# Case Portfolio 2019 Final Year Student Doctor of Dental Medicine (DMD) University of Western Australia           Final Year Student Doctor of Dental Medicine (DMD) University of Western Australia Clinical intraoral photograph showing a severe case of dental malocclusion and crowding. The image captures the anterior view of the maxillary and mandibular arches with significant rotation of teeth, dark discoloration (likely caries or staining), and poor gingival health. Clinical intraoral photograph showing the patient's dentition in occlusion. This image demonstrates a Class I molar relationship but with significant anterior crowding and spacing issues. The teeth appear yellowish, and there is visible wear on the incisal edges. Clinical intraoral photograph showing a full smile view. There are noticeable diastemas (gaps) between the upper central incisors and lateral incisors. The gingiva appears slightly inflamed, and the teeth show signs of wear. Clinical intraoral photograph focusing on the upper anterior region. It highlights a midline diastema between the central incisors and general spacing throughout the arch. The tooth color is uneven. Clinical intraoral photograph showing an anterior view where the lower incisors overlap significantly over the upper incisors (overbite). There is crowding in both arches, particularly in the lower anterior segment, and some teeth appear discolored. Clinical intraoral photograph showing the posterior occlusion. It reveals a crossbite relationship on the left side (patient's right) where the lower buccal segments are positioned outside the upper buccal segments. There is also evidence of missing teeth or gaps in the posterior regions. Clinical intraoral photograph showing a significant anterior open bite. The upper and lower front teeth do not touch when the back teeth are together. There is severe crowding and rotation of the lower incisors. Clinical intraoral photograph showing the posterior occlusion from a different angle. It displays a deep bite with the upper incisors overlapping the lower incisors significantly. There is crowding in the upper arch and spacing in the lower arch. Clinical intraoral photograph showing a complex malocclusion with severe crowding, rotation, and potential missing teeth in the lower anterior region. The alignment is chaotic, making function difficult. Clinical intraoral photograph showing the final or intermediate stage of treatment. The teeth are aligned much better than in the initial photos, though some spacing remains. Metal bands or retainers may be visible on some teeth. # Contents 1. **Aesthetic removable restorative case** – [Redacted]  1.1 Presenting complaint …………………… **3**  1.3 Medical history ………………………………………… **3**  1.17 Problem list ………………………………………… **14**  1.18 Diagnosis ………………………………………… **14**  1.19 Treatment options ………………………………………… **15**  1.20 Management plan …………………… **18**  1.22 Before and after treatment photographs …………………… **26** 2. **Functional removable restorative case** – [Redacted]  2.1 Presenting complaint …………………… **27**  2.3 Medical history …………………… **27**  2.15 Problem list ………………………………………… **36**  2.16 Diagnosis ………………………………………… **36**  2.17 Treatment options ………………………………………… **37**  2.28 Management plan …………………… **39**  2.19 Before and after treatment photographs …………………… **42** 3. **Aesthetic fixed restorative case** – [Redacted]  3.1 Presenting complaint …………………… **43**  3.3 Medical history …………………… **43**  3.14 Problem list ………………………………………… **51**  3.15 Diagnosis ………………………………………… **51**  3.16 Treatment options ………………………………………… **52**  3.17 Management plan …………………… **55**  3.18 Before and after treatment photographs …………………… **60** 4. **Functional fixed restorative case** – [Redacted]  4.1 Presenting complaint …………………… **61**  4.3 Medical history …………………… **61**  4.15 Problem list ………………………………………… **70**  4.16 Diagnosis ………………………………………… **70**  4.17 Treatment options ………………………………………… **71**  4.18 Management plan …………………… **73**  4.19 Before and after treatment photographs …………………… **77** 5. **Multidisciplinary case** – [Redacted]  5.1 Presenting complaint …………………… **78**  5.3 Medical history …………………… **78**  5.16 Problem list ………………………………………… **90**  5.17 Diagnosis ………………………………………… **90**  5.18 Treatment options ………………………………………… **91**  5.19 Management plan …………………… **93**  5.20 Before and after treatment photographs …………………… **98** 6. References …………………… **99** #### 1. Aesthetic removable restorative case - 1.1 Presenting complaint (Page 3) - 1.3 Medical history (Page 3) - 1.17 Problem list (Page 14) - 1.18 Diagnosis (Page 14) - 1.19 Treatment options (Page 15) - 1.20 Management plan (Page 18) - 1.22 Before and after treatment photographs (Page 26) #### 2. Functional removable restorative case - 2.1 Presenting complaint (Page 27) - 2.3 Medical history (Page 27) - 2.15 Problem list (Page 36) - 2.16 Diagnosis (Page 36) - 2.17 Treatment options (Page 37) - 2.28 Management plan (Page 39) - 2.19 Before and after treatment photographs (Page 42) #### 3. Aesthetic fixed restorative case - 3.1 Presenting complaint (Page 43) - 3.3 Medical history (Page 43) - 3.14 Problem list (Page 51) - 3.15 Diagnosis (Page 51) - 3.16 Treatment options (Page 52) - 3.17 Management plan (Page 55) - 3.18 Before and after treatment photographs (Page 60) #### 4. Functional fixed restorative case - 4.1 Presenting complaint (Page 61) - 4.3 Medical history (Page 61) - 4.15 Problem list (Page 70) - 4.16 Diagnosis (Page 70) - 4.17 Treatment options (Page 71) - 4.18 Management plan (Page 73) - 4.19 Before and after treatment photographs (Page 77) #### 5. Multidisciplinary case - 5.1 Presenting complaint (Page 78) - 5.3 Medical history (Page 78) - 5.16 Problem list (Page 90) - 5.17 Diagnosis (Page 90) - 5.18 Treatment options (Page 91) - 5.19 Management plan (Page 93) - 5.20 Before and after treatment photographs (Page 98) #### 6. References - References (Page 99) # 1. Aesthetic removable restorative case ## 1.1 Presenting complaint - “I hate the appearance of my lower teeth, I want them all pulled out”. - “Three of my teeth have snapped off”. - “My upper denture keeps falling out”. ## 1.2 History of presenting complaint - Patient has decided she can no longer put up with her lower teeth after colleagues commented negatively on their appearance last week. Main driving factor for treatment is aesthetics. - Upper denture needs to be “glued in” with PolyDent Denture Adhesive ever since loss of an upper tooth. - Deteriorating dentition for many years: - Patient neglect multiple missed and cancelled dental appointments, patient admits she allowed teeth to decay and gum disease to progress without seeking treatment (very embarrassed of teeth). - Lost faith in dental profession due to multiple restorations that were placed and fell out or needed replacement due to decay within a relatively short time. ## 1.3 Medical history | Conditions | Description | |------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------| | Bipolar disorder type 2* | Major depressive episode for ≥2wks and at least one hypomanic episode. Typically less frequent and less severe manic episodes when compared with Bipolar disorder type 1. | | Hashimoto’s thyroiditis* | Autoimmune condition where immune cells attack the thyroid gland, resulting in impaired ability of the thyroid gland to produce hormones. | | Bursitis* | Inflammation of the bursae that act as cushions at joints. | | Hypercholesterolaemia* | An elevation of total cholesterol and/or LDL cholesterol. May be due to a decrease in HDL cholesterol or an increase in triglycerides. | | Smoker | 2 cigarettes/day for the past 37 years → 4 pack years | *Conditions managed by medication.   #### Presenting Complaint - “I hate the appearance of my lower teeth, I want them all pulled out”. - “Three of my teeth have snapped off”. - “My upper denture keeps falling out”. #### History of Presenting Complaint - **Aesthetics:** The patient decided she can no longer tolerate the appearance of her lower teeth following negative comments from colleagues. This is the main driving factor for treatment. - **Denture Stability:** The upper denture requires daily use of PolyDent Denture Adhesive since the loss of an upper tooth. - **Dental History and Attitude:** - Long-term deteriorating dentition due to patient neglect and multiple missed/cancelled appointments. - Patient expresses embarrassment and admits to allowing decay and gum disease to progress. - Loss of faith in the dental profession due to the failure of previous restorations (falling out or recurring decay). #### Medical History Summary - **Bipolar Disorder Type 2:** Characterized by major depressive episodes (≥2 weeks) and at least one hypomanic episode. - **Hashimoto’s Thyroiditis:** Autoimmune condition resulting in impaired thyroid hormone production. - **Bursitis:** Inflammation of the joint bursae. - **Hypercholesterolaemia:** Elevated total or LDL cholesterol. - **Smoking Status:** 2 cigarettes/day for 37 years (4 pack years). Clinical photo panel showing five views of a patient's face with eyes redacted: frontal smiling view, frontal neutral view, three-quarter smiling view, left profile view, and right profile view. These images document the aesthetic presentation relevant to the case of lower teeth dissatisfaction and denture issues. Table titled '1.3 Medical history' listing patient conditions and their descriptions: Bipolar disorder type 2 (with episode criteria), Hashimoto’s thyroiditis (autoimmune thyroid dysfunction), Bursitis (joint cushion inflammation), Hypercholesterolaemia (elevated cholesterol levels), and Smoker (2 cigarettes/day for 37 years = 4 pack years). All marked conditions are managed by medication. | Medications | Dosage | Use / Mechanism of action | Dental implication | | --- | --- | --- | --- | | Clozapine | 350mg tablet orally 1x/day at night | • For bipolar disorder<br>• Atypical antipsychotic - effects mediated by blockade of dopaminergic transmission (all D2 receptors, differential blockade of D1 receptors, antagonism of 5HT2 receptors) in various parts of the brain (AMH, 2019). | • Strong evidence of interference with salivary gland function and inducing xerostomia (Wolff et al, 2016).<br>• Metabolised exclusively by CYP1A2 enzyme, which has elevated activity in smokers (due to polyclic hydrocarbons present in smoke). Smoking cessation & clozapine dosage should be managed under GP to avoid clozapine toxicity. | |Ziprasidone| 80mg tablet orally 1x/day, as required | • As above. | • As above. | | Zopiclone | 2x7.5mg tablet orally 1x/day at night | • For insomnia<br>• Non-benzodiazepine hypnotic agent - potentiates inhibitory effects of GABA (AMH, 2019). | • Moderate evidence for inducing xerostomia (Wolff et al, 2016). | | Tramadol | 200mg tablet orally 1x/day, as required | • For pain assoc with bursitis<br>• Opioid analgesic - weak μ opioid receptor agonist and norepinephrine / 5-HT reuptake inhibitor (AMH, 2019). | • Moderate evidence for inducing xerostomia (Wolff et al, 2016).<br>• Potentially reduced perception of dental pain. | | Fenofibrate | 145mg tablet orally 1x/day | • For hypercholesterolaemia<br>• Fibrate - activates peroxisome proliferator-activated nuclear receptors and modulate lipoprotein synthesis and catabolism. Reduce plasma triglyceride, and moderately increase HDL and affect LDL concentration variably (AMH, 2019). | - | | Levothyroxine | 150μg tablet 2x/day | • For Hashimoto's thyroiditis<br>• Thyroxine replaces / supplements thyroid hormone, which is normally produced by the thyroid gland (AMH, 2019). | • Poorly managed hypothyroidism can manifest as macroglossia, dysgeusia, poor periodontal health, and delayed wound healing. | * History of hospitalization / surgery * Laser eye surgery in **██** * No known allergies 4  #### Current Medications | Medication | Dosage | Use / Mechanism | Dental Implications | | :--- | :--- | :--- | :--- | | **Clozapine** | 350mg daily (night) | Atypical antipsychotic for bipolar disorder. | Strong evidence of xerostomia. Metabolized by CYP1A2; smoking cessation requires GP management to avoid toxicity. | | **Ziprasidone** | 80mg daily (PRN) | Atypical antipsychotic for bipolar disorder. | Risk of xerostomia. | | **Zopiclone** | 15mg daily (night) | Non-benzodiazepine hypnotic for insomnia. | Moderate evidence for inducing xerostomia. | | **Tramadol** | 200mg daily (PRN) | Opioid analgesic for bursitis pain. | Moderate evidence for xerostomia; potentially reduced perception of dental pain. | | **Fenofibrate** | 145mg daily | Fibrate for hypercholesterolaemia. | None noted. | | **Levothyroxine** | 150μg 2x/day | Thyroid hormone replacement. | Poorly managed hypothyroidism may cause macroglossia, dysgeusia, and delayed healing. | #### Hospitalization and Allergies - **Surgery:** Laser eye surgery. - **Allergies:** No known allergies. A table summarizing medications, their dosages, uses/mechanisms of action, and dental implications. Columns include: Medications (Clozapine, Ziprasidone, Zopiclone, Tramadol, Fenofibrate, Levothyroxine), Dosage, Use/Mechanism of Action, and Dental Implication. Each row provides detailed clinical context relevant to dental practice. <figure> Extra-oral examination showing front, 45-degree smiling, and profile views of a female patient with blue reference lines and black bars obscuring the eyes </figure> 1.4 Dental history * History of repeated temporary restorations for rampant caries over the past 5 years. * Loss of multiple teeth or snapping of teeth over the years due to untreated or unsuccessfully treated caries and periodontal disease. * CrCo P/ made 4yrs ago in OHCWA, but patient dissatisfied with unsatisfactory retention after snapping an abutment tooth. 1.5 Oral hygiene * Toothbrushing 2x/day with electric toothbrush and non fluoridated toothpaste (charcoal toothpaste). * No other dental products used. 1.6 Social history * Lives at home alone but is regularly visited by her mother, daughter and grandchildren. * Works in a bakery. * Has tried to quit smoking for the past few years, but has been unsuccessful. Smokes 2 cigarettes/day. * Drinks alcohol rarely; 1 or 2 times per month. 1.7 Extra-oral examination | Facial appearance | Healthy, clear complexion | | Facial symmetry | Symmetrical, deviation of nose tip to R | | Thyroid gland | No noticeable enlargement or tenderness to palpation | | Muscles of mastication | No noticeable enlargement or tenderness to palpation or clenching | | **TMJ** | Smooth movement in translation and rotation on both sides | | Facial thirds | Elongated lower third of face | | Facial fifths | Balanced and symmetrical facial fifths | | Upper lip | **Distinct vermillion border, smooth vermillion, healthy appearance** | | Lower lip | Distinct vermillion border, smooth vermillion, healthy appearance | | **Smile analysis** | On smile, 95% incisal display, 0% gingival display<br>At rest, 0% incisal display<br>Wide Bu corridors (due to missing upper posterior teeth) | | Profile | Convex | ### 5   #### Dental and Social History - **Restorative History:** Repeated temporary restorations for rampant caries over the past 5 years. Multiple teeth lost or fractured due to untreated caries and periodontal disease. - **Prosthetic History:** Chrome Cobalt partial denture (CrCo P/-) made 4 years ago; patient is dissatisfied with retention following the fracture of an abutment tooth. - **Oral Hygiene:** Brushes 2x/day with an electric toothbrush and charcoal (non-fluoridated) toothpaste. No interdental cleaning. - **Social Factors:** Works in a bakery; lives alone but has regular family visits. Occasional alcohol consumption (1-2 times per month). #### Extra-Oral Examination Findings - **Facial Features:** Symmetrical face with a slight deviation of the nose tip to the right. Healthy complexion. - **Anatomy:** No enlargement or tenderness of the thyroid gland or muscles of mastication. TMJ shows smooth movement in translation and rotation. - **Proportions:** Elongated lower third of the face; balanced facial fifths. Convex profile. - **Lips:** Distinct vermillion borders with a healthy appearance. - **Smile Analysis:** - 95% incisal display on smile; 0% gingival display. - 0% incisal display at rest. - Wide buccal corridors due to missing upper posterior teeth. Table summarizing the extra-oral examination findings. Columns include 'Facial appearance', 'Facial symmetry', 'Thyroid gland', 'Muscles of mastication', 'TMJ', 'Facial thirds', 'Facial fifths', 'Upper lip', 'Lower lip', 'Smile analysis', and 'Profile'. Key values listed include 'Elongated lower third of face' for Facial thirds, '95% incisal display' for Smile analysis, and 'Convex' for Profile. Clinical photography showing a female patient's facial features from three angles: frontal view with blue horizontal reference lines marking facial thirds, smiling view showing upper teeth exposure, and profile view with a vertical line indicating convexity. Eyes are obscured by black bars for privacy. 