Oral Diagnosis And Treatment Planning: Part 6. Preventive And Treatment .
Oral diagnosis and treatmentplanning: part 6. Preventiveand treatment planning forperiodontal diseaseIN BRIEF PRACTICE Highlights the aim of periodontaltherapy: to preserve dentition, withacceptable appearance and function, fora patient’s lifetime.Stresses the ability of patients to achieveeffective plaque control is an extremelyimportant factor for subsequentperiodontal treatment planning.Discusses the close interdependencebetween restorative treatments andperiodontal treatments.E. Corbet1 and R. Smales2VERIFIABLE CPD PAPERA high level of sustained personal plaque control is fundamental for successful treatment outcomes in patients with activeperiodontal disease and, hence, oral hygiene instructions are the cornerstone of periodontal treatment planning. Other riskfactors for periodontal disease also should be identified and modified where possible. Many restorative dental treatmentsin particular require the establishment of healthy periodontal tissues for their clinical success. Failure by patients to controldental plaque because of inappropriate designs and materials for restorations and prostheses will result in the long-termfailure of the restorations and the loss of supporting tissues. Periodontal treatment planning considerations are also veryrelevant to endodontic, orthodontic and osseointegrated dental implant conditions and proposed therapies.PRINCIPLES OF PERIODONTALTREATMENT PLANNINGThe aim of periodontal therapy is to preserve for a patient’s lifetime a dentitionwhich, although affected by periodontitis,ORAL DIAGNOSISAND TREATMENT PLANNING*Part 1. Introduction to oral diagnosisand treatment planningPart 2.Dental caries and assessment of riskPart 3. Periodontal disease and assessmentof riskPart 4. Non-carious tooth surface lossand assessment of riskPart 5. Preventive and treatmentplanning for dental cariesPart 6. Preventive and treatmentplanning for periodontal diseasePart 7. Treatment planning formissing teethPart 8. Reviews and maintenanceof restorations*This series represents chapters 1, 7, 8, 9, 14, 15, 16 and 19 fromthe BDJ book A Clinical Guide to Oral Diagnosis and TreatmentPlanning, edited by Roger Smales and Kevin Yip. All otherchapters are published in the complete clinical guide availablefrom the BDJ Books online shop.Professor in Periodontology, Faculty of Dentistry,The University of Hong Kong, Hong Kong; 2* VisitingResearch Fellow, School of Dentistry, Faculty of HealthSciences, The University of Adelaide, Adelaide, SouthAustralia 5005, Australia*Correspondence to: Roger J. SmalesEmail: roger.smales@adelaide.edu.au1Accepted 7 June 2012DOI: 10.1038/sj.bdj.2012.837 British Dental Journal 2012; 213: 277-284has levels of appearance and function thatare acceptable to the patient. This is a longterm aim, which only on death comes to berecognised as having been realised, or not.Because of this, indeterminate outcomes orintermediate stand-in (surrogate) goals areusually set for periodontal therapy. The first and foremost is the attainmentof sustained high levels of achievementin personal plaque control, reflectedas sustained full-mouth bleeding onprobing scores below, say, 20‑25%.The absence of bleeding on probingover repeated examinations is thebest indicator of periodontal stabilitycurrently available Probing pocket depths of no greaterthan 5 mm, including horizontalprobing in furcations of less than5 mm, is another worthwhile aim whichrenders long-term care a more practicalproposition. Furcations fully exposedand involved in a through-and-throughmanner should be fully cleansable bythe patient on a daily basis Tooth hypermobility should be suchthat it does not impair the patient’splaque control efforts and allows thepatient to function to an acceptablelevel in comfort.To achieve the aim and the intermediategoals, the treatment of patients presenting with periodontitis, perhaps includingvarious sequelae of periodontitis suchas tooth drifting and tooth loss, may bedescribed under headings for variousphases of treatment.Emergency care phaseof periodontal therapyAs far as periodontitis is concerned, theemergency care phase usually is for therelief of pain due to pericoronitis andabscesses within the periodontal tissuesand, perhaps less commonly, pain dueto acute necrotising ulcerative gingivitis(ANUG). ANUG should be differentiatedfrom acute gingivitis, and any possible association with systemic diseasesor immuno-suppressive drugs should beinvestigated as appropriate.Risk management phaseof periodontal therapyThis phase of periodontal treatment, whichcan run concurrently with the followingphases, seeks to address all modifiable riskfactors associated with susceptibility toperiodontal destruction. Obviously in thisphase, counselling for smoking cessation forthose patients who smoke will take place.Consultations with specialists regarding diabetes control in patients with diabetes mellitus is another example. Encouraging patientsunder stress to receive counselling on stressmanagement could