Diagnosis, Restorability and Prognosis

11.12.18 Shiyana Eliyas

Consultant in Restorative Dentistry, St George’s Hospitals, London Specialist in Restorative Dentistry, Hodsoll House Dental Practice, Kent.

My Experience §  Qualified in 2002 from KCL §  VT, SHO in Rest Dent, SHO in Maxfac §  2 years in general practice (NHS and Private) §  Pre-registrar training at St George’s Hospital §  Specialty Registrar at Sheffield Teaching Hospital §  Head and Neck Oncology Fellowship at MRI, The

Christie, Liverpool Dental and Aintree Hospitals §  Locum consultant at Sheffield, Leicester/Derby,

Guys, St George’s Hospitals §  Consultant at St George’s Hospital since Nov 2015 §  Specialist practitioner at Hodsoll House Dental

practice since Aug 2017

Aims & Objectives

Aims §  Consider diagnosis and the factors that affect restorability to include tooth

factors, strategic worth and patient modifying factors.

Learning objectives §  Improve knowledge, understanding and clinical application knowledge of the

area around tooth restoration and worth. §  Improve confidence in treatment planning when many options are possible –

with evidence to guide discussion §  Improve communication and messaging to patients around complex treatment

planning – making them aware of their role in the decision-making. §  Understand when a natural tooth that is broken down is valuable and can be

predictably restored and when the opposite applies.

Diagnosis

What would diagnosis in Rest Dent look like for AI?

Dentine hypersensitivity

Reversible pulpitis

Irreversible pulpitis

Chronic apical periodontitis

Acute apical periodontitis

Chronic apical abscess

Acute apical abscess

Lateral periodontal

abscess

Pericoronitis

Non-odontogenic

pain

Muscular spasm / TMJD

Erupting 8s, dry socket

ANUG/ANUP

ORN / MRONJ

But they start from what a patient might say to the computer…

Pain

Short, sharp, shooting

Elicited by hot, cold, sweet

Caries, dentine hypersensitivity (lost filling, recession, erosion, attrition, abrasion)

Elicited on biting Cracked cusp, fractured tooth, loose filling, high spot

Extreme intense lingering pain

Swelling, temperature, malaise Acute apical periodontitis

Cannot locate tooth, sensitive to hot Acute irreversible pulpitis

Dull, throbbing, lingering pain

Localised

Tooth TTP Apical periodontitis, sinusitis

Gingival inflammation

Periodontal (food packing), pericoronitis

Generalised

Inflammation and necrosis ANUG/ANUP

Diffuse Dry socket

TMJD Atypical pain

But then you have to look inside the mouth and find something to explain the diagnosis

Recession Abrasion Attrition Erosion

Cracked cusp Caries

Fracture Food trapping Perio pockets Large fillings

Exposed bone Odd lesions

Light, mirror and periodontal probe

Magnification

Tooth slooth

Electric pulp tester

Hot / cold

Radiograph +/- GP point

Excellence in specialist and community healthcare

Table 1A: Staging of periodontal disease (Papapanou et al., J Clin Periodontol 2018(S20):S162-170)

Table 1B: Grading of periodontal disease (Papapanou et al., J Clin Periodontol 2018(S20):S162-170)

S164  |     PAPAPANOU et Al.

new classification framework along with case definitions. To this end, five position papers were commissioned, authored, peer‐reviewed, and accepted. The first reviewed the classification and diagnosis of aggressive periodontitis (Fine et al.2 2018); the second focused on the age‐dependent distribution of clinical at-tachment loss in two population‐representative, cross‐sectional studies (Billings et al.3 2018); the third reviewed progression data of clinical attachment loss from existing prospective, longi-tudinal studies (Needleman at al.4 2018); the fourth reviewed the diagnosis, pathobiology, and clinical presentation of acute peri-odontal lesions (periodontal abscesses, necrotizing periodontal diseases and endo‐periodontal lesions; Herrera et al.5 2018); lastly, the fifth focused on periodontitis case definitions (Tonetti et al.6 2018), Table 1.

The workgroup reviewed, debated and agreed by consensus on the overall conclusions of the five position papers, that can be largely summarized as follows:

1. The conflicting literature findings on aggressive periodontitis are primarily due to the fact that (i) the currently adopted classification is too broad, (ii) the disease has not been studied from its inception, and (iii) there is paucity of lon-gitudinal studies including multiple time points and different populations. The position paper argued that a more restrictive definition might be better suited to take advantage of modern methodologies to enhance knowledge on the diagnosis, pathogenesis, and management of this form of periodontitis.

TA B L E 1 A   Classification of periodontitis based on stages defined by severity (according to the level of interdental clinical attachment loss, radiographic bone loss and tooth loss), complexity and extent and distribution

The initial stage should be determined using clinical attachment loss (CAL); if not available then radiographic bone loss (RBL) should be used. Information on tooth loss that can be attributed primarily to periodontitis – if available – may modify stage definition. This is the case even in the absence of com-plexity factors. Complexity factors may shift the stage to a higher level, for example furcation II or III would shift to either stage III or IV irrespective of CAL. The distinction between stage III and stage IV is primarily based on complexity factors. For example, a high level of tooth mobility and/or posterior bite collapse would indicate a stage IV diagnosis. For any given case only some, not all, complexity factors may be present, however, in general it only takes one complexity factor to shift the diagnosis to a higher stage. It should be emphasized that these case definitions are guidelines that should be applied using sound clinical judgment to arrive at the most appropriate clinical diagnosis.For post‐treatment patients, CAL and RBL are still the primary stage determinants. If a stage‐shifting complexity factor(s) is eliminated by treatment, the stage should not retrogress to a lower stage since the original stage complexity factor should always be considered in maintenance phase management.

     |  S165PAPAPANOU et Al.

