Case Presentation

Question 1

Why was your patient not concerned about his appearance until now?

Answer 1

He has a complex home life and his appearance wasn’t his priority. Being promoted to a managerial position at work has made him more conscious of his appearance and his partner has also been pushing him to take better care of his oral health and appearance.

Question 2

What was wrong with the immediate denture provided 3 years ago?

Answer 2

The denture was fitted on the day of the extractions. The patient felt that the dentist fitted a denture that didn’t actually fit his mouth. He was unable to seat it or tolerate it. At the time, the spaces didn’t concern him and he was still able to function so did not return to have this resolved.

Question 3

Why does the patient want a denture now?

Answer 3

He is now more aware of his appearance and wants to improve on this. He is also aware that he is in need of further treatment including extractions and wants to be able to wear a denture rather than be left completely edentulous.

Question 4

What does the patient expect from a new denture?

Answer 4

Mainly aesthetics. He wants a denture that he will be able to tolerate in public to improve his appearance and replace missing teeth. He is aware that tolerating a denture will be difficult but is keen to persevere. He is happy to wear a denture outwith his home, and can function without a denture at home for meal times if he does find them too uncomfortable

Question 5

Why does the patient take omeprazole?

Answer 5

He takes it for prevention of gastric ulcer relapse. He has a history of gastric ulcers but is currently asymptomatic. He has no history of reflux and doesn’t remember when he last had gastric issues.

Question 6

What is omeprazole and how does it work?

Answer 6

It is a proton pump inhibitor.
It inhibits gastric acid secretion by blocking the proton pump system of the gastric parietal cells

Question 7

Are there any side effects of omeprazole that could impact the patients oral health?

Answer 7

Dry mouth is listed as a common side effect, however the patient has not had a dry mouth on examination and does not complain of any side effects.
Nausea and vomitting are also common side effects, but the patient does not complain of having suffered this.

Question 8

Will the patients’ allergy to penicillin affect your treatment?

Answer 8

No changes will have to be made to the treatment plan. However, if a script for ABs was needed, I would prescribe metronidazole instead at 400mg 3 x daily for 5 days

Question 9

what are the signs and symptoms of anaphylaxis?

Answer 9

*Flushing
*Sweating
*Nausea and abdominal pain
*Possible rash
*Swelling of soft tissues
*Swelling of throat and tongue
*Wheezing
*Difficulty breathing
*Increased heart rate

Question 10

What actions should be taken in the event of anaphylaxis?

Answer 10

*Reassure the patient
*Carry out A-E assessment
*Dial 999 for ambulance
*Administer oxygen at 15 litres per minute
*Raise patients legs to help restore their BP
*If symptoms are life threatening, administer IM injection of adrenaline into outer aspect of thigh
*Can be repeated after 5 minutes on opposite thigh
*0.5ml adults, 0.3ml 6-12years, 0.15ml 6mo-6yr
*Continue to assess and reassure patient

Question 11

What is the pack years of your patient?

Answer 11

20 pack years = 20 cigs per day for 20 years

Question 12

Did you offer smoking cessation advice to your patient?

Answer 12

Yes, initially offered cessation advice in the format of the 3 As

Ask - establish and record smoking status

Advise - on personal benefits of quitting in light of findings in the mouth

Act - Offer help and sign post to local stop smoking services

Patient declined advice. Has never quit, is not interested in quitting.

Advised patient that a referral can be made if he changes his mind, he can also approach me or a pharmacist in the future if he changes his mind. Also advised him that I will revisit his smoking status at future appointments

Question 13

What are some oral side effects of tobacco use?

Answer 13

* Smokers are 2-4 x more likely to develop potentially malignant lesions

* Smoking is an independent risk factor for periodontal disease (relative risk 2-6 x that of non smokers)

* Smoking increases dental treatment risks and problems ie dry socket following extraction

* Smokers have significanly greater medical risks, compromised health and more days of illness

* Tobacco and alcohol are the main determinants of oral cancer, if both are present, the risks are synergistic

Question 14

Name two potentially malignant lesions that can present in a smoker

Answer 14

Leukoplakia

Erythroplakia

Question 15

What is the connection between smoking and periodontal disease?

