case pres Flashcards
summarise patient case: presenting complaint
Mr. C, a 32-year-old chef, initially presented with discomfort due to a broken composite restoration on UR3. He described it as a sharp edge noticeable with his tongue, but without associated pain. The issue arose one week after restoration placement, prompting his visit.”
Introduce the subsequent complaint: “Between appointments, the patient developed pain in LL8, particularly during eating and exacerbated by biting on hard foods. The pain was sharp, non-radiating, lasted a few seconds, and was rated 6–7/10 in severity.
summarise patient case: history
- This patient is fit and well; recently quit smoking cigarettes (former smoker of 12 years). Now vapes daily. Keen to quit vaping too so was referred to smoking cessation. His occupation is a chef.
- For dental history I will mentioned the:
o Last treatment: previously had an RCT completed on UR3 and the composite placed as coronal seal and UR2 extirpated.
o Oral hygiene routine: brushing once a day; no flossing/interdental brushes.
o Diet: Frequency snacking, having fizzy drinks throughout the day.
summarise pt case: examination + special tests
- EO all NAD
- IO
o calculus and gingival inflammation, bleeding on probing
o restored dentition, visible carious lesions?, overeruption of UL6, edentulous region on both upper and lower arches due to history of extractions.
o BPE 334 (4 on UL) and 433 (4 on LR). - Charting including assessing existing restorations, taking 6PPC and full mouth PA due to BPE 4 as per BSP guidelines
- Special investigations used were to assess whether any teeth were tender to percussion (which may suggest periapical Infection) or response to endofrost (to assess sensibility). Results are on the poster.
o What is the reason for the LL8 being hyperesponsive to endofrost? In reversible pulpitis, the pulp becomes inflamed due to irritation (commonly from caries). According to the hydrodynamic theory, stimuli such as temperature changes cause movement of the fluid within the dentinal tubules resulting in mechanically stimulated nerve fibres sending heightened pain signals compared to the control teeth. - Radiographs taken and some are on the poster. The rest of the radiographs helped with diagnosing the extent of the periodontal disease.
Summarise patient case: diagnosis
o Generalised periodontitis stage 2, grade B currently unstable, RF: former smoker 10/day for 12 years, now vapes.
o UR7 – Unrestorable cavity.
o LL8 - Reversible pulpitis.
o UR2 – Chronic periapical periodontitis.
o Caries
summarise patient case: risk assessment + explain why for each one
o Caries = high due to 2+ lesions so high carious cavity, diet, fluoride use due to only brushing once a day; occupational risk (chef),oral hygiene poor and poor plaque control.
o Periodontal = high. This is due to history of smoking and local factors such as calculus
o Oral cancer = medium due to history of smoking for 12 years.
o Toothwear = medium due to extrinsic acid exposure – high consumption of fizzy drinks and BEWE of 1 in all sextants (double check submission)
summarise patient case: treatment plan
Acute, prevention, stabilising, review, definitive and maintenance
addressing patient’s complaints of the composite being chipped off on UR3 so placed composite to address the existing deficiency when part of the restoration broke off. I also addressed the acute LL8 pain by doing a sandwich GIC and composite restoration.
o Prevention is tailored for high caries risk in line with DBOH including OHI such as increasing brushing frequency use of interdental aids, diet sheet and advice, using fluoride supplements such as fluoride toothpaste TDS ideally high fluoride 5000ppm initially until risk levels are lowered, tailored advice due to occupation for instance, if tasting particularly sugary or acidic sauces, consider a water rinse afterward.
o Supragingival and subgingival PMPR guided by the 6PPC; + restorations of several teeth, UR2 RCT. I have not completed all the restorations so could only take mid treatment photographs.
o Review stage: atleast every three months due to high perio and caries risk.
o Definitive: XLA UR7 and replace missing teeth. Need to ensure plaque and bleeding score is optimal and mouth is stabilised.
o Maintenance with GDP once discharged
Can you elaborate on the patient’s chief complaint and how it guided your diagnosis?
