Transcribed by Amit Amin July 08

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, 2014

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[Diagnosis of Oral Diseases] [2] [Introduction to Diagnosis] by [Dr. Vogel]

[No slides]]
[Dr. Vogel] Good morning did I scare everybody away yesterday? Is that what this
is? So we are in the middle of a discussion on one that we started 8-9 months ago in
respect to diagnosis process. The whole idea is to really know what youre looking
for. To know what the questions are. It then becomes obvious what source youre
going to get the answers (patient, mom/ dad, book, computer). If you dont know the
questions youre lost. Is there something broke which weve defined in pathological
(not working well, it hurts, going down hill, adversely effecting another system) and
systemic (not esthetically pleasing to patient). And if it is broke by any of those
definitions then the question is what is the break, how bad is the break, what caused
it to be broken, and finally basically what is the outcome if I do nothing or I do A, B,
C, D, or E. And the other thing is the susceptibility to break. We do this in the process
called the diagnostic process. It doesnt matter if youre a physician, dentist,
podiatrist; it all works the same way. Chief complaint (something is broke), history
(what, why, and how), medical (systemically). It will tell you if something is broke or
susceptible to break. If the patient has endocarditis in the past, it might not be broke
now but will be susceptible in the future. Dental history is under medical history.
We talked about the review of systems in the mouth (chew, dry mouth). Family
history tells you susceptibility but generally not about the mouth. Family history,
social history, patients who smoke. Patients who drink, oral cancer, etc. etc. then you
have the physical evaluation which will tell you both with respect to something
broke or susceptible to break. We started out with this patient that we will quickly
review and this is what we found out demographically. We knew what the questions
were and you helped w/ this process. 40-year-old Caucasian female. A few of them
were esthetics. Drifting of the lower incisors, missing bicuspid, and protruding
upper incisors. She was concerned about her bleeding gums b/c she thought
something was really bad. History of chief complaints: teeth moving over the last
few years, bicuspid was removed b/c it was loose, and bleeding gums was for a
couple years. Dentist told her to brush better. Medical history is non-significant.
Hasnt seen a primary physician in a while. Last saw a DDS a couple years ago.
Nothing significant in a review of system. Chief complaint was that she had
significant bleeding. Make sure it was local and not a systemic disease. Dismentaria
(idea of bleeding in bowl movement or shaving. Problem control bleeding). Mother
is type II diabetic. Wife and sedentary. Obese, w/ high b.p. Head exam was NWLS.
Severe perio inflammation and bone loss. Occlusion shows migration and mobility
patters of 1 &2. She has caries, large restorations undermining cusps. Caries on a
temporary crown on tooth #10 which Ill show you in a moment. Looking at her
clinically you can see recurrent carries on the mesial of the bicuspid. That class 5 on
the lower molar, the margins were opened. There seemed to be recurrent carries in
that area. Again, there was bleeding and probing throughout. Significant pocket
depth, well show you those as we go through it. Restorations. That was not caries
on the palatal root. That was debris there. Theyre not ideal but that doesnt mean
they are broke. Those margins were intact. No sign of caries or recurrent carries.
Left side we have a cross bite. We have on that buccal class 5 some corrosion on the
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amalgam but it was intact. Some beautiful restorations down here on the lower left.
There was swelling of the amalgams but they were intact. The concern here that the
size of the restorations on the molar and the bicuspid that there was concern about
susceptibility of bacteria. The two fractures you can fracture vertically or
horizontally. Vertically, it can fracture sub-gingivially. If that happens you can lose a
tooth. Again, lot of inflammation. Restorations are not beautifully carved or polished
but intact in respect to margins. There were some rough sub-gingival margins. This
is what youre looking at when youre doing a clinical exam that we came up with. A
lot of inflammation. Protrusion of the max. Central incisors. Spacing shows they are
getting bigger in the lower incisors as well. Significant calculus. Significant edema.
Inflammation here. You can see the temporary crown that was placed 2 years ago.
The margins were not really intact. The lower right. Again you can see the recurrent
carries on the mesial of the bicuspid. Large restorations. Distal of the bicuspid there
might be some recurrent carries there. Calculus and spacing of the teeth is evident.