Answer 15

* Smoking associagted with increased rates of alveolar bone loss, attachment loss and pocket formation

* 40% of chronic periodontitis is attributable to smoking

* Smoking demonstrates a dose response with periodontal disease

* Smoking has a masking effect on gingival symptoms of inflammation

Question 16

List some other tobacco related oral lesions

Answer 16

* Staining of teeth, restorations and dentures

* Halitosis

* Nicotine stomatitis (smokers palate)

* Smokers melanosis

* Black hairy tongue

* Extractions take longer to heal

Question 17

What are some systemic risks of smoking?

Answer 17

* Stroke

* Cancer of lips, tongue, throat, larynx, oesophagus

* Heart attack

* COPD

* Chest infections

* Lung cancer

* Stomach ulcers

* Delayed healing

Question 18

What are some benefits of stopping smoking?

Answer 18

* CO returns to normal within 48 hours

* Nicotine leaves the body within 72 hours

* Breathing improves within 2 weeks to 3 months

* After one year, the risk of cardiovascular disease is half that of a smoker

* Financial benefits

Question 19

What is the link to smoking and alcohol consumption to oral cancer risk?

Answer 19

Smoking and drinking in combination can increase oral cancer risk by up to 30%

There is also a link between oral cancer and poor diet. This is not something I have discussed with my patient. This is something I plan to visit with him on the return of the diet diary

Question 20

Was your patient prescribed duraphat? What concentration?

Answer 20

I did consider the prescription of duraphat and it was a discussion I had with my supervising clinician. As the patient has not been very engaging, and due to oral hygiene being so suboptimal, it was decided that prescribing high fluoride toothpaste would have minimal benefit.

The patients home life was also taken into consideration, the risk of his daughter having access to the duraphat.

However, if it were to be prescribed, it would have een 5,000 ppmF

Question 21

What impact could the patients social history have on his oral health?

Answer 21

The patient has a high stress home and work life.

He often works 7 days per week, and although he genuinely enjoys his job, it means he spends long hours away from home.

As the manager, his time and attention is in high demand.

He is expected to be the first person to arrive and the last person to leave.

He has frequent coffee and cigarette breaks and food is usually bought out of convinience.

At home he lives with his partner and their teenage daughter. His daughter is autistic and is currently home schooled. This is a responsibility his partner has taken on and so it falls on him to provide for the family financially.

This also means that time spent at home is not relaxing, after working hours he takes on his share of the household tasks too.

He is a very dedicated father and is often doing things to please his daughter such as DIY to make home and garden improvements as well as taking on responsibilities as a pet owner. The family currently have two adult dogs and two of their pups (but recently had all 7 pups until the others found homes). They also have ginuea pigs

Question 22

What preventive advice was given to your patient?

Answer 22

* Tooth brushing advice. Patient states he brushes 2 x daily with colgate toothpaste. Reassured patient that this is ideal, and to ensure he is spending 2 minutes twice daily. Discussed and demonstrated brushing gums as well as teeth, and emphasised the importance of brushing before bed.

* Advised pt to spit excess toothpaste and not rinse.

* Recommended the use of disclosing tablets

* Advised pt that manual toothbrush is adequate with good technique but offered advice on the use of an electric toothbrush also.

* Sized and demonstrated the use of interdental brushes. Patient given a variety of brushes to try at home. States he is using the brushes severeral times per week (not always daily) but evidence of this lacking.

Question 23

What is the BPE?

Answer 23

The BPE is a screening tool employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis or periodontitis, irrespective of historical attachment loss and bone loss. As such, the BPE guides the need for further diagnostic measures prior to establishing a definitive periodontal diagnosis and appropriate treatment planning

Question 24

What are the definitions of periodontal health?