2. Despite substantial differences in the overall severity of attach-ment loss between the two population samples analyzed by Billings et al.3, suggesting presence of cohort effects, common patterns of CAL were identified across different ages, along with consistencies in the relative contribution of recession and pocket depth to CAL. The findings suggest that it is feasible to introduce empirical evi-dence‐driven thresholds of attachment loss that signify dispropor-tionate severity of periodontitis with respect to age.

3. Longitudinal mean annual attachment level change was found to vary considerably both within and between populations. Surprisingly, neither age nor sex had any discernible effects on CAL change, but geographic location was associated with differences. Overall, the position paper argued that the existing evidence neither supports nor refutes the differentiation between forms of periodontal dis-eases based upon progression of attachment level change.

4. Necrotizing periodontal diseases are characterized by three typical clinical features (papilla necrosis, bleeding, and pain) and are associated with host immune response impairments,

which should be considered in the classification of these condi-tions (Table 2).

Endodontic‐periodontal lesions are defined by a pathological communication between the pulpal and periodontal tissues at a given tooth, occur in either an acute or a chronic form, and should be classified according to signs and symptoms that have direct impact on their prognosis and treatment (i.e., presence or absence of fractures and perforations, and presence or absence of perio-dontitis) (Table 3).

Periodontal abscesses most frequently occur in pre‐existing peri-odontal pockets and should be classified according to their etiol-ogy. They are characterized by localized accumulation of pus within the gingival wall of the periodontal pocket/sulcus, cause rapid tissue destruction which may compromise tooth prognosis, and are associated with risk for systemic dissemination (Table 4).

5. A periodontitis case definition system should include three compo-nents: (a) identification of a patient as a periodontitis case, (b) iden-tification of the specific type of periodontitis, and (c) description of

TA B L E 1 B   Classification of periodontitis based on grades that reflect biologic features of the disease including evidence of, or risk for, rapid progression, anticipated treatment response, and effects on systemic health

Grade should be used as an indicator of the rate of periodontitis progression. The primary criteria are either direct or indirect evidence of progression. Whenever available, direct evidence is used; in its absence indirect estimation is made using bone loss as a function of age at the most affected tooth or case presentation (radiographic bone loss expressed as percentage of root length divided by the age of the subject, RBL/age). Clinicians should ini-tially assume grade B disease and seek specific evidence to shift towards grade A or C, if available. Once grade is established based on evidence of progression, it can be modified based on the presence of risk factors. CAL = clinical attachment loss; HbA1c = glycated hemoglobin A1c; RBL = radio-graphic bone loss.

New perio classification – BSP to release guidance

on how to use it soon

Lateral periodontal abscess Perio-endo lesion Root fracture

Single deep pocket and swelling/sinus in attached gingivae

Heat is good at telling you when a tooth is

diseased

Cold and EPT are good at telling you when a

tooth is healthy

Restorability

Abbott 2004 Aus Dent J. 2004;49(1):33-39

245 teeth - assessed before and after restoration removal

56% chance of detecting caries, cracks or marginal breakdown from clinical and radiographic examinations

95% of the teeth had one or more factors that could have contributed to pulpal and periapical disease

Before restoration removal

After restoration removal

Caries 47 (19.2%) 211 (86.1%) Cracks 57 (23.3%) 147 (60%) Marginal breakdown 96 (39.2%) 244 (99.6%)

Ferrule A band that completely encircles the external

dimensions of the tooth

§  Resists lateral forces therefore fracture resistance1

§  Must be on sound tooth structure (not the core)2 §  Axial walls must be parallel and minimum thickness of 1mm2 §  The longer the ferrule the better with min 1mm3 §  Do not invade periodontal attachment i.e. > 0.4mm from gingival crevice4

1 Hemmings et al. J Prosthet Dent. 1991;66:325-9 2 Cohen S & Hargreaves KM. Pathways of the pulp. 9th Edition. Mosby Elsevier. 2006

3 Sorensen & Martinoff. J Prosthet Dent. 1990;63:529 4Goodacre. Dent Clin North Am. 2004;48(2):359-85

Ferrule A band that completely encircles the external

dimensions of the tooth

§  Resists lateral forces therefore fracture resistance1

§  Must be on sound tooth structure (not the core)2 §  Axial walls must be parallel and minimum thickness of 1mm2 §  The longer the ferrule the better with min 1mm3 §  Do not invade periodontal attachment i.e. > 0.4mm from gingival crevice4

1 Hemmings et al. J Prosthet Dent. 1991;66:325-9 2 Cohen S & Hargreaves KM. Pathways of the pulp. 9th Edition. Mosby Elsevier. 2006

3 Sorensen & Martinoff. J Prosthet Dent. 1990;63:529 4Goodacre. Dent Clin North Am. 2004;48(2):359-85

Compromised teeth What is left: All may be good

Some may be compromised All may be compromised (hopeless - extraction)

Predictors of remaining tooth tissue: Does the RD clamp retain well?