You can see the beginning of furcation in the first molar. Again, so significant bone
loss. Possibly having an E1/E2 lesions b/w the bicuspids. Not into the dentin.
Possibly also b/w the molar and the bicuspid. Very slight. There is the that rough
sub gingival class 5 on the palatal of the molar we talked about. Significant bone
loss. Some overhanging restorations. If those restorations are subginivial
epidemiologically we know that if we look at a cross section of a population those
invdls will have 1-2mm loss of attachment then those who dont have loss of
attachment. We cant change flora in that area and continuous inflammation leading
to resoprtion loss of attachment. Significant loss of attachment. Clinically we would
see that. Radiographically talk about bone loss. You can see that open margin on the
left lateral incisor. Again, significant los for attachment. This was the charting that
we found. Pockets as 9mm and loss of attachment 7-8mm. Proximal furcations on
maxillary molars (right 1
st
-distal class II furcation). Teeth that have furcations have
that (long-term prognosis have to be questionable since we cant debride the area as
well and thus flora is left leading to continuous loss of attachment. Perhaps abscess
formation as well). So were up to the point of a problem list. We asked you to do
some hw. Could I have somebody act as a scribe for me? Thank you. So, what are the
patients problems? No order. Generally a problem list is made up as you make a
problem. Generally the first problem is the first thing you find. Its generally done in
that order. Not this is more important than that or were going to do this before we
do that. As you find things you put it down as a problem. A problem is something
that is broke or susceptible to break. What are the problems? Give me one? Bone
loss. Let me put it in a different way though. We can give it a diagnosis. General
periodontitis. Shes had significant loss of attachment. Another problem, In a
problem list we dont generally list the tooth number. Were not looking at the
specifics. (General problems). Teeth that have large restorations or are susceptible
to fractures. What else? Missing tooth. Why is that a problem? Ah, so the problem is
not a missing tooth. Missing tooth is never the problem. That problem is that the
patient has an esthetic problem w/ a missing bicuspid. If a missing tooth is a
problem we will ALWAYS replace a missing tooth. WE shouldnt always do it though.
The problem is that the missing upper right bicuspid basically is an esthetic problem
to the patient. On the palatal and some interproximal as well, that it acts as an
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plaque trap (faulty restorations). Well that goes along w/ the diagnosis w/
periodontitis. So that really all encompassing. Once you say a patient has perio it
implies that there is gingival inflammation and there has been loss of attachment
b/c of that inflammation. Yes. Bleeding on probing is actually the earliest sign of
gingival inflammation. It is the first and the earliest sign. If you have someone has no
inflammation (study done in 1961). He took dental students and paid them. Brought
them to a state of health and then had no brushing on half of their mouths for 21
days. Everyone developed gingivitis and the first sign was bleeding b/c the
epithelium proliferates and does it to the point where there is no vascularity and
micro-ulcers. When you probe it, it bleeds. It wells you whats exactly happening in
that area where you would have loss of attachment. Didnt deal w/ the depth.
Doesnt matter if its 1mm or 29mm. You can have an 8mm sulcus or a 9mm pocket.
Im a Periodontist; I have to talk about this. Doctor. Problem. Yes you. Im a son of a
gun; I call on people and do things like that. Doctor, problem. You have no other
problems on this case. We said Periodontist, we went through all this stuff and all
we have is perio and (stuff the scribe said). Thats it, you cant think of anything
else? Youve been in dental school for over a year and thats it? Yes, is that a
problem? I cant fly is it a problem? Why? Malocclusion which all meals bad
occlusion. Why is a cross bite a problem? No it doesnt. So again, this is something
we talked about 8-9 months ago. Its important to differentiate physiological from
ideal anatomy. If you would stand up and youd show me the left side or right side of
the face, they would be different. Your arm lengths will be different. Thats not ideal.
Should we shorten one or lengthen the other. People have dextrocardia. The heart
tilts right. Not a problem. A problem is that something that is broke and we define
that as functional, esthetics, pain, or susceptibility. There is no evidence cross-bites
are susceptible. The cross bite that its an area that its an esthetic problem, we have
a problem but just like a missing tooth its important to differentiate b/w
physiologically and pathology. If not, youll do a lot of unneeded treatments. Say that
again. A floral deficient environment. Actually to a great degree. The original study
on flora were done in NY state (upstate). Basically, they fluoridated one town
(Kingston on either side of the river). 60% less caries. You wouldnt find that
anymore. Why is that? Because basically people are getting fluoride even if the town
isnt. If you process food, which goes into state w/ the idea, they are getting it in
dentifrices. They are getting it in milk products. Im not saying its a big difference
but to going to that. Lets say Ms. Jones lived in a town w/ no fluoride and the last
time she had a lesion was when she was 9. Lets say she was getting no fluoride.
