Number
2102646424
Initial exam summary
C/O – infection and pain in front teeth
HPC – referred by GDP 15th January 2024
S – upper left central and lateral incisor
O – December 2023
C – dull pain
R – no radiation
A – no associated symptoms
T – constant
E – no painkillers, antibiotics helped pain S – 4/10
PMH – fit and well, no medications, no allergies
PDH – regular attender at GDP
– brushes twice daily with ETB
– flosses once daily
SH – non-smoker
– drinks alcohol occasionally
– works as medical secretary at QEUH (4 days)
E/O
- Lymph nodes, glands, MOM, asymmetry - NAD - TMJ – click LHS, no pain associated
I/O
- Mucosa, palate, tongue, FOM – NAD
- OH inadequate, gingival inflammation - Grade 1 mobility – 16, 48
Special investigations
Radiographs
- Right and left BWs
- PA of 12, 11, 21, 22, 15
Clinical photographs
MPBS – Plaque 64%, Bleeding 46%
Sensibility test - 15
Radiograph report
Radiographs are diagnostically acceptable.
Bone levels
- Generalised horizontal bone loss 20-50%
- Worst site at 16d – 50%
Restorations
As seen clinically, with the following additions;
- 12 cast post MCC with RCT (inadequate)
- 11 screw post MCC with RCT (adequate)
- 21 cast post MCC with RCT (inadequate)
- 22 screw post MCC with RCT (inadequate)
Pathology
15 – deep caries into inner third of dentine
21 – periapical radiolucency and widening of PDL, inadequate RCT
22 – periapical radiolucency and widening of PDL, inadequate RCT
25 – mesial overhang
48 – buccal caries
11 – deficient, carious crown margin
21 – query carious crown margin (mesial)
Diagnoses
Generalised periodontitis stage 3 grade B currently unstable, no known risk factors
Caries – 11 crown margin, 15do, 48b
11 – previously treated, normal apical tissues
21 – previously treated, symptomatic periapical periodontitis
22 – previously treated, symptomatic periapical periodontitis
Tx plan
Immediate
Nil
Initial
1. Step 1 BSP S3 guidelines
a. OHI and education
b. Supragingival PMPR
c. Adjustmentof25mesialoverhang
2. Step 2 BSP S3 guidelines a. Subgingival PMPR
3. Caries removal and restoration of 48 4. Caries removal and restoration of 15 Re-evaluation
5. Review periodontal condition
a. 6PPC of quadrants scoring BPE 3 Reconstructive
6. Construct temporary prosthesis for 21, 22 ± 11 7. Post removal and re-RCT 21
8. Post removal and re-RCT 22
9. Post placement and crown 21
10.Post placement and crown 22
Maintenance
11. Review periodontal condition and SPT
Antibiotics
- Dental abscesses are usually streptococci or gram-negative bacteria
- Local measures should be used in the first instance
- Amoxicillin 500mg TID for 5 days
Systems enquiry
- CV
- Resp
- GI
- Neuro
- Liver and kidneys
- MSK and skin
- Endocrine
- Blood
- Allergies
TMJ click
- Click is due to discoordination of condyle and articular disc
- Condyle has to overcome mechanical obstruction (disc) before full range of movement achieved
- Disc displaces anteriorly by the condyle, disc then reduces = click and full movement
TMJ tx
- If pain – counsel, jaw rest, bite raising appliance, surgery if severe
- Michigan splint = Full coverage splint for either jaw - Hard PMMA
- BRAs stabilise occlusion and improve function of masticatory muscles, which decreases parafunction
Mobility
- Tooth mobility is described is relation to the bucco-lingual movement observed, detected using a finger and instrument either side of the tooth
- Grade 1 = <1mm but more than physiological movement
- Grade 2 = 1-2mm
- Grade 3 = >2mm ± rotation or depression
BSP stage
- Stage = site of worst bone loss
- 1 = <15%
- 2 = coronal third of root
- 3 = middle third of root
- 4 = apical third of root
BSP grade
- Describes the patient’s susceptibility to the disease
- A = slow progression, bone loss < ½ patient’s age
- B = moderate progression, ½ patient’s age < bone loss < patient’s age
- C = rapid progression, bone loss > patient’s age
BSP distribution
- Distribution = how many teeth affected
- <30% = localised
- > 30% = generalised
- Molar/incisor pattern
BSP stability
- Stable = BOP <10%, PPD 4mm, no BOP at 4mm sites
- Remission = BOP >/= 10%, PPD </= 4mm, no BOP at 4mm sites
- Unstable = PPD >/= 5mm or BOP at sites of 4mm
Subsequent MBPS
Plaque - 56%
Bleeding - 50%
IRMER
IRMER 2017 (ionising radiations medical exposure regulations)
- Protects patients
- ALARP
- All exposures should be justified, optimised and limited
- Roles – dentist can be ALL
Referrer
- Referral for imaging
Practitioner
- Justification for imaging (benefit vs risk)
Operator
- Authorise and carry out imaging
- Assess and report image
Employer
- Provides referral criteria
- Deems staff competent (referrer, practitioner, operator)
IRR
IRR 2017 (ionising radiations regulations)
- Protects healthcare workers and general public
- Controlled areas with local rules for equipment
- 1.5m from x-ray tube
- Risk assessments
Tooth 11 - dental practicability index
Structural integrity level 6 – insufficient tooth structure to allow a well-adapted restoration
- Inadequate ferrule
- Subgingival margins
- Once tooth prepared and caries free – near crestal level
Endodontic treatment need level 0
- Asymptomatic and no radiographic signs of infection
Tooth 21 - dental practicability index
Structural integrity level 2
- Post retained restoration
- Carious crown margin (mesial) but adequate supracrestal dentine
Endodontic treatment need 1
- Previously treated, inadequate filling, easily retrievable, straight canal
- Symptomatic and radiographic evidence of infection
Tooth 22 - dental practicability index
Structural integrity level 2
- Post retained restoration
Endodontic treatment need 1
- Previously treated, inadequate filling, easily retrievable, straight canal
- Symptomatic and radiographic evidence of infection
Risks of tx 21, 22
- Root fracture
- Post fracture
- Tooth may be unrestorable
- Tooth may already be fractured
- Replacement options
Risks of tx 11
Likely unrestorable
- Crown margin is grossly carious and deficient
- Once tooth caries free, likely subcrestal preparation
- Unable to clamp and place dam to isolate for RCT
- Inadequate ferrule
Impinging on biologic width
- Root fracture
- Post fracture
- Tooth may be unrestorable
- Tooth may already be fractured
- Replacement options
What are the constituents of saliva?
- water
- ions (Na, Cl, K, bicarbonate)
- protein (amylase, protease, lipase)
- immunoglobulins
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1 - Bridgework40
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2 - Bridgework 219
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3 - Bridgework 319
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4 - Wear40
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5 - Wear 224
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6 - Wear 314
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7 - Shortened dental arch22
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8 - Tooth wear 124
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9 - Tooth wear 27
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10 - Tooth wear 319
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11 - Implant planning and placement39
-
12 - Implant restoration19
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13 - Endodontic interface22
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PCS - Wear 16
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PCS - Wear 24
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PCS - Wear 32
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PCS - Fibre post3
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CASE PRES38