Has the crown / post crown previously de-cemented? How many crowns have been made previously?

Restorative worth: How useful is the tooth to the patient?

Aesthetic impact? Functional impact? Prosthodontic impact?

Jorgensen 1955: •  Retention - the direction of the path

of insertion (occlusal direction) •  Resistance form any other lateral

direction Both are a function of:

•  Taper •  Surface area/bulk of preparation •  Surface roughness

Retention and resistance form?

Jorgensen 1955: •  Retention - the direction of the path

of insertion (occlusal direction) •  Resistance form any other lateral

direction Both are a function of:

•  Taper •  Surface area/bulk of preparation •  Surface roughness

Retention and resistance form?

Simpler in 2018: Minimally invasive dentistry and adhesive dentistry (Chana et al 2000, Briggs et al 2002)

•  No retention / resistance grooves as pre-cementation retention has no relevance to cemented performance (Osman et al 2010)

•  Minimal interocclusal preparation •  No ‘offsets’ / bevels •  Preservation of enamel with supra-gingival margins whenever

possible

Tooth Restorability Index McDonald & Setchell. Dental Update. 2005;32:343-348

*ULY�!UGUST ���� $ENTAL5PDATE ���

2ESTORATIVE$ENTISTRY

BE ASSIGNED WHERE THE OPERATOR FINDS ITIMPOSSIBLE TO DETERMINE WHETHER A SCORE OF� OR � IS MORE APPROPRIATE�� n !DEQUATE4HERE IS SUFFICIENT CORONAL DENTINE IN TERMSOF HEIGHT� THICKNESS AND DISTRIBUTION FORTHE OPERATOR TO FEEL CONFIDENT THAT THISSEXTANT WILL CONTRIBUTE FULLY TO RETENTION ANDRESISTANCE OF THE CORE AND FINAL RESTORATION�

4HUS A MAXIMUM OF �� COULD BESCORED FOR EACH TOOTH� %VIDENCE OF VALIDATIONOF THIS INDEX IS INCLUDED IN A PAPERSUBMITTED FOR PUBLICATION AND IS THEREFORENOT INCLUDED HERE�

&IGURES �n� DEMONSTRATE THEREMAINING DENTINE PRIOR TO CORE PLACEMENT�REMAINING DENTINE AFTER CROWN PREPARATIONWITH CORE IN PLACE AND REMAINING DENTINEAFTER CROWN PREPARATION BUT WITHOUT COREPLACEMENT� 4HE 42) CAN BE APPLIED TO ANYREMAINING DENTINE PRIOR TO PLACEMENT OFTHE CORE MATERIAL� )F CORE PLACEMENT HASOCCURRED� THE OPERATOR MUST VISUALIZETHE AMOUNT OF CORONAL DENTINE AFTER FINALCROWN PREPARATION� )N GENERAL� OPERATORSFIND IT DIFFICULT TO IMAGINE BOTH THE FINALTHICKNESS OF CORONAL DENTINE WALLS AFTER AXIALREDUCTION FOR A CAST RESTORATION� AND ALSO TOREMEMBER THE DIMENSIONS OF THE CORONALDENTINE AFTER THE CORE HAS BEEN PLACED� )THAS BEEN SUGGESTED THAT ASSESSMENT OF THEDENTINE WALL THICKNESS WOULD BE HELPEDBY PLACING THE CORE MATERIAL AFTER THE FINALCROWN PREPARATION� 0LACEMENT OF THE MATRIXBAND AND CORE MAY BE MADE DIFFICULT WITHTHIS TECHNIQUE� BUT CONVERSELY IT FACILITATES

A RELIABLE VISUAL ASSESSMENT OF THE DENTINEWALL THICKNESS�

4HE SCORING SYSTEM IS SUBJECTIVEAND IS DEPENDENT ON THE EXAMINER�S CLINICALOPINION� )T ALLOWS THE CONTRIBUTION OF EACHPART OF THE TOOTH TO BE ASSESSED AND�WHILE AN OVERALL MEAN SCORE IS POSSIBLE� ITIS THE SEXTANTS WITH A SCORE OF THREE THATWILL ARGUABLY MAKE A MAJOR CONTRIBUTIONTO THE TOOTH�S RESTORABILITY� !N EXAMPLEOF THIS MAY BE SEEN IN &IGURES �n�� !SSTATED EARLIER� THE PERIODONTAL SUPPORT�INVOLVEMENT IN THE OCCLUSAL SCHEME�PRESENCE OF PARAFUNCTION AND INTENDEDFUNCTION OF THE TOOTH� FOR EXAMPLE ASA SINGLE UNIT RESTORATION� OVERDENTURE�REMOVABLE PARTIAL DENTURE OR BRIDGEABUTMENT� ARE IMPORTANT WHEN DECIDINGHOW MUCH DENTINE IS NEEDED FOR THISTOOTH�S REQUIREMENTS� 4ABLE � SUMMARIZES