Would a fluoride deficient environment be her problem? No. You dont need
prophylaxis unless youre susceptible. By definition thats what it means
(prevention). We dont do preventive therapeutics on someone that is not
susceptible to a disease. Vaccination are a good thing. Yes, another problem? She has
some faulty restorations including that crown. Right? She has some faulty
restorations. Im sorry I didnt. She has a lot of calculus. So once you define she has
perio youre saying that (I have no problem w/ that). Its almost implied thats the
problem and then youre looking at the solution. Its almost implied w/ respect to
the disease process itself. She has recurrent caries and de novo caries. Her esthetic
problems are not just the bicuspid but its the protrusion of the maxillary incisor
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and some of the mandibular incisors. Why is that a problem? Wasnt a problem to
her? She had no sensitivity. Right. Its just not there so its not a problem. It could be.
She could also have significant root caries and the recession could be a problem.
Where she had class V was probably not caries there to being with. Thats just a
guess. There was a big concavity and someone just filled it up. What other
problems? Shes obese. Yes. More than overweight. Shes critically obese by
definition. Why is that a problem? No. Why is it a problem? Not what is the problem?
Youre a dentist. Well actually it could. Youre a health professional. If you go to,
well go to you as a female b/c young males dont go to one. If that OBSGYN sees a
lesion on your shoulder thats yellow or they say youre obese they arent going to
say oh thats not my anatomy, Im not dealing w/ that. They might not treat it but
they will make appropriate referrals as a proper health care provider. By an act of
congress, youre a primary health care provider. Theres a relationship b/w obesity
and periodontal disease b/c you make more pro-inflammatory mediators. Thats not
the important part though. Whats the important part? Why are we worried about
our population being obese? Because it effects our mouth? Cancer, cardiovascular
disease, stroke, hypertension, kidney failure. All kinds of good stuff. Whats another
one? Diabetes, metabolic syndrome. Right? Hopefully were not just going to look at
the tooth and say Im just a tooth doctor. Overweight? Absolutely. No. Cross bite
doesnt cause any more forces on teeth. We do believe there was increasing degrees
of mobility. There was significant. It went beyond the mobility patterns. Theres no
way of proving that but we thought the forces were such that they were not only
causing migration but some of the teeth were getting looser. There was loss of
attachment for you to find. If you think its going to get looser, the patient will say
this really bothers me. Downhill is a sign of broke. Any other problems? Yea but that
only goes to an etiology problem. If a patient has a strep throat they have strep
mutans. That may be the cause of it. Thats really associated w/ that in that aspect.
Anything else? Just one or two more. Family history susceptibility of diabetes. For
two years. Only goes to OBSGYN. If they did any blood tests the answer is no. She
hasnt been to a primary physician in over 2 years. No. Its not going to effect her
bleeding. Obviously one is more susceptible to capillary bursting in the CNS in the
kidneys, etc. but its not related to gingival bleeding. To hell with the periodontia,
and Im a periodontitis. Im worried about her kidneys, her brain, and
cardiovascular disease. Those are more important than periodontal disease. Is the
relationship, yes, to any infection? Whats important on this earth? If I compared
diabetes systemically to diabetes on periodontitis, this isnt a close call. Youre a
health care professional. When you examine a patient, youre never going to say
OMG I forgot to look at their teeth. IF you look at a radiography you look at the
growth pathology first. Youre going to look at the teeth. Its the other stuff that will
wipe someone off the Earth. In June, two squamous cell carcinomas I picked up in 2
weeks that unfortunately were seen by two dentist recently. Big lesions. That should
never happen. Ok, so lets look at least what I thought the problem was. Esthetics.
