Quartz 4

Case Presentation Abbott

25 min read

Case Presentation1

Dr Lyndon P Abbott

lyndon.abbott@uwa.edu.au

Patient Profile and History2

  • Age/Gender: 68-year-old male
  • Chief Complaint: Progressive shortness of breath and dry cough over the past six months.
  • Medical History:
    • Hypertension (controlled with Lisinopril)
    • Type 2 Diabetes Mellitus (managed with Metformin)
    • No history of asthma or known allergies
  • Social History:
    • Former smoker (20 pack-years, quit 15 years ago)
    • Retired construction worker with potential occupational dust exposure

Clinical Presentation

Upon physical examination, the patient exhibited fine bibasilar inspiratory crackles (velcro-like) and mild digital clubbing. Oxygen saturation was 92% on room air at rest, dropping to 88% during a six-minute walk test.

Diagnostic Investigations3

  1. Pulmonary Function Tests (PFTs):

    • Restrictive pattern observed
    • Reduced Forced Vital Capacity (FVC)
    • Decreased Total Lung Capacity (TLC)
    • Significantly reduced Diffusion Capacity of the Lungs for Carbon Monoxide (DLCO)

  2. Imaging:

    • Chest X-ray: Showed increased reticular markings in the lower lung zones.
    • High-Resolution Computed Tomography (HRCT): Revealed subpleural honeycombing, traction bronchiectasis, and reticular opacities consistent with a Usual Interstitial Pneumonia (UIP) pattern.

Laboratory Results

  • Autoimmune serology (ANA, RF, anti-CCP) returned negative, ruling out common connective tissue diseases as the primary cause of the interstitial lung disease.

Case Presentation General Principles

Presenter Information4

  • Dr Lyndon P Abbott
  • Graduated DMD in 2019
  • Current Dental Graduate Officer at UWA

Purpose of the Examination5

The case presentation exam ensures you are safe to practice ethical, appropriate and evidenced based dentistry.

Presentation Objectives6

  • Showcase your hard work
  • Convince the examiners you can practice ethical, appropriate and evidenced based dentistry

Factors Outside Your Control7891011

  • Date and time
  • Venue
  • Projector, IT
  • Questions

Factors Within Your Control

  • Chosen patient

  • Examination and diagnosis

  • Amount of research papers you read

  • Amount of tutors you talk to

  • Amount of time spent preparing and rehearsing your case presentation

  • Date and time

  • Venue

  • Projector, IT

  • Questions

  • Chosen patient

  • Examination and diagnosis

  • Amount of research papers you read

  • Amount of tutors you talk to

  • Amount of time spent preparing and rehearsing your case presentation

Start early.

  1. PLAN
  2. PREPARE
  3. PERFORM

Examination and Treatment Planning Guidelines

Purpose and Scope12

The aim of this Clinical Guideline is to provide advice to OHCWA students and clinicians regarding comprehensive oral exam and treatment planning. Evidence-based clinical guidelines are intended to provide guidance, and are not a standard of care, requirement, or regulation. However, the application of clinical guidelines in publicly-provided oral health services allows for consistency to occur across large patient cohorts with a variety of oral health clinicians.

This Clinical Guideline plans to:

  • Standardise the way in which all patients are assessed
  • Establish a standardised sequence for a thorough comprehensive examination to reduce overlooking any area to be examined

Goals of Dental Treatment

The aim of dental treatment is to assess, restore and maintain the health, function and efficiency of dental and related tissues, and thereby improve the oral, general and psychological health of a patient. Treatment should be designed to prevent further dental disease and to restore lost tissue and function. Patients should be educated to an awareness of the importance of their dental health and how such health may be maintained.

Examination Template (011)13

  • P/C (Presenting Complaint):

    • Pain/discomfort:
    • Loss of function:
    • Appearance:
    • Expectations:

  • HPC (History of Presenting Complaint):

  • MH (Medical History): updated, see medical notes

    • Adverse Drug Reactions: none declared

Consent obtained to carry out dental examination

  • EO (Extra-oral): TMJ, MOM, LN, thyroid, lips – all NAD

  • IO (Intra-oral): Buccal mucosa, hard palate, soft palate, glossopharyngeal, tongue, FOM – all NAD

  • Teeth as per odontogram:

    • TTP:
    • TT pal:
    • Mobility:

  • Occlusion:

    • OJ:
    • OB:
    • Molar class:
    • Crossbite:
    • Crowding:
    • Super-eruption:

Patient Selection and Preparation14

Selection Strategy15

  • Patient selection
  • Multidisciplinary
  • Select your patients early and treat all patients as possible case presentation patients

Take photos!!!

