Sample Portfolio 2

Case Portfolio¹

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DMD 4 [REDACTED]

Table Of Contents

Case 1: Multi-disciplinary (Page 4)²

• The patient (5)
• Examination and diagnostics (9)
• Diagnoses and problem list (19)
• Prognosis (20)
• Treatment options (22)
• Management plan (25)
• Treatment delivery (26)

Case 2: Fixed Aesthetic (Page 42)

• The patient (43)
• Examination and diagnostics (45)
• Diagnoses and problem list (56)
• Prognosis (58)
• Treatment options (60)
• Management plan (64)
• Treatment delivery (66)

Case 3: Removable Aesthetic (Page 76)

• The patient (77)
• Examination and diagnostics (45)
• Diagnoses and problem list (88)
• Prognosis (89)
• Treatment options (92)
• Management plan (95)
• Treatment delivery (96)

Case 4: Fixed Occlusal Rehabilitation (Page 100)

• The patient (101)
• Examination and diagnostics (105)
• Diagnoses and problem list (114)
• Prognosis (115)
• Treatment options (117)

Case 4: Fixed Occlusal Rehabilitation (Continued)³

• Management plan (120)
• Treatment delivery (121)

Case 5: Removable Occlusal Rehabilitation (Page 129)

• The patient (130)
• Examination and diagnostics (134)
• Diagnoses and problem list (143)
• Prognosis (144)
• Treatment options (146)
• Management plan (148)
• Treatment delivery (149)

References

• References (158)

Case 1: Multi-disciplinary

Case Overview⁴

• Case Type: Multi-disciplinary

The Patient

Patient Details⁵

• Age: 64-year-old male

Presenting Complaints (January 2019)

1. Intermittent pain in teeth 37 and 47, and in the gums.
2. Cavity in tooth 22 causing sensitivity and food impaction.
3. Desire for dentures to replace missing teeth.

History of Presenting Complaints

• Lower Left: Dull, throbbing pain lingering with minor temperature changes.
• Lower Right: Recent spontaneous dull pain with minor temperature changes.
• Gingiva: Pain and bleeding during brushing.

Medical History and Dental Implications⁶

Medical Condition	Description	Dental Implications
Chronic Obstructive Pulmonary Disease (COPD)	Respiratory narrowing causing wheezing and shortness of breath.	Mouth breathing; increased xerostomia risk; difficulty with horizontal positioning and rubber dam.
Abdominal Hernia / Reflux Oesophagitis	Protrusion of organs; associated with esophageal reflux and gastric acid insult.	Difficulty with horizontal positioning; acid erosion and accelerated tooth wear.
Osteoarthritis	Joint inflammation affecting shoulders, fingers, legs, and back.	Difficulty performing adequate oral hygiene.
Stents (L & R legs)	Inserted for blocked arteries.	Difficulty with long dental appointments.
Post-Traumatic Stress Disorder (PTSD)	Triggered by terrifying events; causes flashbacks and severe anxiety.	Difficulty coping with plan changes; easily frustrated.
Previous Hospitalization	April 2018 (COPD/back pain); Feb 2019 (leg numbness).	Nil.

Medications

Medication	Dosage	Mechanism of Action	Dental Implications
Breo Ellipta	100 mg / 25 mg q.d.	Corticosteroid/β₂ agonist for asthma.	Increased susceptibility to dental caries, periodontal disease, and oral candidiasis.
Bricanyl Turbuhaler	500 mcg q.d.	β₂-agonist for asthma.	Reduction in buffering capacity and salivary flow; dental erosion.
Ventolin	100 mcg p.r.n.	β₂-adrenergic agonist for asthma.	Dehydration of mucosa; alteration of immune response; decreased mineral bone density.

Medication Management and Allergies⁷

Additional Medications

• Management Strategy: Education, regular check-ups, caries prevention, mouth rinsing after inhaler use, increased water intake, and sugar-free gum.
• Esomeprazole (20 mg q.d.): Proton pump inhibitor; nil dental implications.
• Pregabalin (75 mg q.d. - ceased): Used for neuropathic pain/epilepsy; adverse effect includes dry mouth (caries risk).
• Panadol (p.r.n.): Analgesic/anti-pyretic; may alter perception of dental pain during diagnostics.

Allergies

• Penicillin: Anaphylactic reaction. Penicillin is contraindicated; use alternatives like Clindamycin.

Social Habits

• Tobacco: Never smoker.
• Alcohol: Current drinker (1-2 standard drinks per month). Increases risk of oral cavity cancer.

Dental History and Attitude⁸

• History:
  • Attended government clinics (2016) and free dental days (2017) for extractions, fillings, and cleans.
  • History of extractions due to decay; never worn dentures.
  • Long waitlists previously prevented regular care.
• Attitude:
  • Functionally motivated; understands the link between oral and overall health.
  • Highly motivated and compliant; perfect attendance record.

Oral Hygiene

• Status: Poor.
• Routine: Brushes 2-3 times daily (manual brush, fluoride toothpaste); occasional floss picks; daily salt-water rinses.

Social History

• Born in Melbourne, raised in Israel.
• Former Ultra-Orthodox Jewish Rabbi and UN Human Rights Commission worker; suffered physical/psychological injuries.
• Retired in Perth, living alone on a disability pension; active volunteer.

Examination And Diagnostics

Extra-oral Examination Findings⁹

• Facial Symmetry/Skin: Symmetrical; skin, lips, and commissures are intact and healthy.
• TMJ: Bilateral clicking on closing and lateral excursion to the right; no pain or tenderness.
• Lymph Nodes/Muscles: No lymphadenopathy; muscles of mastication are non-tender.
• Thyroid: No abnormal enlargement.

Dentofacial Analysis

• Proportions: Proportional facial thirds and fifths.
• Symmetry: Parallel interpupillary/incisal lines. Mild facial asymmetry (mandible left of midline).
• Midlines: Facial and dental midlines coincide; however, mandibular dental midline is deviated 4-5 mm to the left.
• Smile Analysis: High smile line, average width, wide buccal corridors, flat occlusal curve.
• Profile: Indications of Class I skeletal relationship.

Intraoral Examination Findings¹⁰

• Mucosa/Sulci: Labial and buccal mucosa normal; adequate sulci depth.
• Frenal Attachments: Normal maxillary (labial/buccal) and mandibular (labial/lingual) attachments.
• Palate: Prominent rugae on hard palate; soft palate normal.
• Gingivae:
  • Thick scalloped phenotype.
  • Generalised inflammation.
  • Generalised recession and blunted papillae.
• Tongue: Fissuring and plaque accumulation on the dorsum.
• Floor of Mouth: Nil abnormalities detected.

Intraoral Findings by View¹¹

Maxillary Occlusal

• Teeth: Partially dentate (Kennedy-Applegate Class I); incisal wear into dentine (13-23); large cavity 22D.
• Restorations: Large composites (11, 14, 15); composites (12, 21, 25).

