I understand that you know how to brush your teeth. But if you don't mind, I
　would like to introduce one better and efficient way to brush your teeth. This
　method is called "The Bass Method (Sulcus Cleansing)".
Maxillary teeth: Facial and facioproximal surface.
　Place the head of a soft-to-medium brush parallel with the occlusal plane with
　the "tip" of the brush distal to the last molar. Place the bristles at the gingival
　margins, establish an apical angle of 45o to the long axis of the teeth, exert
　gentle vibratory pressure in the long axisof the bristles, and force the bristle
　ends into the facial gingival sulci as well as into the interproximal embrasures.
　This should produce perceptible blanching of the gingiva. Activate the brush
　with a short back-and-forth motion without dislodging the tips of the bristles
　(massage the gingival tissue) . Complete 20 same strokes in the same
　position.Then lift the brush, move it anteriorly, and repeat the process in the
　premolar and canine area. And then continue on the anterior teeth. Continue
　on the opposite side of the arch, section by section, covering three teeth at a
　time, until the whole maxillary dentition is completed.
Maxillary teeth: Palatal and palatoproximal surfaces.　
　Engage the brush at a 45o apical angle in the molar and premolar areas,
　covering three teeth at a time. Clean each segment with 20 short
　back-and-forth strokes. To reach the palatal surface of the anterior teeth, insert
　the brush vertically.
Mandibular teeth: Facioproximal, lingual and linguoproximal surfaces.
　The same as the maxillary teeth. In the anterior lingual region the brush is
　inserted vertically, using the lingual surface of the mandible as a guide plane,
　and with the bristles angulated into the gingival sulci.
Occlusal surface:
　Press the bristles firmly on the occlusal surfaces with the ends as deeply
　as possible into the pits and fissures. Activate the brush with 20 short
　back-and-forth strokes, advancing section by section until all posterior teeth in
　all four quadrants are cleaned.
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Topic Thirteen:　Journel Paper　From: JADA - 1994 - 9　　
1. Why is glass ionomer cement so popular?
　 * G.I. is now most widely used luting agent worldwide.
　 * Cement is the least improved dental material relative to physical & working
　　characteristics. - hard to obtain adhesion to a wet substance such as dentin.
　 * G.I. is 1) Easy mixing. 2) High-flow characteristics. 3) Cariostatic - most. 4)
　　Adhesion to tooth - moderate bond. 5) Time - minimal mixing time. 6)
　　Money - relatively inexpensive. 7) Fluoride release.
　　But 1) Not easy to use properly. 2) Cause significant postoperative tooth
　　sensitivity. 3) Moderately soluble in mouth -only resin is insoluble 4) Slightly
　　less than optimal strength - resin nearly tooth structure strength is best.
　* Resin modifications of glass ionomer cements may be the ideal ones.
2. Tetracycline - loaded fibers as adjunctive treatment in periodontal disease.
　* Effective antibacterial concentrations are difficult to maintain for a sufficient
　　period in pocket: 1) poor concentration by mouth rinse. 2) rapid dissipation
　　of irrigation solutions. 3) relatively low concentrations achievable with high
　　systemic doses of antibiotics.
　* Concentrations in gingival fluid are more than 100 times peak level than
　　systemic oral TC administration.
　* Result: 1) Reduction in pocket depth - 2.8 mm average. 2)Bleeding on
　　probing - 24 to 37 % less. 3) Adverse effect - swelling, redness, itching and
　　mild gingival erythema and soreness(2 patients dropped)
　* Fiber placed in periodontal pocket to deliver TC continuously for 10 days
　　was effective in reducing pocket depth and bleeding on probing when used
　　as an adjunct to scaling and root planing in refractory disease sites.
3. Effectiveness, side effect and long-term status of night guard vital bleaching.
　* The use of 10% carbamide peroxide solution in the bleaching of vital teeth is
　　very common and successful.
　 * Discoloring teeth - inherent, aging, trauma, fluorosis and TC staining.
　 * About the research: 1) Materials and method - 10% carbamide peroxide,
　　night guard, 6 to 8 hours for 6 weeks, success determining. 2) Result - a>
　　75% of TC gr. and 96.7% of non-TC gr. succeed in 6 weeks. b> 74% in 13
　　to 25 mths and 62% in 31 to 42 mths still successful. 3) Side effect - a>
　　tooth sensitivity caused by the easy passage of the hydrogen peroxide and
　　urea through the teeth to the pulp, resulting in a reversible pulpitis. b>
　　gingival irritation caused by either mechanical irritation from the nightguard
　　or chemical irritation of the solution. c> but none reported any lasting side
　　effect. 4) TC gr. has less successful rate due to internal staining.
