Session 1: 5/22/23 Flashcards
what should you always vacuum mix? what should you never vacuum mix?
always: yellow stone and green stone
never: plaster
what are the four different ways a patient is presented?
- healthy
- diseased teeth
- tooth/teeth partially missing: partially edentulous
- completely edentulous
what must you do when pt presents diseased teeth
extract -> restore
what must you do when pt is partially edentulous
restore thru PRDP, FDP, or implant
complexity from least to most complex cases
Implants
PRDP
FDP
PRDP -> FDP -> Implants
as complexity increases, cost increases
what can “Partial” also be called?
- partial removable dental prosthesis (PRDP)
- removable partial denture (RPD)
what can a “Bridge” also be called?
fixed dental prosthesis (FDP)
which is the most superior: esthetics, function, or success of prosthesis?
all are the same. not one is superior than the other
what are the 2 kinds of partials
- transitional/interim partials
- definitive patials
what type of partial has a transitional time period
transitional/interim
what type of partial lacks a metal infrastructure
transitional/interim
what type of partial uses wrought wires (PGP, SS)
transitional/interim
what type of partial is used long term
definitive partial
what type of partial has a metal infrastructure
definitive partials
what type of partial uses cast metal (CoCr)
definitive partials
what type of partial uses autopolymerizing PMMA and leads to discolorization?
transitional/interim partials
what type of partials has versatility in adjustments and is placed at time of extraction?
transitional/interim partials
what type of partial uses heat cured PMMA, has not discolorization but shrinks a little
definitive partials
what type of partial is difficult to adjust in metal and is used after healing is complete?
definitive partials
during an acute phase, what type of limited treatment can be completed
replace teeth for esthetics
what prosthesis can you create for disease control
transitional prosthesis
what does tx planning for patients include
- chief concern
- medical and dental history
- findings
- diagnosis (physiologic, structural, psychologic)
- tx plan options
- tx
- prognosis
what should be done before definitive PRDP tx
- periodontally stable dentition
- orthodontic tx
- individualized tooth restored to stabilize arch
- FDP needed
- pre-proshtetic surgery completed
- articulated casts/occlusal plane established
- PRDP
goals of PRDP tx
- promotion of oral health (stabilize the individual arch)
- organize inter arch function by control of inter arch contacts
6 phases of partial denture service
- pt education
- tx planning to include PRDP design
- support for distal extension bases
- establishment of occlusal relations
- initial placement (delivery)
- post-insertion care and recall
what is the study of dental caries and their development
cariology
are caries a transmissible infection
YES
acidogenic bacteria
- mutans streptococci
- lactobacilli
“warriors”
teeth
armor: carbonated HAP
“defense strategies”
- remineralization
- protective factors
“invaders”
acidogenic bacteria
“strategic attacks”
- disease indicators
- biological or environmental risk factors
medical model of caries
transmissible and infectious disease
T/F: one must treat pt by noting their specific oral health state. disease must be in mangeable condition
TRUE
what can be used to determine caries risk assessment
- software-based prediction tools
- medicaid program CRA tools
- CAMBRA
examples of software-base prediction tools
- cariogram
- previser
what does CAMBRA include
- ICDAS/ICCMS
- ADA/AAPD -> FDA
what does CAMBRA stand for
caries management by risk assessment
when was the latest CAMBRA publication
January 2019
the caries management protocol assesses and documents baseline caries as ___, ___, ___, or ___ utilizing a standardized ___
low, moderate, high, extreme
CRA form
caries risk components of CAMBRA
- disease indicators
- biological or environmental risk factors
- protective factors
xerostomia + disease indictor = ___
extreme risk
disease indicators
- cavitated lesions or radiographic evidence of progression into dentin
- white spot lesions on smooth surfaces
- radiographic evidence of non-cavitated demineralization into enamel
- existing restoration placed due to caries in the last three years for new patient or the last year for a patient of record
does one or more disease indicators classify a new patient to be high risk?
YES
are patients of record high risk if disease indicators present themselves?
