substitution

 

 

 

All designated laboratory procedure will be completed by the 2nd floor implant prosthodontics lab technician training program.  All surgical procedures will be performed in the Straumann Implant Center.  Prior to submitting the case to be lab, and appropriate lab request form will need to be completed.

 

The student will be responsible for the following as necessary (see grade sheets for details):

 

1.               Study casts mounted with facebow and CR records (partially edentulous patients only)

 

2.               Developing a comphensive treatment plan in writing.  (Format to be used will be given to the students)

 

3.               Completing a diagnostic wax up (partially edentulous patients only)

 

4.               Designing and fabricating surgical templates to be used during surgical placement

 

5.               Participating in the surgical placement as the 3rd and 4th assistant

 

6.               Fabricating and delivering provisional prostheses as needed

 

7.               Making master impressions, pouring master casts, and mounting this cast and the opposing cast on an articulator with facebow transfer and centric relation records

 

8.               Work with the laboratory technician student, the lab supervisor, and assigned faculty in fabricating the proposed implant prosthesis of tissue bar

 

9.               Delivery and follow-up

 

 

All prosthodontic procedures will be conducted in 3rd floor Removable Prosthodontics geographic area (B0-129) and supervised by faculty from the Section of Removable Prosthodontics, and all surgical procedures will be conducted and supervised by faculty from the Sections of Oral Surgery and Periodontics as required.

 

Implant instrumentation (screen driver, impression copings, etc., will be provided in the Straumann Implant Center.  All grade sheets (see enclosed) must be signed by the appropriate faculty in order to receive credit.

 

Before beginning treatment, all perspective patients need to be screened in the Straumann Implant Center and approved for predoctoral care.  When such approval is obtained, grade sheets can be obtained and the case logged in at the Straumann Implant Center Office (B0-129).

All proposed implant treatment cases have to be presented during the Implant Consult block on Thursday afternoon (1-5pm) and approved by Dr Beumer or Dr Shah. During these sessions, the patient has to be present along with accurately mounted diagnostic casts and recent appropriate radiographs. The student is expected to review all prior related lectures and CDs and be prepared to answer pertinent questions related to his/her patient treatment. Once approved, these cases will be scheduled only on Wednesday morning sessions in the removable prosthodontics clinic with Dr Shah.

The following provides a guideline for suitable pre-doctoral implant treatment cases:

Single or Multiple Units restorations:

  • Posterior single unit restoration without a need for any augmentation or grafting procedures
  • 3-units FPD (or less) in the posterior mandible.

 

Complete Dentures:

  • Only Mandibular 2-implant implant assisted overdenture; (Cases without extreme resorption or with adequate attached tissue)
  • No Maxillary implant assisted or implant supported overdentures.

 

Note: A student has to completed the entire procedure form start to finish in order to obtain credit for the case. Incomplete or transfer cases will require student to perform additional procedures of the missing stages in order to get credit.


  • UCLA can’t do free dentistry
  • Clinic carries balance maximum 90 days
  • It is the student’s responsibility to collect on the day of treatment
  • Remind the patient of amount and that payment can be cash, check, or credit card when calling patient to re-confirm an appointment
  • Avoid interruption in continuity of care; the patient who is a bad debt risk will have his SOE account locked
  • Partial payment of 50% at the start and other 50% before sending case to lab for processing
  • “Can you get the money from…?
  • Getting a DentiCal Tx Authorization Request (TAR) every month from billing office is the student’s responsibility
    • No TAR for emergency, exam, radiographs, most extractions, dental repair