CASE PRES Flashcards
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
What is the function of phosphate in saliva?
Buffer in low flow
What is the function of bicarbonate in saliva?
Buffer in high flow
What is the function of chloride in saliva?
Activates amylase
Risk factors for developing disease?
- diet may induce T2DM
Preparation for MCC
- 1.5mm occlusal reduction
- +0.5mm working cusp occlusal reduction
- 0.5mm chamfer margin (lingual)
- 1.3mm shoulder margin (buccal)
- <6 degree taper
- removal of undercuts
Material for MCC
- CoCr metal substructure
- metal oxide layer
- zirconia
Bonding between layers of MCC
- mircomechanical retention (ceramic flows into metal surface, sandblasting aids this)
- compression fit (ceramic shrinks on to metal, “stressed skin”)
- chemical (metal oxide layer bonds with ceramic)
Cement MCC
Dual cure luting cement with metal bonding agent eg 10-MDP or 4-META (eg Panavia)
Temporary prosthesis
- Essix retainer
- can incorporate old crowns if removed conservatively
- can use acrylic denture teeth / composite if crown not available
- can take teeth in/out of retainer as required for treatment
Describe the radiographic appearance of 11
Within 2mm of apex – adequate
Describe the radiographic appearance of 21
- Short
- Void
- Compromises seal, predisposes to leakage and possible failure of RCT
Describe the radiographic appearance of 22
- Short
- Void
- Compromises seal, predisposes to leakage and possible failure of RCT
- 22 is ledged – precurved file to navigate
Describe the radiographic appearance of 12
- Extruded
- Short (>2mm short of apex) have a better SR than long root fillings
- Possibility that it may fail in future – KUO
- Compromises seal, predisposes to leakage and possible failure of RCT
Radiation - effectieve dose
Effective dose (uSv) is the equivalent dose multiplied by the tissue weighting factor
- Intraoral = 4
- OPT = 20
