Case Presentation Questions Flashcards
Medication - Amlodipine
○ Calcium channel blocker. Calcium channel blockers are medications used to lower blood pressure. They work by preventing calcium from entering the cells of the heart and arteries. Calcium causes the heart and arteries to squeeze (contract) more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open.
○ Used to treat hypertension.
○ Blocks calcium channels in the smooth muscle to relax and vasodilate the peripheral blood vessels and lowers blood pressure, and increases the supply of blood and oxygen to the heart while reducing its workload.
○ Dental side effect - gingival hyperplasia.
Amlodipine is an oral dihydropyridine calcium channel blocker. Compared to nifedipine and other medications in the dihydropyridine class, amlodipine has the longest half-life at 30 to 50 hours. The benefit of such a long half-life is the ability to have once-daily dosing.
Amlodipine dihydropyridine - how do dihydropyridines work?
Refer to picture in notes.
Captopril medication
○ ACE inhibitor.
○ Angiotensin converting enzyme inhibitor, inhibiting the conversion of angiotensin I to angiotensin II.
○ Angiotensin II is a peripheral vasoconstrictor. It also acts on the adrenal cortex to promote the release of aldosterone which increases sodium resorption in the cortical collecting ducts.
○ Renin-angiotensin-aldosterone system.
○ ACE inhibitors therefore reduce blood pressure and reduces excess salt and water retention also.
Associated side effects of ACE inhibitors include cough, hypotension, oral angio-oedema (contra-indication) and lichenoid reactions.
Allopurinol
○ Allopurinol is in a class of medications called xanthine oxidase inhibitors. It works by reducing the production of uric acid in the body. High levels of uric acid may cause gout attacks or kidney stones.
○ Allopurinol is used to prevent gout attacks, not to treat them once they occur.
Allopurinol works by inhibiting xanthine oxidase (XO), the enzyme responsible for converting hypoxanthine to uric acid which is deposited as crystals in the joints of gout sufferers.
Simvastatin
○ Statin - lipid lowering medication.
○ HMG coA reductase inhibitor.
○ Simvastatin is a prodrug meaning it is metabolised in the liver to give the active form.
○ It inhibits cholesterol synthesis in the liver.
○ Reduces total cholesterol and LDL cholesterol.
○ Reducing cholesterol can reduce the chance of atherosclerosis building up and it reduces the levels of atherosclerosis over time.
○ Needs to be taken for 10-20 years to see the benefit.
○ Total cholesterol - a measure of the total amount of cholesterol in your blood. It includes both low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol. LDL (bad) cholesterol - the main source of cholesterol buildup and blockage in the arteries.
○ HDL (high-density lipoprotein) cholesterol, sometimes called “good” cholesterol, absorbs cholesterol in the blood and carries it back to the liver. The liver then flushes it from the body. High levels of HDL cholesterol can lower your risk for heart disease and stroke.
○ Statins primarily inhibit hepatocyte cholesterol synthesis and increase LDL receptor transcription and hepatic LDL cholesterol uptake. Consequently, statins reduce systemic concentrations of LDL cholesterol by 25–55%. Plasma HDL cholesterol levels may rise by 8–10% with atorvastatin.
○ Side effects - possible myositis associated with some drug interactions ie some antifungals.
Myositis is muscle inflammation.
Omeprazole
○ Proton Pump Inhibitor - reduces acid secretion. Completely block acid secretion.
To treat GORD
Omeprazole - how do PPI’s work?
Refer to picture in notes.
Reasons for not restoring porcelain 11 veneer
- Very erythematous gingivae surrounding the veneer - PRF.
- Pt liked the look of it.
- It was a veneer that had been replaced 3 times as it kept falling out but this one had been in for at least a couple of years - difficult restoration.
- It was established that due to the perio condition, it would be better to get the perio under better control so that we could get a better idea of the gingival margin level (gingivitis to go down) and we could possibly revisit this further down the line.
