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Phase 1. Urgent and Problem SolvingPhase 1Urgent18 Let’s start with urgent. It’s easyto define: Pain. Bleeding.Swelling. Infections. But alsogiving a patient a front tooth sothey can go to work can beurgent. We’ve covered pain already,and you will learn options forthat missing front tooth inProsthodontics. Bleeding (likefrom trauma) will be handled inOral Surgery. What about swelling? Usuallyswelling means an infection.JK Mitchell, DDSSpace InfectionsGeneral concepts on management:1. Once the infection is out into the fascial spaces,just starting endo or removing the tooth is notenough. First, the space infection must bemanaged, then the original problem (endo, 3rdmolar, etc) is addressed.2. “Pus must pass” - an incision must be made intothe infected area and a drain put in.3. Generally, these should be managed by an Oraland Maxillofacial Surgeon. Make friends with oneyou can really learn a lot from them

Red Flags19 Any of these symptoms shouldmake you sit up and pay attention! FeverSwellingTrouble swallowingTrouble breathingTrismus If you can’t find the origin of theproblem, or are not sure you havesolved the problem, get thepatient to someone who can (iean Oral Surgeon)! Follow these patients! Call themeven if they don’t come back tothe clinic.JK Mitchell, DDS

Applied Head and NeckLet’s put your Head and Neck Anatomyclasses to practical use!This is a drawing I made to help visualizeand remember space infections.Key concepts:- Infections usually start from the apex ofan abscessed tooth or pericoronitis on a 3rdmolar.- Drainage direction and structure location(like muscle origin and insertion) determinewhich space is infected.-Some of the spaces are connectedinfection can flow around. Life-threatening:Ludwigs Angina is bilaterally submental ,sublingual, and submandibular, leaving noroom for the tongue but into the airway.Parapharyngeal space can go into the neckspaces which blocks off the airway.Both of these can compromise theairway and are life-threatening.- There are only 10 of these spaces, and ifyou think about where the muscles are andhow they relate to the teeth, you can have apretty good guess of which space is which.There’s a copy of this on the class website.Print it out so you can read it.You may need it some day JK Mitchell, DDS20Back toReview

Case 1. SuzannePhase 1Urgent21 Which space is this mostlikely to be? aSubmandibular bSubmental cSublingual Which tooth is most likelyThis patient remembers having a badtoothache “a month or two ago” and then adull ache that started about 5 days ago. Twodays ago she woke up with a swelling whichhas rapidly worsened to this condition. Theswelling is relatively hard with a softfluctuant central area. She has a temp of101.2.JK Mitchell, DDSto be the origin? a#26 b#29 c#31

Indications for AntibioticsPhase 1Urgent22Not indicated:Indicated for:PulpitisPersistent infectionsNecrotic pulp radiolucencyApical periodontitisSinus tractSystemic illness:Temp 100, Malaise,LymphadenopathyLocalized, fluctuant swelling(may need to be drained, butstill may not need AB’s)Progressive infection:Trismus, Cellulitis,Increasing swelling“I don’t have time to takethat tooth out or start aroot canal today, so I’ll giveyou this to hold you till Ican get you in.”Osteomyelitis (OMFSreferral!)“I’d feel more comfortableif you took some antibiotics”The patient wants aprescription for something JK Mitchell, DDS While we’re talking about this,let’s make sure you understandwhen antibiotics work and whenthey don’t work. Antibiotics are still hugelyoverprescribed for many things,dentistry among them. The idea that antibiotics willhelp control pain in pulpitis orperiapical inflammation hasbeen disproven in study afterstudy but many dentists stillstubbornly cling to the belief,even when confronted with theevidence.“Don’t be that guy”Back toReview