THE SUBJECTIVE RECOMMENDATIONS OF THETHREE EXAMINERS WITH REGARDS TO THEDENTINE REQUIREMENTS FOR A SINGLE UNITCROWN�

4HE FINAL 42) SCORINGS OF THETHREE EXAMINERS WERE WITHIN � 42) SCOREFOR ��� OF THE TEETH IN THE STUDY� 4HEDETAILS OF THESE RESULTS ARE INCLUDEDIN THE PAPER CURRENTLY SUBMITTEDFOR PUBLICATION THAT SUMMARIZES THEDISSERTATION��� 3IMILARLY� GOOD INTRA EXAMINER REPRODUCIBILITY WAS CONFIRMED�)N OUR EXPERIENCE� ASSESSORS ENCOUNTEREDSOME DIFFICULTY IN SCORING SEXTANTS WHENTHE HEIGHT TO WIDTH RATIO WAS POOR� BUTHAD LITTLE DIFFICULTY WHEN THERE WAS EITHERAMPLE� OR AN ABSENCE OF� TOOTH STRUCTURE� 7EHAVE FOUND THAT THERE IS A GOOD CORRELATIONBETWEEN THE VOLUME OF TOOTH STRUCTUREREMAINING AND THE 42)������

&IGURE �� 2EMAINING DENTINE IN A MOLAR� PRIOR TOCORE PLACEMENT�

&IGURE �� 2EMAINING DENTINE IN THE SAME MOLARAFTER CROWN PREPARATION�

&IGURE �� 2EMAINING DENTINE IN THE SAME MOLAR�AFTER CROWN PREPARATION BUT WITHOUT CORE IN PLACE�

4OOTH 3TRUCTURE 2EMAINING #LINICAL $ECISION

4EETH WITH A 42) OF �� AND GREATER !CCEPTABLE

4EETH WITH SCORES OF �n�� 1UESTIONABLE AND DEPENDENTON NUMBER OF SEXTANTSWITH A SCORE OF �� !CCEPTABLE IF�n� SEXTANTS HAVE ACHIEVED ACOMFORTABLE � SCORE�

3CORE � � 5NACCEPTABLE TO RETAIN APLASTIC CORE�#ONSIDER�� CROWN LENGTHEN�� CAST POST AND CORE�

4ABLE �� 4OOTH RESTORABILITY INDEX �42)� 4HIS IS BASED ON THE SUBJECTIVE RECOMMENDATIONS OF THREEEXAMINERS WITH REGARDS TO THE DENTINE REQUIREMENTS FOR A SINGLE UNIT CROWN�

§  Height & width of axial dentine after restoration removal + crown prep

§  0 = None (no axial dentine above finishing line) §  1 = Inadequate (dentine walls <1.5mm thick or more than 2x as high as their thinnest part)

§  2 = Questionable (between 1 and 3) §  3 = Adequate (adequate height, thickness and distribution of axial dentine walls)

2ESTORATIVE$ENTISTRY

��� $ENTAL5PDATE *ULY�!UGUST ����

RESISTANCE WAS SUBSTANTIALLY INCREASED BYUTILIZING THE ROOT CANAL SPACE� )T HAS ALSOBEEN SUGGESTED� ALTHOUGH NOT PUBLISHED�THAT PLACEMENT OF A BACTERIOSTATIC MATERIALIN THE ROOT CANAL OPENINGS BENEATH A COREMAY BE BENEFICIAL TO REDUCE THE EFFECTS OFMICROLEAKAGE� )T THEREFORE SEEMS THAT THENEED TO EXTEND THE AMALGAM CORE INTOTHE ROOT CANALS IS UNCLEAR UNLESS THE PULPCHAMBER HEIGHT IS COMPROMISED�

)F THERE IS INSUFFICIENT DENTINEREMAINING� CONSIDERATION SHOULD BE GIVENTO SURGICAL CROWN LENGTHENING OF THETOOTH���&IGURES �� � � &IRST� THE PATIENT�SDESIRE AND SUITABILITY TO UNDERGO A SURGICALPROCEDURE WILL NEED TO BE ESTABLISHED�FOLLOWED BY A COMPREHENSIVE PERIODONTALEXAMINATION� ! PERIAPICAL RADIOGRAPH IS ANIMPORTANT AID TO MAKING A CLINICAL DECISIONIN ORDER TO EVALUATE�� 4HE LENGTH OF THE ROOT�� 4HE CROWN� ROOT RATIO�� 4HE LOCATION OF THE FURCATION AND� 4HE TAPER OF THE ROOTS�)N SHORT� THE ROOT WILL NEED TO BE SUFFICIENTLYLONG TO ALLOW BONE REMOVAL WITHOUTCOMPROMISING THE CROWN� ROOT RATIO� ANDTHE LEVEL OF THE FURCATION WILL FREQUENTLY