1.8 Intra-oral examination | La mucosa | R ulcer 2x2mm with yellow base, diffuse red halo, no induration<br>Ddx:<ul><li>Aphthous ulcer (most likely given hx of recurrent aphthous ulcers)</li><li>Traumatic ulcer</li><li>OSCC</li></ul>Management: 2wk review. | | --- | --- | | Sulci | Smooth, pink, in-tact mucosa | | Frena | Smooth, pink, in-tact mucosa | | Gingiva | Edematous (loss of stippling), erythematous, very painful to probing, BoP+,<br>blunting of interdental papilla, recession | | Palate | U-shaped arch, diffuse erythematous and edematous appearance of anterior hard palate<br>Ddx:<ul><li>Denture stomatitis (most likely given poorly retentive P/- glued in with PolyDent Denture Adhesive daily)</li><li>Traumatic lesion</li><li>Allergic reaction</li></ul>Management: Remove likely cause (leave P/- out as much as possible, esp at night & clean meticulously) & 2wk review. | | Oropharynx | Smooth, pink, in-tact mucosa | | Alveolar ridge | Large, bulbous anterior alveolar ridge supporting prominent Mx anterior incisors,<br>comparatively small posterior alveolar ridges | | Bu mucosa | Smooth, pink, in-tact mucosa | | Tongue | White dorsal surface; pink, in-tact mucosa on ventral surface | | Floor of mouth | No tenderness to palpation or evidence of swelling | | Saliva | Appears inadequate - dry appearance of gingiva, tongue, cheeks and teeth | | Dentition | Partially dentate Mx and Md<br>Mx & Md dental midlines coincident<br>Mx dental midline L of facial midline | 6   #### Intra-Oral Soft Tissue Examination - **Labial Mucosa:** 2x2mm ulcer with yellow base and red halo (Right side). Differential Diagnosis: Aphthous ulcer (most likely), Traumatic ulcer, or OSCC. Management: 2-week review. - **Palate:** Diffuse erythematous and edematous appearance of the anterior hard palate. Differential Diagnosis: Denture stomatitis (most likely due to poor retention and adhesive use), Traumatic lesion, or Allergic reaction. Management: Leave denture out at night, clean meticulously, and 2-week review. - **Gingiva:** Edematous, erythematous, and painful to probing. Positive Bleeding on Probing (BoP+), blunting of interdental papilla, and recession. - **Saliva:** Inadequate volume; dry appearance of gingiva, tongue, cheeks, and teeth. - **Alveolar Ridge:** Large, bulbous anterior maxillary ridge; comparatively small posterior ridges. - **Other:** White dorsal surface of the tongue. Sulci, frena, oropharynx, buccal mucosa, and floor of mouth appear healthy and intact. #### Occlusion and Alignment - Partially dentate Maxilla (Mx) and Mandible (Md). - Dental midlines are coincident, but the Mx dental midline is left of the facial midline. Composite clinical photograph labeled '1.8 Intra-oral examination'. The figure contains six distinct panels showing various views of a patient's oral cavity: frontal views (upper and lower), occlusal view of the maxillary arch, lateral view of the mandibular arch, occlusal view of the mandibular arch, and an intraoral view focusing on the right buccal area. These images visually demonstrate the findings described in the table below, such as gingival inflammation, dental status, and specific lesions. Clinical documentation table titled 'Intra-oral examination'. The table lists anatomical regions (La mucosa, Sulci, Frena, Gingiva, Palate, Oropharynx, Alveolar ridge, Bu mucosa, Tongue, Floor of mouth, Saliva, Dentition) in the left column and corresponding clinical findings in the right column. Key findings include a right ulcer on the labial mucosa, edematous and erythematous gingiva with recession, U-shaped palatal arch with diffuse erythema, and inadequate saliva. The table also includes differential diagnoses (Ddx) and management plans for specific findings like the ulcer and palate lesion. The page contains no unique text content beyond the header context. **1.11 Tooth charting** [Image: A tooth chart showing findings and a legend for CPITN.] ### Tooth Chart | | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | | :--- | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | | | | | | | | **P/ap R** | | | **P/ap R** | | | | | | | | **CO<sub>2</sub>** | | | | | | - | | | - | + | + | - | | | | | **Mob** | | | | | | 0 | | | II | II | 0 | I | 0 | | | | **TTP** | | | | | | - | | | - | - | | | | | | | **P/ap R** | | | | | | | | | | | | | | | | | | | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | | :--- | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | | UE | | | | | | | | | | | | | | | | | **ICDAS5** | | | | | | | | | | | | | | | | | **ICDAS5** | | | | | | | | | | | | | | | | | **ICDAS5** | | | | | | | | | | | | | | | | | **ICDAS5** | | | | | | | | | | | | | | | | | **ICDAS5** | | | | | | | | | | | | | | | | | **ICDAS5** | | | | | | | | | | | | | | | | | **UE** | | | | | | | | | | | | | | | | | **CO<sub>2</sub>** | + | + | - | + | + | + | - | - | + | + | | | | + | | **Mob** | I | I | 0 | II | II | II | II | 0 | 0 | 0 | | | | | **TTP** | - | - | - | - | - | - | - | - | - | | | | | + | | **P/ap R** | - | - | - | - | - | - | - | P/ap R | P/ap R | - | | | | - | ### Legend **Restrations / findings** | Cell Color | Iconation | | :--- | :--- | | Yellow | Comp / GIC - sat | | Gray | Amalgam - sat | | Dark Brown | Caries | | Black | Root stump | | Maroon | Unsat restn due to caries | | Red | Unsat restn for other reasons | | Pink | NCTSL | | Blue outline | P/ap R Periapical radiolucency | | White with no color | UE Unerupted | **CPITN - Community Periodontal Index of Treatment Needs** | | Index | Description | | :--- | :--- | | 1 | Gingival bleeding after gentle probing | | 2 | Supragingival or subgingival calculus | | 3 | Pathologic pockets 4-5mm | | 4 | Pathologic pockets $\ge$6mm | | * | Fucation involvement or recession $\ge$4mm |   #### Tooth Charting and Vitality Testing **Maxillary Findings:** - **Vitality (CO2):** Negative for 13, 21, 24. Positive for 22, 23. - **Mobility:** Grade II (21, 22), Grade I (24). - **Radiographic Findings:** Periapical radiolucencies (P/ap R) noted at 13 and 21. **Mandibular Findings:** - **Vitality (CO2):** Positive for 48, 47, 45, 44, 43, 31, 32, 36. Negative for 46, 42, 41. - **Mobility:** Grade II (45, 44, 43, 42), Grade I (48, 47). - **Radiographic Findings:** Periapical radiolucencies (P/ap R) noted at 41 and 31. - **Tenderness to Percussion (TTP):** Positive at 36. #### Charting Legend - **Caries:** Dark Brown - **Root Stump:** Black - **Unsatisfactory Restoration (Caries):** Maroon - **Unsatisfactory Restoration (Other):** Red - **Non-Carious Tooth Surface Loss (NCTSL):** Pink - **Sound Restorations:** Yellow (Comp/GIC), Gray (Amalgam) #### Community Periodontal Index of Treatment Needs (CPITN) 1. Gingival bleeding after gentle probing 2. Supragingival or subgingival calculus 3. Pathologic pockets 4-5mm 4. Pathologic pockets ≥6mm * Furcation involvement or recession ≥4mm A comprehensive dental tooth chart (FDI notation) displaying findings for both upper and lower arches. The chart features a grid with columns representing teeth 18-28 (upper) and 48-38 (lower). Rows include clinical metrics: CO2 (caries), Mob (mobility), TTP (toothache), P/ap R (periapical radiolucency), and ICDAS5 scores. The chart utilizes specific color-coded icons to represent restorations and conditions, including Yellow (Comp/GIC), Gray (Amalgam), Dark Brown (Caries), Black (Root stump), Maroon (Unsat restn due to caries), Red (Unsat restn other reasons), Pink (NCTSL), Blue outline (P/ap R), and White/UE (Unerupted). A reference table titled 'LEGEND' divided into two sections. The left section ('Restorations / findings') maps colors to clinical findings (e.g., Yellow = Comp / GIC - sat, Black = Root stump). The right section defines the 'CPITN - Community Periodontal Index of Treatment Needs', listing indices 1 through 4 and an asterisk (*) corresponding to specific periodontal conditions like gingival bleeding, calculus, or pathologic pockets. The page contains no unique text content beyond the header context. **1.13 Radiographs** • 2x OPGs taken 31st Mar [BLACKED OUT] and 16th July [BLACKED OUT] - Dramatic change in caries experience. - In 2016, moderately restored dentition & Cr Co P/ . - By 2018, frank cavitation affecting almost every tooth. P/ap lesions involving 13, 21, 24, 33, 32. - Moderate to severe levels of bone loss. Relatively constant bone levels between [BLACKED OUT] and [BLACKED OUT]. <div style="page-break-before:always"></div> <div style="page-break-before:always"></div> <div style="page-break-before:always"></div> 10 #### Radiographic Interpretation - **Comparison (2016 vs 2018):** Significant increase in caries