Use SOCRATES for Pain Analysis
Site: LL8
Onset: Developed between appointments
Character: Sharp pain
Radiation: No radiating pain
Associated Symptoms: None reported
Timing: During eating, lasting a few seconds
Exacerbating/Relieving Factors: Worse when biting hard food, avoided chewing on affected side
Severity: 6–7/10
While addressing the UR3 restoration issue, further investigations revealed additional concerns, including LL8 reversible pulpitis, chronic periapical periodontitis in UR2, and generalised periodontitis. The heightened response to sensibility testing (EndoFrost) on LL8 suggested pulpal inflammation, correlating with his symptoms.
What were the key findings from the clinical examination and investigations that confirmed your diagnosis?
- Extraoral Examination (EO)
No abnormalities detected (NAD), meaning no swelling, asymmetry, or external signs of pathology. - Intraoral Examination (IO)
General Findings:
Evidence of calculus and gingival inflammation with bleeding on probing.
Restored dentition with visible carious lesions.
Overeruption of UL6 due to missing opposing tooth.
Edentulous regions present due to previous extractions.
Basic Periodontal Examination (BPE):
Scores: 334 (score 4 on UL) and 433 (score 4 on LR)
Indicating generalised periodontitis requiring full periodontal assessment (6PPC and radiographs).
- Special Investigations
Endofrost Sensibility Testing:
LL8 showed a hyper-responsive reaction indicative of reversible pulpitis.
UR2 displayed a delayed and lingering response, consistent with chronic periapical periodontitis.
Percussion Test:
UR2 was tender to percussion, suggesting periapical inflammation.
Radiographic Findings:
Full mouth PAs taken due to periodontal concerns (BPE score 4).
Images on the poster confirmed:
LL8: Signs of deep dentinal caries, consistent with reversible pulpitis.
UR2: Periapical radiolucency, aligning with chronic periapical periodontitis.
Generalised periodontitis: Evidence of bone loss confirming stage 2 grade B status.
Conclusion
These findings collectively confirmed the diagnosis of:
Generalised periodontitis (Stage 2, Grade B, currently unstable)
LL8 reversible pulpitis based on sensibility test results.
UR2 chronic periapical periodontitis with radiographic evidence.
UR7 unrestorable cavity indicating extraction required.
Caries with radiographic evidence indicating restorations required
What influenced your treatment plan choices for this patient?
“The treatment plan was guided by the patient’s high caries and periodontal risk, occupational factors, and his chief complaints. Since he’s a chef, frequent tasting exposes his dentition to sugars and acids, increasing caries susceptibility. Additionally, his history of smoking—now vaping—contributes to periodontal instability.
To address these risks, I tailored prevention strategies from the ‘Delivering Better Oral Health’ guidelines. I incorporated high-fluoride toothpaste (5000ppm) to improve remineralization, modified oral hygiene instructions, and emphasized hydration due to his work environment.
For the LL8 reversible pulpitis, a sandwich GIC-composite restoration was chosen to provide a strong coronal seal while minimizing bacterial infiltration. UR7 was deemed unrestorable, requiring extraction, and UR2 was scheduled for RCT due to periapical involvement.
Stabilizing periodontal health was essential, so I planned regular periodontal maintenance guided by the 6PPC assessment, including PMPR and monitoring plaque/bleeding scores over subsequent visits.
Overall, the approach balanced acute management with long-term stabilisation, ensuring restorations were viable before definitive treatment such as XLA UR7 and prosthetic replacements
What were the risk factors associated with this patient’s condition?
The key risk factors identified included:
High caries risk: Due to 2+ active lesions, dietary habits (frequent snacking, fizzy drinks), and poor plaque control.
Periodontal risk: Previous smoking history (12 years, 10/day) and ongoing vaping, contributing to periodontal instability. Calculus presence worsened plaque-induced inflammation.
