COAD (clean out and diagnose)

October 1, 2013

contributed by Chandan Jaspal

COAD is a procedure used to determine the restorability of a tooth.

Instruments needed:

  1. High/Slow Speed Dental Drill
  2. Rubber Dam Kit
  3. Basic Restorative Kit
  4. Round Burs
  5. Caries Dye
  6. Local Anesthesia

Examples Include: A crown on a tooth with unknown restorability , a failing root canal with an existing crown, and/ or a failing FPD.


  1. Give Local Anesthesia
  2. Rubber dam is used, and retainer applied to 2 teeth distal to the tooth.
  3. With a High Speed Dental Drill we start peripherally using a large round bur.
  4. The DEJ should be completely clean and decay free “squeaky clean.”
  5. With a Slow speed Dental Drill we start cleaning out decay in the inside of the tooth.
  6. Using the slow speed dental drill and only applying slight pressure take the round bur all over the cavity, until cheesy flakes of dentin are removed.
  7. Using a Caries Dye, we can check for decay and for cracks in the tooth. Apply Caries Indicator Dye and Rinse out. Make sure there is no decay/cracks/old restoration left behind.

Things never to do:

  1. Don’t Use High Speed Dental Drill other than for periphery.
  2. Don’t apply a lot of pressure with the dental drill while doing  COAD, you don’t want to end up with an pulp exposure.

Finishing the COAD Procedure:

  1. If the caries has led into the pulp chamber, a Pulpectomy is needed, along with a root canal and the Restorative Crown.
  2. If the caries has reached proximal to the bone, a procedure called Crown Lengthening is needed. Depending on where the caries extended to, we usually have to open up a periodontal flap and remove bone using a Round bur. There should be about 2.5mm to 3.0mm gap from the margin of the restoration (Ex. Crown) to the bone, this is done so we don’t invade biological width.  Extraction may also be a viable option here as well depending on the situation.
  3. If the caries has extended into the furcation of a tooth, we must do extraction.
  4. If the caries, has extended peripherally everywhere and no walls remain, we must consider extraction. Then the treatment plan would be a FPD or Implants.
  5. If the tooth is restorable, and the tooth is symptomatic, after the COAD procedure we can build the tooth up with GIC as a temporary material and make the patient come back in a few weeks to see if the symptoms are getting better.
  6. If the tooth is restorable, and a build-up is needed. We can use CORE FLO to build up the tooth and prep for a crown, for the permanent restoration.
  7. If the tooth has been root canal treated and the COAD has left only 2 walls remaining. Considering a safer side, we usually use a prefabricated post for retention. To do this, we remove Gutta Percha from the largest and straightest canal. We leave about 5mm of Gutta percha behind and using a Pre-fabricated post, we build-up the tooth. A final restoration (permanent restoration, example: PFM/EMAX/GOLD Crown) is needed after building up the tooth.


Called the “2,4,2” Rule:

  • The numbers 2,4,2 stand for 2mm, 4mm, and 2mm.
  • To determine if the tooth is restorable we should have these 2 numbers in check:  2mm of ferrule (this has to be tooth structure, this cannot be build up material, 4mm of at least 2 walls (this can have 2 walls which are tooth material, and 2 walls which are build-up material), 2mm of inter-occlusal space.
  • Having these 3 numbers in check, you will have a solid plan for that tooth.


Case Presentation: CEREC Emax #11

August 7, 2013

contributed by Chandan Jaspal:

Summary – Tooth # 11 had large composite fillings with recurrent decay. The patient came with pieces of the composite in his hand. After doing the COAD (Clean Out And DIagnose and determining the restorability, we decided to restore the tooth with an Emax Crown using the CEREC CAD/CAM System.  Our rationale for using Emax was due to the lack of interarch space due to wear.  Our team felt that using a high strength monolithic material would not only provide better esthetics, but better use the space offered by the occlusal and axial reduction.  To match this new crown with the natural looking canine on the other side of the arch (tooth #6), we utilized  “Biogeneric reference” on the CEREC machine.  The biogeneric reference function asked us if we wanted to mirror the contralateral tooth. Tooth #6 had a flat incisal surface, and the crown proposed by the CEREC came out with a normal architecture “triangular” shape.  Minor modifications were made, but the patient wound up loving the computer’s design better than his existing tooth both in apperance and feel.  It did raise an issue however that the proposal using biogeneric reference did NOT really resemble the tooth we wished to copy.  This is probably why Biogeneric Copy using a diagnostic wax-up is still the preferred method to use for CEREC crowns made in the anterior region.

Decayed Tooth

Decayed Canine


Tooth structure remaining after COAD procedure.  Tooth remained Asymptomatic after Fuji Lining LC and definitive Core Flow build up was placed.




Final Occlusal View


Final Buccal view after occlusion was checked.