experience. - **Caries:** Frank cavitation now affects almost every tooth. - **Endodontic Status:** Periapical lesions involving teeth 13, 21, 24, 33, and 32. - **Periodontal Status:** Moderate to severe bone loss. Bone levels have remained relatively constant between recent imaging intervals. **6x PAs taken 16th Aug** **1.14** *Caries risk assessment* (**Evans et al, 2008**) **Diet assessment** (Usual 24h snacking questionnaire) * Breakfast banana, oats * 3 cups of coffee with 2tsp sugar drunk throughout the morning * 2 3 sweet lollies * Lunch toasted sandwich * Handful of potato chips (usually in one sitting) * Cake or pastries at work * Pepsi Max 375mL sipped throughout the afternoon * 1 2 cups of coffee before dinner * Dinner weight watchers set meals, typically meat, veg and rice * Occasionally cake or ice cream * Patient does not drink tap water during a typical day **Plaque score - 59% (40/68)** **Saliva assessment -** | | Resting saliva | | | | | :--- | :--- | :--- | :--- | :--- | | | Hydration | Viscosity | pH | | | >60s | | Sticky/stringy | 5.0-5.8 | | | 30-60s | | Frothy/bubbly | **6.0-6.6** | | | <30s | | Watery/clear | 6.8-7.8 | | | | Stimulated saliva | | | | :--- | :--- | :--- | :--- | | | Quantity | pH | Buffering | | <3.5mL | | 5.0-5.8 | 0-5pt | | 3.5-5.0mL | | **6.0-6.6** | 6-9pt | | >5.0mL | | 6.8-7.8 | **10-12pt** |     #### Diet and Plaque Assessment - **Dietary Habits:** High frequency of sugar and acid. Includes 3-5 cups of coffee with sugar, sweet lollies, cake/pastries at work, and Pepsi Max sipped throughout the afternoon. No tap water consumption. - **Plaque Score:** 59% (40/68 sites). #### Saliva Assessment **Resting Saliva:** - **Hydration:** >60s (Poor) - **Viscosity:** Sticky/stringy - **pH:** 6.0-6.6 **Stimulated Saliva:** - **Quantity:** 3.5-5.0mL (Low-Normal) - **pH:** 6.0-6.6 - **Buffering:** 10-12pt (High) Clinical composite of 6 Periapical (PA) radiographs taken on 16th Aug. The images display various teeth with visible restorations (fillings) and anatomical structures relevant to caries risk assessment. Visual representation of Plaque score (59% / 40/68). A grid chart displaying tooth positions with yellow cross-hatched squares indicating the presence of plaque in specific areas. Table titled 'Resting saliva'. It categorizes saliva hydration levels (>60s, 30-60s, <30s), corresponding viscosity descriptions (Sticky/stringy, Frothy/bubbly, Watery/clear), and pH ranges (5.0-5.8, 6.0-6.6, 6.8-7.8). Table titled 'Stimulated saliva'. It categorizes saliva quantity (<3.5mL, 3.5-5.0mL, >5.0mL), corresponding pH ranges (5.0-5.8, 6.0-6.6, 6.8-7.8), and buffering scores (0-5pt, 6-9pt, 10-12pt). * Clinical examination / radiographic assessment - + Multiple untreated frank cavities + Multiple deep carious lesions that radiolucency appear to extend into the pulp chamber + Multiple periapical radiolucencies * Caries risk: **HIGH** 1.15 Periodontal risk assessment (**Lang & Tonetti**, 2003) | | | | | :--- | :--- | :--- | | **BOP%** = 80% | Age | 51 | | PD≥5mm | Number of teeth and implants | 17 (1 - 32) | | **Envir.** | Number of sites per tooth / implant | 2 4 6 | | | Number of BOP-pos. sites | 82 of 102 | | Syst./Gen. | Number of sites with PPD≥5mm | 21 | | Tooth loss | Number of missing teeth | 11 | | BL/Age = 1.37254 | % Alveolar bone loss (estimated in % or 10% per 1mm) | 70 % | | | Syst./Gen. | Yes No | | | Envir. | Non smoker (NS)<br>Former smoker (FS)<br>Occasional smoker (**OS**)<br>Smoker (S)<br>Heavy smoker (HS) | | Polygon surface: 130.769 | | | | Periodontal Risk: **high** | | | | Suggested Recall interval: 3 Months | | | * Periodontal risk: **HIGH**  #### Risk Summary - **Caries Risk: HIGH** - Multiple untreated frank cavities. - Deep carious lesions extending into pulp chambers. - Multiple periapical radiolucencies. - **Periodontal Risk: HIGH** - **Bleeding on Probing (BOP):** 80% (82 of 102 sites). - **Probing Depths:** 21 sites with PPD ≥5mm. - **Bone Loss:** Estimated at 70% (BL/Age ratio = 1.37). - **Missing Teeth:** 11. - **Environmental Factors:** Occasional smoker. - **Recall Interval:** 3 months suggested. Periodontal risk assessment chart based on Lang & Tonetti (2003). The visual consists of a radar chart on the left and a data entry panel on the right. The radar chart displays a shaded polygon representing patient scores across six axes: BOP% (80%), PD≥5mm, Tooth loss, BL/Age (1.37254), Syst./Gen., and Envir. The chart indicates a 'Polygon surface' of 130.769 and concludes with a 'Periodontal Risk: high' result and a suggested recall interval of 3 months. The adjacent data panel lists specific values: Age 51, Number of teeth/implants 17, Sites per tooth 6, BOP-pos sites 82 of 102, PPD≥5mm sites 21, Missing teeth 11, Alveolar bone loss 70%, Systemic factors 'No', and Environmental factor 'Occasional smoker (OS)'. A summary line below states 'Periodontal risk: HIGH'. 1.16 Prognosis (Samet & Jotkowitz, 2009) • Individual tooth prognosis - * Prognosis categories are based on a classification proposed by Samet & Jotkowitz (2009), where overall prognosis is the worst of periodontal, restorative, endodontic and occlusal prognoses. Anatomic, iatrogenic and patient factors modify the overall prognosis. ** Overall tooth prognosis modified downward by patient factors - poor OH, cariogenic diet, smoking, aesthetics as motivation for treatment, and high aesthetic expectations. • Overall dentition prognosis POOR to HOPELESS * Prognosis categories are based on a classification proposed by Samet & Jotkowitz (2009), where overall prognosis is the worst of periodontal, restorative, endodontic and occlusal prognoses. Anatomic, iatrogenic and patient factors modify the overall prognosis. ** Overall tooth prognosis modified downward by patient factors - poor OH, cariogenic diet, smoking, aesthetics as motivation for treatment, and high aesthetic expectations. * Overall dentition prognosis ** POOR to HOPELESS **  #### Individual and Overall Prognosis - **Prognosis Determination:** Based on Samet & Jotkowitz (2009), integrating periodontal, restorative, endodontic, and occlusal factors. - **Modifying Factors:** Prognosis is adjusted downward due to poor oral hygiene, cariogenic diet, smoking, and high aesthetic expectations. - **Overall Dentition Prognosis:** POOR to HOPELESS. A comprehensive dental prognosis reference table titled '1.16 Prognosis (Samet & Jotkowitz, 2009)'. It includes columns for tooth positions (e.g., 13, 11, 21), prognoses per category (Perio, Resto, Endo, Occ), and overall status with color-coded cells: green (Good/G), yellow (Fair/F), orange (Questionable/Q), red (Poor/P), black (Hopeless/H), brown (Caries), dark grey (Root stump), light grey (Amalgam), and white/blue outlines (UE/Unerupted). The bottom section contains a legend explaining restorations/findings and CPITN indices. 1.17 Problem list - Poor smile aesthetics and unsat CrCo P/ (presenting complaint) o Multiple root stumps, discolouration due to caries o Unsat CrCo P/ design and loss of retention due to fracture of abutment tooth 24 - Host related o Bipolar disorder & hypothyroidism managed by medication o Dry mouth o Smoker o Frequent and high intake of sugary & acidic foods and drinks o Questionable OH compliance / dental attendance record - Pathology o Carious root stumps 24, 33, 43 o Frank cavitation due to caries 11, 13, 21, 22, 23, 31, 32, 34, 35, 41, 44, 45 o Moderate to severe generalized chronic periodontitis modified by smoking (AAPD, 1999) / Periodontitis Stage 4 Grade C modified by smoking (Papapanou et al, 2017) o Pulpless and infected root canal system and chronic apical periodontitis due to caries 24, 32, 33 (Abbott & Yu, 2007; Abbott, 2004) o Recurrent aphthous ulcerative disease o Denture stomatitis of the anterior hard palate - Morphology o Skeletal Cl II and dental Cl II div 1 o Vertically impacted 38, 48 o Hypercementosis 13, 23, 24, 34, 35, 44, 45 o Missing teeth Mx Kennedy Cl I, Md Kennedy Cl II Mod 1 o Large, bulbous Mx anterior alveolar ridge o Loss of posterior support 1.18 Diagnoses - Poor smile aesthetics and unsat CrCo P/ (presenting complaint) - Root stumps / “unrestorable” teeth - Caries - Periodontal disease - Endodontically involved teeth - Mx Kennedy Cl I - Md Kennedy Cl II Mod 1 #### Problem List **Aesthetics and Prosthetics:** - Poor smile aesthetics and unsatisfactory CrCo P/-. - Multiple root stumps and carious discoloration. - Fractured abutment tooth (24) causing loss of denture retention. **Host and Behavioral Factors:** - Systemic: Bipolar disorder and hypothyroidism (medicated). - Oral Environment: Dry mouth (xerostomia). - Habits: Smoker; frequent high intake of sugar/acidic food and drinks. - Compliance: Questionable oral hygiene and attendance record. **Pathology:** - Carious root stumps: 24, 33, 43. - Frank cavitation: 11, 13, 21, 22, 23, 31, 32, 34, 35, 41, 44, 45. - Periodontal: Stage 4 Grade C Periodontitis (modified by smoking). - Endodontic: Infected root canal systems and chronic apical periodontitis (24, 32, 33). - Soft Tissue: Recurrent aphthous ulcers and denture stomatitis. **Morphology:** - Skeletal/Dental: Class II Division 1. - Impactions: Vertically impacted 38, 48. - Anatomy: Hypercementosis (multiple teeth); large bulbous maxillary anterior ridge. - Arch Status: Maxillary Kennedy Class I; Mandibular Kennedy Class II Modification 1; loss of posterior support. #### Diagnoses - Poor smile aesthetics and unsatisfactory CrCo P/-. - Unrestorable teeth / Root stumps. - Dental Caries. - Periodontal Disease. - Endodontic Involvement. - Maxillary Kennedy Class I. - Mandibular Kennedy Class II Modification 1. 