Patient Background16

  • Patient Details
    • Importance of Social History
  • Medical History
    • How does this medical history impact the overall dental management of this patient

Clinical Diagnosis and Problem List

Presentation of Diagnoses17

  • Have a systematic way of presenting the patient’s examination
  • Don’t waste time just listing diagnoses but instead use your time to explain the critical thinking underpinning each diagnosis

Treatment Planning and Communication

Treatment Planning Strategy18

  • Discuss the different options
  • Keep all the dental diagnosis and problem lists in context with the overall patient
  • Treatment alternative tables
  • Delivery of Treatment

Treatment Alternatives – Oral Surgery Considerations

ProblemTreatment optionsAdvantagesDisadvantagesRationale
Retained roots 27, 47; Unrestorable caries 26No treatment- No cost – time or money
- Reduced risk of post-operative complications		- Doesn’t control disease
- Fabricating a prosthesis will be less predictable, less stable and require more adjustments		Removing teeth with hopeless prognoses not only removes disease but establishes a sound base to then fabricate a dental prosthesis. This process gives further stability and predictability to the dental prosthesis and addresses the patient’s primary concern in the most systematic way.
Extract retained roots 27, 47 and unrestorable 26- Controls disease
- Allows a prosthesis to be fabricated on sound tooth structure and adjacent soft tissues		- Iatrogenic complications
- Excessive haemorrhage
- Post-operative pain, swelling, trismus
- Fracture of roots
- Damage to adjacent teeth
- Infection
- Alveolar osteitis
- Peripheral trigeminal nerve injury
- Oral Antrum Communication (OAC)
- After extraction bone resorption occurs which can compromise the fit of a prosthesis

Communication and Rehearsal19

  • Practice makes perfect
  • Consider writing a script and having things on the slides to help jog your memory
  • Time yourself
  • Deep breaths to slow your heart rate

Handling Questions20

  • The questions will be related to your case so prepare answers by researching relevant topics to your patient
  • See this as an opportunity to demonstrate your breath of knowledge
  • The examiners want you to do well

Strategic Treatment Planning21

  • Formulate a comprehensive treatment plan that addresses the patient’s primary concerns while ensuring clinical efficacy.
  • Prioritize procedures based on urgency, patient health, and long-term stability.
  • Develop alternative treatment options to provide the patient with a range of choices regarding cost, time, and complexity.

Effective Patient Communication

  • Use clear, non-technical language to explain diagnoses and proposed interventions.
  • Utilize visual aids, such as digital scans, radiographs, or intraoral photos, to enhance patient understanding.
  • Ensure informed consent by discussing the risks, benefits, and potential outcomes of each treatment path.
  • Address patient expectations early to align clinical goals with the patient’s desired results.

Patient Case Background

Patient Information and Social History22

Patient Information and Details Kym Duane Hales 57 years old (28/09/1962) Currently unemployed – bricklayer by trade Not married, lives alone Date of first dental appointment: 8/3/2018

Medical History and Risk Factors2324252627282930

Medical History

• No current medications • No known allergies • Hypertension - 150/85 • Myocardial infarction 2007 • Smokes 20 cigarettes per day for 30 years (30 pack years) • interested in quitting • Drinks 20 standard alcoholic drinks per week

• Virdis A, Giannarelli C, Fritsch Neves M, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Current pharmaceutical design. 2010 Aug 1;16(23):2518-25. • Johnson N, Bain C. Tobacco and oral disease. British Dental Journal. 2000 Aug 26;189(4). • Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontol 2000. 2007 Jun;44(1):178-94. • Wong, Tsc, and Wiesenfeld, D. “Oral Cancer.” Australian Dental Journal 63.S1 (2018): S91-S99.

The University of Western Australia

Medical History

  • No current medications

  • No known allergies

  • Hypertension - 150/85

  • Myocardial infarction 2007

  • Smokes 20 cigarettes per day for 30 years (30 pack years)

    • interested in quitting

  • Drinks 20 standard alcoholic drinks per week

  • Vrdis A, Giannarelli C, Fritsch Neves M, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Current pharmaceutical design. 2010 Aug 1;16(23):2518-25.

