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Dr SUGHU MALAYIL KOSHY

BDS,MSc (Comm.Dent),DDPH RCS(England)
Patient recall guidelines &
Treatment Phase-
Comprehensive Treatment
planning -2
Recall intervals for scale and polish treatments
the prescription and timing of dental radiographs
Intervals between examinations that are not routine dental
recall, that is intervals between examinations relating to
ongoing courses of treatment
Emergency dental interventions or intervals between
episodes of specialist care
DENTAL RECALL GUIDELINES: Nice guideline UK ,
Clinical guideline 19,2004
This guideline does not cover:
The recommended interval between en oral health
reviews should be determined specifically for each patient
and tailored to meet his or her needs, on the basis of an
assessment of disease levels and risk of or from dental
disease.
This assessment should integrate the evidence presented in
this guideline with the clinical judgement and expertise of the
dental team, and should be discussed with the patient.
During an oral health review, the dental team (led by
the dentist) should ensure that comprehensive histories
are taken, examinations are conducted and initial
preventive advice is given.
This will allow the dental team and the patient (and/or
his or her parent, guardian or carer to discuss,where
appropriate:
The effects of oral hygiene, diet, fluoride use, tobacco and
alcohol on oral health
The risk factors that may influence the patients oral health,
and their implications for deciding the appropriate recall interval
The outcome of previous care episodes and the suitability of
previously recommended intervals
The patients ability or desire to visit the dentist at the
recommended interval
The financial costs to the patient of having the oral health
review and any subsequent treatments
The interval before the next oral health review should be
chosen, either at the end of an oral health review if no further
treatment is indicated, or on completion of a specific treatment
journey.
The recommended shortest and longest intervals between
oral health reviews are as follows:
The shortest interval between oral health reviews for all
patients should be 3 months.
The longest interval between oral health reviews for patients
younger than 18 years should be 12 months.
The longest interval between oral health reviews for patients
aged 18 years & older should be 24 months
For practical reasons, the patient should be assigned a
recall interval of 3, 6, 9 or 12 months if he or she is younger
than 18 years old, or 3, 6, 9, 12, 15,18, 21 or 24 months if he
or she is aged 18 years or older.
The dentist should discuss the recommended recall interval
with the patient and record this interval, and the patients
agreement or disagreement with it, in the current record-
keeping system.
The recall interval should be reviewed again at the next oral
health review, to learn from the patients responses to the oral
care provided and the health outcomes achieved.
This feedback and the findings of the oral health review
should be used to adjust the next recall interval chosen.
Patients should be informed that their recommended call
interval may vary over time.
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RESTORATIVE TREATMENT:
Initial treatment:
Control etiology: Eg:Dental Caries
Advice on diet
Oral hygeine
Use of Fluorides
Oral prophylaxis
Dietary advice:
Should be personal, practical & positive
Adopt less cariogenic diet
- Eat less sugar & eat sugar less often
Reduce consumption of sugars & fats
Increase consumption of fiber rich starchy foods.
Fresh fruit & vegetables
Meals provide a better nutritional balance than
snacks, hence good eating/slash drinking at meal
times avoiding between meal snacking is healthy
Use of intense sweeteners Eg: Saccharin & aspartime are
non cariogenic, but to be used with caution due to the effect
on the gastrointestinal system.
Chewing gums- sugar free chewing gums (Xylitlol)
simulates saliva & thus increases salivary buffers & enhances
wash out of sugar.
Carbonated beverage have a 2-3 PH & can cause marked
loss of tooth structure via erosion.
Detersive food stuffs like carrots & apples etc. are of little or
benefit in removal of plaque
Effective plaque removal is dependent on tooth brushing
only
Diet & Dental caries:
Pre-requsite for dental caries is a carbohydrate form that can
be metobolised by oral bacteria.
Classification of sugars:
Intrinsic sugars: Sugars forming an integral part of certain
unprocessed food stuffs.
Called intrinsic because they are enclosed within a cell
Found in whole fruits & vegetable, mainly as fructose, sucrose
& glucose.
Contd.
Extrinsic Sugars:
Found in food outside the cellular structure
Further classifies as:
Milk extrinsic sugars- In milk & milk containing
products mainly lactose. This is of low cariogenicity
Non Milk extrinsic sugars: found in confectioneries,
soft drinks, biscuits & cakes. Includes sucrose, fructose
& glucose. These have the greatest cariogenic potential
Factors influencing the cariogenicity of food:
Consistency: Sticky retensive foods are more cariogenic than
liquid non retensive forms
Frequency of consumption: Snacking or grazing results in
lower PH, where net outflow of calcium & phosphate ions from
tooth surface occurs from prolonged period of time.