Thyroid Disorders and Dentistry

July 10, 2013

contributed by: Chandan Jaspal


Hypothyroidism is defined as a state in which the thyroid gland does not produce a sufficient amount of the thyroid hormones T3 and T4. Mostly seen in women.


Hyperthyroidism is a condition caused by unregulated production of T3 and T4. Grave’s Disease is most common cause of it.

Role of the Dentist: Understanding the Thyroid dysfunction is important for the dentist for 2 reasons:

1) Dentist may be the first to suspect a serious thyroid disorder and aid in early diagnosis.

2) To avoid possible dental complications resulting from treating patients with the thyroid disorders.

To protect the thyroid gland we use a thyroid collar while taking X-rays. Our thyroid gland is very sensitive to radiation, and an excess of it is a risk factor for several thyroid conditions.



• It may decrease the ability of small blood vessels to constrict which may result in increased bleeding.

• P/t’s may have delayed wound healing due to decreased metabolic activity in fibroblasts.

Delayed wound healing will result in more exposure to pathogenic organisms, which may lead to infections.

• Susceptible to cardiovascular disease. Before treating such patients, consult with their primary care providers who can provide information on their cardiovascular statuses. Patients can be on anticoagulation therapy and might require antibiotic prophylaxis before invasive procedures. If valvular pathology is present, the need for antibiotic prophylaxis must be assessed.

• P/t’s are sensitive to CNS depressants and barbiturates.

• It has been found that recent exposure to a surgical antiseptic that includes iodine (such as Povidone) can increase the risk of thyroiditis or hypothyroidism.

Crown Lengthening

June 5, 2013

contributed by:  Chandan Jaspal

INDICATIONS: (2 types, Restorative and Aesthetic)

Restorative/functional crown lengthening Indications

  • To access to subgingival caries
  • To increase the clinical crown height reduced by tooth wear, caries or a
  • fracture extending subgingivally
  • To assist in creating a ‘ferrule’ effect
  • Correcting the position of the restorative margin when there has been invasion
  • of the biologic width
  • Access to superficial root perforations (e.g. following pin placement)

Aesthetic crown lengthening Indications

  • Correction of short clinical crowns due to wear or altered passive eruption
  • Creating gingival symmetry in the smile line
  • Correcting irregular/uneven gingival margins
  • Correcting for excessive gingival “Gummy smile” or hyperplasic tissue overgrowth

Contraindications to Crown Lengthening

  •  Smoking is a contra-indication to most gum surgeries including crown lengthening.
  •  Thin gum tissue
  •  Poor oral hygiene
  •  Where the furcation between the roots of a molar tooth will become exposed following crown lengthening.
  •  Unfavorable crown to root ration being created by crown lengthening.  I.E. The crown becoming longer than the root following crown lengthening surgery.
  •  Front teeth with long clinical crowns.
  •  An un-restorable tooth after surgery


  • Invisalign or Orthodontic Bracket tooth extrusion
  • Extraction of the tooth and replacing it with a dental Implant or a dental bridge.
(Photos to follow)

Always look at your adjacent tooth

May 6, 2013


contributed by Shahed Al Khalifah

Direct filling appointments like these can be very efficient and productive.  The title of this post is Always look at your adjacent tooth.  Dr. Al Khalifah found caries on the bicuspid while working on the first molar.  She elected to repair it using a direct approach and not prepping the marginal ridge.  She prepared the distal side of the bicuspid while the mesial of the molar was wide open, giving her adequate access.  At the same time she did the occlusal  fillings on both molars.   The marginal ridge is typically a very strong area of the tooth so preserving it when possible is great for the patient.  Polishing the adjacent contacts before making composite contacts or taking final impressions for crowns will improve your outcomes significantly.


Implant Impressions

February 4, 2013

contributed by: Khaled Alghulikah

Here we highlight 2 different techniques for taking an implant impression.  For single units especially, either method produces acceptable results.


Remove healing abutment and place closed tray impression coping.


Verify with radiograph that the coping is seated all the way.  The one below is NOT!


The coping below is properly seated and ready for an impression.


PVS material and a stock impression tray are used to take an impression.  The closed tray coping, lab analog, and impression are sent to the lab for fabrication.



Remove the healing abutment.


Place the open tray impression coping into the implant body.


Open tray impression coping is in place.


A radiograph is taken to verify complete seating.  Note also the sinus lift and grafted bone that was completed via a lateral window approach.


A stock tray with a relief hole is used to take the impression.


When the impression material sets, the coping is unscrewed and trapped in the impression.


Completed PVS impression is sent to the lab with the analog and lab screw.


New Vicodin Formulations

June 12, 2012

Vicodin (hydrocodone bitartrate and acetominophen tablets, USP) 5mg/300mg

Vicodin ES (hydrocodone bitartrate and acetominophen tablets, USP) 7.5mg/300mg

*Daily dosage of Acetominophen should not exceed 4000mg per day.  Total daily dosage should NOT exceed 8 tablets!