DICTATE THE EXTENT OF BONE REMOVAL IN THISAREA AS IT IS PREFERABLE TO AVOID FURCATIONEXPOSURE� 4HE TAPER OF THE ROOTS WILLVARY FROM ONE TOOTH TO THE NEXT AND ISPARTICULARLY IMPORTANT TO THE SIZE OF CERVICALEMBRASURE SPACE THAT WILL BE PRODUCED BYCROWN LENGTHENING� /RTHODONTIC EXTRUSIONIS ANOTHER WAY OF INCREASING CROWN HEIGHT�(OWEVER� IF THE PATIENT IS PERIODONTALLYHEALTHY� THE ALVEOLAR BONE AND SOFTTISSUES WILL ACCOMPANY THE EXTRUDED ROOT�AND SURGICAL CROWN LENGTHENING WILL BENECESSARY TO MAINTAIN THE CORRECT GINGIVALCONTOUR�

4HE 4OOTH 2ESTORABILITY )NDEX!LTHOUGH IT IS ASSUMED THAT

CORONAL DENTINE REMAINING AFTER CROWNPREPARATION MAY BE IMPORTANT TO THE LONG TERM SUCCESS OR FAILURE OF CASTINGS USED TORESTORE ROOT TREATED TEETH� NO PROSPECTIVECLINICAL EVIDENCE EXISTS TO SUPPORT THISTHEORY� 4WO RECENT PROSPECTIVE RESEARCHPROJECTS HAVE SET OUT TO RECORD THE AMOUNTOF CORONAL TOOTH STRUCTURE REMAININGIN ROOT TREATED TEETH AFTER PREPARATIONFOR COMPLETE OR PARTIAL COVERAGE CASTRESTORATIONS������ /NE OF THESE STUDIES�� HASBEEN SUBMITTED FOR PUBLICATION AND THESECOND IS IN PREPARATION��� 7E ARE THEREFORENOT AT LIBERTY TO DETAIL THESE PROJECTS BUTHAVE SUMMARIZED THE SALIENT FINDINGS ASFOLLOWS�� #ALCULATION OF THE REMAINING DENTINEVOLUME WAS ACHIEVED BY EITHER SCANNINGTHE CAST USING A LASER PROFILOMETER OR� IFUNDERCUTS EXISTED� WEIGHING THE REMAININGDIE STONE AND CALCULATING THE EQUIVALENTDENTINE VOLUME�� !S THE VOLUME OF REMAINING DENTINEMAY NOT REFLECT ITS STRATEGIC CONTRIBUTION� ITBECAME APPARENT THAT AN INDEX ASSESSINGTHE VALUE OF SMALL SECTIONS OF DENTINE WOULDBE USEFUL�� ! 4OOTH 2ESTORABILITY )NDEX �42)WAS DEVELOPED TO PROVIDE A STRUCTUREDASSESSMENT USING DEFINED PARAMETERS TOEVALUATE REMAINING CORONAL TISSUE�� )T WAS DECIDED TO DIVIDE THE TOOTH INTO �EQUAL SEXTANTS� � PROXIMAL� � BUCCAL AND �LINGUAL AREAS �&IGURE ��� 4HE 42) ALLOWED SCORES OF � TO � IN EACHTOOTH SEXTANT� WITH A MAXIMUM SCORE OF ��PER TOOTH�� )N THIS WAY� THE CONTRIBUTION OF EACH TOOTHSEXTANT OF REMAINING DENTINE TO RETENTION

AND RESISTANCE FORM CAN BE RECORDED�� 4HIS INDEX HAS BEEN EVALUATED USINGCASTS OF THE REMAINING TOOTH DENTINE FROMEXTENSIVELY BROKEN DOWN TEETH IN ORDERTO ASSESS THE AGREEMENT BETWEEN THREEEXPERIENCED CLINICIANS���

! SCORING SYSTEM OF � TO � WASALLOCATED TO EACH SECTION�� n @.ONE�4HROUGHOUT TWO THIRDS OR MORE OF THE TOOTHSEXTANT UNDER CONSIDERATION THERE IS NO AXIALWALL OF DENTINE �IE A BOX OR MISSING CUSP�OR ANY DENTINE PRESENT ABOVE THE FINISHINGLINE IS SO LACKING IN HEIGHT AS TO BE UNABLETO CONTRIBUTE TO RETENTION AND RESISTANCE OFA CORE OR CROWN� 4HIS SCORE IS APPROPRIATEWHERE A MARGIN IS VISIBLE JUST APICAL TO THELIMIT OF A MISSING WALL BUT THERE IS ONLYA SMALL BEVEL OR CHAMFER COMPRISING THEPREPARATION DENTINE�� n )NADEQUATE#ORONAL DENTINE IS PRESENT IN THE TOOTHSEXTANT BUT� IN TERMS OF THICKNESS� HEIGHTOR DISTRIBUTION �EXAMPLE� AN UNDERMININGUNDERCUT IS� IN THE OPERATOR�S CLINICALOPINION� INSUFFICIENT TO MAKE ANYPREDICTABLE CONTRIBUTION TO RETENTION ANDRESISTANCE� $ENTINE WALLS THAT ARE LESS THAN��� MM THICK �A TURBINE BUR SHANK IS ���MM OR MORE THAN TWICE AS HIGH AS THEIRTHINNEST PART WOULD BE INCLUDED IN THISCATEGORY�� n 1UESTIONABLE-ORE DENTINE IS PRESENT THAN IN �� BUT INONE�S CLINICAL OPINION IT IS NOT POSSIBLE TOBE CONFIDENT WHETHER OR NOT IT WILL MAKEA PREDICTABLE CONTRIBUTION TO RETENTIONAND RESISTANCE� 4HIS SCORE SHOULD ONLY