also be considered inthis phase. Of course, less-than-adequateBRITISH DENTAL JOURNAL VOLUME 213 NO. 6 SEP 22 2012 277 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICEpersonal plaque control is a major modifiable risk factor for periodontitis, but sustained improvements in plaque control formthe cornerstone of all phases of periodontaltherapy, as is explained below.Fundamental phaseof periodontal therapyThis phase is also commonly referred toas the ‘initial phase’ or ‘hygiene phase’of periodontal therapy. The term ‘initial’means ‘of, or occurring at, the beginning’. Thus, in many senses this term ismisleading in that while this phase doesoccur at the beginning, what this phaseentails actually continues throughout allphases of treatment and is not confinedto only the beginning of treatment. Also,this term is misleading because often thisis the only phase of active therapy requiredand is, therefore, both the beginning andthe end. Another common term for thisphase of therapy is ‘cause-related therapy’.Again, this term implies that it is only inthis phase of periodontal therapy in whichattention is paid to the cause of periodontitis, namely plaque, and this is patentlymisleading. ‘Fundamental’ means ‘formingthe basis on which others depend or fromwhich others derive’ and, hence, seemsappropriate to describe this phase.The fundamental aspect of periodontaltherapy is the control of plaque. In the fundamental phase of periodontal therapy, thepatient is both instructed on how and motivated to perform optimal personal plaquecontrol. All plaque retentive factors such ascalculus, overhanging restorations, etc, aremanaged appropriately through scaling,reshaping, etc. All subgingival plaque onroot surfaces is disrupted through root surface debridement. All that constitutes nonsurgical periodontal therapy is completedin this fundamental phase of therapy. Thisphase may be completed within 24 hours,in the so-called ‘full-mouth debridement’approach. Sufficient time must be givento allow for all tissue changes consequentto this fundamental periodontal therapy tooccur fully, before conducting a periodontal re-evaluation, which forms the assessment stage for the planning of furtherphases of periodontal therapy. This phaseof periodontal therapy can be repeatedwith benefit, as periodontal tissue healing responses following a previous roundof fundamental therapy will have reduced278 periodontal pocket probing depths, allowing for greater accessibility to root surfacesin previously deep pocket depths.Corrective phaseof periodontal therapyIn the corrective phase of periodontaltherapy, the treatment approaches to beadopted depend heavily on the patient’ssuccess in controlling plaque on a dailybasis and on the response to the preceding fundamental phase of therapy. Forexample, periodontal surgical approachesfor ‘correcting’ residual periodontal defectsare not successful in patients with plaqueinfected dentitions, who are not performingadequate oral hygiene. In addition to the‘correction’ of residual periodontal defectsamenable to treatment, this corrective phasemay also entail the orthodontic repositioning of drifted teeth and the replacement, bywhatever means, of missing teeth.This phase can often be a period during which periodontal defects heal andremodel in response to fundamental therapy, and sufficient time must be allowedfor the healing to be completed.Fig. 1 Examples of oral hygiene aids forremoving dental plaque from proximal toothsurfacesSupportive care phaseof periodontal therapyThis phase of periodontal therapy isalso called the ‘maintenance phase’ orsometimes ‘supportive periodontal therapy’. However, ‘care’ implies more than‘therapy’ in supporting periodontallysusceptible patients in the retention ofaesthetically and functionally acceptableperiodontally affected dentitions for life.The highest aim of supportive periodontalcare is the prevention of new or recurrentperiodontitis lesions. In practice, however, supportive periodontal care often,through appropriately timed recalls, additionally allows for the early diagnosis ofand prompt intervention for new, recurrentor residual periodontal lesions. Supportiveperiodontal care also entails the prevention and management of the sequelae ofperiodontal destruction, such as cervicaldentine sensitivity (dentine hypersensitivity, root sensitivity), root surface caries,tooth hypermobility, etc.CONTROL OF DENTAL PLAQUEThe ability of patients to achieve effective, or otherwise, plaque control is anextremely important factor for subsequentFig. 