  • Johnson N, Bain C. Tobacco and oral disease. British Dental Journal. 2000 Aug 26;189(4).*

  • Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontology 2000. 2007 Jun;44(1):178-94.*

  • Wong, T.c, and Wiesenfeld, D. “Oral Cancer.” Australian Dental Journal 63.51 (2018): S91–S99.

  • No current medications

  • No known allergies

  • Hypertension - 150/85

  • Myocardial infarction 2007

  • Smokes 20 cigarettes per day for 30 years (30 pack years)

    • interested in quitting

  • Drinks 20 standard alcoholic drinks per week

  • Virdis A, Giannarelli C, Fritsch Neves M, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Current pharmaceutical design. 2010 Aug 1;16(23):2518-25.

  • Johnson N, Bain C. Tobacco and oral disease. British Dental Journal. 2000 Aug 26;189(4).

  • Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontology 2000. 2007 Jun;44(1):178-94.

  • Wong, Tsc, and Wiesenfeld, D. “Oral Cancer.” Australian Dental Journal 63.S1 (2018): S91-S99.

Medical History

  • No current medications

  • No known allergies

  • Hypertension - 150/85

  • Myocardial infarction 2007

  • Smokes 20 cigarettes per day for 30 years (30 pack years)

    • interested in quitting

  • Drinks 20 standard alcoholic drinks per week

  • Viridis A., Giannarelli C., Fritsch Neves M., Taddei S., Ghiadoni L. Cigarette smoking and hypertension. Current pharmaceutical design. 2010 Aug 16(23):2518-25.

  • Johnson N., Bain C. Tobacco and oral disease. British Dental Journal. 2000 Aug 26;189(4).

  • Johnson GK., Guther Miller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontology 2000. 2007 Jun;44(1):178-94.

  • Wong Tsc, and Wiesenfeld D. “Oral Cancer.” Australian Dental Journal 63.51 (2018): 591–599.

Presenting Complaint and Dental History3132

Presenting complaint, Dental History Presenting Complaint

  • Would like to replace his missing teeth
    • Trauma – 2013 years ago aluminium flashing hit front teeth
    • Longstanding dental neglect

Dental History

  • Hasn’t visited the dentist in 10 years
  • No current pain or discomfort from dentition
  • Lack of function due to multiple missing teeth
  • Socially, very self conscious and doesn’t like leaving his house
  • Expectations are to replace his currently missing teeth and improve function

Oral Hygiene: Brushes teeth twice per day with manual toothbrush and fluoridated toothpaste. Doesn’t floss or use interdental brushes

Presenting complaint, Dental History

{%mark%}

Presenting Complaint

  • Would like to replace his missing teeth
    • Trauma – 2013 years ago aluminium flashing hit front teeth
    • Longstanding dental neglect

Dental History

  • Hasn’t visited the dentist in 10 years
  • No current pain or discomfort from dentition
  • Lack of function due to multiple missing teeth
  • Socially, very self conscious and doesn’t like leaving his house
  • Expectations are to replace his currently missing teeth and improve function

Oral Hygiene: Brushes teeth twice per day with manual toothbrush and fluoridated toothpaste. Doesn’t floss or use interdental brushes

{%endmark%}

Patient Examination and Assessment3334353637

The University of Western Australia

Dr Thomas F. Melia BSc, DASV, PGDM, ADC

Clinical Presentation and History38

The patient is a 64-year-old male who presented with a primary complaint of persistent discomfort and localized swelling in the lower right quadrant of the mandible.

Physical Examination Findings

  • Extraoral Examination: No significant lymphadenopathy or facial asymmetry was noted. The temporomandibular joints functioned within normal limits.
  • Intraoral Examination:
    • Moderate gingival inflammation and recession were observed in the posterior mandible.
    • A localized, firm swelling was palpable on the buccal aspect of the alveolar ridge near the second molar.
    • Tooth #31 exhibited Grade II mobility and was sensitive to percussion.

Periodontal Assessment

  • Probing Depths: Generalized 3–4 mm, with localized 6–8 mm pockets around the distal and buccal aspects of tooth #31.
  • Bleeding on Probing (BOP): Present in 45% of sites, indicating active periodontal inflammation.
  • Attachment Loss: Significant clinical attachment loss was noted in the lower right molar region.