4. Guided tissue regeneration: An adjunct to endodontic surgery.
　* Membrane barriers (Gore-tex) used in conjunction with periodontal surgery
　　have promoted regeneration of lost marginal attachment. Membrane barriers
　　also may be indicated during surgical endodontics, in selected cases, where
　　primary apical lesions are complicated by the loss of marginal attachment.
　* GTR restored periodontal support with bone formation in class II furcations,
　　as well as in two- and three- walled vertical defects.
　* Researchers found that a membrane barrier,such as Gore-tex placed over the
　　surgical defect before flap replacement, prevents the downward epithelial
　　proliferation. -> periodontal ligament cells repopulate the denuded root
　　surface -> then these cells can recreate the periodontal attachment and
　　attract cells from the alveolar crest that can differentiate into bone.
　* Epithelial proliferation may result in a long junctional epithelial and chronic
　　periodontal defect.
　 * Drawbacks - expense, additional treatment time and re-entry required to
　　remove the material (one resorbable membrane received approval only).
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Topic Fourteen:　About Dental X Ray
　
1. The radiation of full mouth X ray (20 or 22 PA + BW) equals:
　A. One chest X ray.
　B. The radiation you get from the sun for one year under normal condition.
2. Is pregnant lady suitable for dental X ray?
　Waiting for your answer.
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Topic Fifteen:　TREATMENT PLAN PRESENTATION
　
TABLE OF CONTENTS
SUBJECT
A.　　PATIENT PROFILE
B.　　HISTORICAL INFORMATION
　　　1. CHIEF COMPLAINT
　　　2. DESIRE FOR TREATMENT
C.　　MEDICAL HISTORY
D.　　DENTAL HISTORY
E.　　PSYCHOLOGICAL HISTORY
F.　　CLINICAL EXAMINATION
　　　1. EXTERNAL EXAMINATION
　　　2. INTRA-ORAL SOFT TISSUE EXAMINATION
　　　3. DENTITION
　　　4. PERIODONTAL EXAMINATION
　　　5. OCCLUSAL EXAMINATION
　　　6. RADIOGRAPHIC EXAMINATION
　　　7. EXAMINATION OF INDIVIDUAL TOOTH
G.　　CONSULTATION
H.　　DIAGNOSIS
I.　　PROGNOSIS
J.　　TREATMENT PLAN OBJECTIVE
K.　　OPTIMAL TREATMENT PLAN
L.　　IDEAL TREATMENT PLAN
M.　　ORAL HEALTH FOLLOW-UP AND MAINTENANCE
　　

A.　PATIENT PROFILE
　　Name:　　　　　　Pang, Dan-Hung
　　Sex:　　　　　　　Male
　　Age:　　　　　　　27
　　Race:　　　　　　　Oriental
　　Marital Status:　　　Single
　　Occupation:　　　　Sudent

B.　HISTORICAL INFORMATION
　　1. CHIEF COMPLAINT
　　　The patient wants to have a complete dental check up.
　　2. DESIRE FOR TREATMENT
　　　He wants all his carious teeth be treated as soon as possible. As for the
　　　unfitting crowns, patient needs some more time to save money for further
　　　treatment.

C.　MEDICAL HISTORY
　　Height:　　　　　　　5'11"
　　Weight:　　　　　　　180 lbs
　　Serious Past illness:　　Hepatitis B
　　　　　　　　　　　　Patient suffered from Hepatitis B in 1979. After he
　　　　　　　　　　　　received the treatment, patient was told by his
　　　　　　　　　　　　physician that he was cured.
　　Patient has smoked for 15 years. He smokes 20 cigarettes every day.
　　He used to drink a lot of alcohol. But he quit drinking two years ago.
　　ASA Class II.

D.　DENTAL HISTORY
　　Patient suffers generalized moderate gingivitis and localized early adult
　　periodontitis due to inadequate oral hygiene. And he also has several
　　amalgam and composite fillings. By the way, there are five Endo treated
　　teeth and six FVCs in his mouth.He went to a private dental clinic for
　　composite filling for tooth #6 in May 1993 which was his last dental visit.

E.　PSYCHOLOGICAL HISTORY
　　The patient is very cooperative and patient. And he is Class I philosophical.
　　
F.　CLINICAL EXAMINATION
　　1. EXTERNAL EXAMINATION
　　　@ Straight profile
　　　@ Lip length: normal
　　　@ Lip line : medium
　　　@ Symmetrical appearance
　　　@ No palpable enlarged preauricular, submandibular or cervical lymph
　　　　nodes.