2 Plaque disclosing gels, such as theone shown, allow patients to monitor theeffectiveness of plaque removalperiodontal treatment planning. Effectivelong-term repeated removal of dentalplaque is fundamental to the provisionof periodontal therapy and the controlof inflammatory periodontal disease. Toachieve effective plaque removal daily athome, patients must be sufficiently educated and motivated, have adequate dexterity, and be able to obtain access to alltooth surfaces using appropriate mechanical and chemical cleaning methods. Itshould be made clear to patients that theyare responsible for the continued controlof their dental plaque. The acceptance of abehavioural change by the patient is usually required for effective plaque control,which is demonstrated by the normal colour and firmness of gingival tissues andthe absence of bleeding on gentle probing.Mechanical cleaning methods shouldBRITISH DENTAL JOURNAL VOLUME 213 NO. 6 SEP 22 2012 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICEbe both practical and effective when usedin a systematic manner, without causing damage to the periodontal tissues,tooth enamel and exposed root surfaces,and restorations. Manual and poweredtoothbrushes are not capable of removing plaque from all tooth surfaces, evenwhen carried out correctly using a smallsoft multi-tufted brush. The bristles havea limited penetration into inter-proximalgingival embrasures, root furcations,gingival crevices and periodontal pockets. Proximal tooth surfaces are cleanedmore effectively using dental floss or tape(waxed or unwaxed) when dental papillaefill the gingival embrasures, or using thintriangular woodsticks when space permitstheir gentle insertion. Larger interdentalspaces with exposed root surfaces may becleaned with various-sized small interdental brushes, which can also be usedto convey casein-derived pastes, fluoridedentifrices and fluoride gels to proximaltooth surfaces (Fig. 1).Unlike dental floss, the brushes areeffective in cleaning plaque from proximalroot surface concavities and root furcations, and there is less risk of damagingperiodontal tissues and cutting groovesinto root surfaces, which may occur withimproper use of dental floss. The use ofdental floss also requires more manualdexterity, and there are often problemswith the floss fraying and breaking whenattempting to use it on restored proximaltooth contacts. Removing jammed frayedfibres from between the teeth is often verydifficult for patients. The thicker fibresof Superfloss (Oral‑B) have an embedded floss-threader to pass the Superflossthrough the gingival embrasures whenspace permits. Superfloss can also beused to clean the undersurfaces of pontics of fixed prostheses and the proximalsurfaces of teeth adjacent to edentulousspaces. Single-tufted brushes are veryuseful for cleaning tooth root surfaceswith concavities and furcation entrances.Pulsating streams of water can physicallyremove loose debris from around orthodontic bands. Oral irrigating devices suchas the Ultra Dental Waterjet (WaterpikTechnologies, Inc.) may also be useful forgently flushing periodontal pockets withantimicrobials, such as 0.12% chlorhexidine solution, although this would not bea usual practice.Fig. 3 Poorly fitting margins of interimcrowns placed on the maxillary central incisortooth preparations have resulted in plaqueretention and gingivitisFig. 4 Margins of these 12-year-old fixedprostheses have been placed supragingivalwhere possible. Open gingival embrasuresfacilitate access for plaque removalChemical plaque control approachesinclude the daily use of chlorhexidine oressential-oils mouthrinses in particular.Routine use is not a prerequisite for goodgingival health. The antimicrobial effectsof mouthrinses are largely limited tosupragingival plaque, unless the solutionsare used for the subgingival irrigation ofperiodontal pockets, though any bleedinginactivates chlorhexidine.During the learning phase of effectiveplaque removal, disclosing agents (solutions, gels, chewable tablets) that stainthe plaque will provide useful feedback topatients (Fig. 2). The agents should be usedin combination with a systematic cleaningmethod that focuses on removing dentalplaque from all tooth surfaces adjacent tothe gingival tissues. Brushing the dorsumof the tongue, though not having beenshown to be required, completes the routine for many. Learning effective plaquecontrol occurs in stages, with continuedreinforcement and re-instruction required.during tooth preparations and the placement of restorative materials. Correct contouring of matrix bands and their carefulsubgingival placement, together with thecareful placement of anatomic wedges,should result in minimal gingival tissuedamage. Care also should be taken whenplacing rubber dam clamps to avoid unintended damage to the gingival tissues. Athin, narrow band of keratinised attachedgingiva is easily damaged during gingival retraction and impression taking, andby poorly fitting plaque-retentive gingival margins of interim (temporary) restorations (Fig. 3), leading to subsequentgingival recession that may expose discoloured root surfaces in aesthetically criticalregions of the mouth. Thus, special careand attention should be paid to the preservation of healthy gingival tissues duringthe aesthetic restoration of teeth in aesthetically critical areas of the mouth, inparticular when the gingival tissue is of athin and scalloped bio-type.Where possible, tooth preparationmargins should be placed supragingival,ideally 1‑2 mm coronal to the free gingival margins (Fig. 