Radiographic Analysis

  • Periapical and Bitewing X-rays: Revealed extensive horizontal bone loss throughout the arch.
  • Specific Findings for Tooth #31:
    • Vertical bone defect on the distal aspect.
    • Evidence of furcation involvement (Class II).
    • Widened periodontal ligament space, suggesting secondary occlusal trauma.

Radiographic Examination3940

Clinical Findings and Charting

Vitality Testing (8/3/2018)41

  • Electric Pulp Test (EPT):
    • Teeth 17, 23, 24: Responded
    • Teeth 27, 23, 24, 26, 16, 22: Responded
  • CO2 Thermal Test:
    • All teeth tested (18-28 and 48-38)
    • Tooth 26: Unresponsive

Clinical Findings: Tooth 26

  • Distal caries with cavitation (ICDAS 6)
  • Not tender to percussion (TTP)
  • Mobility: Grade I
  • Vitality: Unresponsive to CO2 and EPT

Pulpal and Periapical Diagnosis

  • Tooth 26: Pulpless and infected root canal system with chronic apical periodontitis caused by caries.

Periodontal Screening (8/3/2018)42

CPITN Scores:

  • Maxillary: 3 | 4*
  • Mandibular: 3 | 4 | -
Transclude of o5666w67541e7-9VQUb5n-yhol9-pWlyNTeW5rTfV90I7gVvYkX1X8F4vV8e4Y6X0s3Wf631v75s85s246w7X8Q8=240

Gingival Assessment43

  • Colour: Erythematous free gingival margin
  • Texture: Oedematous free gingival margin
  • Contour: Loss of interdental papilla, blunted
  • Biotype: Normal

Plaque Control

  • Plaque Score (17/4/2018): 95%

Periodontal Diagnosis

  • Generalised periodontitis Stage IV, Grade C

Risk Assessment and Problem List4445

Biological and Behavioral Factors46

  • Biological: Normal salivary flow, multiple missing teeth, history of trauma.
  • Behavioral: Poor oral hygiene, cariogenic diet, smoker.
  • CAMBRA: High Caries Risk.

Saliva and Diet Analysis (22/3/2018)

  • Saliva Screening:
    • pH: 7.0
    • Quantity: Normal
    • Buffering capacity: Normal
  • Dietary Habits:
    • High consumption of simple carbohydrates.
    • Five cups of coffee per day with 2 teaspoons of sugar each.
    • Minimal snacking between meals.