Understanding Pain ManagementPhase 1Urgent23 You will take your Pharmacology coursein the Junior year, but in the mean time,here is the basic plan for dealing withpain. Over the counter medications are quiteeffective for mild-moderate pain. We’vegot research. Reassure your patientconfidence works. Ibuprofen is dose-dependant. It is agood pain reliever at lower doses: 400 mg every 4 hours (q4h)600 mg every 6 hours (qid)But for it to be anti-inflammatory, itneeds to be the highest dose: 800 mg every 8 hours (tid)And Ibuprofen has a very slow onset ofrelief (40 minutes). Start pts on it beforeanesthetic wears off, and have themtake it by the clock instead of waitinguntil they hurt.JK Mitchell, DDSMild Aspirin Tylenol Ibuprofen 400mg, 600 mgModerate Ibuprofen 800 mg threetimes a day (tid) by the clock Consider adding narcoticsSevere Mod breakthrough med: Narcotics q4h as needed

Case 1. SuzannePhase 1Urgent24You take a radiograph and see this image.The patient wishes to save the tooth.What do you do?Start a non-surgical root canal treatmenta (endo) and drain through the access, startantibiotics.and drain the abscess surgically,b Inciseplace a drain, and when the acuteinfection is resolved start endo.Incise and drain the abscess surgically,c place a drain and start endo the same dayto remove the source of the infection.After the procedure, what will youprescribe/recommend?Suzanne is an otherwise healthypatient with no allergies to anymedications.a Antibioticsb Over the counter pain medicationsc Narcotic pain medicationsJK Mitchell, DDS

Acute Periodontal InfectionsPhase 1Urgent25 Remember learning about an acute periodontal abscess?There is another kind of periodontal disease that is quitepainful.It used to be called “trench mouth” because it was commonin the trenches in WWI. They thought it was an infectiousdisease, but really it was only because in the trenches theywere getting shot at so they were stressed out and nutritionwas poor.It was common again in the early days of HIV before currentmedications were available. Now you can see it on collegecampuses during finals (cold pizza, anyone?) or boot camps orin anyone who is stressed. It’s called NUP or NecrotizingUlcerative Periodontitis.The bacteria invade the gingival papilla causing rapid loss ofpapilla, bone, and attachment mechanism. It has a classicgrayish slimy “pseudomenbrane” and “punched out” papillaeand a really vile smell that you will never forget once youhave gotten a whiff. Tends to attack first molars andmandibular anterior molars.Treatment? Sleep, good nutrition, and good oral hygiene aswell as antibiotics.JK Mitchell, DDS“Pseudomembrane”“Punched out” papillaeScratch n’ sniff forcharacteristic odor

Phase 1. Problem SolvingPhase 1ProblemSolving26 Problem solving is a harderconcept, and we need to spendsome time on this one. Let’s look at the kinds ofquestions we might be asking: Let’s look at #19Let’s assume that we would really liketo keep #19 for the treatment plan. Sowhat are you thinking .1. Does it need endo?2. Is it restorable?JK Mitchell, DDS Is that soft tissue lesion anythingwe should worry about?Is this tooth restorable?Does the endo need to be redonebefore I put a crown on it?Can I plan implants for that space?How many will I need?Should we do ortho first?

Answer Medical Questions27 As you were taught in OralMedicine, you are the besttrained person to know theparameters for dental care. But if there are issues inthe medical history thatrequire clarification ortesting, the time to get theanswers you need is beforeyou start treatment.JK Mitchell, DDSPhase 1ProblemSolving

Specialty Consults: OrthodonticsPhase 1ProblemSolving28 Ortho- it’s not just for kids anyThis patient had a single large spacebetween his centrals partly closed withcomposite. Imagine how BIG these teethwould be if veneers were placed on themin this position! But after ortho, the spacewas shared and the teeth could be sizednormally for a nice result.JK Mitchell, DDSmore! It can be quite helpful in settingup restorative care. You will learn more in your orthoclass, but for now, consider orthowhen dealing with:1.Space or crowding issues ifyou’re doing Fixed Pros2.Implants! Once they are in,you can’t move them, or theteeth around them. Think ofortho before you put inimplants!