4. Restoration / temporisation of remaining teeth ± 24 tooth addition to existing CrCo P/- (not recommended) SRD and temporary restoration of remaining teeth. Potential addition of tooth 24 for CrCo P/. | Advantages | Disadvantages | |---|---| | • Fastest way to address pt’s presenting complaint. | • Short-term outcome only. | | | • Highly compromised result. | 5. Immediate or conventional acrylic F/F (not recommended) full clearance followed by immediate F/F insert or conventional F/F insert following 3 6mths for healing / ridge resorption. | Advantages | Disadvantages | |---|---| | • Significant improvement in aesthetics achievable in a relatively short period of time. | • Sudden change from dentate to edentulous → likely issues with adaptation. | | • Eliminates dental caries, odontogenic infections & periodontal disease. | • Poor retention of -/F. | 6. No treatment | Advantages | Disadvantages | |---|---| | • No further action required by pt. | • Oral diseases will progress → eventual loss of teeth in the short to medium term ± pain and infection, in an unpredictable fashion. | | | • Aesthetics will worsen over the short to medium term. | #### Rejected Treatment Options **Option 4: Limited Restoration and Denture Modification** - **Description:** Stabilize remaining teeth and add tooth 24 to existing CrCo P/-. - **Advantages:** Fastest address of complaint. - **Disadvantages:** Short-term outcome; highly compromised result. **Option 5: Full Clearance and Complete Dentures (F/F)** - **Description:** Immediate or conventional full dentures. - **Advantages:** Significant aesthetic improvement; eliminates all dental disease. - **Disadvantages:** Difficult transition to edentulous state; poor retention of mandibular denture. **Option 6: No Treatment** - **Advantages:** No patient action required. - **Disadvantages:** Unpredictable progression of pain and infection; worsening aesthetics; eventual tooth loss. • Patient decided on treatment option 1 Immediate acrylic F/P due to: * Potential for significant improvement in aesthetics * Relatively low cost of tx * Significant reduction in disease burden assoc with removal of teeth with hopeless prognosis * Simplified course of tx * Patient refused to go without teeth for any period of time **LEGEND:** ━━━━━━━━━━━━━━━━━━━━━━━━━━laration━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ **Restorations / findings** * **\d** COMP / GIC - sat * **amalgam - sat** * **Caries** * **Root stump** * **Unsat restn due to caries** * **Unsat restn for other reasons** P/ap R Periodontal Index of Treatment Needs ━━━━━━━━━━━━━━━━━━━━━━━━━━━Prognoses━━━━━━━━━━━━━━━━━━━━━━━ | P | Q | H | F | E | |---|---|---|---|---| | Good prognosis | Questionable prognosis | Hopeless prognosis | Fair prognosis | Extraction | **Treatment** | A | R | E | L | |---|---|---|---| | Adjustment | Restore/replace | Leave unrestored | Monitor | ━━━━━━━━━━━━━━━━━━━━━━━━━━━CPITN - Community Periodontal Index of Treatment Needs━━━━━━━━━━━━━━━━━━━━━━━━━━ | - | 3 | 4* | 4 | |---|---|---|---| | 1 | 2 | 3 | 4 | 1. Gingival bleeding after gentle probing 2. Supragingival or subgingival calculus 3. Pathologic pockets 4-5mm 4. Pathologic pockets ≥6mm * | | | |   #### Selected Treatment Plan **Option 1: Immediate Acrylic Maxillary Full / Mandibular Partial Denture (F/P)** **Rationale for Selection:** - Significant aesthetic improvement potential. - Relatively low cost. - Reduction of disease burden via extraction of hopeless teeth. - Simplified treatment course. - Patient refusal to be without teeth during healing. #### Clinical Coding Legend - **Prognosis:** Good (P), Questionable (Q), Hopeless (H), Fair (F), Extraction (E). - **Treatment:** Adjustment (A), Restore/Replace (R), Leave Unrestored (L), Monitor (M). - **CPITN:** 1 (Bleeding), 2 (Calculus), 3 (4-5mm pockets), 4 (≥6mm pockets). A detailed dental chart (likely a digital dentition map) showing the status of teeth in the upper and lower arches. The chart includes columns for tooth numbers (e.g., 18-28, 48-38), restorations/conditions (visualized as colored icons like black squares or blue outlines), prognoses (Perio, Resto, Endo, Occ, Overall), and treatment plans (Tx). Specific notes indicate 'ICDAS5' scores and 'UE' (Unerupted) teeth. A legend is present below the main grid explaining symbols for restorations (Comp/GIC, Amalgam, Caries, Root stump), prognoses (G=Good, F=Fair, Q=Questionable, P=Poor, H=Hopeless), and treatments (A=Adjustment, E=Extraction, R=Restore/replace, I=Investigate, L=Leave unrestored). A reference table containing legends and definitions for the data presented in the dental chart above. It defines abbreviations for 'Restorations/findings', lists specific 'Prognoses' with their color codes (Green for Good, Yellow for Fair, Orange for Questionable, Red for Poor, Black for Hopeless), and details 'Treatment' options. Additionally, it includes a section for 'CPITN - Community Periodontal Index of Treatment Needs' which maps numerical codes to periodontal conditions such as gingival bleeding, calculus, and pathologic pockets. The page contains no unique text content beyond the header context. The page contains no unique text content beyond the header context. * Base & rims fabrication for facebow & bite registration (constructed denture to conform to patient’s existing OVD) → mounted master casts * Shade selection Vita Classical shade B3 * Mx and Md casts marked with PPDs for teeth to be extracted (13, 11, 21, 22, 23, 24, 31, 32, 33, 41, 42, 43) to guide lab decoronation of teeth to be extracted on casts → duplicates of master casts formed & cross mounted * In this case, a wax try in was not possible due to teeth being not yet extracted. The patient was shown the waxed up prosthesis on articulated casts to give an idea of the final result. * Lab instructed to reduce Mx incisal display of natural teeth by 1-2 mm when setting Mx denture teeth. Also instructed to set Mx denture teeth following Pal surfaces of Mx natural teeth in order to reduce overjet and CI II appearance (which would be exaggerated with a F/ ), and to set Md teeth following line of occlusion. * Fabrication of acrylic F/P on mounted duplicates after decoronation of teeth to be extracted. Check of fit and occlusion by cross mounting.   #### Prosthetic Fabrication Procedures - **Registration:** Base and rims fabricated for facebow and bite registration, maintaining existing Occlusal Vertical Dimension (OVD). - **Shade:** Vita Classical shade B3. - **Lab Instructions:** - Maxillary and Mandibular casts marked with PPDs to guide decoronation. - Reduce maxillary incisal display by 1-2mm. - Set maxillary teeth following palatal surfaces of natural teeth to reduce overjet and Class II appearance. - Set mandibular teeth following the line of occlusion. - **Try-in:** Wax try-in was not possible due to remaining teeth; patient viewed the wax-up on articulated casts. Clinical photos showing shade selection for Vita Classical shade B3. Left image shows an intraoral view of the patient's mouth with teeth and gums visible, while the right image displays a close-up of a tooth being compared to natural teeth using a shade guide. Photos of dental casts marked with PPDs (pink dots) for teeth to be extracted (13, 11, 21, 22, 23, 24, 31, 32, 33, 41, 42, 43). The images show master casts from different angles, highlighting the marked areas that guide lab decoronation of teeth to be extracted on casts. - **Reinforce pre-operative warnings for extractions** (risk of bleeding, bruising, swelling, and infection following extraction). Patient understands the risks involved and is willing to proceed. - **Reinforced things to expect with immediate F/P** - Likely to require a significant period of adjustment because transitioning from natural teeth to a removable prosthesis. May experience problems with function (mastication & speech) while adapting to F/P. - Soreness (moderate to severe pain) immediately following exos to be expected and for a few days afterward as exos sites heal. - F/P expected to become loose after 4-6 wks due to resorption of bone following exos. Temporary chairside relines will be performed every 3-4 wks after the exos until a definitive reline at 6-12 mths can be performed (once stability is achieved and no additional soft liners are required). - Due to the amount of guess work involved, there is a possibility that the fit, aesthetics, occlusion and/or comfort of the immediate F/P will be unsatisfactory and not easily repairable. In this case, a new set of F/P dentures will need to be made. - Patient understands the limitations of the immediate F/P, and is still willing to proceed with tx after having the main issues reinforced.  #### Pre-Operative Counseling - **Surgical Risks:** Patient informed of risks including bleeding, bruising, swelling, and infection. - **Immediate Denture Expectations:** - Significant adjustment period for speech and mastication. - Post-extraction soreness and pain expected during initial healing. - Looseness expected within 4-6 weeks due to bone resorption. - Requirement for temporary chairside relines every 3-4 weeks. - Definitive reline planned for 6-12 months post-extraction. - Possibility of unsatisfactory fit/aesthetics requiring a complete remake. Clinical photograph set demonstrating immediate Full/Partial (F/P) dentures on study models. The top row displays three views: left lateral, frontal occlusion, and right lateral of the upper arch with a metal clasp visible on the lower arch. The bottom row shows the occlusal view of the maxillary denture and the buccal view of the mandibular denture. These images visually demonstrate the prostheses discussed in the text regarding 'immediate F/P', showing the physical objects that may become loose due to bone resorption or have unsatisfactory fit. Definitive phase (Jogezai et al, 2018) • Extractions (Jogezai et al, 2018) • Insert of acrylic F/P (Jogezai et al, 2018) • Post-operative instructions for immediate F/P (Jogezai et al, 2018) • Post-operative extraction instructions (Jogezai et al, 2018) Page 22   #### Definitive Phase - Execution of extractions. - Insertion of the immediate acrylic F/P denture. - Provision of post-operative instructions for both the extractions and the new prosthesis. Clinical photo showing the patient's upper palate with multiple extraction sockets visible as dark, open wounds in the gum tissue. Clinical photo showing the lower jaw with remaining teeth and an acrylic full denture (F/P) inserted into the mouth. The denture covers the extraction sites. - **24hr review (20/2/••)** - Patient returned sore and swollen. However, she was extremely pleased with the aesthetic result. Reassurance at this appointment made a huge impact on the patient. - Checked occlusion and refined for balanced occlusion. Warned patient that if significant changes are required for a satisfactory result in the short to medium term, a denture remake may be necessary. - Reinforced post operative instructions. Re emphasised home care routine for the next week. 23    #### 24-Hour Review - **Patient Status:** Sore and swollen but extremely pleased with the aesthetic result. - **Clinical Actions:** - Occlusion checked and refined for balanced contacts. - Reinforced post-operative instructions and home care routine. - Advised that a future remake may be necessary if significant changes occur. Clinical facial photos showing a patient's smile from three angles (frontal, profile, and three-quarter view). The eyes are redacted for privacy. These images demonstrate the aesthetic result of the dental treatment mentioned in the text, specifically addressing the patient's pleasure with the outcome. Clinical intraoral photos showing the patient's dentition. The left image displays the full arch of teeth with a metal clasp visible on the lower right molar, indicating a partial denture or bridge. The right image shows the upper and lower teeth in occlusion, demonstrating the balanced bite mentioned in the OCR context. Clinical intraoral photos showing detailed views of the teeth and gums. The top center image shows the upper arch, while the bottom center image shows the lower arch with a clear view of the metal framework of the prosthesis. The side images provide close-up views of the anterior teeth and gingival health. - **1wk review (26/2/□)** - Patient remained extremely pleased with the aesthetic result, and reported that many of her colleagues and family members had complimented her new smile. - Although the patient was still getting used to the dentures, she felt positively about the whole experience, especially since the majority of soreness and swelling had resolved by this time. - Minor areas of the dentures were adjusted to relieve sore spots. - Reinforced the home care routine, and that it is expected the acrylic F/P will become “loose” over the next few weeks as bone resorption takes place. - **First 3-4wk review (21/3/□)** - Patient reported that the F/P was starting to feel slightly loose. She was not concerned because she had been pre warned, but wanted the looseness addressed promptly. - Minor areas of the dentures were adjusted to relieve any sharp edges. - Viscogel soft liner was added to the intaglio surface of the F/P to improve retention and stability.   #### Follow-up Reviews **1-Week Review:** - Patient reported high satisfaction and positive feedback from others. - Soreness and swelling mostly resolved. - Minor adjustments made to relieve sore spots. - Reiteration of expected looseness due to bone resorption. **First 3-4 Week Review:** - Patient reported slight looseness of the F/P. - Minor adjustments to sharp edges. - **Action:** Viscogel soft liner added to the intaglio surface to improve retention and stability. Clinical facial photos of the patient showing the aesthetic result of the dentures. Three views are provided: a frontal view with the patient smiling, a profile view from the left side, and a three-quarter view from the right side. These images demonstrate the smile line and facial profile as noted in the '1wk review' text. Intraoral clinical photos showing the denture placement. The image consists of three panels: a frontal view of the upper and lower teeth in occlusion, a full arch view showing the entire dental arch, and a lateral view of the teeth. These images support the '1wk review' section regarding the aesthetic result and the condition of the acrylic F/P (Fixed Partial Denture/Full Plate). - Perio review (18/3/25) o Review perio chart revealed significant improvements in oral hygiene, although periodontal pocket depths remained. SRD was performed. Positive lifestyle changes and oral hygiene instructions were reinforced. | **Mean Probing Depth = 0.5 mm** | **Mean Attachment Level = -0.8 mm** | 9% Plaque | 10% Bleeding on Probing | | :--- | :--- | :--- | :--- | | **Note** | **UE** | | | | | | | | | | **UE** | | Furcation | | | | | | | | | | | | | Bleeding on Probing | | | <br> **[Red]**<br>**[Red]** | | | | | | **[Red]**<br>**[Red]** | | | | | Plaque | | | <br> **[Blue]**<br>**[Blue]** | | | | | | **[Blue]** | | | | | Gingival Margin | 0 0 0 | | -2 -1 -1 | -1 -1 0 | | | -1 -2 -2 | -3 -3 -3 | -2 -2 -2 | 0 0 0 | | Probing Depth | 0 0 0 | | 2 1 4 | 3 1 2 | | | 1 1 2 | 1 1 2 | 2 3 4 | 0 0 0 | | Gingival Margin | 0 0 0 | | -2 -2 0 | -1 -1 0 | | | -2 -3 -1 | -1 -3 -3 | | -2 -2 -2 | 0 0 0 | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Probing Depth | 0 0 0 | | 2 1 4 | 3 1 2 | | | 3 1 2 | 3 1 2 | | 1 3 5 | 0 0 0 | | Plaque | | | **[Blue]**<br>**[Blue]** | **[Blue]** | | | **[Blue]** | **[Blue]** | | **[Blue]** | | | Bleeding on Probing | | | **[Red]**<br>**[Red]** | **[Red]**<br>**[Red]** | | | **[Red]**<br>**[Red]**<br>**[Red]** | | | **[Red]**<br>**[Red]** | | | Furcation | | | | | | | | | | | | | | | | :--- | :--- | :--- | :--- | | Implant | | | | | Mobility | 0 | 0 | 0 | 0 | **48 47 46** 45 **44 43 42 41** 31 32 33 34 35 36 37 38 - Second 3-4wk review (2/4/25 and 5/4/25) o