&IGURE �� -OLAR TOOTH PRIOR TO CROWN LENGTHENING�

&IGURE �� -OLAR TOOTH AFTER CROWN LENGTHENING�

&IGURE �� $IAGRAM OF REMAINING TOOTH STRUCTUREWITH SCORING OF SEXTANTS USING THE 42)�

Informed Consent

§  EBD - Best available evidence, clinical judgment, patient choice

§  Tooth may or may not be restorable §  If restorable – want to get in there and do RCT asap,

longer you leave it the more virulent the microbes may be §  If unrestorable premature loss of tooth especially if patient

is asymptomatic

§  Have a denture ready for anterior teeth

•  Context is important – patient modifying factors?

•  Depends on what the patient wants and why – motivation / caries / plaque control etc.

•  Will patient want space restored following extraction?

•  It has a good buccal wall, it will need some removal of lingual soft tissue vs bone removal?

•  The tooth is not stand alone and protected both mesial and distal – but a fracture, unpredictable endo and poor uncontrolled perio will be the game changers

Context is important

‘Adhesive’ Restorability Stripped down anterior tooth to natural tooth tissue

•  Amount of and quality of dental tissue type - % of enamel : dentine

•  The amount of useable peripheral enamel •  Position of Enamel – Amount of supra-gingival

coronal enamel? •  Challenges with marginal moisture control at

cementation? •  If yes, are they fixable? – advanced Rubber Dam

skills needed •  Can I use BisGMA – luting technology in this

scenario?

‘Adhesive’ Restorability Strip down posterior tooth to natural tooth-tissue

•  Amount of and quality of dental tissue type - % of enamel : dentine

•  Position of Enamel – Amount of supra-gingival coronal enamel?

•  Challenges with marginal moisture control at cementation?

•  If yes, are they fixable? – advanced Rubber Dam skills

•  Think differently about function of cores – block out undercuts rather than structural support and provide retention for crown

Restorability of posterior teeth §  Bitewing radiographs

§  Strategic value - Is it opposed? Is it going to be an abutment?

Endo Crowns: we can use cast metal and resin-active cements to help avoid undertaking procedures with which we can struggle (e.g. posts)

Intra-radicular resin-bonded gold hats

Endo Crowns – all ceramic

Where does amalgam fit with the vital

compromised tooth with thin walls? – does it still have a place in 2018 and

beyond?

Does amalgam have advantages with difficult compromised teeth over crowns?

D. McComb. 2008 PEAK articles

Prognosis

Pulp death under crowns and

bridges

How long will a composite last

compared to an amalgam?

Endodontics vs. Implants?

What about bridges?

What about posts?

How do I motivate the patient?

Why not dentures?

Prognosis Depends on what you are measuring…

Close all spaces vs. make the canines look less pointy

Nayyar core amalgam (May 2016) Review (May 2018) Separated instrument LR7)

PESH & SHEEP •  Perio •  Endo •  Structure •  History

•  Structure •  History •  Endo •  Experience (and

Skill) of the operator

•  Perio

Consider: Required Function of Tooth / Teeth / Strategic Importance? / Cosmetic and Biological Implant Risk of patient?

Parafunction might be highest risk for well maintained dentitions

PESH & SHEEP •  Perio •  Endo •  Structure •  History

•  Structure •  History •  Endo •  Experience (and

Skill) of the operator

•  Perio

Consider: Required Function of Tooth / Teeth / Strategic Importance? / Cosmetic and Biological Implant Risk of patient?

Parafunction might be highest risk for well maintained dentitions

The more destructive and ‘belts and braces’ the restoration – the more significant will be the

mechanical and biological price at failure

§  Lasted 22 years §  Presented with 8mm pockets

around the mesial implant

§  Can I fix it? §  Can I achieve what the

patient wants? §  How long will it last? §  How will it fail? §  Can I fix it when it fails?

Complication rate over 10 year period: Smokers with Perio = 40% Smokers without Perio = 6%

For Smoking and Perio = 20% greater failure & 7 times greater complications when compared to smokers without perio Smokers with a history of Periodontitis = Survival rate: 80% compared with 100% for smokers with no history of periodontitis over a 10 year period

Long-term prognosis in patients with and without a history of periodontitis: a 10-year prospective cohort study of the ITI dental implant system. Karoussis IK, Salvi GE et al Clin Oral Impl res 2003; 14:329-339

•  Total number of implants 146

•  Implants lost during the study period = 18 – 12.3%

Roccuzzo et al 2012

•  Total number of implants 146

•  Implants lost during the study period = 18 – 12.3%

During the 10-year SPT, 129 teeth were extracted, corresponding to 6.0% of the 2143 teeth – compared to 12.3%

of implants lost over the same time period

Roccuzzo et al 2012

Predicting the prognosis of periodontally involved teeth

Patients must ‘earn’ their RSD (professional therapy) if lots of inflammation (means poor OH) - it is a waste of time providing RSD

for long term change. No use starting with the scaling!