Financial and Personal Factors

  • Motivated for treatment and understands current needs.
  • Realistic aesthetic expectations.
  • Currently unemployed (financial consideration).
Problem ListAetiologyObjectives of Treatment Plan
High blood pressure, myocardial infarct 2007Environmental/heredity factors, ischemic heart diseaseMedical referral; short, relaxed appointments
Smokes 20 cigarettes/day, 20 standard drinks/weekPersonal lifestyle choicesSmoking and alcohol cessation advice
Dental neglect, poor hygiene, high plaque/calculusPersonal lifestyle choicesOral hygiene education, debridement, reviews
Cariogenic dietPersonal lifestyle choicesDietary advice and motivation
Periodontal diseaseBacterial plaque and host factorsDebridement and regular reviews
Retained roots 27, 47; Caries 26 DistalCaries and periodontal diseaseInformed consent for extractions
Arrested caries 46 BuccalRemineralisation/tertiary dentineMonitor or restore
Possible external inflammatory root resorption 31, 32Bacterial triggersRe-examine after debridement
Frictional keratosisPhysical irritationMonitor; refer if persistent
Missing teeth, partially dentateTrauma, dental neglectRestore aesthetics and function
Self-conscious about teethPsychosocial implicationsAesthetic dental prosthesis
Unerupted 28Lack of space/impactionMonitor for symptoms
Mole bottom lip RHSMelanocyte clusterContinual monitoring
Suboptimal Panoramic RadiographPoor patient positioningRetake radiograph
Skeletal Class IIPrognathic mandibleCompensatory prosthesis design
High frenal attachments, mandibular toriGenetic/occlusal forcesRelieve prosthesis to prevent sore spots
Speech issues (“S” sounds)Missing maxillary incisorsProsthesis for tongue placement; speech pathology referral if needed
UnemployedFinancial considerationsAppropriate treatment plan for financial situation
Problem ListPathologyObjectives of Treatment Plan
High blood pressure, myocardial infarct 2007Environmental/heredity factors, ischaemic heart diseaseMedical referral; short, relaxed appointments
Smokes 20 cigarettes/day, 20 standard drinks/weekPersonal lifestyle choicesSmoking and alcohol cessation advice
Dental neglect, poor hygiene, high plaque/calculusPersonal lifestyle choicesOral hygiene education, debridement, reviews
Cariogenic dietPersonal lifestyle choicesDietary advice and motivation
Periodontal diseaseBacterial plaque and host factorsDebridement and regular reviews
Retained roots 37, 47; Caries 28 DistalCaries and periodontal diseaseInformed consent for extractions
Arrested caries 46 BuccalRemineralisation/tertiary dentineMonitor or restore
Possible external inflammatory root resorption 31, 32Bacterial triggersRe-examine after debridement
Frictional keratosisPhysical irritationMonitor; refer if persistent
Missing teeth, partially dentateTrauma, dental neglectRestore aesthetics and function
Self-conscious about teethPsychosocial implicationsAesthetic dental prosthesis
Impacted 28Lack of space/impactionMonitor for symptoms
Mole bottom lip RHSMelanocyte clusterContinual monitoring
Suboptimal Panoramic RadiographPoor patient positioningRetake radiograph
Skeletal Class IIIPrognathic mandibleCompensatory prosthesis design
High frenal attachments, mandibular toriGenetic/occlusal forcesRelieve prosthesis to prevent sore spots
Speech issues (“S” sounds)Missing maxillary incisorsProsthesis for tongue placement; speech pathology referral if needed
UnemployedFinancial considerationsAppropriate treatment plan for financial situation

Individual Tooth Assessment and Prognosis47

Individual Tooth Assessment (Samet & Jotkowitz, 2009)48

ToothPeriodontalRestorabilityEndodonticOcclusalAnatomicIatrogenicOverall Prognosis
23QuestionableGoodGoodFairNoNoGood
24QuestionableGoodGoodFairNoNoFair
25CompromisedGoodGoodFairNoNoFair
26HopelessHopelessHopelessFairNoNoHopeless
27CompromisedHopelessHopelessFairNoNoHopeless
33QuestionableGoodGoodFairNoNoFair
32QuestionableGoodGoodFairNoNoFair
31QuestionableGoodGoodFairNoNoFair
41QuestionableGoodGoodFairNoNoFair
42QuestionableGoodGoodFairNoNoFair
43QuestionableGoodGoodFairNoNoFair
45CompromisedGoodGoodFairNoNoQuestionable
47CompromisedHopelessHopelessFairNoNoHopeless
ToothPeriodontalRestorabilityEndodonticOcclusalAnatomicIatrogenicOverall Prognosis
23QuestionableGoodGoodFairNoNoFair
24QuestionableGoodGoodFairNoNoFair
25CompromisedGoodGoodFairNoNoFair
26HopelessHopelessHopelessNoNoNoFair
27CompromisedHopelessHopelessFairNoNoHopeless
33QuestionableGoodGoodFairNoNoFair
32QuestionableGoodGoodFairNoNoFair
31QuestionableGoodGoodFairNoNoFair
41QuestionableGoodGoodFairNoNoFair
42QuestionableGoodGoodFairNoNoFair
43QuestionableGoodGoodFairNoNoFair
45QuestionableGoodGoodFairNoNoFair
46CompromisedGoodGoodFairNoNoQuestionable
47CompromisedHopelessHopelessFairNoNoHopeless

Treatment Alternatives

Periodontal Considerations4950

Periodontal Diagnosis51

  • Generalised Periodontitis Stage IV, Grade C

Treatment Options

  1. No treatment
    • Advantages
    • Disadvantages
  2. Periodontal Debridement of teeth
    • Advantages
    • Disadvantages

Rationale

  • Rationale for selected approach provided in clinical assessment.

References

  • Latheef P, Sirajuddin S, et al. Suppl 1: M7: Iatrogenic Damage to the Periodontium Caused by Periodontal Treatment Procedures. The open dentistry journal. 2015,9:203.