Why is it the first one? Its the first one I found out about. Im here b/c how my
lower teeth look. The spacing. The maxillary protrusion. The space left by maxillary
left bicuspid. Bleeding gums. Thats why she was there. Third one I got from the
medical/ family history and by looking at her and that she has possible metabolic
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syndrome. Shes obese, elevated BP. Shes compatible w/ her mothers history of
diabetes. Thats a problem I need to deal w/ since Im the one I found it. Generalized
Periodontist. Lower incisors, molars, etc. w/ furcations. Patient wants to keep her
teeth. Thats on a problem list. Thats put there to give you a bit of history on whats
there. Theres another problem that you didnt mention. That is susceptibility. The
greatest indicator of susceptibility to loss of attachment is previous loss of
attachment. Which means this patient basically is an annuity. You have to see them
on constant recalls forever. Patient has caries. Is that the next one? Or is that the
next one? Ill go to caries quickly. We didnt talk about susceptibility to caries. If
susceptible youre going to do things that you would if they were susceptible. If you
just fill the holes, the infection is still there. I hope you didnt go to school all these
years to just fill holes. Pathological occlusion. How do I know? Teeth arent stable.
Teeth arent moving, they are getting looser. The patient is telling me that the teeth
are constantly migrating. Its not only an esthetic problem, but its ongoing. Her
occlusion is not stable. Thats a separate problem. All Ive dealt w/ is the esthetic
problem. I put a bridge for the first bicuspid, and condensed the arches
orthodontically. Guess what will happen? Teeth will move back to their spot b/c
they dont have a stable occlusion. A problem list is extremely important. W/o that
you dont know what youre doing. It basically defines what is wrong and from there
you take the steps what am I going to do, we going to do bout the problem. The
patient can say I dont want to do anything about the problem. Thats their right. Its
my obligation to tell them the problem and what will happen if we dont treat it. We
talked about the large restorations. This is pretty much a problem list. The lateral
incisors. She has a temporary on the left lateral incisor. Now notice the problem are
not carries on this tooth, this tooth, this tooth. The problem is caries. The treatment
plan will address the individual teeth. The problem list not only serves a discussion
or treatment plan w/ the patient but its also a way to basically keep you honest.
That is looking and seeing now whether I filled tooth #14 w/ a MOD, that I solved
the problem of caries. Did I show the patient homecare. Did I solve the susceptibility
of caries. That was the initial problem. There for, Ive got to do something different
w/ respect to susceptibility than I did initially. The definition of insanity is doing the
same thing irrespective to the results. Now we know the patients problems. Im
going to give you 5 minutes to come up w/ a treatment plan. What do you want to
do for the patient. Im asking for tooth by tooth. Go! You have 5 minutes. You can
discuss w/ each other. Do whatever you do. Im asking you to make a treatment
plan. Youre basically giving possibilities to the patient and the patient is the one
who actually makes the treatment plan. Lets assume you were making a treatment
plan. What would the plan look like that would address these problems.

Right now youre going to make the assumption that there are no barriers to
treatment. It could be money or time. Patients can throw a lot of money at me but
they didnt want to spend the time. So youre going to make two assumptions. 1.
Youre going to do a decent drop. 2. The patient will do a decent job and be
compliant. That determines prognosis. You make those assumptions then. What do
you want to do first? Scaling and root planning first. Have you had the lectures on
what you try to do w/ scaling. W/ scaling youre trying to change the subgingvial
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floor. Changing gram negative to gram positive since its more conducive to health.
That said, I can do that but if I dont have really good home care that sub-gingival
floor will revert back to a more pathological flora in at least 3 weeks. W/o home
care, Im doing a walletectomy. Thats what Im doing on that. Youve got to have a
clean supergingival environment. Thats not going to do anything. Youre taking up
their time. Youre traumatizing them and youre charging them money. And youre
not going to get a result. You have to do that first. So maybe oral hygiene might be
first. You got that right. Thats number one. This patient is screaming that Im a
diabetic and so the first thing you might do is refer the patient w/ the history, etc.