Patient reported she was adapting well to the dentures, however some looseness had developed. A second chairside reline of F/P was performed using Viscogel soft liner. o Plan for a third chairside reline in May, followed by definitive F/P reline by the end of year. - Third 3-4wk review (1/8/25) o Patient was away travelling so delayed review appointment. Patient reported minimal looseness of F/P, extremely pleased with appearance and happy with comfort. o Final chairside reline performed using Viscogel soft liner. o Informed patient definitive F/P reline can now take place as soft tissue stability has been achieved. Warned patient she will be without her dentures for at least 3 days. Appointments scheduled according to a time convenient for the patient in Nov. 25  #### Periodontal and Maintenance Reviews **Periodontal Review:** - Significant improvement in oral hygiene (Plaque 9%, BoP 10%). - Mean Probing Depth: 0.5mm; Mean Attachment Level: -0.8mm. - Subgingival Debridement (SRD) performed on remaining teeth. **Subsequent Denture Reviews:** - **Second 3-4 Week Review:** Further looseness addressed with a second Viscogel soft liner application. - **Third 3-4 Week Review:** Patient reported minimal looseness and high satisfaction with comfort and appearance. - **Final Chairside Reline:** Performed with Viscogel. - **Long-term Plan:** Definitive reline scheduled for November, as soft tissue stability has been achieved. A comprehensive Periodontal (Perio) chart for a dental review dated 18/3. The visual is divided into two main sections: Upper Extremity (UE) on the left and Lower Extremity (UE) on the right. Top section displays summary statistics: Mean Probing Depth = 0.5 mm, Mean Attachment Level = -0.8 mm, 9% Plaque, and 10% Bleeding on Probing. The middle section features detailed diagrams of teeth from Lingual and Buccal views, annotated with red lines indicating gingival margins and blue shaded areas highlighting periodontal pockets or inflammation. Below the diagrams are data grids listing measurements for Gingival Margin, Probing Depth, Plaque (marked in Blue), Bleeding on Probing (marked in Red), Furcation, Implant, and Mobility. Specific tooth numbers (48 to 38) are listed at the bottom. #### Initial Clinical Assessment The patient presented with a chief complaint regarding the poor aesthetics and lack of stability of her existing maxillary partial denture. Clinical examination revealed: - Multiple missing maxillary teeth. - Advanced periodontal bone loss on remaining abutments. - Generalized mobility of the remaining maxillary dentition. - Compromised occlusal vertical dimension. #### Treatment Planning and Sequence Following a comprehensive evaluation, a treatment plan was developed to restore function and aesthetics using a removable prosthetic approach. The sequence included: 1. **Phase I: Stabilization** - Periodontal therapy and extraction of non-retainable teeth. - Fabrication of a transitional maxillary complete denture to evaluate aesthetics and vertical dimension. 2. **Phase II: Definitive Restoration** - Final impressions using a border-molded custom tray technique. - Maxillomandibular relationship records at the established vertical dimension. - Trial evaluation of the wax tooth arrangement to confirm phonetics and lip support. #### Final Delivery and Follow-up The definitive maxillary removable prosthesis was processed and delivered. Post-insertion reviews focused on: - **Occlusal Harmony:** Verification of bilateral simultaneous contacts in centric relation. - **Tissue Adaptation:** Assessment of the intaglio surface for pressure points. - **Patient Satisfaction:** The patient reported significant improvement in confidence, speech, and masticatory efficiency. # 2. Functional removable restorative case **2.1 Presenting complaint** * “My upper denture is loose. It comes out when I chew.” * “I’ve never really liked the look of the big tooth in the middle of my bottom denture.” **2.2 History of presenting complaint** * Patient has noticed over the past 2–3 months that his upper denture dislodges when he eats hard foods. * Otherwise, the upper denture stays in place i.e. when speaking, laughing or sneezing. **2.3 Medical history** | Conditions | Description | | :--- | :--- | | History of gastric cancer in 2014 | * Pt underwent surgery to remove a significant portion of the stomach & chemotherapy. * Currently presents to oncologist 6mthly for CT scans to monitor condition. * Recent visits (Mar 2019) to GP / oncologist for blood tests & evaluation of scans revealed no abnormalities & were consistent with health. | | Asthma* | * Chronic inflammatory disorder of the airways associated with airway hypersensitivity that leads to recurrent episodes of wheezing, breathlessness, chest tightness & coughing. | | Gastro-oesophageal reflux disease (GORD) | * Chronic digestive disease with symptoms of esophageal burning and heartburn. | | \*Conditions managed by medication. | | | Medications | Dosage | Use / Mechanism of action | Dental implication | | :--- | :--- | :--- | :--- | | Pantoprazole | 40mg tablet orally 1x/day | * For GORD * Proton pump inhibitor - irreversibly inactivates the hydrogen/potassium ATPase enzyme system (proton pump), suppressing both stimulated & basal acid secretion (AMH, 2019). | * Chronic regurgitation of gastric contents (pH as low as 1) can cause dental erosion. | 27    #### Presenting Complaint - "My upper denture is loose. It comes out when I chew." - "I’ve never really liked the look of the big tooth in the middle of my bottom denture." #### History of Presenting Complaint - Patient has noticed over the past 2–3 months that his upper denture dislodges when he eats hard foods. - Otherwise, the upper denture stays in place (e.g., when speaking, laughing, or sneezing). #### Medical History | Conditions | Description | | :--- | :--- | | History of gastric cancer (2014) | - Pt underwent surgery to remove a significant portion of the stomach & chemotherapy.<br>- Currently presents to oncologist 6-monthly for CT scans to monitor condition.<br>- Recent visits (Mar 2019) to GP / oncologist for blood tests & evaluation of scans revealed no abnormalities & were consistent with health. | | Asthma* | - Chronic inflammatory disorder of the airways associated with airway hypersensitivity that leads to recurrent episodes of wheezing, breathlessness, chest tightness & coughing. | | Gastro-oesophageal reflux disease (GORD) | - Chronic digestive disease with symptoms of esophageal burning and heartburn. | \*Conditions managed by medication. #### Medications | Medications | Dosage | Use / Mechanism of Action | Dental Implication | | :--- | :--- | :--- | :--- | | Pantoprazole | 40mg tablet orally 1x/day | - For GORD<br>- Proton pump inhibitor - irreversibly inactivates the hydrogen/potassium ATPase enzyme system (proton pump), suppressing both stimulated & basal acid secretion (AMH, 2019). | - Chronic regurgitation of gastric contents (pH as low as 1) can cause dental erosion. | Clinical photo series of a patient's face from multiple angles (frontal, smiling, and profile) showing the upper denture in situ. The images serve to visually document the functional status of the removable restorative case mentioned in the title. Table titled '2.3 Medical history'. It lists medical conditions including 'History of gastric cancer in 2014', 'Asthma*', and 'Gastro-oesophageal reflux disease (GORD)', with corresponding descriptions detailing surgeries, monitoring schedules, and symptom definitions. Table listing medications. Specifically details 'Pantoprazole' dosage (40mg tablet orally 1x/day), its mechanism of action as a proton pump inhibitor for GORD, and the dental implication regarding chronic regurgitation causing dental erosion. ```html <table border="1"> <tr> <td>Paracetamol</td> <td>500mg tablet<br>orally 1x/day, as<br>required</td> <td>• For stomach pain<br>• Mode of action not fully<br>determined - may include<br>inhibition of central<br>prostaglandin synthesis &<br>modulation of inhibitory<br>descending serotonergic<br>pathways (AMH, 2019).</td> <td>•<br>May affect perception of<br>dental pain if taken recently.</td> </tr> <tr> <td>Indometacin</td> <td>25mg capsule<br>orally 1x/day, as<br>required</td> <td>• For neck pain<br>• Non-selective NSAID -<br>inhibits synthesis of<br>prostaglandins by inhibiting<br>COX-1 and COX-2 (AMH,<br>2019).</td> <td>•<br>May affect perception of<br>dental pain if taken recently.