4). However, in manyinstances this is not possible becauseof previous damage and discolourationof tooth structure, the requirement foradequate retention of the restorations,and the dictates of an attractive appearance. In taking impressions that aim tocapture the subgingivally prepared toothmargins, retraction cords, often with various haemostatic agents incorporated, arefrequently placed in the gingival sulcus.Care should be taken to remove fully anyretraction cords or other materials placed.Preparation of deep subgingival marginson root surfaces will encroach upon thebiologic width of the periodontal tissues.The biologic width, approximately 2 mm,PERIODONTAL CONSIDERATIONSRELATED TO RESTORATIVEDENTISTRYThere is a close interdependent associationbetween restorative treatments and periodontal treatments that affects the biological health, function and appearance of theteeth and supporting tissues.Periodontal tissue handlingThe periodontal tissues should be as healthyas is possible, without bleeding on probing,before elective restorative procedures areundertaken that impinge on the free gingival margins. The potential for iatrogenictissue damage occurs during all operativedental treatment procedures. The gingivaltissues should be handled gently, with caretaken not to damage them unnecessarilyBRITISH DENTAL JOURNAL VOLUME 213 NO. 6 SEP 22 2012 279 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICEcomprises the supra-alveolar crestal connective tissue attachment and the junctional epithelium (epithelial attachment).When encroached upon, the periodontaltissues may become inflamed. The biologicwidth is generally re-established with theloss of alveolar crestal bone, and pocketformation in thick gingival tissues, butrecession in thin gingival tissues. In someinstances, clinical crown lengthening mayoffer a satisfactory solution to this problem.Orthodontic root extrusion is another viableapproach if the patient accepts the plan.However, these procedures lead to the exposure of tapered roots, resulting in narrowerroot cross-sections and wider interdentalgingival embrasure spaces. This creation ofunsightly ‘black holes’ or ‘black triangles’between the teeth may also occur followingperiodontal therapy and when large diastemas are present, and often results in foodimpaction and even in occasional speechproblems. The combination of narrowtooth roots and wide interdental gingivalspaces, together with long clinical crowns,creates a difficult restorative situation.Overcontouring the proximal surfaces ofrestorations to improve the appearance ofthe patient by reducing the size of the triangular spaces must be performed with care toavoid overhanging margins, which wouldcause difficulties in removing plaque deposits, leading to chronic gingivitis (Fig. 5).After periodontal surgery, plaque accumulation on the exposed proximal rootsurfaces of teeth may on occasions lead toroot surface caries which, again, creates adifficult restorative situation for posteriorteeth in particular. In some instances thepatients, usually elderly, may be unable toremove the plaque effectively when usingmechanical methods, because of deteriorating physical and/or mental capabilities.This deterioration may occur quite rapidly.Such patients require regular recall appointments and vigorous preventive dental treatments, often also enlisting the assistance ofanother person’s help at home. The homeuse application of GC Tooth Mousse Plus(GC Corp.) crème/paste to exposed rootsurfaces promotes the remineralisation ofdemineralised dentine and also reduces anydentine sensitivity present.Restoration contoursThe correct placement, contouring, andfinishing and polishing of restorations is280 important for the physical protection ofthe periodontal tissues, and to reduce theaccumulation and facilitate the removal ofdental plaque. Overcontoured restorationsresult in increased challenges to plaquecontrol at the gingival margin areas, whileundercontoured restorations and openapproximal contact areas may result inlateral and vertical food impaction which,while uncomfortable for the patient, maynot itself adversely affect the periodontalhealth (Fig. 6).Opposing occlusal contacts should beexamined carefully in all instances offibrous food wedging, which usually affectsthe terminal tooth in the arch. Deflectivecusp inclines may displace the affectedtooth distally during chewing, causing aslight opening of the approximal contactbetween adjacent teeth, which then allowsthe fibrous food to enter the space, andattempted return of the distal tooth to itsoriginal position traps the fibrous food. Inrestoring the adjacent surfaces of approximating teeth, the marginal ridges shouldbe placed at the same height to reducethe likelihood of food wedging causedby an opposing so-called ‘plunger cusp’.Contouring of restoration surfaces shouldreproduce the correct occlusal, gingival,facial and lingual embrasure forms, andthe correct approximal contact area forms,for the particular tooth site. Dental flossshould pass through the contacts withoutjamming