YES
___ automatically places the patient in at least the moderate risk
ortho/RPD
examples of biological/environmental risk factors
- heavy plaque
- frequent snacking
- medications causing xerostomia
- reduced salivary function - low flow rate
- deep pits and fissures
- recreational drug use
- exposed tooth roots
- ortho/RPD
T/F: even if patient doesn’t present xerostomia, if taking a medication with the risk, it bumps pt up to higher risk
TRUE
stimulate vs. unstimulated low flow rate
stimulated: whole saliva </= 0.7 mL/min
unstimulated: whole saliva <0.1 mL/min
what factors mostly deal w/ topical fluoride usage
protective factors
examples of protective factors
- fluoridated drinking water
- fluoride toothpaste once daily
- fluoride toothpaste twice daily
- high concentration prescription fluoride twice daily
- fluoride varnish applied in last 6 months
- uses 0.05% sodium fluoride mouthrinse daily
- uses 0.12% CHX gluconate mouthrinse daily for one week each month
- adequate salivary flow
“yes” in column 1 of CAMBRA indicates
indicates high or extreme risk (due to having disease indicators)
“yes” in column 2 and 3 of CAMBRA indicates
consideration of caries balance (due to biological or ennvironmental factors (2) and protective factors (3))
disease indicators
WREB
White spots
Restorations: 3 years
Enamel lesions
Cavities/dentin
risk/biological factors
BADREDO
Bad bacteria
Absence of saliva
Dietary habits poor
Recreational drug usage
Exposed root surfaces
Deep pits and fissures
Ortho/RPD
protective factors
SAFE
Saliva and sealants
Antibacterials
Fluoride
Effective diet
what are the different intervals for recall and review appropriate to caries risk status
low: 12 months
moderate: 6 months
high: 4-6 months
extreme: 3-4 months
what should you do at a recall according to caries management protocol
reassess and document caries risk level and modify treatment plan as necessary
e.g. high and extreme need antibacterial therapy, dietary modification, fluoride therapy and minimally invasive restorative procedures
what should be done prior to definitive treatment
complete a designated re-evalulation appt after disease control
don’t simply move to definitive tx phase unless proof of stable environment
every appt is a chance for re-evaluation and education, including limited exams (change of meds/med conditions, modifications in oral hygiene)
what should be closely followed once definitive tx has begun?
with past dental hx in mind:
radiographs and caries risk assessments at periodic interbals
1. ortho/RPDS
2. med chances
3. dexterity changes
4. OH habit changes
how is caries risk a dynamic process
it involves evaluation at baseline and specific time intervals
- track record
- open patient communication (2 way convo)
- patient oriented care
are caries risk level/caries disease indicators significantly reduced in CAMBRA prevention group?
YES
can principles and philosophy of CAMBRA could be successfully implemented into academic and dental practice environments
YES
ICDAS
international caries detection and assessment system
2002 expert panel
ICCMS
international caries classification and management system
2013-2014 workshops and symposia
ICCMS goals
- translate current understanding of pathogenesis, prevention, and control of caries
- comprehensive assessment and personalized (holistic) caries care plan
- manage risk factors by periodic monitoring and reviewing
ICCMS disease indicators and behavioral risk factors are similar to what
CAMBRA biological factors
ADA subscribes to what philosophy
CAMBRA philosophy
- low risk: only conditions in low risk
- moderate risk: only conditions in low risk and/or moderate risk columns
- high risk: one or more conditions in the high risk column present
protective factors of ADA CRA
- fluoride exposure
- dental home
environmental factors of ADA CRA
- sugary foods or drinks
- special health care needs
- chemo/radiation therapy
- eating disorders
- medications that reduce salivary flow
- drug/alcohol abuse
- visible plaque
- unsual tooth morph
- exposed root surfaces
- dental/ortho appliance
- severe dry mouth/xerostomia
disease indicators of ADA CRA
- cavitates or non-cavitated carious lesions or restorations
- teeth missing due to caries in past 36 months
- interproximal restorations (1 or more)
- restorations with overhangs and/or open margins, open contacts with food impaction
who should complete posterior bitewing exam at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe
recall pt w/ clinical caries or at increased risk for caries
child w/ primary dentition, child w/ transitional dentition, adolescent w/ permanent dentition
who should complete posterior bitewing exam at 6-18 month intervals
recall pt w/ clinical caries or at increased risk for caries
adult, dentate or partially edentulous
who should complete posterior bitewing exam at 12-24 month intervals if proximal surface cannot be examined visually w a probe
recall patients w NO clinical caries and NOT at increased risk for caries
child w/ primary dentition, child with transitional dentition
who should complete posterior bitewing exam at 18-36 month intervals
recall patients w NO clinical caries and NOT at increased risk for caries
adolescent w/ permanent dentition
who should complete posterior bitewing exam at 24-36 month intervals
recall patients w NO clinical caries and NOT at increased risk for caries
adult, dentate, or partially edentulous
do all sophomore textbooks specifically subscribe to CAMBRA philosophy?