- Once perio condition settled, gingivae surrounding the veneer was much healthier and less erythematous. Pt was advised to focus on this area in terms of thier OH and advised that the veneer may need to be replaced in the future.
Patient very motivated in terms of OH.
Reason for denture over fixed prostheses
- Patient used to dentures.
- Cochrane review published in 2012 regarding the interventions for replacing missing teeth: partially absent dentition does say there is not any evidence so suggest that one form of tooth replacement is best, but a fixed option is preferrable to removable.
- Kayser 1981 Shortened dental arch - oral function can be maintained with a reduced dentition alone without any prosthetic replacement - need 9 or 10 occluding pairs. We only have 4 occluding pairs in this example.
Dentures
- Kennedy Classes:
○ Upper - class 1 mod 1.
○ Lower - class II mod 1.- Craddock classes:
○ Upper and lower - class III. - Acrylic baseplate and wrought stainless steel clasps (0.5mm undercut and 7mm length).
- Co-Cr Vs PMMA:
○ Co-Cr rigid and strong. Whereas, PMMA is flexible and has poor strength.
○ In Co-Cr, rests and clasps are integral to the base. Whereas, clasps are incorporated mechanically within the base, creating weak points (mechanical rather than chemical bond) which can lead to denture failure.
○ PMMA is better to be used when opposing forces are light. - Retention is achieved by mechanical means, muscular and physical means.
- Physical retention - adhesion cohesion forces. Negative pressure/peripheral seal.
- Craddock classes:
Radiographic justifications
- Full mouth OPT - bone levels.
- PA’s:
○ PA pathology.
○ Caries.
○ Supporting bone.
EWL radiograph - 13.
- PA’s:
Justification for RCT of 13
- Key tooth for dentures - good tooth to clasp, long roots etc.
- Pulp necrosis and asymptomatic periapical periodontitis - prevention of tooth becoming asymptomatic.
Aim to save the tooth rather than the need for extraction if untreated.
- Pulp necrosis and asymptomatic periapical periodontitis - prevention of tooth becoming asymptomatic.
Justification for leaving the RR 36
- Discussed with pt.
- Explained that it would be a surgical procedure to be removed as the root is not visible clinically.
- Not causing the pt any problems.
- Pt aware it may need to be extracted in the future.
Consequences of retained root - passive eruption, may come through at a later stage, it may become symptomatic - very rare. Radicular cyst.
Why only review 6PPC?
Following XLA of teeth of poor prognosis - 27, 33, 47 (prioritised due to discomfort), BPE’s were of 2’s and 3’s. Therefore, only 6PPC following HPT only (no BPE’s of 4).
- 2 3
3 - -
Why did I not sensibility test 33?
- Due to the true extent of the mobility of the tooth and the active suppuration. Felt the sensibility test would not have altered our tx plan, we will be taking the tooth out regardless.
- We also had a PA radiograph available to show the true extent of the mesial bone loss ~90% - difficult to detect PA pathology due to bone loss but it looks like there is most probably no PA pathology - no caries.
In retrospect, we could have taken a sensibility test but I do not think it would have altered the tx in any way.
In retrospect, it would have been helpful to distinguish between perio abscess or perio endo lesion.
- We also had a PA radiograph available to show the true extent of the mesial bone loss ~90% - difficult to detect PA pathology due to bone loss but it looks like there is most probably no PA pathology - no caries.
33 not caries
Not caries on the 33 - could be a divet caused by toothwear (toothbrush abrasion), scaling, could be natural root shape.
Reasons for toothwear
- Reasons for toothwear - alcohol intake, previous GORD experience, lack of posterior support from poorly fitting denture.
Educated patient about the effects that alcohol was having on the patients teeth and talked about their risk for oral cancer. Could possibly signpost or refer to alcohol services in the future if toothwear were to continue to progress and patient showed no signs of cutting alcohol intake after advice given - only if patient gave consent and was motivated.