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Oral Hygeine Refer Previous lecture on oral hygeine &
plaque control:
Fluorides:
Series of systematic reviews published by the cochrane
library have concluded that children who brush their teeth at
least one a day with fluoridated tooth paste will have less tooth
decay.
Has a caries prevention action when delivered in vehicles
other than tooth paste also.
Fluoride Mode of action
Systemic Pre-eruptive effect:
Fluoride ions are incorporated into the enamel structure in the
form of fluor appetite during the period of tooth formation
Topical -post eruptive effect:
Fluoride is either incorporated into the crystal lattice or by
binding to crystal surface.
Calcium Fluoride at the tooth surface not only reduces the
solubility of the appetite but also encourages re-mineralisation
Fluoride causes decrease acid production by cariogenic
bacteria
Topical effect at the tooth surface, post eruption is more
effective than systemic effect
Pain history:
Essential in diagnosing pulpal pain
Pain quality :
Sharpness - Sharp pain can indicate, exposed dentinal
tubules & fractured cusp
Dullness - May indicate pulpal hyperemia
Throbbing pain Particularly if constant may indicate an
irreversible pulpitis
Duration:
Short pain- Few seconds, can indicate reversible pulpitis but
may also indicate pain of non dental origin.
Eg: Trigeminal neuralgia
Constant pain- Often indicates irreversible pulpitis or one of its
sequelae
Stimuli:
Reaction to heat Irreversible pulpitis reacts to heat but not
cold
Reaction to cold - Reversible pulpitis
Reaction to pressure- May indicate periapical or periodontal
abcess.
Release of pressure- may indicate a cracked cusp
Reaction to sweet stimuli- Reversible pulpitis or exposed
dentin
Time of Pain:
Pain pattern day & night is important.
Pulpal pain is often worse at night
Conclusion:
A pain history gives the dentist a guide as to the source
of pulpal pain.
It does not produce a diagnosis on its own
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Site & radiation:
History indicates primary site of pain & where it
radiates.
Pain in teeth adjacent to the tooth the patient
suspect as the cause of pain or the opposing arch is
common.
Referred pain from non dental causes- Eg:
Sinusitis
Pain localisation in difficult in low grade reversible
pulpitis & in children
Pulpal Diseases:
Reversible pulpitis:
Symptoms:
Pain of short duration as response to Hot, cold & sweet
Relieved by analgesics
Poor pain localisation
Irreversible pulpitis:
Pain of long duration
Throbbing, dull in nature
Worse with hot stimuli
Better localisation of pain
Not always relieved by analgesics
Periapical periodontitis:
Symptoms:
Dull, throbbing constant pain
Frequently keeps patient awake
Can localize pain to particular tooth
Tender to chew
Poor relief from analgesics
Stabilisation Phase:
Extract unrestorable teeth
Restore by simple means- Intra coronal
restorations. Amalgam composite restorations etc.
Simple endodontic treatment to key teeth
Stablisation phase restore by simple means
Removal of carious tissue
Minimize pulpal and /or periodontal damage
Cavity should be prepared such that the restorative
material to be used can restore function & appearance of the
tooth, & is retained in the tooth
Fundamental guiding principle of cavity preparation, is that
the preparation should only be as large as the carious lesion.
However follow the basic steps in the preparation of
cavities, like outline form, resistance & retension form,
management of remaining caries, enamel margin finishing &
cavity toilet.
Simple endodontic treatment for offending tooth:
Indirect pulp capping- Should be used for all cavities
where it is considered there may be a micro exposure or
where removing further remnants of caries is likely to cause
classic pulpal exposure
A layer of Calcium hydroxide (setting) is placed over the
dentine closest to the micro exposure. This is reinforced by a
structural lining.
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2. Direct Pulp capping:
An exposed vital pulp may be pulp capped. This is
less sucessful than indirect pulp capping but most likely
to succeed in circumstances where:
pulpal exposure is small (less than 1-2 mm)
pulp is free of salivary contamination
carious exposure is not present
tooth was symptom free prior to cavity preparation
Patient is young (Better pulpal blood supply)
Reassess Response to treatment
Assess patients motivation
Oral hygiene
Diet
Reasess problem teeth
Reasess treatment plan in poorly motivated patient,
complex treatment will inevitably fail due to poor oral
hygeine
In some patients no further treatment is required
Definitive treatment:
Premolar Molar Endodontic treatment
Endodontic retreatment
Post-core restorations
Crown & Bridge
Removable prosthesis
Implants
CONCLUSION:
In the formulation & carrying out of treatment:
Keep treatment as simple as possible
Construct treatment plan where there is scope to
reassess & change plan
Know your own professional limitations
Know your patients limitations
When planning restorative treatment, the dentist
should take into account not just the teeth but the
individual patients total oral health & general health
needs
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