Oral cancer risk: Medium risk due to previous tobacco use.
Tooth wear risk: Extrinsic acid exposure from frequent fizzy drink consumption, assessed via BEWE scoring (score 1 across sextants).
These risks informed the tailored prevention plan, which included fluoride supplementation, dietary adjustments, and advanced periodontal management to stabilise his oral health.
How did the radiographic findings support your diagnosis?
Radiographs confirmed multiple aspects of the diagnosis:
Generalised periodontitis: Full mouth periapicals showed bone loss consistent with Stage 2, Grade B disease.
LL8 reversible pulpitis: Radiographs revealed deep caries close to the pulp but without periapical pathology, supporting the reversible nature of pulp inflammation.
UR2 chronic periapical periodontitis: Evident periapical radiolucency confirming pathology.
UR7 unrestorable cavity: Extensive tooth structure loss with compromised coronal structure so crown cannot be placed due to periapical pathology and not enough tooth structure for ferrule necessitating extraction.
These findings were crucial in determining the treatment strategy, ensuring interventions were evidence-based and aligned with prognosis considerations
Why did you choose this specific treatment plan for your patient, and what alternative options were considered?
I chose this treatment plan based on the patient’s high caries and periodontal risk, occupational factors, and long-term oral health stability.
This plan balances acute symptom management, preventive strategies, and long-term stability, ensuring restorations are completed in phases aligned with prognosis considerations. The structured approach adheres to Delivering Better Oral Health (DBOH) guidelines and best practices for periodontal and restorative treatment sequencing. Here’s the reasoning behind my approach:
- Addressing Acute Concerns
UR3 Restoration Repair: Since the patient initially presented with discomfort due to a chipped composite restoration, I restored the defect to prevent further deterioration.
LL8 Reversible Pulpitis Management: A sandwich restoration using GIC and composite was chosen to provide a strong coronal seal while minimizing bacterial infiltration. Fluroide release good esp in high caries risk. This approach preserves pulp vitality while addressing caries.
- Preventive Strategies
Tailored Oral Hygiene Advice: Given the patient’s occupation as a chef (frequent tasting, exposure to acids/sugars), I recommended high-fluoride toothpaste (5000ppm), increased brushing frequency, and interdental cleaning.
Dietary Modifications: Advised reducing fizzy drink consumption, reduce snack consumption and implementing water rinsing after tasting acidic or sugary foods.
Smoking Cessation Support: Since the patient recently quit smoking and now vapes, I referred him to vaping cessation services to further reduce periodontal risk.
- Periodontal Stabilization
Supragingival and Subgingival PMPR: Guided by 6PPC assessment, addressing calculus and inflammation.
Regular Reviews: Due to high periodontal and caries risk, I scheduled three-monthly reviews to monitor plaque and bleeding scores.
Restorations ad RCT: UR2 had been extirpated, but definitive RCT completion and final restoration completed such as LL8 among others top stabilise the carious teeth. Reasons for restoring teeth: addressing pain, plaque control
- Definitive Treatment Planning
UR7 Extraction: The cavity was deemed unrestorable, requiring extraction.
Future Prosthetic Replacement: Once periodontal health stabilizes, missing teeth will be replaced.
Alternative Options Considered
LL8 Extraction Instead of Restoration
Extraction was considered but avoided since the pulp was still vital, and the patient preferred a conservative approach.
Temporary Filling Instead of GIC-Composite
A temporary restoration could have been placed, but a definitive restoration was preferred to prevent bacterial ingress.
Non-Surgical Periodontal Therapy Alone
While PMPR was essential, restorative interventions were needed to stabilize caries risk before periodontal maintenance.
Monitoring UR2 Instead of RCT
Given the periapical radiolucency, delaying RCT could have led to worsening symptoms, so proactive treatment was chosen.