NO! but are utilizing caries-risk info in same way
is caries stopped/controlled by placing a restoration?
NO! must stop downward restoration at source - treat the disease not just the symptoms
what are the most important factors in predicting future caries activity
recent caries experience and current disease activity
what is the process of incorporating pt wants, needs, and desires and the appropriate tx options based on evidence and clinical experience to reach a mutually acceptable tx
treatment planning
what is a path of logical and organized sequential steps to achieve tx plan
sequencing
phases of treatment planning
- systemic review
- phase 1: limited tx
- phase 2: disease control
- phase 3: comprehensive/definitive tx
- phase 4: recall/maintenance
what occurs during systemic review
- patient chief concern
- health/dental histories
- decision made to continue, alter, or delay tx based on health and other factors
what occurs during phase 1 - limited tx
- address chief concern if: pain, swelling, trauma, etc. present
- treatment options: extraction, I&D, pulpotomy/pulpectomy, full mouth debridement
what occurs during phase 2 - disease control
- operative - all carious lesions
- Endo - RCT
- Perio - IPT/prophy/OHI
- fixed pros - core buildups
- removable pros
the attempted elimination of any and all disease processes thru removal and/or repair occur during what phase
phase 2 - disease control
patient education and acceptance plays a major role and needs to be accomplished prior to definitive tx during what phase
phase 2 - disease control
*food for thought, not official CUSOD position
do not proceed to phase 3 of tx planning until what
until phase 2 completed and pt has been re-evaluated
what occurs during phase 3 - comprehensive/definitive
- operative - cosmetic
- fixed prosth
- removable prosth
- endo - intentional
you must make sure what happens during phase 3 before proceeding to phase 4
make sure pt is healed
what occurs during phase 4 of tx planning
- annual denture/RPD checks
- periodontal maintenance
- prophy
are phases of tx planning a steadfast rule?
NO. It is a concept and guide
why classify PRDPs
- design features based on classification
- mental image of design can be made prior to surveying cast
- improve communication
requirements of acceptable method of classification
- permit immediate visualization of type of partial edentulous arch
- permit immediate differentiation between tooth-borne and tooth-tissue supported PRDP
- should be univerally acceptable
Kennedy/Applegate classification of RPD
- most posterior space determines class
- other spaces are modifications
- modifications are simply counted
- classification based on partial design
does a Kennedy/Applegate Class IV have a modification space
NO!