You want to have a 90-day history. Have you learned about glycosylated
hemoglobin? We did and a number came back, 6.3 You know what that means? Pre-
diabetic. Below 6 is pre-diabetic. Over 6.5 is diabetic. You want to then control it 7 or
less. She had metabolic syndrome. That was the most important thing I could do for
her. Refer her to a physician who can treat her and hopefully not get the diabetes w/
respect to diet, exercise, and losing weight. It would also control hypertension. She
might have not agreed. What else do we want to know? Um. Well Im a Periodontist
and I can tell you that unless you have significant bony defects that have specific
configurations, the idea of getting back supporting bone is an illusive dream. It can
only be done very locally w/ very specific architecture. Once youve lost attachment
youve lost it for the most part. But thank you, I wish I could do that. Ok. So I dont
want to get again, into the whole idea of periostatin. Its a non-antimicrobial dose of
an antibiotic. It inhibits collagenase activity. Done by some guy in Stonybrook. Thats
well beyond anything we are talking about here. Were going to do homecare,
scaling, root cleaning, and periodontal therapeutics. Weve taken care of the perio.
Ok. An implant. We need to replace it somehow. Implant, bridge, whatever. So we
think wed want to stabilize the occlusion before we did the implant. Id hate to
make one and then an occlusional adjustment and then grind the hell out of this
beautiful tooth. Maybe I should do that first before I do anything else occlusionally?
We can do an occlusional adjustment. We can try to get forces off some teeth and on
to some other teeth. By adjusting enamelplasty in specific areas. Wed want to do
that. Lose teeth are themselves are not an issue. Lose teeth are an issue if one
patient complains they cant eat, they are not functional. Mobility by itself is not
pathology. If I reduce forces on teeth I can control mobility by itself. Its an indicator
I have decreased resistance, increased forces or both. Mobility is me going like this.
Theres nobody in this patients mouth doing like this. Its an indictor of force vs.
resistance. If its not getting worse, there arent esthetic issue, its not pathologic.
Dont splint teeth just b/c they are lose. Sometimes you need to for false teeth,
giving them more resistance. Sometime Id make a 5-unit bridge rather than a 3-unit
bridge b/c of the attachment. Here the problem was, that teeth were getting loser.
We try to stabilize the occlusion by stabilizing forces. We also did orthodontic
movement. The upper teeth we believe were in a state of mobility. We split the
upper teeth such that the teeth would continue to migrate. She wanted to keep her
teeth. We did class III restorations on the lingual on the anterior and putting a small
wire on the mesial/ distal of a tooth and adding a composite, which splinted the
teeth. So lets show you what we actually did on the patient. Again, this is just one
treatment plan. The patient determines the treatment plan. This was about 3-4
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years of therapy. I did the perio, and ortho but not the restorative dentistry. That
amalgam was replaced on the buccal b/c that was open margins like we said. That
restoration on the molar is the same restoration they had during occlusional
adjustment. It was polished. There were caries on the bicuspids and they are new
restorations. From the palatal. The restorations that were not beautiful we left. They
were physiological. They might not have been smooth, but they werent broke. Left.
Again that amalgam was left on the buccal of the lower molar. The patient is still a
cross-bite. We did in fact go posteriorly w/ very long overlaps to something more
like this. She had fleeting contacts and thus less lateral forces. Again those ugly
restorations are still there. There are stains around the restorations are intact. She
did not deal w/ the monetary aspect of crowing them. I wouldnt be doing anything
if I replaced them. Id make them more susceptibility to cracking. If she wasnt going
to shoe those cusps w/ an on lay it was a perfectly good restoration. They are ugly
but the criteria is not if they are pretty to the dentist or not. Theres an amalgam
tattoo there. I caused it. I used a cavitron and a high-speed diamond to get rid of the
overhang on the palatal restoration and I did not clean it up well. I got some
amalgam under the flap. Its not harmful but I was the one that caused it. Those
restorations are still ugly on the bicuspid, the molar (OL) but they are functional.
They are not broke. Were not going to replace them. Talking to a restorative dentist.
She wanted a gold collar. You cant see it here, but you have the class IIIs that were
basically, you can see the restoration here, part of it. And we make the Class III and
put a wire in there and put a composite that splints the teeth. They have long-term
prognosis. The upper incisors were stable after this. They did not move. This was
about 3-4 years after the patient was treated initially. And thats it. The whole idea
of this was not to show you a slide show of what was done previously. Its basically
to show you the idea of the process. What to think about, the questions, the answers,
and if you see something asking why, what, how. Thats what makes you the doctor.