Name: Mary Brown
Age: 64 years
Gender: Female
Occupation: Retired schoolteacher
Location: Fremantle, Australia
Chief Complaint: “My gums bleed when I brush, I can’t chew properly, I have pain on one of my back teeth on upper LHS and one of my back teeth on lower RHS broke a few months ago.”

Cardiovascular: Hypertension (moderately controlled), atrial fibrillation (on Warfarin, INR 2.5-3.0), history of TIA (4 years ago).
Endocrine/Metabolic: Type 2 diabetes mellitus (15 years, HbA1c 8.9%), hyperlipidaemia.
Musculoskeletal: Osteoporosis (10 years, on bisphosphonate therapy), rheumatoid arthritis (on methotrexate + prednisone).
Respiratory: COPD (mild, inhaler use).
Gastrointestinal: Gastro-esophageal reflux disease (GERD).
Oncology: History of breast cancer (treated with mastectomy + radiotherapy 12 years ago, no recurrence).

Extraoral Examination:
- Mild bilateral angular cheilitis
- TMJ: Mild crepitus on right side on opening
- No lymphadenopathy
Intraoral Examination:
- Oral hygiene: Poor with thick plaque deposits
- Gingiva: Swollen, erythematous, bleeding on probing, recession present
- Missing teeth: 14, 18, 38

Tooth 26:
- Finding: Heavily restored with secondary caries.
- Pulp Test (CO2): [-] (Negative)
- Percussion Test (TTP): [VT] (Very Tender)
Tooth 47:
- Finding: Fractured MB cusp with M (Mesial) secondary caries.
- Pulp Test (CO2): [++] (Positive/Responsive)
- Percussion Test (TTP): [VT] (Very Tender)
NCTSL (Non-Carious Tooth Surface Loss):
- Finding: Generalised erosion of palatal surfaces of maxillary anterior teeth.
- Sensitivity: 12, 11, 21, 22 sensitive to triple syringe air and water.

Diagnosis List and Additional Testing

Pain in Upper LHS ‘==pain ; caries (infection), presenting complaint therefore acute ’
- 26
  - Mesial Caries into outer 1/3 dentine
  - Distal Caries into inner 1/2 dentine
  - Disto occlusal decay under restoration
  - 26 has previously had a pulpotomy
  - and MOD Amalgam restoration
    - some amalgam might be in pulp chamber
“One of my back teeth broke” ==pain caries (infection) , presenting complaint therefore acute
- 47
  - Primary acute apical periodontitis
    - pain (differentites it from chronic)
    - No radiolucnecy (differentiates it from chronic)
  - Mesial Caries Extending into pulp (or inner third dentine) under the restoratoin
  - Broken MB cusp
Periodontal = Gums Bleed when I brush - Generalized Inflammation and gingivitis - 86% BOP - Poor OHI - 96% Plaque Index -

Additional Testing

Periodontal
- Since a BPE of 4 is present we must record a 6 point pocket chart in the dentiion