Mandibular Occlusal

• Teeth: Partially dentate (Kennedy-Applegate Class III Mod 1); incisal wear into dentine (33-43).
• Restorations: Large composites (37, 38).
• Soft Tissues: Narrow alveolar ridge in 36-35 area.

Right/Left Buccal

• Missing Teeth: 16, 17, 46 (Right); 26, 27, 35, 36 (Left).
• Occlusion: 47 and 37 intrude into opposing prosthetic spaces.
• Observations: Yellow-brown cervical bands (likely intrinsic tetracycline staining); abundant plaque; marginal gingival inflammation; generalised recession.

Anterior

• Teeth: Caries 23M; abundant plaque/calculus; mandibular midline deviation to the left.
• Soft Tissues: Blunted papillae and inflammation.

Occlusal Analysis¹²

• Overjet: 3 mm
• Overbite: 2 mm
• Canine Class: LHS Class I; RHS Class III
• Molar Class: Not applicable (missing teeth)
• Alignment: Tilting (34, 37, 47); Rotation (22); Supraeruption (37, 47).
• Occlusal Scheme: Group function.
• Other: Crossbite, crowding, and spacing are absent.

Periodontal Assessment¹³

CPITN Scores

• Sextants 1, 2, 4, 5: Score 3 (Max probing depth 5mm, generalised BOP).
• Sextants 3, 6: Score 3 (Max probing depth 4mm, generalised BOP).
• Note: Sextant 5 was extremely tender to probing.

Clinical Findings

• Gingiva: Oedematous, pink/red marginal inflammation, thick biotype, generalised recession.
• Plaque/Calculus: 43% plaque score; abundant interproximal plaque; generalised supragingival and subgingival calculus (heavy on lower lingual anterior).
• Plaque-Retentive Factors: Overhangs (11), rotation (22), tilting (34, 37).
• Halitosis: Present.

Radiographic Findings

• Bone Levels: Generalised mild horizontal bone loss in both arches.

Periodontal and Pulp Testing¹⁴

Periodontal Tests

• TTP (Tenderness to Percussion): Positive (++) on 47; strongly positive (+++) on 37.
• Mobility: Grade I (GI) noted on teeth 31, 32, and 37.
• TTPalp (Tenderness to Palpation): Negative across all tested teeth.

Clinical Rationale

• CPITN results necessitated a full periodontal chart.
• Baseline data required to evaluate periodontal treatment success and suitability for removable prostheses.

Periodontal Risk Assessment (PRA)¹⁵

• Patient Data: Age 64; 21 teeth present.
• BOP: 57% (72 of 126 sites).
• Probing Depths: 7 sites with PPD ≥ 5mm.
• Bone Loss: 25% alveolar bone loss (BL/Age = 0.39).
• Risk Level: Medium.
• Suggested Recall: 6 Months.

Pulp Sensibility Tests

Tooth	EPT	CO2	Clinical Status
15	15	+	Vital
14	73	++	Vital
13	37	++	Vital
11	0	-	Non-responsive
21	36	-	Non-responsive
22	36	-	Non-responsive
23	67	-	Non-responsive
37	0	+	Responsive
47	0	-	Non-responsive

Radiographic Findings: Orthopantogram (OPG)¹⁶

• General Structures: Ossified stylohyoid ligaments; thin mandibular rami; normal maxillary sinus and nasal cavity.
• Bone Pattern: Normal density; generalised mild horizontal bone loss; no furcation involvement.
• Teeth Observations:
  • Missing: 17, 16, 26, 27, 36, 35, 46.
  • Gross caries: 37.
  • Heavily restored: 15, 14, 47.
  • Mesial tilt: 37, 47.
  • Artefact: Rectangular radiolucency in right body of mandible.

Radiographic Findings: Bitewings and Periapicals¹⁷

Bitewing - Right

• Caries: 13D, 47D, 47 secondary caries.
• Restorations: 15MODc (suspicious margins), 14MODc (overhang), 45Dc, 47MOc.
• Periodontium: 14D PDL widening; mild horizontal bone loss.

Periapical - 47

• Caries: Deep 47D into dentine.
• Periodontium: Possible periapical radiolucency at distal root; intact PDL space elsewhere.
• Other: 47 mesial tilt.

Periapical - 21-25

• Caries: 21D, 22M&D, 23M.
• Periodontium: 21 slight PDL space widening; no PA radiolucency detected.
• Other: Incisal wear on anterior teeth.

Caries Risk Assessment¹⁸

Dietary Factors

• High sugar/fermentable carbohydrate intake.
• Coffee with sugar (4-6x daily), fruit juice, bread, pasta, cakes, and ice cream.
• Frequent snacking (2-3x daily).

Saliva Testing

• Unstimulated: Low flow rate (<60s); sticky/frothy consistency; pH 5.0-5.8.
• Stimulated: Very low quantity (<3.5 mL at 5 mins); low buffering capacity.

CAMBRA Summary

• Risk Level: High.
• Indicators: Visible caries, dentine penetration, heavy plaque, frequent snacking, and low salivary flow.
• Management: 5000 ppm fluoride toothpaste, Chlorhexidine rinse (1 week/month), Xylitol gum, fluoride varnish, and 3-month recall.

Diagnoses And Problem List

Diagnoses¹⁹

• Pathological:
  • Multiple active caries and unsatisfactory restorations.
  • Endodontic: 37 Chronic irreversible pulpitis; 47 Necrotic/infected; 22 Chronic reversible pulpitis (calcified).
  • Periodontal: Generalised Stage III Grade B unstable periodontitis.
  • TSL: Attrition and erosion of anterior teeth.
• Morphological:
  • Angle Class I skeletal; Class III habitual posture.
  • Bilateral posterior crossbite; multiple missing posterior teeth; unstable occlusion.
• Host Factors: Poor hygiene, high sugar diet, limited manual dexterity, mouth breathing, and strong gag reflex.

Problem List

• Pulpal pathology (37, 47, 22).
• Extensive caries (multiple sites including 13, 12, 21, 22, 23, 24, 25, 37, 34, 42, 43, 47).
• Unsatisfactory restorations (15, 14, 12, 11, 22, 37, 45, 47).
• Lack of posterior support and occlusal instability.

Prognosis

Individual Tooth Prognosis²⁰

Prognosis Classification

• Good: 11, 12, 13, 21, 23, 24, 25, 31, 32, 33, 34, 41, 42, 43, 44, 45.
• Fair/Guarded: 14, 15, 47.
• Poor: 22 (minimal tooth structure, iatrogenic factors).
• Hopeless: 37 (gross destruction, unrestorable).

Evaluation Criteria

• Periodontal: Based on bone support (80-100% for Good).
• Restorability: Based on remaining sound coronal structure and ferrule.
• Endodontic: Based on predictability of primary or re-treatment.
• Occlusal: Based on tooth position and plane alignment.

Patient-Level Risk Factors²¹

• Favourable: High motivation, available resources, willingness to commit to treatment, reasonable aesthetic expectations.
• Questionable: Poor manual dexterity, history of caries-related tooth loss.
• Unfavourable: Poor oral hygiene, high cariogenic diet.