and fraying. The gingival emergence angles of the tooth surfaces shouldbe retained when replacing damaged toothstructure with restorations. The marginsof the restorations should blend smoothlywith those of the adjacent remainingsound tooth structure.In some instances, old plastic restorations and artificial crowns may berecontoured and repolished (refurbished)satisfactorily to enable plaque control atgingival margins in particular, to improveaccess for plaque removal (Figs 7 and 8).Care must be taken not to damage the periodontal tissues and tooth structure duringsuch procedures.Restoration surfacesRough restoration surfaces, irrespectiveof the material, and open marginal gapsbetween restorations and contiguoustooth surfaces favour the attachment andgrowth of dental plaque. The surfaces ofFig. 5 Overhanging proximal margins ofthe resin composite restorations placed onthe maxillary central incisors have resultedin plaque-induced gingivitis with gingivalhyperplasiaFig. 6 Incorrect contours and overhangingmargins of these preformed stainless steelprostheses, together with poor oral hygiene,have resulted in chronic periodontitisFig. 7 Poor contours and overhangingamalgam restoration margins, together withsubgingival calculus, are associated withalveolar bone lossrestorative materials adjacent to gingivaltissues and in contact with adjacent teethin particular should be no rougher thansound tooth enamel. Glazed and highlypolished dense porcelain surfaces retainless plaque than sound tooth enamel.Other materials may retain the same orgreater amounts of plaque than soundenamel. Plaque colonisation increasessignificantly at an average surface roughness of approximately 0.2 μm, which isexceeded by conventional glass-ionomercements after polishing and also after theapplication of 1.23% acidulated phosphatefluoride gel. The initial antibacterial effectof glass-ionomer restorations also is lostsoon after their placement, because ofBRITISH DENTAL JOURNAL VOLUME 213 NO. 6 SEP 22 2012 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICEFig. 8 Several of the amalgam restorationsshown in Fig. 7 have been recountouredto facilitate the removal of plaque fromproximal tooth surfacesFig. 10 The patient is wearing a toothsupported upper removable partial dentureFig. 9 In these two different fixed prosthesesdesigns, modified ridge lap pontics thatfacilitate plaque control have replaced amaxillary left lateral incisor and a right canineFig. 11 Removal of the denture shown inFig. 10 reveals that poor oral and denturehygiene have resulted in inflamed gingivaland palatal tissuesdiminishing fluoride release, and plaqueretention is not obviously less than onother plastic restorative materials placedin similar tooth sites. For some materials,mastication of foods of varying abrasiveness leads to roughening of the occlusalsurfaces of highly polished restorations,and to some polishing of rough restoration surfaces.periodontal probing depths and gains inclinical attachment in response to periodontal therapy, due to the lesser resistanceto probing offered by periodontal tissuessurrounding mobile teeth. In instances ofvery advanced periodontal destructionresulting from periodontitis, increased (oreven normal) occlusal forces may becometantamount to extraction forces leadingto progressively increasing tooth mobility,with the surrounding tissues offering lessand less resistance to periodontal probing. Hence, though not necessarily relatedto the progression of periodontal disease,occlusal adjustments of high restorationsand of functionally overloaded teethimprove the ‘occlusal comfort’ of patientsby distributing occlusal forces to includeother teeth.Restoration occlusionThe placement of non-yielding restorationsthat are ‘high’ usually results in some acutediscomfort, which varies with the level ofocclusal forces transmitted to the periodontal and other tissues and the adaptivecapacity of the patient. If untreated, thenin some instances the affected overloadedteeth may become increasingly mobile following alveolar bone resorption at sitesof tissue injury, but there is no associated clinical attachment loss. Excessiveocclusal forces, resulting in trauma fromocclusion (occlusal trauma) as diagnosedby various clinical indicators, alone donot initiate either gingivitis or the formation of periodontal pockets. However,the presence of persistent occlusal discrepancies may result in persistent toothmobility and less favourable reductions inFixed and removable prosthesesDental implant and natural tooth abutments for fixed partial dentures (FPDs)and removable partial dentures requireparticular attention for adequate plaquecontrol. The design of the prosthesesshould minimise the accumulation ofplaque and, for fixed tooth and implantsupported superstructures also provideoptimal access for plaque removal. Whereappearance is not critical, then an ovateor spheroidal pontic is preferred for FPDs.Buccolingually narrowed ‘sanitary’ ponticsshould be well clear of or lightly contactand follow the contours of the edentulousridge, avoiding