  • Generalised Periodontitis Stage IV, Grade C

  1. No treatment
    • Advantages
    • Disadvantages
  2. Periodontal Debridement of teeth
    • Advantages
    • Disadvantages

  • Rationale for selected approach provided in clinical assessment.

  • Latheef P, Sirajuddin S, et al. Suppl 1: M7: Iatrogenic Damage to the Periodontium Caused by Periodontal Treatment Procedures. The open dentistry journal. 2015;9.203.

Oral Surgery Considerations

Problem: Retained Roots and Unrestorable Teeth52

  • Affected Teeth: Retained roots 27, 47; unrestorable 26
  • Options:
    • No treatment
      • Advantages
      • Disadvantages
    • Extraction of 26, 27 and 46
      • Advantages
      • Disadvantages
  • Rationale: Clinical justification for surgical intervention.

Problem: Retained Unerupted Tooth

  • Affected Tooth: Retained unerupted 28
  • Options:
    • No treatment
      • Advantages
      • Disadvantages
    • Extraction of 28
      • Advantages
      • Disadvantages
  • Rationale: Clinical justification for surgical intervention.

References

  • Steed MB. The indications for third-molar extractions. The Journal of the American Dental Association. 2014 Jun 1;145(6):570-3.

Problem: Retained Roots and Unrepairable Teeth53

  • Affected Teeth: Retained roots 27, 47; unrepairable 26

  • Options:

    • No treatment
      • Advantages
      • Disadvantages
    • Extraction of 26, 27 and 46
      • Advantages
      • Disadvantages

  • Rationale: Clinical justification for surgical intervention.

  • Affected Tooth: Retained unerupted 28

  • Options:

    • No treatment
      • Advantages
      • Disadvantages
    • Extraction of 28
      • Advantages
      • Disadvantages

  • Rationale: Clinical justification for surgical intervention.

  • Steele, MS. The indications for third-molar extractions. The Journal of the American Dental Association. 2014 Jun 1;145(6):570-0.

Prosthodontic Considerations5455

Problem: Missing Teeth56

  • Partially dentate status.

Treatment Options

  • No treatment
  • Partial acrylic maxillary and mandibular dentures
  • Full maxillary acrylic denture and partial acrylic mandibular denture
  • Partial Co/Cr maxillary and mandibular denture
  • Implant supported removable or fixed prosthesis

Clinical Evaluation

  • Advantages
  • Disadvantages
  • Rationale

Clinical Philosophy

“Whatever treatment mode is selected should minimize the long-term biological and soft tissue costs to the patient” — McCord, Smales 2012

References

  • Suwal P, Singh RK, Ayer A, Ray DK, Roy RK. Cast Partial Denture versus Acrylic Partial Denture for Replacement of Missing Teeth in Partially Edentulous Patients. Journal of Dental Materials and Techniques. 2017 Mar 1;6(1):27-34.

  • McCord F, Smales R. Oral diagnosis and treatment planning: part 7. Treatment planning for missing teeth. British dental journal. 2012 Oct;213(7):341.

  • Petridis H, Hempston TJ. Periodontal considerations in removable partial denture treatment: a review of the literature. The international journal of prosthodontics. 2001;14(2):164-72.

  • Partially dentate status.

  • No treatment

  • Partial acrylic maxillary and mandibular dentures

  • Full maxillary acrylic denture and partial acrylic mandibular denture

  • Partial Co/Cr maxillary and mandibular denture

  • Implant supported removable or fixed prosthesis

  • Advantages

  • Disadvantages

  • Rationale

“Whatever treatment mode is selected should minimize the long-term biological and soft tissue costs to the patient” — McCord, Smales 2012

  • Suwal P, Singh RK, Ayer A, Roy DK, Roy RK. Cast Partial Denture versus Acrylic Partial Denture for Replacement of Missing Teeth in Partially Edentulous Patients. Journal of Dental Materials and Techniques. 2017 Mar 1;6(1):27-34.
  • McCord F, Smales R. Oral diagnosis and treatment planning: part 7. Treatment planning for missing teeth. British dental journal. 2012 Oct;213(7):341.
  • Petridis H, Hempton TJ. Periodontal considerations in removable partial denture treatment: a review of the literature. The international journal of prosthodontics. 2001;14(2):164-72.