Overall Prognosis Summary

• Current Status: Guarded for 14, 15, 47; Poor for 22; Hopeless for 37.
• Risk of No Treatment: Progression of caries and pulpal/periodontal disease, leading to total edentulism and reduced quality of life.
• Mitigating Factors: Patient is highly compliant and open to education, which improves the long-term outlook if dietary and hygiene habits are modified.

Treatment Options

Pulpal and Carious Pathology

Tooth 37

• Option: Extraction.
• Rationale: Hopeless prognosis; addresses pain and infection with minimal commitment.

Tooth 47

• Option: Endodontic treatment followed by restoration.
• Rationale: High strategic value; patient wishes to save the tooth despite difficult access and questionable longevity.

Tooth 22

• Option: Endodontic treatment, post/core, and crown.
• Rationale: Patient wishes to save the anterior tooth; extraction would cause aesthetic concerns in a visible region.

Caries (Multiple Teeth)

• Option: Direct restorations.
• Rationale: Prevent further breakdown and pulpal involvement; aligns with patient’s goal to keep natural teeth.

Restorations, Periodontics, and Maxillary Edentulism

Unsatisfactory Restorations (14, 15)

• Option: Remove caries/old restorations and restore (Onlays).
• Rationale: Maximise longevity of teeth intended as denture abutments.

Periodontal Disease (Stage III Grade B)

• Option: Non-surgical periodontal therapy and OHI.
• Rationale: Reduce disease progression and create a healthy environment for indirect prostheses.

Missing Maxillary Posterior Teeth (17-16, 26-27)

• Option: Cobalt-Chrome (Co-Cr) Partial Denture.
• Rationale: Addresses lack of posterior support and stability; patient desires occlusal rehabilitation.

Mandibular Edentulism

Missing Mandibular Posterior Teeth (37-36, 46)

• Option 1: No treatment (Shortened Dental Arch).
• Option 2: Co-Cr Partial Denture.
• Decision: Option 2.
• Rationale: Patient specifically requested dentures to improve function and stability. Success depends on long-term hygiene maintenance.

Management Plan

Management Plan Phases²²

Control Phase

• Periodontal debridement, OHI, and fluoride application.
• Caries control and replacement of restorations (13, 12, 21, 23, 24, 25, 34, 42, 43).
• Extraction of 37.
• Endodontic investigation/treatment of 22 and 47.

Holding Phase

• 6-week periodontal review.
• Completion of root fillings for 22 and 47 if asymptomatic.

Reconstructive Phase

• 22: Cast post-core and crown.
• 47: Survey crown.
• 14 & 15: Onlays.
• Maxillary and Mandibular Co-Cr partial dentures.

Maintenance Phase

• 3-monthly periodontal reviews and denture hygiene reinforcement.

Treatment Delivery

Treatment Timeline (2019-2020)²³

2019 Highlights

• Jan-Mar: Exam, education, and hygienic periodontal phase.
• Apr-Aug: 47 endodontic treatment and obturation; 37 extraction.
• May-Aug: Caries control and restoration replacement.
• Sep-Oct: 22 endodontic start; 15 onlay preparation.

2020 Highlights

• Jan-Feb: 22 obturation and cast post-core cementation.
• Mar-Aug: Preparations for 14, 47 (survey crown), and final impressions for all indirect restorations.
• Aug-Oct: Cementation of crowns/onlays; fabrication and insertion of Co-Cr partial dentures; post-insert reviews.

Initial Periodontal Therapy (Feb 2019)²⁴

• Baseline Data:
  • Plaque Score: 100%.
  • Bleeding on Probing (BOP): 57%.
  • PPD ≥ 4mm: 24% of sites.
  • Mobility: Grade I on 31, 32, 37.
• Clinical Notes: Extreme gingival pain during probing. Patient instructed on electric toothbrush use and interproximal brushes.
• Education: Patient educated on caries aetiology (diet, bacteria, time) and encouraged to keep a food diary.

Periodontal Review and Caries Control²⁵

• Periodontal Progress (May-Sep 2019):
  • Plaque score reduced from 43% to 21%.
  • BOP reduced to 20%.
  • PPD ≥ 4mm reduced to 0%.
  • Diagnosis revised to “Periodontitis in remission.”
• Dietary Changes: Substituted sugar with Stevia; reduced coffee and snacking; increased dairy and vegetable intake.
• Surgical: 37 extracted due to symptomatic, extensive subgingival caries.

Tooth 47: Endodontics and Core Build-up²⁶

• Endodontic Treatment: Completed between April and September 2019.
• Definitive Restoration:
  • Stainless steel direct post placed in the distal canal (largest/straightest).
  • Amalgam Nayyar core technique utilized.
  • Rationale: Amalgam provides high strength and low solubility, though it requires setting time before preparation.

Tooth 47 Survey Crown and Tooth 22 Endodontics²⁷

• 47 Survey Crown: Prepared for a Zirconia crown to serve as a posterior denture abutment. Zirconia selected for superior mechanical strength.
• 22 Endodontic Treatment:
  • Treatment spanned May 2019 to January 2020.
  • Challenge: Canal was severely calcified; required specialist endodontic assistance for access.
  • Temporized with a GIC dome restoration during the process.

Tooth 22: Cast Post-Core²⁸

• Rationale: Post required due to insufficient tooth substance to support a crown.
• Design: Cast gold alloy (Type III/IV) used for its modulus of elasticity similar to enamel and high compressive strength.
• Specifications: Parallel, passive post design; length extended to half the root supported by bone; 3-6 mm apical gutta-percha preserved.
• Procedure: Post space prepared and impression taken with PVS.

Tooth 22: Crown Preparation²⁹

• Cementation: Cast post-core cemented with Panavia.
• Crown Selection: Zirconia crown chosen.
• Rationale: While lithium disilicate is often used for anterior teeth, Zirconia was selected here to mask the dark metallic shade of the cast gold post-core. Opaque cement was also utilized for masking.

Teeth 14 and 15: Onlay Preparations³⁰

• Findings: Removal of old MOD composites revealed cracks in tooth 15.
• Design: Buccal and palatal walls reduced for cuspal coverage to prevent tooth failure from flexure.
• Temporization: Stainless steel bands and IRM used while onlays were fabricated.

Final Cementation of Indirect Restorations³¹

• 14 & 15 Onlays: Cemented with Variolink.
• 22 Crown: Cemented with Panavia.
• 47 Survey Crown: Cemented with Permacem.

Removable Partial Denture (RPD) Design³²

• Material: Cobalt-Chrome (Co-Cr) selected over acrylic for better adaptation, thermal conductivity, and strength.
• Mouth Preparation:
  • Rest seats: 15M, 14M, 47M (in restorations); 24M, 25M, 33P, 45D.
  • Guide planes: 15D, 47M (in restorations); 25D, 34D.
• Impressions: Final maxillary and mandibular impressions taken using PVS.