Orthodontic Adjunctive Care:Molar Uprighting293. Problem: Tipped molar. Sometimesyou want to use for an FPD abutment,but you can’t prepare it correctly if it’stipped too far- you’ll see why in FixedPros lab. But notice the center of rotation- apoint in the center of the root. This usually means the crownrotates above the plane ofocclusion- keep that in mind foryour planning. Finally, ortho is NOT a fairy-dustanswer: you can’t just say “oh, I’llmove those teeth” without knowingthat it is feasible. You have to moveteeth where there is bone, forexample. It’s harder than it looks .JK Mitchell, DDSIn this case, the toothis well below the planeof occlusion, so afteruprighting it willprobably only needminor adjustment. Butif it was at or above theplane, it would end upwell above it andmaybe unusable.Phase 1ProblemSolving

Adjunctive Orthodontic CarePhase 1ProblemSolving30BUT Before an orthodontist will considerthe case, they will ask the referringdentist two questions: Is the patient caries active?Does the patient have active periodisease? Why? Because Ortho treatment willaggravate both of these diseasesand the patient will be worse offthan if they had not had thetreatment. You want to have a good workingrelationship with your referringorthodontists to get these diseasesunder control before placingappliances.JK Mitchell, DDSNote the pattern of caries and white spotlesions around areas where the bracketswere bonded, where the S.Mutans ladenplaque builds up. This is not the estheticresult orthodontists want to show on theirwebsites! It’s much harder to brush andfloss around ortho appliances, too, so periodisease is a consideration. Back toReview

ImplantsPhase 1ProblemSolving31 We will talk more aboutimplants in a later tutorial,but for now let’s say thepatient is interested. Areimplants a feasible option? The major questions are: Is there enough bone to supportan implant?Is there enough space for thecrown /FPD?Is the patient a good candidatehealth-wise and psychologically? You will go through patientservices, who will assign themto one of three departmentsfor an evaluation. (OralSurgery, Perio, GPR)JK Mitchell, DDS

Periodontics32 The question- Is tooth #7 savableperiodontally? If so, what wouldbe required? This patient would require aD0180 rather than just a prophy,right? Your perio exam will look at eachtooth on it’s own, but also keepin mind your overall treatmentplan, and what role this toothmight play. Are you thinking of using thattooth to support an FPD? AnRPD? You might run that pastthe periodontist as part of theoverall consideration.JK Mitchell, DDSPhase 1ProblemSolving

EndodonticsPhase 1ProblemSolving33 You’ve already learned how toWhat if you are thinking of putting crowns onthese teeth for esthetics? Would you need toredo these endo txs first? Would it be smart todo that? I’d sure ask an endodontist.JK Mitchell, DDSevaluate a tooth endodonticallygenerally do your own diagnosisbefore you refer. But what if the tooth is alreadyendodontically treated, but doesn’tlook right radiographically orclinically? Best answer is an endoconsult. What if an endo treated tooth still hasnot been restored correctly? If theendo fill itself (the gutta percha) hasbeen exposed to saliva for more than3-4 weeks, consider redoing the endo.The oral bacteria have contaminatedthe endo fill and it may fail. Again, tell the Endodontist yourrestorative plan so they can give youthe best advice!

Is this tooth restorable?Phase 1ProblemSolving34Let’s get to the bottom line: You generally can’ttell from a radiograph or even visually if a toothis restorable or not if it’s borderline. What works? Remove the caries and see if youcan get a matrix band on it. If you can get amatrix band on it, then you can restore it. Crucial concept: you must determine if thetooth is restorable before you do the endo.Why?1. Let’s say you don’t, and after the endo youfind out the tooth is NOT restorable! Ouch!(Pull out your checkbook ) Planning keepsyou from the embarrassing position of takingout a tooth you just did a root canal on.2. A good restoration helps hold on the rubberdam retainer.3. With a good restoration in place, you canbetter control the sodium hypochlorite(bleach) that’s used to irrigate the root canalspace- it won’t leak out through the deepcavity if there’s a nice restoration in it. JK Mitchell, DDSBack toReview

Summary: Overview of estionsRestore form,function, BleedingSwellingPhase 1.Urgent & DiagnosticJK Mitchell, DDSPhase 2.Disease ControlPreparatoryPhase 3.Rehabilitation