Delivery of Treatment

Control Phase

Treatment Timeline57

8/3/2018

  • Referral to medical practitioner

10/4/2018

  • Informed consent to carry out treatment plan
  • Extraction of teeth 26, 27, and 47

17/4/2018

  • Review of extraction sockets
  • Periodontal debridement

30/4/2018

  • Periapical radiograph (PA): 25 distal arrested caries

8/5/2018

  • Dietary advice
  • Oral hygiene instruction
  • Fluoride application
  • Motivational interviewing for smoking and alcohol cessation

Holding Phase

Clinical Reviews and Preparations58

23/5/2018

  • Periodontal review
  • Periapical radiograph (PA): 41 and 31 for possible external inflammatory resorption
  • Plaque score: 50%
  • Oral hygiene instruction
  • Periodontal debridement

13/7/2018

  • Diagnostic base and rim

26/7/18

  • 46 Buccal (BUC) composite restoration
  • Pulp testing to reassess abutment teeth

31/7/18

  • Panoramic radiograph

The holding phase of treatment focused on maintaining the progress achieved during the intensive intervention period while gradually transitioning the patient toward self-management. This phase was characterized by a reduction in the frequency of clinical sessions and an increased emphasis on the patient’s application of learned strategies in real-world environments.

Clinical Objectives and Monitoring59

  • Stability Maintenance: Regular check-ins were conducted to ensure that the patient remained stable and that there was no regression in functional gains.
  • Symptom Surveillance: Ongoing monitoring for any emerging symptoms or triggers that might necessitate a temporary return to more intensive support.
  • Medication Management: Continued oversight of the pharmacological regimen to ensure adherence and to evaluate the long-term efficacy of the prescribed dosages.

Transition to Self-Management

  • Skill Generalization: Encouraging the patient to utilize coping mechanisms and behavioral techniques independently in various social and professional contexts.
  • Support System Integration: Strengthening the patient’s reliance on their natural support networks, including family, friends, and community resources, to decrease clinical dependency.
  • Relapse Prevention Planning: Refining the patient’s individualized relapse prevention plan, ensuring they could identify early warning signs and knew the specific steps to take if symptoms exacerbated.

Holding Stage Review60

  • 31/7/2018

Reconstructive Phase61

Clinical Timeline62

  • 22/7/2018: Denture design sign off
  • 31/7/2018: Secondary impressions and Face-bow
  • 15/8/2018: Maxillomandibular Relationship (MMR)
  • 5/9/2018: Anterior tooth set up
  • 14/9/2018: Posterior tooth set up
  • 3/10/2018: Insertion of P/P acrylic denture

References

  • Davenport JC, Basker RM, et al. Prosthetics: A system of design. British dental journal. 2000 Dec; 189(11): 586.

Insertion of Acrylic P/P63

  • 3/10/2018

Dental presentation slide showing various views of a mouth with an acrylic prosthesis in place, head and shoulders of presenter.

Maintenance Phase64

Clinical Timeline65

  • 10/10/2018: Denture review
  • 19/10/2018: Denture review 2
  • 21/1/2019:
    • Periodic oral examination
    • Plaque score 30%
    • CPITN:
      • 2 2
      • 2 -
    • Debridement
    • Fluoride application
  • 6/6/2019:
    • Periodic oral examination
    • Full periodontal chart
    • Debridement
    • Refer to oral surgery
  • 5/7/2019:
    • Oral hygiene review
    • Removal of calculus (subsequent visit)
    • Fluoride application
  • 13/11/2019:
    • Periodic oral examination
    • Full periodontal chart
  • 19/11/2019:
    • Debridement
    • Motivation for oral and denture hygiene

Review Appointment66

  • 6/6/2019

  • Denture in situ

  • 6/6/2019

  • Denture in situ

Clinical Outcomes and Complications

Periodontal Staging and Grading Summary Table67

StagingFlinard PhaseStage 1Stage 2Stage 3Stage 4
SeverityStage I-IIIStage I-IVStage VStage VIStage VII
ComplexityLocalisedModerateSevereGeneralisedGeneralised
Reference DistributionAdd to degree of involvementAdd to degree of involvementAdd to degree of involvementAdd to degree of involvementAdd to degree of involvement
ProgressionModerateModerateModerateModerateModerate
Reference ClassificationNo referenceNo referenceNo referenceNo referenceNo reference
StagingStagingStagingStagingStagingStaging

Periodontal Diagnosis: Generalised periodontitis Stage IV, Grade C

References

  • Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of periodontology. 2018 Jun;89(5):173-82.