RPD Framework Try-in and Insertion³³

• Framework Try-in: Maxillary framework required a re-impression due to non-passive fit. Second framework was acceptable. Mandibular framework fit correctly.
• Try-in with Teeth: Satisfactory aesthetics, phonetics, and occlusion.
• Insertion: Maxillary denture required clasp adjustment for stability. Patient reported high satisfaction.
• Clinical Rationale: Although the patient has 21 teeth (Shortened Dental Arch), dentures were provided to meet functional and psychological needs.

Patient Choice and Long-term Success³⁴

• The patient elected for removable partial dentures despite having 21 teeth.
• Success is contingent upon the patient’s adaptation to the prostheses and strict adherence to oral/denture hygiene and regular periodontal maintenance.

Treatment Progress Summary (2019)³⁵

• Jan 2019: Diagnostic phase.
• May 2019: Initial periodontal therapy complete; caries control and 47 endodontics in progress.
• Aug 2019: 37 extracted; 22 and 47 endodontics in progress; periodontal status stable.
• Sep 2019: Caries control complete; 47 endodontics complete; 22 endodontics in progress.

Treatment Progress Summary (2019-2020)³⁶

• Oct 2019: 47 post/core complete; 15 preparation in progress.
• Mar 2020: 22 endodontics and cast post-core complete; crown preparations for 14, 15, 22, 47 in progress.
• Aug 2020: All indirect fixed restorations (14, 15, 22, 47) completed.
• Oct 2020: Removable prostheses inserted; periodontal status maintained.

Clinical Outcomes And Reflection

Clinical Outcomes³⁷

• Patient Satisfaction: Very satisfied; reported improved bite stability.
• Complaint Resolution:
  • Pain in 37, 47, and gums resolved.
  • Sensitivity in 22 resolved.
  • Missing teeth replaced with Co-Cr dentures.
• Compliance: Patient successfully modified diet and hygiene habits. Highly compliant with appointments and maintenance.

Reflection on Challenges³⁸

Patient-Related Challenges

• Medical: Managed leg spasms by reinforcing medication adherence; managed back pain with frequent breaks and cushioning.
• Anxiety/PTSD: Managed with constant reassurance and preventing stressful situations.
• Mouth Breathing: Managed rubber dam intolerance through education and gradual adjustment.

Clinical Challenges

• Rubber Dam Leakage: Occurred during 47 treatment; managed by prompt removal, rinsing, and re-medication.
• Subgingival Margins: Managed with temporary GIC and retraction cords to allow tissue healing.
• Shade Matching: Difficult due to tetracycline staining; managed by patient education on aesthetic limitations.
• Technical Issues: Managed canal transportation by stopping preparation; managed non-passive Co-Cr framework with re-impressions.

Case 2: Fixed Aesthetic³⁹

Fixed Aesthetic

The Patient

Patient Details⁴⁰

• 61 year-old female

Presenting Complaints

Patient presented to student clinic in May 2019 with the following complaints:

1. “I don’t smile anymore because my front teeth are so bad. The front tooth (21) is brown, they’re all mismatched. I want the teeth (13-21) to look the same colour because when I smile, I’m self-conscious.”
2. “My crown (11) has fallen off and been stuck on again – I’m afraid it will fall off again.”
3. “I had some sensitivity last week when eating sweet foods (47).”

History of Presenting Complaints

• Upper anterior crowns (11, 12) were inserted 20-30 years ago. 11 crown de-bonded and was re-cemented 7 years ago.
• Noticed occasional sensitivity on lower right-hand side after eating sweet foods. Happened about a week ago. No sensitivity to thermal stimuli. Did not cause patient to wake at night. Relieved by ibuprofen.

Medical History⁴¹

Medical condition	Description	Dental implications
History of asthma attack	Wheezing, coughing, chest tightness or shortness of breath.	Asthma attack in dental chair. Sit person upright, reassure. Give 4 puffs blue/grey reliever every 4 minutes.

Medications: Not currently taking any medication/s.

Allergies: No known allergies.

Alcohol & Tobacco Use

• Former smoker: Smoked in twenties (5-6 cigarettes a day for 4 years; 1 pack year). Quit and has not smoked since. Time since quitting is statistically protective against periodontal disease.
• Current drinker: 1 glass of wine (1.5 standard drinks) a fortnight. Alcohol consumption raises risk of oral cavity cancer.

Dental History

• Attended dentist in Ireland every six months for routine examinations, cleans, and restorations. Last attended 2018.
• History of extractions and orthodontic treatment in teenage years.
• History of endodontic treatment (11, 12) due to dental infection.
• No history of trauma.
• Attended OHCWA screening clinic February 2019; initial examination May 2019.

Dental Attitude

• Aesthetic motivation.
• Apprehensive to radiation exposure.
• Strong gag reflex.
• Lack of trust in student clinicians.
• Never missed an appointment.

Oral Hygiene⁴²

• Status: Fair oral hygiene.
• Routine: Brushes twice daily with electric toothbrush and fluoride toothpaste.
• Adjuncts: Uses floss once a week; no other cleaning adjuncts.

Social History

• Born and raised in Ireland; moved to Australia in November 2018.
• Lives alone; works in aged care.
• Two children (son in Sydney, daughter in Perth).
• Enjoys playing competitive golf.
• Considering moving to Sydney in the future.

Examination And Diagnostics

Extra-oral Examination (May 2019)⁴³

Feature	Findings
Facial symmetry	Absence of facial swelling; relatively symmetrical
Facial skin	Dry, peeling skin and hyperpigmentation
Lips	Dry, cracked lips and indistinct vermilion border (Confirmed actinic cheilitis)
TMJ	Minor crepitus on opening/closing bilaterally; no pain or tenderness
Lymph nodes	No lymphadenopathy; no pain or tenderness
Muscles of mastication	Absence of pain and tenderness on palpation
Thyroid gland	No obvious abnormal enlargement

Dentofacial Analysis

• Horizontal facial proportions: Elongated lower facial third; elongated philtrum.
• Vertical facial proportions: Proportional facial fifths.
• Horizontal symmetry: Incisal plane lacks parallelism with interpupillary lines; cants downward to right.
• Vertical symmetry: Facial and dental midlines do not coincide (discrepancy not detectable at conversational distance).
• Smile analysis: Low smile line; extra wide smile width; normal buccal corridors; flat incisal/occlusal curve.
• Profile: Convex (indicative of Class II skeletal profile).

Intraoral Soft Tissue Findings

• Labial mucosa: No abnormalities detected.
• Buccal mucosa: Bilateral, symmetrical horizontal white lines (frictional hyperkeratosis).
• Gingivae: 5 mm x 3 mm soft, slate grey macule buccal of 45 (amalgam tattoo).
• Floor of mouth: Bilateral lingual tori.

Intraoral Findings by Region⁴⁴

Maxillary Occlusal

• Teeth: Heavily restored; missing 14, 24; tooth surface loss 33I; brown discolouration 13, 21; calculus on posterior buccal.
• Restorations: Metallic crown 17; Amalgams 16, 15, 25, 26, 27; Metal-ceramic crown 12 (visible margin) and 11 (fractured/repaired); Composites 21, 22.