excessively wide-opengingival embrasures that lead to foodstagnation and retention (Fig. 4). Whereappearance is important, then the modified ridge-lap pontic is used to minimisecontact with soft tissues (Fig. 9), but effortsshould be made to ensure that the entireundersurface of the pontic can be cleaned.Connectors should not displace the dentalpapillae, and all soft and hard tissue contacting surfaces must be highly polishedand non-porous.Following cementation, all adherentexcess cement on tooth/implant and restoration surfaces, and loose cement fragments in the gingival crevices, must beremoved. Permanent, fixed and removablecast metal splints are seldom required tostabilise mobile and drifted teeth following periodontal treatment, orthodontic tooth repositioning and minorocclusal adjustments.Removable partial dentures are associated with an increased risk of periodontal disease and dental caries affectingthe remaining teeth in contact with theprostheses, and an increased resorption ofalveolar bone beneath non-tooth bornemucosal-supported denture bases (saddles). These problems are more closelyrelated with denture hygiene than withthe material from which the denture ismade (Figs 10 and 11). In middle-aged andolder patients, following tooth extractions,there is often relatively little movementof the adjacent teeth and, hence, the needto replace the extracted teeth to maintainocclusal stability in older adults may bereduced. Therefore, in many instances,‘the shortened dental arch is preferableto the extended prosthetic arch’. A shortened dental arch has sufficient teeth forthe patient’s comfortable function and tosatisfy the aesthetic requirements of thepatient for the dentition.PERIODONTAL CONSIDERATIONSRELATED TO ENDODONTICSThe periodontal tissues and the dentalpulp are intimately linked. Communicationbetween the two structures may occur viaapical root canal foramina, accessoryBRITISH DENTAL JOURNAL VOLUME 213 NO. 6 SEP 22 2012 281 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICElateral and furcal canals, patent exposeddentine tubules, root fractures, and rootcanal perforations caused by root resorption and operative procedures.Though a vital inflamed pulp may beassociated with small clinically-detectableregions of periodontitis adjacent to rootcanal and accessory root canal foramina,the periodontitis is usually caused byinfection spreading from a non-vital pulp.Subsequently, a periapical, lateral or furcal abscess may form within the periodontal tissues. Occasionally, the abscess maydrain into an existing periodontal pocket,or track coronally along the periodontalligament to discharge via a narrow sinusin the gingival sulcus. (The tubular tractformed may be confused with the narrowperiodontal pocket found in associationwith a developmental radicular groove,which may be present on the palatal rootsurfaces of maxillary central and lateral incisors in particular). This coronaldrainage route is also likely to occur withabscesses associated with root fracturesand root canal perforations. Although usually draining buccally, an abscess may alsodrain lingually or palatally, sometimes at adistance of one or two teeth removed fromthe non-vital tooth.In all situations it is important to determine the correct sensibility status of thepulp and the cause of the abscess, so asto exclude inappropriate treatment planning based on the incorrect assumptionof a periodontal origin for the abscess.False-positive sensitivity tests can occurin multi-rooted teeth where one or moreroot canals may contain some nerve tissue even though there is no blood supplywithin the pulp chamber and the other rootcanals. False-positive sensibility tests havealso been reported in teeth associated withadvanced angular and furcation periodontal lesions. False-negative sensibility testsmay occur from narrowed root canals andpulp chambers following extensive deposition of dentine or calcified material, andfrom insulation of the pulp by restorations.A gutta-percha point (cone) inserted intoa sinus tract before taking one or moreperiapical radiographs is useful to assist inthe diagnosis of the origin of the abscess.Over-instrumentation of root canalswith the extrusion of infected root-canalcontents, and overfilling or extrusion ofrestorative materials, into the periodontal282 ligament will result in periodontitis tovarying degrees. Usually, the clinicalsigns and symptoms resolve within a shortperiod. Operative procedures such as rootcanal and post channel (post space) preparations may result in root canal perforations and, subsequently, root fractures mayoccur from weakening of tooth structure.Ancillary pin placeme
Part 2. ental caries and assessment of risk D Part 3.eriodontal disease and assessment P of risk. Part 4.on-carious tooth surface loss N . and assessment of risk Part 5.reventive and treatment P planning for dental caries. Part 6.reventive and treatment P . planning for periodontal disease. Part 7.reatment planning for T missing teeth
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