　　　@ Facial skin and palpation of muscles: no significant findings.
　　　@ TMJ Examination: no pain or clicking sound when opening mouth.
　　2. INTRA-ORAL SOFT TISSUE EXAMINATION
　　　Lip, floor of mouth, tongue, soft palate, oropharynx, salivary gland and
　　　mucosa present no abnormalities. Salivary flow and neuromuscular
　　　coordination are within normal limit. There is melanin pigmentation over
　　　maxillary and mandibular gingivae.
　　3. DENTITION
　　　@ Missing teeth # 1, 16, 17, 32
　　　@ Wear facet on # 23, 24, 25
　　　@ Defective amalgam restoration # 4, 13
　　　@ Defective composite restoration # 2, 15, 20
　　　@ Caries # 2(D), 3(DLG), 5(M,D), 6(D), 12(D), 15(B)
　　　@ Slight crowding on #23, 24, 25, 26
　　4. PERIODONTAL EXAMINATION
　　　@ Poor oral hygiene
　　　@ Gingiva: Generalized moderate plaque induced gingivitis.
　　　　　　　　Defective restoration associated gingivitis on # 3, 4, 13, 14,
　　　　　　　　15, 18, 19, 29, 30 and 31.
　　　　　　　　Gingiva index: 2 - 3.
　　　　　　　　All marginal gingiva is slightly red and swollen due to
　　　　　　　　inflammation. And general bleeding on probing can be seen.
　　　@ Plaque index: 2.
　　　@ Calculus code: 2. Especially on the buccal side of # 2, 3, 14, and 15
　　　　　　　　and the lingual side of # 23, 24, 25 and 26, a lot of calculus
　　　　　　　　present.
　　　@ Localized early adult periodontitis: # 18, 19 and 28.
　　　@ Periapical periodontitis: # 19 and 29 (Endo related).
　　　@ Pocket depth: between 2 and 4 mm, except on the mid-lingual part of
　　　　　　　　# 18 (7mm) and disto-palatal part of # 14 (5mm).
　　　@ Mobility: overall normal except # 18 and 19 (1).
　　　@ Furcation involvement: Grade II on both buccal and lingual sides of #
　　　　　　　　18 , 19 with horizontal depth 2mm. Grade I on both buccal
　　　　　　　　and lingual sides of # 30 and buccal side of # 31.
　　　@ No gingival recession.
　　5. OCCLUSAL EXAMINATION
　　　@ Arch form: square.
　　　@ Arch relations: - Molar: Cl III.
　　　　　　　　　　 - Canine: Cl I.
　　　　　　　　　　 - Incisor: edge to edge.
　　　@ Midline:　 no deviation.
　　　@ Anterior vertical overbite: No (because edge to edge).
　　　@ Anterior horizontal overbite: No.
　　　@ Occlusal plane: Smooth curve of Spee.
　　　@ Centric stop: #2-31, #14-19 and #15-18.
　　　@ Right lateral movement: - Working side: canine guidance.
　　　　　　　　　　　　　　- Balancing side:　 no contact.
　　　@ Left lateral movement: - Working side: canine guidance.
　　　　　　　　　　　　　 - Balancing side:　 no contact.
　　　@ Protrusive movement: anterior guidance, no deviation.
　　　@ Occlusal scheme: canine guidance.
　　　@ Mandibular deviation upon opening: no.
　　6. RADIOGRAPHIC EXAMINATION　
　　　@ Character of bone: Good bone trabeculation.
　　　@ Lamina dura: Continuous around all the teeth except apical area of
　　　　　　　　　　distal root of tooth #19 and root of tooth #29 and the
　　　　　　　　　　furcation area of tooth #19.
　　　@ PDL:　 Consistent, even normal widths.
　　　@ Caries: #2 (D) #3 (MO) #4 (DO) #5 (M,D) #6 (D) #12 (D) #13(DO)
　　　　　　　　　　#20 (DO)
　　　@ Clinically, crown/root ratio: favorable.
　　　@ Apical radiolucence: Distal root of tooth #19 and root of tooth #29.
　　　@ Restoration: Crown overhang of teeth #18, #19, #29 and #30.
　　　　　　　　　Amalgam overhang of teeth #3, #4 and #15.
　　　@ Endo filling: Undercondensed filling of teeth #14, #30 and #31.
　　　　　　　　　Under filling of tooth #19.
　　　　　　　　　Faded paste filling of tooth #29.