Mandibular Occlusal

• Teeth: Heavily restored; missing 34, 44; tooth surface loss 32I; 33 buccally malposed; calculus on anterior lingual.
• Restorations: Amalgams 47 (broken ML), 36, 37; Metallic crown 46; Composite 45 (leakage); GIC 35.

Right Buccal

• Teeth: White-brown opacities 16B, 47B; Enamel infraction 13B; 12 distally inclined.
• Soft Tissues: Gingival recession at 12; mild marginal inflammation.

Left Buccal

• Teeth: 22 distally inclined; white-brown opacities 26B, 27B, 37B, 36B; 33 buccally malposed.
• Soft Tissues: Gingival zenith 22 flat and coronal to 23; loss of interdental papilla 22M, 33M.

Anterior

• Teeth: Disharmonious/asymmetric (11, 21 differ in colour, shape, size); 21 square shape; incisal plane cants downward to right.
• Midline: Mandibular midline deviates 3.5 mm to the right of maxillary midline.

Anterior Restorative and Soft Tissue Details⁴⁵

Restorations

• 12 Crown: Metal-ceramic; visible margins; poor colour (white hue, high value).
• 11 Crown: Metal-ceramic; square shape; poor colour (white hue, high value).
• 21/22 Composites: Poor contour at gingival margins; 22 is translucent.
• Embrasures: Asymmetric (larger on left than right).

Soft Tissues

• Gingiva: Recession at 12; non-ideal gingival zenith 13-23; loss of interdental papilla 12-22.
• Discolouration: Gingival discolouration 12-11; mild marginal inflammation.

Clinical Notes

• Missing premolars suggest history of orthodontic extractions.
• Discolouration on 13/21 may be intrinsic or extrinsic (tea/coffee).
• Midline discrepancies are common post-orthodontics; thresholds for acceptability are approximately 2.92mm.
• Aesthetic gingival zenith for central incisors and canines should be apical to lateral incisors.

Occlusal Analysis⁴⁶

Parameter	Findings
Overjet	3 mm
Overbite	2 mm
Canine Class	LHS: Class II; RHS: Class I
Molar Class	LHS: Class II; RHS: ½ Class II
Crossbite	Absent
Crowding / Spacing	Lower anterior crowding; 33 malposed buccally
Occlusal Scheme	Canine guidance
Rotation / Supraeruption	Absent

Periodontal Assessment⁴⁷

CPITN Scores

• Sextant 1: 3 (17MB 5mm pocket due to over-contoured crown)
• Sextant 2: 2
• Sextant 3: 2
• Sextant 4: 2
• Sextant 5: 2
• Sextant 6: 2
• Generalised BOP, plaque, and calculus.

Clinical Findings

• Gingiva: Light pink, oedematous, blunted papillae, medium biotype.
• Plaque Score: 70% (abundant interproximally).
• Calculus: Generalised; abundant on upper posterior buccal and lower anterior lingual.
• Plaque-retentive factors: Overhangs (16, 15, 21, 22, 37, 45, 46, 47), open contact (36), over-contoured crown (17), crowding, and malposition (33).
• Radiographic: Generalised mild horizontal bone loss.

Periodontal Risk Assessment (PRA)⁴⁸

• BOP%: 69%
• Sites with PPD ≥ 5mm: 1
• Bone Loss: Estimated 25% alveolar bone loss.
• Environmental: Former smoker.
• Overall Risk: Medium.
• Recall Interval: 6 Months.

Pulp Sensibility Tests

• CO2 (Cold Test): Positive response for all teeth tested except 24 (missing) and 12/11 (RCT).
• EPT (Electric Pulp Test): Positive responses across dentition; 12 and 11 showed no response (consistent with RCT status).

Radiographic Findings: OPG⁴⁹

• Mandible: Continuous cortices; two radiopaque spots on right body (amalgam tattoos).
• Maxilla: Normal density; radiopaque shadows in sinuses (superimposition of nasal conchae).
• Alveolar Processes: Generalised mild horizontal bone loss; no furcation involvement.
• Teeth: Heavily restored; endodontically treated (12, 11, 36); missing one premolar per quadrant; third molars present.

Bitewing Radiographs⁵⁰

Left Side

• Caries: 36D (secondary).
• Restorations: Multiple amalgams; 37MO overhang; 36MOD open contact.
• Pulp: 36 RCT (radiographically deficient RCF).
• Periodontium: 25M PDL widening.

Right Side

• Caries: 47M (secondary).
• Restorations: 17 crown over-contoured; 16, 15, 45, 46, 47 all show overhangs.
• Pulp: 46 retention pins near pulp; 47 history of pulp capping.

Periapical Radiographs: 11-12

• Caries: 21M (secondary).
• Restorations: 12 cast post-core (wide post); 11 post-core (short, non-parallel, gap to RCF).
• Pulp: 12 RCT (satisfactory); 11 RCT (short and deficient).
• Other: 12 shows blunted root apex (external apical root resorption from orthodontics).

Periapical Radiographs: Quadrants 3 & 4⁵¹

Quadrant 3 (35, 36, 37)

• Caries: 36D (secondary).
• Restorations: 37MO overhang; 36MOD open contact.
• Pulp: 36 RCT (deficient RCF); radiopaque liner present.
• Periodontium: Possible PA radiolucency at 36.

Quadrant 4 (45, 46, 47)

• Caries: 46M, 47M (secondary).
• Restorations: 45MOD, 46 crown, 47MO all show overhangs.
• Pulp: 46 retention pins near pulp horns.

Teeth 21-22

• Caries: 21 M&D (secondary), 22M?.
• Restorations: 21 M overhang.

Caries Risk Assessment⁵²

Dietary Assessment

• Low sugar and acid intake.
• Moderate fermentable carbohydrates.
• Limited snacking; lacking dairy.

Saliva Test

• Unstimulated: Low flow rate; sticky/frothy consistency; pH 5.0-5.8 (Low).
• Stimulated: Very low quantity (<3.5 mL at 5 mins); very low buffering capacity.

CAMBRA Analysis

• Indicators: Visible cavities and radiographic dentine penetration.
• Risk Factors: Visible heavy plaque.
• Protective Factors: Fluoridated community; fluoride toothpaste use; adequate stimulated flow (noted as factor despite test results).

Suggested Management (Moderate Risk)

• 1000 ppm fluoride toothpaste 2x daily.
• 0.05% NaF rinse 1x daily.
• Xylitol gum/candies 4x daily.

Diagnoses And Problem List

Pathological Diagnoses⁵³

• Caries: Multiple teeth with secondary caries.
• Restorations: Heavily restored; several unsatisfactory.
• Endodontic:
  • 47: Chronic reversible pulpitis.
  • 11, 12, 36: Previous RCT; no current signs of infection.
• Periodontal: Generalised Stage II Grade B unstable periodontitis.
• Oral Medicine: Actinic cheilitis; bilateral frictional keratosis; amalgam tattoo (45).
• Other: Tooth surface loss (13I, 23I, 32I); cracked teeth (27, 36, 47).