Treatment Complications and Issues68

Clinical Issues (8/5/2018)69

  • Arrested Caries: Detected on 25 Distal after 26 was extracted.
    • Management: PA, Fluoride, Monitor.
  • Secondary Impressions: Overfilled the maxillary special tray with PVS.
  • Oral Hygiene: Requirement for continual motivation.
  • Aesthetics: Maxillary midline alignment during anterior tooth set up.
  • Eruption Issues: Partially erupted 28.

References

  • Evans RW, Pakdaman A, Dennison PI, Howe EL. The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Australian dental journal. 2008 Mar;53(1):83-92

  • After the 26 was extracted arrested caries was detected on 25 Distal PA

  • Fluoride

  • Monitor

  • Secondary impressions: Overfilled the maxillary special tray with PVS

  • Oral Hygiene: Continual motivation

  • Maxillary midline during anterior tooth set up

  • Partially erupted 28

  • Evans RW, Pakdaman A, Dennison PJ, Howe EL. The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Australian dental journal. 2008 Mar;53(1):83-92

Periodontal Prognosis7071

Prognostic Factors72

  • Dependent of the ability of the patient to maintain their oral environment.
  • Success Rates: 95% success rate after five years (Buchmann, Nunn 2002).
  • Treatment Outcomes (Bouziane, Benrachadi 2014):
    • Baseline: 7.94mm
    • Re-evaluation: 4.33mm
    • Post-treatment: 3.54mm
    • Inflammation was resolved and angular bone defects were repaired in all cases.
  • Impact of Smoking:
    • Smoking showed a 3.8 times increase in non-responding patients (Hughes, Syed 2006).
    • Smokers had a 0.7mm less reduction in pocket depths (Darby, Hodge 2005).

References

  • Buchmann R, Nunn ME, et al. Aggressive periodontitis: 5-year follow-up of treatment. Journal of Periodontology. 2002 Jun;73(6):675-83.

  • Bouziane A, Benrachadi L, et al. Outcomes of nonsurgical periodontal therapy in severe generalized aggressive periodontitis. Journal of periodontal & implant science. 2014 Aug 1;44(4):201-6.

  • Hughes FJ, Syed M, et al. Prognostic factors in the treatment of generalized aggressive periodontitis: II. Effects of smoking on initial outcome. Journal of clinical periodontology. 2006 Sep;33(9):671-6.

  • Darby IB, Hodge PI, et al. Clinical and microbiological effect of scaling and root planing in smoker and non-smoker chronic and aggressive periodontitis patients. Journal of clinical periodontology. 2005 Feb;32(2):200-6.

  • Dependent of the ability of the patient to maintain their oral environment

  • Buchmann, Nunn 2002: 95% success rate after five years

  • Bouziane, Benrachadi 2014:

    • Baseline 7.94mm
    • Re-evaluation 4.33mm
    • Post-treatment 3.54mm
    • Inflammation was resolved and angular bone defects were repaired in all cases

  • Smoking Impact:

    • 3.8 times increase in non-responding patients (Hughes, Syed 2006)
    • 0.7mm less reduction in pocket depths (Darby, Hodge 2005)

  • Buchmann R, Nunn ME, et al. Aggressive periodontitis: 5-year follow-up of treatment. Journal of Periodontology. 2002 Jun;73(6):675-83.

  • Bouziane A, Benrachadi L, et al. Outcomes of nonsurgical periodontal therapy in severe generalized aggressive periodontitis. Journal of periodontal & implant science. 2014 Aug 1;44(4):201-6.

  • Hughes FI, Syed M, et al. Prognostic factors in the treatment of generalized aggressive periodontitis: II. Effects of smoking on initial outcome. Journal of clinical periodontology. 2006 Sep;33(9):671-6.

  • Darby IB, Hodge PJ, et al. Clinical and microbiological effect of scaling and root planing in smoker and non-smoker chronic and aggressive periodontitis patients. Journal of clinical periodontology. 2005 Feb;32(2):200-6.

Prosthodontic Prognosis

Footnotes

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