　　7. EXAMINATION OF INDIVIDUAL TOOTH
　　　7-1. Examination of individual tooth
　　　　Tooth#　Tooth Position　Existing Restoration　　　Defect
　　　　　1　　　　Missing
　　　　　2　　　　Normal　　DLG, M pit composite　D, M pit caries
　　　　　3　　　　Normal　　MO amalgam　　　　　DLG, MO caries
　　　　　4　　　　Normal　　DO amalgam　　　　　DO 2nd caries
　　　　　5　　　　Normal　　M, D caries
　　　　　6　　　　Normal　　M composite　　　　　D caries
　　　　　7　　　　Normal　　B composite (V)
　　　　　8　　　　Normal　　　　　　　　　　　　Incisal crack
　　　　　9　　　　Normal
　　　　10　　　　Normal
　　　　　11　　　　Normal　　　　　　　　　　　　B craze line
　　　　　12　　　　Normal　　　　　　　　　　　　D caries
　　　　　13　　　　Normal　　DO amalgam　　　　　DO 2nd caries
　　　　　14　　　　Normal　　FVC　　　　　　　　Open margin,
　　　　　　　　　　　　　　　　　　　　　　　　Undercondensed
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Endo
　　　　　15　　　　Normal　　MO, L amalgam　　　　B, D pit caries
　　　　　16　　　　Missing
　　　　　17　　　　Missing
　　　　　18　　　　Normal　　FVC　　　　　　　　Open margin
　　　　　19　　　　Normal　　FVC　　　　　　　　Underfilling Endo
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　radiolucence over
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　D root apex
　　　　20　　　　Normal　　DO composite　　　　DO 2nd caries
　　　　　21　　　　Normal
　　　　　22　　　　Normal
　　　　　23　　　　Crowding
　　　　　24　　　　Crowding
　　　　　25　　　　Crowding
　　　　　26　　　　Crowding
　　　　　27　　　　Normal
　　　　　28　　　　Normal
　　　　　29　　　　Normal　　FVC　　　　　　　　　Faded Endo paste
　　　　　　　　　　　　　　　　　　　　　　　　　filling, Apical
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　radiolucence
　　　　　30　　　　Normal　　FVC　　　　　　　　　Underfilling Endo,
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Open margin
　　　　　31　　　　Normal　　FVC　　　　　　　　　Underfilling Endo,
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Open margin
　　　　　32　　　　Missing
　　
G.　CONSULTATION
　　1. Periodontal consultation: Scaling and root planing. Provisional treatment
　　　　　　　　of defective restorations. After Endo treatment, reevaluate
　　　　　　　　the periodontal condition. It is possible to perform osseous
　　　　　　　　surgery for crown lengthening in UL, LL, and LR quadrants.
　　2. Endodontic consultation: Retreat teeth #14, #19, #29, #30 and #31.
　　3. Operative dentistry consultation: Pulpal diagnosis: teeth #13, #15, #18,
　　　　　　　　#20. Amalgam filling of teeth #2 (OD,M pit), #3 (MO,DLG),
　　　　　　　　#4 (DO), #5 (MO,DO), #12 (DO), #13 (DO) and #20 (DO).
　　　　　　　　Composite filling of teeth #6 (D) and #8 (Incisal).
　　4. Restorative consultation: After endodontic treatment, cast post and core
　　　　　　　　of teeth #14, #19, #29, #30 and #31. FVC of teeth #14, #15,
　　　　　　　　#18, #19, #29, #30 and #31.
　　5. Orthodontic consultation: Basically patient's malocclusion is caused by
　　　　　　　　dental problem. Patient's occlusion is slight Cl III with
　　　　　　　　edge-to-edge relationship of anterior teeth. Besides P't has
　　　　　　　　lower anterior teeth crowding. It will take almost 9 to 12
　　　　　　　　months to finish Ortho treatment. The treatment will get an
　　　　　　　　ideal result of overjet and overbite with full mouth wire and
　　　　　　　　bracket. And because of the lower anterior crowding, it is
　　　　　　　　possible to strip the lower anterior teeth in order to get
　　　　　　　　adequate space.
　
H.　DIAGNOSIS
　　　@ Generalized moderate plaque induced gingivitis.
　　　@ Defective restoration associated gingivitis.
　　　@ Gingival index: 2 - 3.
　　　@ Plaque index: 2.
　　　@ Calculus index: 2.
　　　@ Localized early adult periodontitis: #18, #19 and #28.
　　　@ Periapical periodontitis: #19 and #29.
　　　@ Unsuccessful Endo.
　　　@ Defective restoration.
　　　@ Caries.