Morphological & Aesthetic Diagnoses

• Malocclusion: Class II skeletal/dental profile; lower anterior crowding.
• Aesthetics: Incisal plane cant; midline discrepancies; high smile line; poor pink aesthetics; disharmony of 13-23.
• Stability: Stable occlusion; canine guidance.

Host-Related Factors

• Psychosocial: High aesthetic concern; slight skepticism/apprehension; good compliance.
• Socioeconomic: Potential relocation to Sydney; employed.
• Functional: Strong gag reflex.

Problem List⁵⁴

• Pulpal: Reversible pulpitis 47.
• Periodontal: Generalised Stage II Grade B unstable periodontitis.
• Aesthetic:
  • Asymmetrical anterior teeth 13-23.
  • Discoloured teeth 13, 21; non-ideal colour 11, 12, 21, 22.
  • Non-ideal size/shape/contours 12, 21, 22.
  • Asymmetric incisal embrasures.
  • Pink aesthetics: High smile line, recession, loss of papillae, gingival discolouration 12-11.
• Restorative/Endodontic:
  • Questionable RCF: 11, 12, 36.
  • Multiple furcation involvements (26, 16, 36, 46).
• Patient Factors: Strong gag reflex; uncertainty regarding relocation to Sydney.

Prognosis

Individual Tooth Prognosis Criteria⁵⁵

• Class A (Good): 80-100% bone support; 80-100% sound structure; straightforward endodontics; correct position.
• Class B (Fair): 50-80% bone support; 50-80% sound structure (adequate ferrule); predictable re-treatment.
• Class C (Questionable): 30-50% bone support; 30-50% sound structure (compromised ferrule/ratio); difficult re-treatment.

Compromising Factors

• 12: Extensive post space preparation (lowers prognosis).
• 27, 36, 47: Cracked teeth from large amalgams (lowers prognosis).

Patient-Level Risk Factors⁵⁶

• Biologic: Favourable (adequate flow, no systemic impairment).
• Behavioural: Favourable (low cariogenic diet, motivated, non-smoker for 40 years).
• Financial/Personal: Questionable (uncertainty regarding relocation timeframes).

Overall Dentition Prognosis

• Favourable factors: Stable occlusal plane; sound periodontal health for most teeth; unremarkable medical history; high motivation.
• Unfavourable factors: History of extensive posterior restorations; skepticism/apprehension; relocation uncertainty.
• Risk of No Treatment: Progression of caries to pulpal infection; further deterioration of aesthetics leading to decreased quality of life.

Treatment Options⁵⁷

Posterior Teeth

Tooth 47 (Pulpitis/Crack/Unsat. Restoration)

• Option 1: No treatment. (Risk: Ongoing pain, caries progression, tooth loss).
• Option 2 (Selected): Remove caries/restoration, endodontic assessment, assess restorability, temporise, and restore. (Rationale: Addresses complaint, prevents further breakdown).

Tooth 46 & 45 (Unsat. Restorations/Caries)

• Option 1: No treatment. (Risk: Plaque trap, infection).
• Option 2 (Selected): Remove caries and restore. (Rationale: Eliminate plaque trap, preserve tooth).

Tooth 36 (Unsat. Restoration/Crack/Questionable RCT)

• Option 1: No treatment. (Risk: Extraction eventually).
• Option 3 (Selected): Endodontic assessment, restorability assessment, endodontic re-treatment, and restore. (Rationale: More predictable outcome than just restoring).

Posterior & Lower Anterior

Tooth 37 (Unsat. Restoration/Overhang)

• Option 2 (Selected): Polish restoration. (Rationale: Conservative; eliminates plaque trap).

Tooth 27 (Cracked Tooth - Asymptomatic)

• Option 1 (Selected): No treatment and monitor. (Rationale: Investigation could render tooth unrestorable; currently asymptomatic).

Tooth 22 (Unsat. Restoration/Poor Aesthetics)

• Option 3 (Selected): Restore. (Rationale: Addresses presenting complaint; recontouring alone insufficient).

Upper Anterior

Tooth 21 (Unsat. Restoration/Caries/Aesthetics)

• Option 2 (Selected): Composite veneer. (Rationale: Conservative attempt before invasive crown; serves as a mock-up).

Tooth 11 (Unsat. Crown/Post/Questionable RCT)

• Option 3 (Selected): Endodontic re-treatment and full coverage crown. (Rationale: Controls RCT quality; provides satisfactory support for restoration).

Tooth 12 (Unsat. Crown/Wide Post/Questionable RCT)

• Option 2 (Selected): Full coverage crown without endodontic re-treatment. (Rationale: Post is biomechanically sound; removal carries high risk of catastrophic root fracture).

Tooth 13 (Extrinsic Staining)

• Option 2 (Selected): External bleaching. (Rationale: Addresses aesthetic complaint).

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Management Plan⁵⁸⁵⁹

Management Plan Phases⁶⁰

Control Phase

• Patient education and consent.
• Periodontal therapy: Scale and clean, local debridement (17MB), fluoride, OHI.
• Recontouring: 16M, 15M, 37M.
• Caries control: 21M&D, 36D, 45MO, 46M, 47M.
• Replace restorations: 22M, 35O.
• Endodontic re-treatment: 11.

Holding Phase

• Assess periodontal response and OHI compliance.
• Monitor symptoms: 36, 47.

Reconstructive Phase

• Indirect restorations (crowns/onlays).
• Post-core: 11.
• External bleaching: 13.

Maintenance Phase

• Recall exams, periodontal maintenance, and OHI reinforcement.

Treatment Sequencing and Constraints⁶¹

• Relocation Risk: Discussed risks of incomplete complex treatment (e.g., dislodged interim restorations, root canal infection) due to potential move to Sydney.
• Sequence Strategy:
  1. Quadrant 4 then Quadrant 3 (Lower arch first).
  2. Upper anterior then upper posterior.
• Aesthetic Timing: Treatment of the aesthetic region was delayed until adequate rapport was established.

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Treatment Delivery^62636465

January 2020 Review

• Recall Findings: Restored teeth asymptomatic; 27B crack noted; 35O GIC crumbling. Plan amended to include 27 investigation and 35 composite restoration.
• Timeline Update: Patient confirmed potential relocation for May 2020. Goal set to finish upper anterior reconstructive phase by March.
• Tooth 21: Caries/restoration removed; replaced with composite. Decision made to eventually use a zirconia crown for definitive aesthetics.
• Tooth 22: Subgingival caries removed; temporised with GIC for 6 weeks to allow gingival healing before composite replacement.

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Final Procedures and Status⁶⁶

• September 2020: 17 cemented with Variolink.
• Indirect Restorations: Post-insert review for 17 Emax crown and 27 Emax onlay.
• Incomplete Treatment: External bleaching of 13 was not completed due to lack of appointments.
• Transfer of Care: Patient transferred to another student for ongoing maintenance and recall exams.
• Occlusion: Maintained conformative occlusal scheme throughout.