Kennedy Class I
bilateral spaces distal to teeth
Kennedy Class II
unilateral space distal to teeth
Kennedy Class III
unilateral space between teeth (e.g. just #9)
Kennedy Class IV
bilateral space between teeth (crosses midline e.g. missing #7, 8, 9, 10)
Kratochvil/Krol classification for Kennedy Class I
Tooth/tissue
(bilateral spaces distal to teeth)
Kratochvil/Krol classification for Kennedy Class II
tooth/tissue
(unilateral space distal to teeth)
Kratochvil/Krol classification for Kennedy Class III
tooth
(unilateral space between teeth)
Kratochvil/Krol classification for Kennedy Class IV
tooth
(bilateral space between teeth crossing midline)
Which Kennedy Class has a fulcrum line/axis of rotation
Kennedy Class I and II (but sometimes III and IV)
fulcrum/axis of rotation occurs on which tooth?
most distal tooth
what is the resiliency of mucosa
0.2mm - 2mm
when would there be a fulcrum line on a Kennedy Class IV
extensive anterior loss
would be present on most anterior tooth NOT distal
if there is extensive Kennedy Class IV, how could we make it a more favorable situation
place tooth/implants anteriorly for support
the number of partially edentulous pt restored w/ dental implants is expected to plateau at ___ of those potentially in need of service
3%-5%
reasons why implant therapy is not provided
- pt not suitable candidate due to lacking sufficient bone volume
- pt is happy w/ RPD
- pt declined surgery when described the nature of procedure
- some studies show implant support FDP vs RPDs are equally effective in improving chewing
why can’t implants be used in posterior quadrants
due to pneumatization of max sinus or insufficient bone over inferior alveolar n.
why do short, wide-diameter implants not have an acceptable level of success
lack of length and lack of width of alveolar bone to enclose the implant
treatment objectives for partially edentulous patient
- stabilize individual arch and protect remaining hard and soft tissues
- organize interarch functions (proper occlusal vertical dimension, occlusal plane, and centric occlusal contact) and esthetics
methods of restoring and stabilizing partially edentulous arch
- repositioning teeth
- individual restorations
- fixed dental prostheses
- osseointegrated implants
- RPDs
what is necessary for long-term successful treatment outcomes of RPD
- supporting structures of residual dentition and mucosa of bone of edentulous bearing surfaces
- establishing proper plane of occlusion
components of RPD
- rests
- major connectors
- minor connector
- proximal plates
- denture base connectors
- retainers
- denture base
what controls the relationship of the prosthesis to supporting structurs and are contoured and positioned to direct occlusal force along long axis of abutment teeth
rests
what is a rigid extension of partial denture that contacts a remaining tooth in prepared seat to transmit vertical or horizontal forces
rests
what joins the components of RPD on one side of arch to those on opposite side
major connectors
what are rigid and provide cross-arch stability for RPD and in some instances enhance support
major connectors
what is the connecting link between major connector of RPD and other units of prosthesis (e.g. clasp assembly, indirect retainers, occlusal rests, or cingulum rests)
minor connector
what are strong, rigid components of RPD that provide stability and can be used to facilitate frictional retention when proximal surfaces are recontoured to be parallel to guiding surfaces
minor connector
what is an extension of minor connector in contact with proximal surface of abutment tooth
proximal plates
what maintains arch integrity by anteroposterior bracing action
proximal plate
according to Kratochvil, ___ are extended to cover gingival margin and extend approximately 2 mm beyond tooth-mucosa junction onto edentulous area
proximal plates
what is part of the RPD to which resin denture base is connected
denture base connectors
what provides strong rigid support structure for attachment of acrylic resin portion of prosthesis containing teeth
denture base connectors
what is the component of RPD used to prevent dislodgement, usually consisting of clasp assembly or precision attachment
retainers
can retainers provide both retention and stability
YES
what does a properly designed retainer control
position of prosthesis in relation to remaining teeth and supporting structures
what is the part of the denture that rests on edentulous bearing surfaces and to which denture teeth are attached
denture base
where does a properly extended denture base does what
significantly enhances support for RPD and limit resorption of underlying bone
is it possible to fabricate RPD frameworks with CAM techniques with accuracy and consistency necessary for clinical use
NOT YET since traditionally “subtractive” but now using additive manufacturing (selective laser melting) techniques with more reasonable accuracy
what is the most cost effective and accurate means of obtaining a full arch master case
conventional impressions but AM/selective laser melting will become increasingly cost-effective over time
what is required of the patient to achieve oral hygiene levels necssary to maintain health of dentition and properly care for prosthesis
patient compliance and reasonable hand-eye coordination
at what level should clinician be seated when soliciting chief complaint, history, med/dent hx etc? why?