Answer 24

• Patients with an intact periodontium
• Patients with a reduced periodontium due to causes other that periodontitis
• Patients with a reduced periodontium due to periodontitis

Question 25

Describe gingival health

Answer 25

• Clinical gingival health on an intact periodontium is characterised by the absence of BoP, erythema and edema, patient symptoms, and attachment and bone loss
• Physiological bone levels range from 1-3mm apical to the cemento-enamel junction
• For an intact periodontium and a reduced and stable periodontium, gingival health is defined as <10% bleeding sites with probing depths <3mm

Question 26

What are the clinical signs of improved health following HPT?

Answer 26

* Pocket depths <4mm *BoP <10% * Plaque score <15%

Question 27

How do you rate the assessment of current periodontal status?

Answer 27

Currently stable; BoP <10%, PPD = 4mm, No BoP at 4mm sites

Currently in remission; BOP >/= 10%, PPD = 4mm, no BoP at 4mm sites

Currently unstable; PPD >/= 5mm

PPD >/= 4mm and BoP

Question 28

What is TIPPS?

Answer 28

Delivery method of OHI

Talk, instruct, practice, plan, support

Question 29

What does a BPE of 3 and 4 indicate?

Answer 29

3 = probing depth of 3.5-5.5mm

4 = probing depth >5.5mm

May also have calculus, overhangs or other plaque retentive factors

Question 30

Why was a 6 point pocket chart carried out? What guidance was followed?

Answer 30

Followed SDCEP which recommends 6PPC for all sextancts of scores of 3 and above BEFORE and AFTER treatment.

This differs from BSP which recommends 6PPC after initial treatment of OHI and removal of supra and subgingival plaque and calculus.

Question 31

Why were full mouth PAs taken? Why not an OPT?

Answer 31

As per BSP guidelines, radiographs should be taken for all code 3 and 4 sextants. Each tooth should be assessed individually.

OPT may have overlap therefore obscure the view of some teeth/roots/surrounding alveolar bone. And so PAs were more appropriate

Question 32

How did your patients plaque and bleeding scores improve?

Answer 32

Plaque improved from 83% to 64%

Bleeding improved from 64% to 21%

Question 33

Why were clinical photos taken?

Answer 33

To supplement radiographs and assist in treatment planning. Something that can be utilised when the patient is not present

Question 34

What sensibility tests were carried out and why?

Answer 34

ECl and EPT of 31, 41 and 42

31 Requires extraction due to unrestorable root caries

41 shows a periapical radiolucency on the radiograph and sensibility testing helped make an appropriate diagnosis of pulpal necrosis

42 apprears sound, however poor periodontal prognosis and the decision was made to extract due to that and it being a lone standing tooth if left

Question 35

What materials are being used for 23 and 26 and why?

Answer 35

23 would like to use composite as it is strong and aesthetic but depends on moisure control. May have to use GI as an alternative.

26 plan to use amalgam as patient not concerned about appearance and moisture control requirements lesser than for composit

Question 36

Why consider Colbalt chrome in future?

Answer 36

Design may be easier to tolerate due to thin cross section.

Cleaning may be easier as less encroachment on gingivae.

More difficult to add to if further extractions requires so not being provided initially

Question 37

Define an engaging patient

Answer 37

Favourable improvement in OH indicated by 50% improvement in plaque and marginal bleeding scores or

Plaque levels below 20% and bleeding scores below 30% or

Patient has met targets outlined in their personal self care plan as determined by their health care practitioner

Question 38

Define a non engaging patient

Answer 38

Insufficient improvement in OH

Plaque levels >20% and bleeding levels >30%

or patient states preference to palliative approach to periodontal care

Question 39

Give four examples of how fluoride works

Answer 39

* slows down the development of decay by stopping demineralisation of dentine * makes enamel more resistant to acid attack from plaque bacteria *speeds up remineralisation * can stop bacterial metabolism (at high concentration) to produce less acid