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Clinical Outcomes And Reflection

Patient Response to Treatment⁶⁷

• Satisfaction: Patient very satisfied; stated, “I can smile again – I can’t stop smiling!”
• Resolution of Complaints:
  • 12-21 indirect restorations addressed aesthetic concerns (13 incomplete).
  • 11 endodontic re-treatment and new crown addressed fear of crown falling off.
  • 47 investigation and restoration resolved sensitivity to sweets.
• Compliance: Patient became highly compliant despite initial apprehension; never missed an appointment.

Clinical Reflection⁶⁸

Patient Management Challenges

• Strong Gag Reflex: Managed with salt on tongue, Xylocaine spray, distraction, and specific rubber dam clamping techniques.
• Lack of Trust: Addressed by building rapport through transparent communication and proceeding slowly.
• Radiation Apprehension: Managed through patient education on risk vs. benefit.
• Relocation: Sequencing was adjusted; COVID-19 ultimately allowed the patient to stay for the full 2020 treatment period.

Clinical Challenges

• 45 Preparation: Refined to overlay tooth structure to prevent cuspal flexure and suit CAD-CAM fabrication.
• 11 Cast Post-Core: A cement gap was accepted clinically; likely due to impression or casting error.
• Plan Changes: Added 22 (subgingival caries), 35 (crumbling GIC), and 27 (crack) to the active plan.

Case 3: Removable Aesthetic⁶⁹

The Patient⁷⁰⁷¹

Patient Details⁷²

• 82-year-old male

Presenting Complaints

Presented in July 2020 for initial examination with the following complaints:

1. “My fillings (21, 22) have broken off.”
2. “I have a missing tooth (11) that bothers me.”

History of Presenting Complaints

• Tooth 22 restored with pinned composite in July 2020.
• Tooth 21 restored with pinned composite twice (July and August 2020).
• Tooth 11 has been missing for some time.

Medical History and Medications⁷³

Medication/Supplementation	Dose	Mechanism of Action / Indication	Dental Implications
Uremide (Furosemide)	40 mg q.d.	Loop diuretic; inhibits sodium/chloride reabsorption. For oedema and hypertension.	May increase ototoxic/nephrotoxic potential of aminoglycosides/cephalosporins. NSAIDs may reduce antihypertensive effect.
Multivitamin	-	Dietary supplement.	Nil.
Garlic	-	Dietary supplement.	May inhibit platelet aggregation and increase bleeding risk.
Horseradish	-	Dietary supplement.	Nil.
Vitamin C complex	-	Dietary supplement.	Nil.

Allergies and Social Habits

• Allergies: No known allergies.
• Alcohol: 1 standard drink per week. (Raises risk of oral cavity cancer).
• Tobacco: N/A.

Dental History and Attitude

• History:
  • Regular attendance at OHCWA.
  • Previous Co-Cr partial upper dentures were made but not worn due to poor fit.
  • Transferred from another DMD student in July 2020.
• Attitude:
  • High aesthetic motivation; concerned about broken front teeth.
  • No functional issues reported; chews slowly on posterior teeth.
  • Motivated; uses public transport for all appointments.

Oral Hygiene

• Status: Poor.
• Routine: Manual toothbrush and fluoride toothpaste twice daily.
• Adjuncts: No interproximal cleaning aids or other adjuncts used.

Social History

• Retired.
• Spends time reading poetry, farming, and maintaining light aircraft.

Examination And Diagnostics

Intraoral Findings⁷⁴⁷⁵

View	Category	Findings
Maxillary Occlusal	Teeth	Kennedy-Applegate Class II Mod 2. Heavily restored posterior/worn anterior teeth. Fractured 21, 22; crack 26. Rotated 24, 26. Missing 17, 16, 11, 25.
	Restorations	Amalgam 15, 14, 24, 26. Exposed pins and missing restorations 21, 22. Rest seats 15, 24.
	Soft Tissues	Marginal gingival inflammation. Narrow alveolar ridge 11.
Mandibular Occlusal	Teeth	Kennedy-Applegate Class III Mod 1. Heavily restored/worn teeth. Discolouration 41. Missing 36, 35, 45.
	Restorations	Amalgam 36, 34, 33, 44, 47. Composite 41. Metallic crown 46.
	Soft Tissues	Marginal gingival inflammation. Narrow alveolar ridge 36-35.
Right Buccal	Teeth	Discolouration 41. Moderate plaque. Missing 11, 45. Uneven occlusal plane. Posterior crossbite.
	Restorations	Amalgam 15, 14, 44. Composite 41. Metallic crown 46.
	Soft Tissues	Marginal gingival inflammation. Recession 14, 15, 43, 44, 46.
Left Buccal	Teeth	Fractured 21, 22. Enamel infraction 33. Mild plaque. Missing 36, 35. Supraerupted 26. Uneven occlusal plane. Posterior crossbite.
	Restorations	Amalgam 24, 26, 27. Exposed pins 21, 22.
	Soft Tissues	Marginal gingival inflammation. Recession 24, 26, 34, 33.
Anterior	Teeth	Enamel infraction 23, 33. Plaque at margin. Missing 11, 36, 35, 45. Supraerupted 26. Uneven occlusal plane. Bilateral posterior crossbite.
	Restorations	Amalgam 24, 26, 34, 33, 44. Composite 41. Exposed pins 21, 22. Metallic crown 46.
	Soft Tissues	Marginal gingival inflammation. Marked oedema 21. Recession 14, 13, 23, 24, 26, 34, 33, 43, 44, 46. Loss of interdental papilla.

Odontogram Legend⁷⁶

• Amalgam restoration
• Metallic crown
• Composite restoration
• Unsatisfactory restoration
• Non-carious tooth surface loss
• Enamel infraction
• Cracked tooth
• Impacted
• Root-canal treated (RCT)

Periodontal Assessment

Community Index of Periodontal Treatment Needs (CPITN)

• Sextant 1: 15MP 4 mm
• Sextant 2: Generalised staining
• Sextant 3: Generalised staining and recession (especially 26)
• Sextant 4: Generalised staining and recession
• Sextant 5: Generalised staining
• Sextant 6: Generalised staining and recession

CPITN Scores:

3	1	1
1	1	1

Clinical Periodontal Findings

• Gingival Tissues:
  • Bleeding on probing (interproximal)
  • Oedematous texture; pink with red marginal inflammation
  • Blunted papillae (lower anterior)
  • Thick biotype
• Plaque/Calculus:
  • Plaque in interproximal areas
  • Calculus on posterior teeth
• Plaque-retentive factors: Open contacts (21-24, 31-43), buccal groove 46
• Furcation: 46, 47
• Halitosis: No

Radiographic Periodontal Findings

• Bone levels: Generalised mild horizontal bone loss in maxilla and mandible.