in a chair where both clinician and pt are at same eye level. pt can feel threatened if clinican is standing over or above
what factors must be addressed and resolved to achieve a successful clinical outcome
- pt must have will to adjust to and use removable prosthesis
- prosthesis must be accepted as part of body
- clinican must take the pt’s need and turn it into a WANT
should you promise that you can restore the patient to his or her original functional capabilities with use of RPD
NO! give assurance that you will do utmost to maintain health of remaining oral structures to limit further degradation
if a posterior abutment is present and these teeth are immobile, the span and perio support are favorable, and the crown-root ratios are 1:1 or better, what is the most appropriate option?
fixed dental prosthesis (FDP)
if abutments are unrestored or minimally restored and defect spans a single tooth, what is the best choice
single implant
if a distal molar abutment is angled in excess of 25 degrees in any direction, what is an appropriate tx
orthodontic tx prior to proceeding w/ fabrication of RPD
stable and ideal occlusion for pt restored w/ residual natural dentition supplemented w/ RPDs is characterized by (4)
- stable stops on all teeth when condyles are in seated position (CR)
- anterior guidance in harmony w/ border movements of envelope of function
- disocclusion of all posterior teeth during protrusive movements
- disocclusion of all posterior teeth during laterotrusive movements
if patient has lost occlusal vertical dimension (OVD) secondary to wear, erosion or loss of posterior stops, how can it be restored
RPDs
what are the posterior landmarks for occlusal plane
retromolar pads so must be recorded w/ preliminary impression and diagnostic casts
what is the anterior landmark of the occlusal plane dictated by
esthetics and phonetics and therefore by the position of anterior teeth when arches are positioned at appropriate OVD
what is the most common disrupter of the occlusal plane
lone standing posterior molar - may be tilted, supererupted, and elongated to create satisfactory plane of occlusion ( can also grind or reshape teeth)
prior to making impressions for diagnostic casts, what is necessary so contours of dentition and soft tissues can be recorded w/ precision
thorough prophylaxis to remove plaque and debris
impressions needed for creating RPD must include what?
- both arches
- all teeth and soft tissues engaged by RPD
- buccal shelf, retromolar pad, hamular notches and maxillary tuberosities
- contours of floor of mouth and extend to vestibule
- facebow and maxillomandibular records in CR
- OVD
sequence of treatment (intraoral prep) for RPD
- tx of abnormal or inflamed soft tissues of edentulous denture-bearing surfaces
- preprosthetic surgical procedures
- diagnostic wax-up
- periodontal tx as necessary
- endo tx as neccessary
- ortho tx as necessary
- tooth modifications
- needed restorations
- procedures for prosthesis fabrication
inflammatory hyperplasia or inflammation of tissues associated w/ existing prosthesis is triggered by what?
- lack of positive rests on existing prosthesis
- fungal infections
- poor adaptation of existing prosthesis to edentulous denture-bearing surfaces
- hyperocclusion of existing prosthesis
preprosthetic surgical procedures
- teeth - non serviceable should be removed as soon as possible
- bone - large tori should be removed if presence makes it difficult to fabricate a properly designed RPD
- mucosa - hypertrophy of soft tissue can lead to insufficient spacing
- crown lengthening - esp in younger patients bc they lack sufficient undercuts in strategic locations of abutment teeth to retain RPD
mobility of teeth may be triggered by combination of:
- inflammation
- occlusal disharmonies
- lack of bone support
- loss of arch integrity
are endodontically treated teeth good abutments for extension-base RPDs
no, especially teeth w/ rests that control axis of rotation
are endodontically treated root fragments useful when strategically located
yes
recording the final plan of tx
- RPD design drawn on casts in red pencil
- areas of tooth alteration marked on casts in blue
- all restorative procedures marked as appropriate
- all restorative procedures marked in proper sequence