Why acrylic denture rather than Co-Cr
We went for an acrylic denture because we could get good palatal coverage. As some of the teeth remianing were of poor prognosis (looking at 6PPC, still 6mm pocket midpalatally), the acrylic baseplate makes it easier for the denture to be modified later (extra teeth added) - easier than Co-Cr. We also still utilised stainless steel clasps on the acrylic denture to gain more retention.
Refer to picture in notes.
Geographic tongue
- Geographic tongue affects 1-2% of the population.
- Desquamation happens at varied patterns and timings.
- Desquamation - a condition where the outer layer of the skin starts to replace itself. Often, this happens when your skin is damaged, either by diseases or injuries. Usually, peeling skin is not noticeable or a cause for concern.
- It may appear and stay permanently or it may leave over time.
- Geographic tongue - this is a condition where there is an alteration to the maturation and replacement of the normal epithelial surface. In individuals where the tongue surface is being replaced normally, this will happen in random areas of the tongue as the patient goes through life and you will therefore not notice that there is a change tot he epithelium as it is being replaced. In geographic tongue, whole areas of the epithelial surface are replaced on a single occasion. This starts with halting the epithelial replication so the continuing loss of cells from the surface of the tongue without replacement results in thinning of the epithelial layer, making the tongue appear redder because there is less of a barrier between the underlying connective tissue. After a few days, the epithelial reproduction restarts. New epithelial cells are produced in these areas and the thickness of the epithelium increases and the appearance returns to normal and the sensitivity settles.
- This can also be associated with sensitivity to spicy foods as the red areas are closer to nerves.
- Many areas where we have changes between areas of the tongue surrounded by a white and red margin. As the epithelium is produced more slowly, the area will become red as the surface thins and as production switches back on again, the epithelium will be replaced and the tongue surface will return to normal. We often get crescent shaped areas where this is taking place - may be dorsal tongue, lateral margin of the tongue.
- In some patients, this can occur not only on the tongue but maybe on the buccal mucosa and the palate. So if there are small areas of change on the tongue with semi-circular white and red margins are most often geographic tongue.
- larger areas where change is taking place. Erythematous margins and normal epithelium also seen. This pattern is more patchy compared to the LHS which has a more focal appearance.
- Geographic tongue is not a disease but a disorder of maturation and requires no treatment. Most are completely asymptomatic.
- Can start at any age.
- The more sensitive the tongue is, the more likely they are to have problems.
- Children with geographic tongue tend to have more problems with sensitivity than older patients.
- This is a benign condition managed by eating comfortable foods during the periods of geographism. In most cases, there will be symtpoms for a bout a week till the symptoms go away and the process will not repeat for months.
- Symptoms can be intermittent - sensitive to acidic/spicy foods. The patient also may have no symptoms (most patients have no symptoms). If there are symptoms, this may indicate that something else is causing the trouble ie haematinic deficiency such as B12, folate, ferritin. Parafunctional trauma or dysaesthesia.
- Therefore if a patient presents with symptoms of the tongue and you notice geographic tongue, this may not be the cause of the patients symptoms - are the symptoms occurring all of the time or only when the appearance of the tongue changes - ask the patient to take a picture of the tongue when it is symptomatic to allow us to understand if geographic tongue is causing the symptoms.
If we are unsure if a patients symptoms are being caused by geographic tongue or something else, have their haematinics assessed.
Totally benign and not pre-malignant.
Why no immediate denture?
- Teeth were symptomatic so we felt that this was the priority - did not want to suspend the extractions.
- Patient was not concerned about the aesthetics.
- We knew a new denture was on the treatment plan so the patient would not have the immediate for long and they already had a denture that although it did not fit very well, they were coping well with it.
- There was a rest present on the Co-Cr on the 27 but none of the other extracted teeth had any clasps or rests on them - no major effect on the way the denture fit.
- Molars not visible, canine visible but patient not concerned.