•  When I cannot make the patient bleed with the tools I have given to them they are doing their best – means that they are controlling their inflammation

•  If my probe makes them bleed – they then need professional help

•  RSD for pockets of 4mm or more

Patients must earn their right to RSD

Crowns are usually over-contoured compared to natural teeth and therefore tend to deflect toothbrush bristles over and away from the gum – we do not usually need to replace them to resolve this problem, even

when they are far from perfect

Outcome – surrogate end points

«  Do not reassess too soon – greatest changes occur over 3 months but maturation of tissues can take 9-12 months (Morrison et al 1980, Badersten et al 1981, Cugini et al 2000)

«  BOP is not a good indicator of disease but absence is a criteria for disease stability (Lang et al 1986)

Study Baseline At end of active perio Tx At end of supportive Tx Konig et al 2002 (SPT 8yrs)

<4mm 17%

>4mm 83%

<4mm 83.7%

>4mm 16.3%

<4mm 64.4%

>4mm 35.6%

Carnevale et al 2007 (SPT 3-17 yrs)

<3mm 98.5%

>3mm 1.5%

Periodontal Maintenance «  Fardal et al 2004 – 100 patients in rural Norway, 1.5% of teeth were lost over SPT

period of 9-11yrs

«  Lindhe and Nyman 1984 – 61 patients, only 2.3% of teeth were lost over 14yrs

«  Hirschfeld & Wasserman 1978 – 600 pts lost 7.1% of teeth over 15-53yrs 83.2% well maintained (lost 0-3 teeth) 12.6% downhillers (lost 4-9 teeth) 4.2% extreme downhillers (lost 10-23 teeth)

«  McFall 1982 – 100 pts, 9.8% were lost over 15-29yrs 77% well maintained, 15% downhillers, 8% extreme downhillers

Periodontal Maintenance - Position paper Journal of Periodontology 2003;74:1395-1401

«  Hirschfeld & Wasserman 1978 –  17% of teeth with questionable prognosis were lost in WM group –  In ED group almost all of teeth with questionable prognosis were lost –  20% of all teeth lost included teeth that were not deemed

questionable (were maintained for many years and suddenly developed periodontal destruction)

«  McFall 1982 –  about 27% (in WM group) - 91.8% (in ED group) of teeth we deem

questionable are lost during maintenance –  56% of teeth with a favourable prognosis also lost –  57% of questionable teeth with furcations lost

Periodontally involved molars tend

to survive well

Longevity BDJ series

Longevity BDJ series

American Journal of Dentistry, Vol. 23, No. 3, June, 2010

Metal v Ceramic: we know what we would have in our own mouths – survival v aesthetics

Additive Extra-Coronal Composite

Survival – De-Novo 5.8 years - Replacement 4.75 years

Direct Resin Repair of # Ceramic:

Cojet – sandblasting (30microns) Hydrofluoric Acid Silane-Coupling

Resin Retained Bridges

«  Retraction cord «  Sandblast wing and tooth (RD) «  Alloy primer «  Etch tooth + A&B «  Cement with Panavia Opaque «  Remove excess and hold in

place for 4minutes «  Remove retraction cord and

excess with ultrasonic

Durey 2015 (EJPRD) •  Can bond to composite without

losing bond strength

King 2015 (BDJ) •  771 bridges in 621 patients •  10 year survival 80% (95%CI

77.6-83.2%)

Can we predict if our Endo is going to work? Pre-operative: •  Presence of periapical

lesion (49% lower) •  Size of periapical lesion

(14% lower for every 1mm) •  Presence of sinus (48%

lower) •  Presence of root perforation

(56% lower)

Ng, Mann & Gulabivala; International Endodontic Journal, 2011

Intra-operative: •  Achieving patency (Two-fold

increase) •  Canal prepared short of

terminus (12% lower for every 1mm short)

•  Long root filling (62% lower odds of success)

•  Using Chlorhexidine as irrigant (53% lower)

•  Using EDTA (Re-RCTx) (Two-fold increase)

•  Inter-appointment swelling/pain (47% lower)

Post-operative: •  Good coronal

restoration (Eleven-fold increase in odds of success)

Can we predict if our Endo is going to work? Pre-operative: •  Presence of periapical

lesion (49% lower) •  Size of periapical lesion

(14% lower for every 1mm) •  Presence of sinus (48%

lower) •  Presence of root perforation

(56% lower)

Ng, Mann & Gulabivala; International Endodontic Journal, 2011

Intra-operative: •  Achieving patency (Two-fold

increase) •  Canal prepared short of

terminus (12% lower for every 1mm short)

•  Long root filling (62% lower odds of success)

•  Using Chlorhexidine as irrigant (53% lower)

•  Using EDTA (Re-RCTx) (Two-fold increase)

•  Inter-appointment swelling/pain (47% lower)

Post-operative: •  Good coronal

restoration (Eleven-fold increase in odds of success)

•  We ideally want to treat vital cases – no bugs •  We need to get to the end of the real root canal(s) and

achieve apical patency •  We need to cleanse in 3D •  We need to obturate well •  We need to be able to place conservative & predicable

coronal restoration

Any thing that stops these objectives – will reduced success

How long do you wait until restoration after RCT? Can always consider cuspal-protection with either amalgam or direct composite or definitive core and resin

provisional crown

Eight-Year Retrospective Study of the Critical Time Lapse between Root Canal Completion and Crown Placement: Its Influence on the Survival of Endodontically Treated Teeth Pratt I et al 2006. http://dx.doi.org/10.1016/j.joen.2016.08.006 Results: •  Type of restoration after RCT significantly affected the survival of ETT (P = .001). •  ETT that received composite/amalgam build-up restorations were 2.29 times more

likely to be extracted compared with ETT that received crown (hazard ratio, 2.29; confidence interval, 1.29–4.06; P = .005).