Review of Learning Objectives36If you have trouble with any of these, click on the link. Some cover severalpages before the Return to Review button appears. Be sure you know all theterms in blue or red in the tutorial.1. Be able to recognize Key Decision points in a treatment plan.2.Give examples of what treatments go into Phase 1,2,3.Be able to explain space infections, what influences theirlocation, the sequence of treatment, and why Ludwig’s Anginaand Parapharyngeal space infections are a significant threat.4. List when antibiotics are indicated and when they are notindicated.5. List and clinically recognize the three treatment planningindications for considering an orthodontic evaluation.Recognize when a case is disease controlled for referral6. Define how to determine restorability and list the sequence ofrestorative and endodontic treatment.3.JK Mitchell, DDS123456

Now that you know the basics Read Chapter 3 pg 53-65 (before occlusion): Developing theTreatment Plan Read Chapter 6 pg 113-135: Acute Phase of Treatment.Gives you a very good overview of how to handle anemergency patient start to finish. Also has a good review ofthe pain material we covered last semester, but in moredetail.JK Mitchell, DDS

Nicework!Nicework!42St James ChurchChipping CampdenJK Mitchell, DDS

Case 1: You chose a “Submandibular Space” Correct! You probably noticed thatthe swelling is on one sideonly (eliminating theunpaired Submental spacewhich would be right in themiddle) and that it is underthe Mylohyoid muscle. Nice work!ReturnJK Mitchell, DDS

Case 1: You chose b “Submental Space” Probably not. Check the diagram and tryagain!ReturnJK Mitchell, DDS

Case 1: You chose c “Sublingual space” Probably not Check the diagram and tryagain!ReturnJK Mitchell, DDS

Case 1: You chose a “#26” Probably not Check the diagram and tryagain!ReturnJK Mitchell, DDS

Case 1: You chose b “#29” Probably not. Check the diagram and tryagain!ReturnJK Mitchell, DDS

Case 1: You chose c “#31” Correct! You probably noted thatthe most likely tooth to bebelow the mylohyoidinsertion is a second molar,so #31 is a likely option. Nice work!ReturnJK Mitchell, DDS

Case 1. You chose a- Endo Not really the best choice. Read the slide on infectionsand try again!ReturnJK Mitchell, DDS

You chose b.50 I&D, delay endo - Correct! Of course you want to getthe endo done as soon asyou can, but generallypatients like this will havetrouble opening and youwill make them much moresore if you try to do it all atonce. Good job!ReturnJK Mitchell, DDS

Case 1. You chose c- I&D Endo Not really the best choice. Read the slide on infectionsand try again!ReturnJK Mitchell, DDS

Suzanne: You chose AntibioticsNot indicated:Indicated for: YES!PulpitisPersistent infections This is clearly a case forNecrotic pulp radiolucencyApical periodontitisSinus tractSystemic illness:Temp 100, Malaise,LymphadenopathyLocalized, fluctuant swelling(may need to be drained, butstill may not need AB’s)Progressive infection:Trismus, Cellulitis,Increasing swelling“I don’t have time to takethat tooth out or start aroot canal today, so I’ll giveyou this to hold you till Ican get you in.”Osteomyelitis (OMFSreferral!)antibiotics. The patient has afever and a progressinginfection. Good choice, doctor! Keep clicking, though“I’d feel more comfortableif you took some antibiotics”The patient wants aprescription for something ReturnJK Mitchell, DDS

Suzanne: You chose OTC Pain Meds Good idea! Not because that is going to be enough for her pain afterthe I&D surgery (it won’t be) but because it is antiinflammatory. You would give it at the highest dose: 800 mg every 8 hours (tid) She will have less overall pain if the inflammation iscontrolled, not just the pain. Keep looking, thoughReturnJK Mitchell, DDS

Suzanne: You chose Narcotic Pain Meds Of course. This woman is going to be in a lot of pain after weopen up her neck, drain out a lot of pus, and put in adrain. This is not a fun day. Ibuprofen is not going tokeep her comfortable. Patients need narcotics for this sort of pain, and you arewise to prescribe it in advance of the pain. Keep looking, thoughReturnJK Mitchell, DDS

Treatment Planning Board appointment for a few weeks and you’re going to ask “can I start on the directs while I’m waiting for Treatment Planning oard?” Well, you can, if you know the difference between directs that will be done in any treatme