　　　@ Class III maocclusion with anterior teeth edge to edge.

I.　PROGNOSIS
　　1. Periodontal prognosis: overall is fair except for teeth #18 and #19 which
　　　　　　have furcation involvement grade II. Especially the prognosis of
　　　　　　tooth #19 depends mainly on the success of Endo retreatment.
　　　　　　Because it is Endo related periodontitis, with a successful Endo
　　　　　　treatment tooth #19 can have a guarded prognosis. Otherwise it
　　　　　　will be poor prognosis. And it is doomed to be extracted.
　　2. Restorative prognosis: is good as long as the patient is cooperative in
　　　　　　following the treatment plan and really does a good job in
　　　　　　maintaining his oral hygiene. Also the prognosis will depend on the
　　　　　　success of Endo and Perio treatment.

J.　TREATMENT PLAN OBJECTIVE
　　Because of the patient's inadequate oral hygiene, he suffers generalized
　　periodontal disease. And he also has several carious lesions. In order to
　　solve these 2 important problems, we should emphasize on the importance
　　of oral hygiene. After the initial OHI, we still should pay more attention to
　　make sure that patient can keep good oral hygiene. Otherwise no matter
　　how hard we try, the result will end up with failure. Patient has 5 Endo
　　treated teeth in his mouth. But all of their qualities are unacceptable. When
　　we retreat these teeth, not only should we do our best to perform perfect
　　treatment but also we should make routine followup for these teeth.
　　Especially pay great attention to radiographic change (apical radiolucence of
　　teeth #19 and #29). After we confirm patient's ability in maintaining oral
　　hygiene, we can start to perform restorative treatment.

K.　OPTIMAL TREATMENT PLAN
　　Phase 1 : Initial Phase
　　　1. Mounted diagnostic cast
　　　2. FMX taken
　　　3. Study photo taken
　　　4. OHI
　　　5. Reevaluation for patient's oral hygiene - every week
　　　6. Scaling and root planing
　　　7. Reevaluation for Perio - 4 weeks
　　Phase 2 : Restorative Phase
　　　1. Pulpal diagnosis: ##13, #15, #18 and #20.
　　　2. Operative Dentistry:
　　　　　　　#2 - M pit amalgam　　　　　　　　　　　　　　　　　
　　　　　　　#3 - MO and DLG amalgam
　　　　　　　#4 - DO amalgam
　　　　　　　#5 - MO and DO amalgam
　　　　　　　#6 - D composite
　　　　　　　#8 - Incisal composite
　　　　　　　#12 - DO amalgam
　　　　　　　#13 - DO amalgam
　　　　　　　#20 - DO amalgam
　　Phase 3 : Provisional Phase
　　　Make provisional crowns for teeth #14, #18, #19, #29, #30,#31 which
　　　need Endo retreatment.
　　Phase 4 : Endodontic Phase
　　　Retreatment of teeth #14, #19, #29, #30 and #31.
　　Phase 5 : Periodontal Surgery Phase
　　　Osseous surgery for crown lengthening in UL, LL and LR quadrants. But
　　　whether this surgery is needed or not depends on the result of Endo
　　　treatment and the healing condition of periodontal tissue.
　　Phase 6 : Restorative Phase
　　　1. Cast post and core fabrication:
　　　　　　　#14, #19, #29, #30 and #31: prepare post space, cast post and
　　　　　　　core
　　　2. Fix Prosthesis:
　　　　　　　#14 - FVC
　　　　　　　#15 - FVC
　　　　　　　#18 - FVC
　　　　　　　#19 - FVC
　　　　　　　#29 - PFM
　　　　　　　#30 - FVC
　　　　　　　#31 - FVC
　　Phase 7 : Finishing Phase
　　　1. Final occlusal adjustment
　　　2. Polish all restoration
　　　3. Reevaluation
　　　4. Recall : 3 months for periodontal and restorative checkup
　
L.　IDEAL TREATMENT PLAN
　　Phase 1 to Phase 5 are the same as the previous plan.
　　Phase 6 : Orthodontic Phase.
　　　　　　　With full mouth wire and bracket, to get a better occlusion in 9
　　　　　　　to 12 months.
　　Phase 7 : Restorative Phase: The same as previous plan.
　　Phase 8 : Finishing phase: The same as previous plan.
　
M.　ORAL HEALTH FOLLOW-UP AND MAINTENANCE
　　Periodontal prophy every 3 months. If patient can maintain his oral hygiene,
　　it is feasible to make it every 4 months. Check the patient's ability to keep
　　oral hygiene.
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