•  Time of crown placement after RCT was also significantly correlated with survival rate of ETT (P = .001).

•  Teeth that received crown 4 months after RCT were almost 3 times more likely to get extracted compared with teeth that received crown within 4 months of RCT (hazard ratio, 3.38; confidence interval, 1.56–6.33; P = .002).

What type of Post?

Study Type of post Survival Weine 1991 Cast post and cores 99% at 10 years

Mentink 1993 Cast post and cores 82% at 10 years

Creugers 1993 (meta analysis)

Screw post and composite

Cast post and cores

75-87% at 6 years

88-94% at 6 years

Singore 2008 Glass fibre posts and all ceramic crowns

98% at 8 years (root fracture)

Tidehag 2004 Carbon fibre posts 90% at 7 years

Segerstrom 2006

Carbon fibre posts 65% at 6.7 years

Nauman 2005 Glass fibre posts 87% over 2 years (post fracture) !

The ‘Moshonov’ Gap to be avoided No Gap - 83.3% PAH normal

GAP 0-2mm - 53.6% PAH normal

GAP greater than 2mm - 29.4% PAH normal

Greater risk of periapical infection when there is a radiographic

space between the root filling and the post

(Moshonov et al 2005)

Survival Rates: Endodontic Tx Quality of RCT and the Outcome: •  Taiwan: Good quality obturation 34.8% Tooth retention rate 92.9% •  USA: Good quality obturation 42% Tooth retention rate 94.4% & 97% •  UK: Good quality obturation 26.4% Tooth retention rate 90%

Study No of teeth included

Years data collected

Survival rates Country

Lazarski et al 2001

109,542 1993-1998 94.4% at 3.5 years USA

Salehrabi & Rotstein 2004

1,462,936 1995 - 2002 97% at 8 years USA

Chen 2007 1,557,547 1998 91.1% - 95.4% at 5 years Taiwan

Lumley et al 2008

30,843 1991-2001 74% at 10 years UK (NHS)

Tickle et al 2008

174 1998 - 2003 90.8% at 5 years UK (NHS)

Ng et al 2010 (Meta analysis of 14 studies) 86% (95% CI: 75%, 98%) at 2–3 years 93% (95% CI: 92%, 94%) at 4–5 years 87% (95% CI: 82%, 92%) at 8–10 years

(Review - pooled success)

Endodontics vs. other tx modalities (Torabinejad 2007)

?

RCT Accepting a

space or placing a Denture

Bridges

Implant supported

single crowns

No of papers 24 papers ? 31 papers 46 papers

Survival 97% ? 82% 97%

Success 84% ? 80% 95%

Treatment

PA radiograph 2-3 visit RCT Imp for crown

Fit crown Long term

review

+/- Immediate denture 5-6 visits

Long term review

+/- immediate denture +/- long term temps

Imps Fit

Long term review

Cone beam CT +/- bone grafting

+/- soft tissue grafting 2-3 surgical stages

Imp for crown Long term review

Financial Cost ££ £ £££ ££££

Doyle 2006 J Endod 2006;32:822– 827 «  196 implant restorations vs 196 matched RCTs (follow up of 1yr) «  Implant success 74% (survival without intervention 2.6%, with intervention 17.9%) «  Primary RCT success 82% (survival without intervention 8.2%, with intervention 3.6%)

Hannahan 2008 J Endod 2008;34:1302–1305 «  Retrospective (129 implants, 143 RCTs, follow up 15-59 months) «  Success: Implants 98% vs RCTs 99% «  Success when uncertain healing added: Implants 88% vs RCTs 90%

Doyle 2006 J Endod 2006;32:822– 827 «  196 implant restorations vs 196 matched RCTs (follow up of 1yr) «  Implant success 74% (survival without intervention 2.6%, with intervention 17.9%) «  Primary RCT success 82% (survival without intervention 8.2%, with intervention 3.6%)

Hannahan 2008 J Endod 2008;34:1302–1305 «  Retrospective (129 implants, 143 RCTs, follow up 15-59 months) «  Success: Implants 98% vs RCTs 99% «  Success when uncertain healing added: Implants 88% vs RCTs 90%

Single cone obturations

<10% failed at a review period of mean 30 months

UL1 with a history of trauma and possible fracture or resorption of the apical third of the root, with associated peri-radicular pathology. Is an implant inevitable?

Completed over two visits. In between appointments buccal swelling and sinus resolved.

Summary

§  Break diagnosis down to simple parts §  If things do not add up, think differently! §  Understand what and why it happened §  Might need to start treatment/dismantle before seeing the full

picture §  Patient motivation may determine the prognosis/outcome §  Informed patient consent – their role in outcome?