Difficult to add teeth to a Co-Cr denture - did discuss this with the patient but they were not concerned, the extraction of the teeth was the priority.
Why did I do both an EPT and Ethyl chloride sensibility test?
- Sensibility tests are subjective and not the most reliable thing in the world, hence the need for control teeth recordings.
- A diagnosis should not be based solely on sensibility tests.
- The function of a sensibility to test is to try and differentiate a vital from a non-vital teeth. However, sensibility tests do not measure vitality (blood flow), they meausre nerve responses.
- Sensibility tests will detect a false positive in teeth that are partially necrotic.
- We would need laser doppler flowmetry or a true vitality test to truly determine vitality.
- It was thought that if we couple an EPT with an ethyl chloride test, this would perhaps help to increase the reliability of the tests if they detected the same results.
The tests are not very time consuming and we have the materials for both tests which are readily accessible, so may as well do both.
EPT - a delta fibres stimulated by unmyelinated C fibres may not respond.
Dental effects of amlodipine medication
- Amlodipine:
○ Amlodipine causes gingival overgrowth.
○ Gingival overgrowth more common in patients with poor oral hygiene.
Amlodipine reduces Ca2+ cell influx, leading to a reduction in the uptake of folic acid, limiting the production of active collagenase. Collagen is normally degraded by collagenases. Because of reduction in degradation, collagen accumulates in connective tissue matrix of gingiva.
What medications can cause gingival overgrowth?
Anticonvulsants ie phenytoin, immunosuppressants ie cyclosporin, calcium channel blockers ie amlodipine, nifedipine, verapamil - all can cause gingival overgrowth.
When was the veneer placed?
Veneer placed in Jan 2016 after previous one fell off - third veneer.
Why did the patient originally get a veneer?
Initially got veneers due to toothwear associated with GORD. However, the notes are not very clear - first mention of a veneer on 11 back in 2002 in notes.
Drug interactions - simvastatin
- Simvastatin - Do not prescribe:
○ Reacts with clarithromycin antibiotic - increases exposure to simvastatin - Exposure, also called drug exposure, is defined as the drug levels observed in the body after administration. .
○ Reacts with fluconazole antifungal capsules, miconazole antifungal gel.
Grapefruit increases exposure to simvastatin.
Drug interactions - captopril
According to the BNF, Captopril is predicted to increase the risk of hypersensitivity and haematological reactions when given with Allopurinol. Manufacturer advises caution.
Why sensibility test 13?
- Obvious palatal pulpal exposure.
- Determine if tooth is vital or non-vital.
Be utilised alongside HPC, pain history and PA radiograph to determine a periapical diagnosis.
In retrospect, I suppose it probably did not change treatment outcomes or options due to the fact that the pulp was exposed - either would have been RCT or XLA.
- Determine if tooth is vital or non-vital.
How long do veneers last?
- Entirely individual and varies on a case to case basis, but on average, 8-10-15 years, 10 years on average.
- Reasons for early failure of porcelain veneers:
○ Avoid biting down excessively on hard foods, ice cubes and chewing indelible items such as pen tops.
○ Need to ensure good OH to prevent caries and periodontal disease affecting the prognosis of the veneer also.
Bruxism can also affect prognosis.
- Reasons for early failure of porcelain veneers:
Alcohol Advice
- 3 A’s:
○ Ask - how much alcohol is being consumed in a week, what drinks are being consumed, have you tried to reduce or eliminate consumption in the past? How did it go? Are you interested in stopping now?.
○ Advise - 14 units per week, spread over 3 days with several alcohol free days, eating when drinking, alcohol free options, water in between.
○ Act - refer or signpost ie GP referral.- 5 A’s:
○ Ask.
○ Advise.
○ Assess.
○ Assist.
Arrange follow up.
- 5 A’s:
Alcohol units
- Alcohol units:
○ 25ml spirit - 1 unit.
○ Pint has 2-3 units.
Small glass of wine - 1.5 units.