Periodontal Tests⁷⁷⁷⁸

Tooth	48	47	46	15	14	13	12	41	21	22	23	24	36	27	37
Mobility	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0
TTPalp	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
TTP	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-

Periodontal Risk Assessment (PRA)

• BOP%: 17% (22 of 132 sites)
• PPD ≥5mm: 0 sites
• Bone Loss/Age: 0.24
• Missing Teeth: 7
• Alveolar Bone Loss: Estimated 20%
• Systemic/Genetic Factors: Yes
• Environmental: Non-smoker
• Overall Periodontal Risk: Medium
• Suggested Recall: 6 Months

Radiographic Findings⁷⁹

Bitewing – Left

• Restorations: 24DO, 26MO & OP, 27MOr (mesial overhang), 37Or, 34Ba.
• Periodontal: Generalised crestal bone loss; ridge resorption 36 region.
• Other: 23D/34D PDL space widening; 26 supraeruption; 37 mesial tilt.

Bitewing – Right

• Restorations: 16MODBPa (overhang), 15MODBPa (overhang), 14MODBPa, 44MODa, 47Ma (pinned), 46 metallic crown (pinned core).
• Periodontal: Generalised crestal bone loss; ridge resorption 45 region; furcation involvement 46.
• Other: 44D/43D PDL space widening; 13, 12 incisal wear; tight contact 46D & 47M.

Periapical – 21 & 22

• Restorations: 21 pinned composite (failed), 22 pinned composite (failed).
• Findings: Intact PDL space and lamina dura; no periapical radiolucency; missing 11.

Periapical – 26

• Restorations: 24D Or, 26MO & OP, 27MOr, 37Or.
• Findings: Intact PDL space and lamina dura 24, 26, 27; no periapical radiolucency; missing 25; impacted 28.

Caries Risk Assessment⁸⁰

Dietary Assessment

• High fermentable carbohydrates.
• Low sugar and low acid.
• Limited snacking frequency.

Saliva Test Results

• Unstimulated Flow Rate: Low (>60 s)
• Consistency: Sticky/frothy
• pH: 5.0-5.8 (Low)
• Stimulated Quantity (5 mins): Very low (<3.5 mL)
• Buffering Capacity: Very low (0-5)

CAMBRA Assessment

• Disease Indicators: Radiographic approximal enamel lesions.
• Risk Factors: Visible heavy plaque; exposed roots.
• Protective Factors: Fluoridated community; fluoride toothpaste twice daily; fluoride varnish (last 6 months); adequate stimulated flow.
• Overall Caries Risk: Low.

Suggested Management

• OTC toothpaste (1000 ppm fluoride) twice daily.
• 12-month recall.

Diagnoses And Problem List⁸¹

Pathological Diagnoses⁸²

• Restorations: Heavily restored dentition; history of multiple composite failures; metallic crown.
• Endodontic: 41 clinically/radiographically satisfactory RCT.
• Periodontal: Generalised Stage II Grade A stable periodontitis.
• Tooth Surface Loss: Attrition 13-12, 21-23, 34-43.
• Cracked Teeth: 13, 23, 26, 34, 33, 43, 47.
• Traumatic Occlusion: 21.
• Medical: Bilateral atherosclerotic carotid arteries; tonsilloliths.

Morphological Diagnoses

• Malocclusion: Class III (habitual forward posture); bilateral posterior crossbite; rotated 24, 26.
• Overbite/Overjet: Edge to edge.
• Missing/Impacted: Missing 17, 16, 11, 25, 36, 35, 45; impacted 18, 28.
• Impairment: Loss of vertical dimension/prosthetic space; supraerupted 26; tilted 37.
• Aesthetics: Missing 11; fractured 21, 22; discoloured 41.
• Occlusion: Stable; group function guidance; uneven occlusal plane.

Host-Related Factors

• Psychosocial: Excellent presentation; aesthetic concern; motivated.
• Habits: Fair oral hygiene; high fermentable carbohydrate diet.
• Socioeconomic: Financial resources available.
• Medical: Medically compromised; limited manual dexterity.
• Functional: Possible parafunction.

Problem List⁸³

• Carotid artery disease.
• Poor aesthetics (Missing 11, failed restorations 21/22, discoloured 41).
• Tight contact: 46D & 47M.
• Generalised Stage II Grade A stable periodontitis (furcation 46, 47).
• Generalised anterior tooth wear (loss of VDO, uneven plane, group function).
• Missing posterior teeth: 17, 16, 25, 36, 35, 45.
• Impacted 18, 28.
• Tonsilloliths.

Prognosis⁸⁴

Overall Dentition Prognosis⁸⁵

• Periodontal: Sound health except 46, 47 (furcation involvement).
• Pulpal: Sound health except 41 (questionable RCT).
• Restorability: History of extensive posterior restorations and little remaining structure on 12, 21, 22 results in poor to hopeless prognosis for those specific teeth.
• Medical Priority: High risk for stroke (carotid artery disease) makes dental issues a lower systemic priority.
• Favourable Factors: Low cariogenic/acid diet and patient motivation/finances.
• Risks of No Treatment:
  • High risk of stroke.
  • Detrimental psychosocial impact due to aesthetics.
  • Continued tooth loss via wear.

Treatment Options⁸⁶⁸⁷⁸⁸

Anterior Aesthetics and Posterior Contacts

Failed Composite 22

1. No treatment: Does not address complaint.
2. Restore tooth: Addresses complaint but high risk of failure due to minimal tooth structure and history of failure.
3. Extraction and Immediate Partial Denture: Addresses complaint; patient wants to keep tooth as long as possible despite poor prognosis. (Selected Option: 3)

Discolouration 41

1. No treatment: Patient not bothered by discolouration. (Selected Option: 1)
2. Restore tooth: Risk of restoration failure due to little remaining structure.

Tight Contact 46D & 47M

1. No treatment/Monitor: Risk of plaque trapping, caries, and infection. (Selected Option: 1 - Patient declined treatment)
2. Restore tooth: Eliminates food trap but requires extensive work; margins likely subgingival.

Impacted Teeth and Tonsilloliths

Impacted 18, 28

1. No treatment: Asymptomatic; present for long time. (Selected Option: 1)
2. Surgical extraction: Risks of surgery outweigh benefits given medical history.

Tonsilloliths

1. Self-management: Oral hygiene and warm salt water rinses. (Selected Option: 1)
2. GP Referral: For symptomatic/large deposits.

Management Plan

Systemic Phase

• Referral to GP for management of carotid artery disease.

Control Phase (Pain, Infection, Inflammation)

• Patient education and consent.
• Periodontal therapy: Scale and clean, debridement 46 & 47, fluoride, OHI.
• Replace unsatisfactory restoration: 22MDLa.
• Extraction: 21.

Holding Phase

• Assess periodontal response and OH compliance.
• Monitor cracked teeth: 26, 47.

Reconstructive Phase

• Indirect prosthesis: Immediate acrylic upper partial denture replacing 16, 11, 21.

Maintenance Phase

• 1-week post-insert review.
• 6-monthly recall: Periodontal maintenance, reinforce OHI, monitor cracked teeth.
• Review acrylic denture; consider Co-Cr replacement if appropriate.

Clinical Outcomes And Reflection

Case 4: Fixed Occlusal Rehabilitation

The Patient

Examination And Diagnostics

Management Plan

Treatment Delivery

Case 5: Removable Occlusal Rehabilitation

The Patient

Examination And Diagnostics

Footnotes

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