How did you account for the patient’s history including medical history or systemic conditions while formulating the treatment plan?
Risk Assessment & Tailored Prevention
High caries risk → Due to 2+ active lesions, poor oral hygiene, and occupational exposure (chef frequently tasting food).
-> Solution: High-fluoride toothpaste (5000ppm), dietary modifications, and tailored oral hygiene advice.
Periodontal risk → History of smoking and calculus buildup.
-> Solution: Supragingival and subgingival PMPR, guided by 6PPC assessment.
Oral cancer risk → Medium risk due to previous smoking history.
-> Solution: Regular soft tissue checks and smoking cessation referral.
Tooth wear risk → Extrinsic acid exposure from fizzy drinks.
-> Solution: BEWE scoring, dietary advice, and enamel protection strategies.
What successes did you achieve during your patient care?
Patient become more dentally aware and motivated – demonstrated compliance to OHI
Initially didn’t want replacement options but become more interested in implants and saw an implantologist.
Patient Engagement: Patient showed improved motivation—expressed interest in quitting vaping and improving oral hygiene.
Perio related: plaque score went down signs of engaging patient, reduced probing depths, reduced bleeding, implemented OHI based on occupational risk and is using duraphat
What challenges did you face during your patient care, and how did you overcome them?
Periodontal concerns – 32% bleeding score. Needed to return to perio for reviews which affected pace of completing treatment
Acute pain arising when addressing another tooth
Plaque score is still high -> more work needed before tooth replacement options are considered
patient’s busy schedule: Patient went on long hoiliday mid treatment delaying progress of treatment
Returning to review perio often slowed down progress of addressing carious lesions so managing the balance of high perio and caries risk was challenging
How did the patient respond to the treatment, and what post-operative instructions were given where relevant?
Patient Response:
Reported improvement in symptoms post-restoration.
Motivated to follow preventive advice and attend regular reviews.
Post-Operative Instructions:
LL8 restoration: Advised avoiding hard foods for 24 hours, maintaining fluoride use.
Periodontal therapy: Reinforced daily interdental cleaning and hydration.
Smoking cessation: Encouraged continued efforts to quit vaping.
What follow-up protocol did you establish to monitor the success of the case?
hree-Monthly Reviews:
Due to high caries and periodontal risk, scheduled regular plaque and bleeding score assessments.
Radiographic Monitoring:
Planned follow-up PAs to assess periodontal stability and UR2 RCT progress in 1 year.
Long-Term Maintenance:
Once stabilized, patient will transition to GDP-led maintenance for ongoing care.
How did you ensure the patient was fully informed and comfortable throughout the treatment process?
Throughout the treatment process, I prioritized clear communication and patient comfort. I ensured the patient was fully informed by using simple, jargon-free explanations and discussing all treatment options, risks, and benefits and alternatives.
To enhance understanding, I used visual aids, including radiographs and diagrams, to explain findings and procedures. I also encouraged shared decision-making, allowing the patient to express concerns and preferences.
Given his occupation as a chef, I tailored advice to his lifestyle, ensuring practical oral hygiene strategies that fit his schedule. Additionally, I provided written post-operative instructions to reinforce key points and prevent confusion after appointments.
For comfort, I maintained a calm and reassuring approach, ensuring adequate pain control during procedures and checking in regularly to assess his experience. His feedback guided adjustments, ensuring a positive treatment journey
Were there any ethical considerations or special precautions you had to take for the case?
Ethically, I adhered to patient autonomy, ensuring informed consent was obtained before every procedure. I respected his right to make decisions about his care, even when discussing treatment alternatives.
A key precaution was ensuring periodontal stability before definitive restorations—this prevented premature interventions that could compromise long-term outcomes. Additionally, I considered occupational factors, advising strategies to minimize acid exposure from frequent tasting.
safety netting: Informing patient of risk of not XLA UR7 now -: risk of infection.
risk of placing implants before gingival health is reached -