</td> </tr> <tr> <td>Salmeterol +<br>Fluticasone<br>(Seretide)</td> <td>1 puff 2x/day</td> <td>• For asthma<br>• Salmeterol is a β2 agonist -<br>relax bronchial smooth<br>muscle by stimulating β2<br>adrenoreceptors (AMH,<br>2019).<br>• Fluticasone is a<br>corticosteroid - reduces<br>airway inflammation &<br>bronchial hyper-reactivity<br>(AMH, 2019).</td> <td>• Advise pt to rinse mouth out<br>with water following use to<br>reduce risk of<br>oropharyngeal candidiasis &<br>systemic corticosteroid<br>absorption.<br>•<br>Consider potential for<br>adrenal suppression<br>(generally require higher<br>corticosteroid dose).</td> </tr> <tr> <td>Salbutamol</td> <td>1-2 puffs/wk, as<br>required</td> <td>• For asthma<br>• β2 agonist - relax bronchial<br>smooth muscle by<br>stimulating β2<br>adrenoreceptors (AMH,<br>2019).</td> <td>• Advise pt to bring puffer to<br>dental appointment for use<br>in case dental treatment<br>triggers an asthma attack.</td> </tr> <tr> <td>Supplements -<br>magnesium,<br>calcium,<br>vit D,<br>folic acid</td> <td>1 tablet 1x/day<br><sup>“</sup><br><sup>“</sup><br>5mg tablet 1x/day</td> <td>• For general health</td> <td>-</td> </tr> </table> <ul> <li>History of hospitalization / surgery <ul> <li>2014 gastric surgery for stomach cancer</li> </ul> </li> <li>No known allergies</li> </ul> <h4>2.4 Dental history</h4> <ul> <li>Acrylic F/ made 6yrs ago as immediate denture, acrylic /P made 4yrs ago.</li> <li>Previous private practice patient who regularly attended 12mthly dental recalls.</li> </ul> <h4>2.5 Oral hygiene</h4> <ul> <li>Toothbrushing 2x/day with manual toothbrush and 1000ppm fluoride toothpaste.</li> <li>Interdental brushes (Piksters) 1x/day.</li> <li>Acrylic F/P removed at night, brushed with toothpaste & soaked overnight in<br>Sterident solution.</li> </ul> <p>28</p> ```  | Medications | Dosage | Use / Mechanism of Action | Dental Implication | | :--- | :--- | :--- | :--- | | Paracetamol | 500mg tablet orally 1x/day, as required | - For stomach pain<br>- Mode of action not fully determined - may include inhibition of central prostaglandin synthesis & modulation of inhibitory descending serotonergic pathways (AMH, 2019). | - May affect perception of dental pain if taken recently. | | Indometacin | 25mg capsule orally 1x/day, as required | - For neck pain<br>- Non-selective NSAID - inhibits synthesis of prostaglandins by inhibiting COX-1 and COX-2 (AMH, 2019). | - May affect perception of dental pain if taken recently. | | Salmeterol + Fluticasone (Seretide) | 1 puff 2x/day | - For asthma<br>- Salmeterol is a β2 agonist - relax bronchial smooth muscle by stimulating β2 adrenoreceptors (AMH, 2019).<br>- Fluticasone is a corticosteroid - reduces airway inflammation & bronchial hyper-reactivity (AMH, 2019). | - Advise pt to rinse mouth out with water following use to reduce risk of oropharyngeal candidiasis & systemic corticosteroid absorption.<br>- Consider potential for adrenal suppression (generally require higher corticosteroid dose). | | Salbutamol | 1-2 puffs/wk, as required | - For asthma<br>- β2 agonist - relax bronchial smooth muscle by stimulating β2 adrenoreceptors (AMH, 2019). | - Advise pt to bring puffer to dental appointment for use in case dental treatment triggers an asthma attack. | | Supplements | 1 tablet 1x/day | - Magnesium, calcium, vit D, folic acid (5mg) for general health. | - | #### Hospitalization and Surgery - 2014 gastric surgery for stomach cancer. #### Allergies - No known allergies. #### Dental History - Acrylic F/ made 6 years ago as immediate denture. - Acrylic /P made 4 years ago. - Previous private practice patient who regularly attended 12-monthly dental recalls. #### Oral Hygiene - Toothbrushing 2x/day with manual toothbrush and 1000ppm fluoride toothpaste. - Interdental brushes (Piksters) 1x/day. - Acrylic F/P removed at night, brushed with toothpaste & soaked overnight in Sterident solution. Table listing medications and supplements for a patient. Columns include Medication (Paracetamol, Indometacin, Salmeterol + Fluticasone, Salbutamol, Supplements), Dosage/Instructions, Indication/Mechanism of Action, and Clinical Advice. Rows detail specific drugs like Paracetamol (500mg tablet) and Salmeterol (Seretide), their usage instructions (e.g., 'orally 1x/day'), indications (e.g., 'For stomach pain', 'For asthma'), and relevant clinical notes. **2.8 Intra-oral examination** | | | |---|---| | La mucosa | Smooth, pink, in-tact mucosa | | Sulci | Smooth, pink, in-tact mucosa | | Frena | Smooth, pink, in-tact mucosa | | Gingiva | Coral pink, stippled appearance | | Palate | U-shaped arch | | Oropharynx | Smooth, pink, in-tact mucosa | | Alveolar ridge | U-shaped alveolar ridges | | Bu mucosa | Smooth, pink, in-tact mucosa | | Tongue | Dorsal surface - white plaque<br>Ventral surface - pink, in-tact mucosa | | Floor of mouth | No tenderness to palpation or evidence of swelling | | Saliva | Appears adequate | | Dentition | Edentulous Mx<br>Partially dentate Md | 30     #### Intra-oral Examination | Feature | Findings | | :--- | :--- | | Labial Mucosa | Smooth, pink, intact mucosa | | Sulci | Smooth, pink, intact mucosa | | Frena | Smooth, pink, intact mucosa | | Gingiva | Coral pink, stippled appearance | | Palate | U-shaped arch | | Oropharynx | Smooth, pink, intact mucosa | | Alveolar Ridge | U-shaped alveolar ridges | | Buccal Mucosa | Smooth, pink, intact mucosa | | Tongue | Dorsal surface: white plaque; Ventral surface: pink, intact mucosa | | Floor of Mouth | No tenderness to palpation or evidence of swelling | | Saliva | Appears adequate | | Dentition | Edentulous Maxilla (Mx); Partially dentate Mandible (Md) | Clinical photo of the intra-oral examination showing the upper jaw. The image displays a U-shaped arch with edentulous (toothless) maxilla and two remaining teeth in the lower jaw. Clinical photo showing the palatal view of the upper jaw, highlighting the U-shaped alveolar ridge structure. Clinical photo of the lower jaw showing partially dentate mandible with visible teeth. Table summarizing findings from the intra-oral examination. It includes categories such as 'La mucosa', 'Sulci', 'Frena', 'Gingiva', 'Palate', 'Oropharynx', 'Alveolar ridge', 'Bu mucosa', 'Tongue', 'Floor of mouth', 'Saliva', and 'Dentition'. Descriptions include details like 'Smooth, pink, in-tact mucosa' for most soft tissues, 'Coral pink, stippled appearance' for gingiva, 'U-shaped arch' for palate, and notes on dentition status ('Edentulous Mx', 'Partially dentate Md'). # 2.11 Tooth charting  #### Tooth Charting Tooth charting diagram labeled '2.11 Tooth charting' showing a standard dental arch layout with tooth numbers 18–11 (upper left) and 21–28 (upper right), and 48–41 (lower left) and 31–38 (lower right). Specific teeth (e.g., 12, 13, 22, 23) are marked with yellow squares indicating restorations or findings as per legend. Below the chart is a legend explaining symbols: yellow = Comp/GIC-sat, gray = Amalgam-sat, brown = Caries, black = Root stump, red = Unsat restn due to caries, orange-red = Unsat restn for other reasons, P/ap R = Periapical radiolucency, UE = Unerupted. Also included is a CPITN table (Community Periodontal Index of Treatment Needs) with codes 1–4 and *, defining periodontal conditions such as gingival bleeding, calculus, pathologic pockets, recession ≥4mm, and furcation involvement. 2.12 Radiographs • OPG taken 18th Sept [redacted] • 2x PAs taken 22nd Oct [redacted] ○ No evidence of caries, adequate bone support, incisal wear 33    #### Radiographic Findings - OPG taken 18th Sept [redacted] - 2x PAs taken 22nd Oct [redacted] - Findings: No evidence of caries, adequate bone support, incisal wear. Radiograph (OPG) taken on 18th Sept showing a panoramic view of the maxilla and mandible. The image reveals adequate bone support with no evidence of caries or incisal wear. A 'L' marker indicates the left side. Periapical radiograph (PA) labeled 'a', taken on 22nd Oct, showing two teeth with visible roots and surrounding bone structure. Periapical radiograph (PA) labeled 'b', taken on 22nd Oct, showing two teeth with visible roots and surrounding bone structure. 2.14 **Prognosis** (Samet & Jotkowitz, 2009) * Individual tooth prognosis - **LEGEND:** | Restorations / findings | Prognoses | CPITN - Community Periodontal Index of Treatment Needs | | :--- | :--- | :--- | | **Comp / GIC - sat** (Green) | **G** **Good** | - | - | - | **1** Gingival bleeding after gentle probing | | **Amalgam - sat** (Yellow) | **F** **Fair** | - | **2** * | - | **2** Supragingival or subgingival calculus | | **Caries** (Orange) | **Q** **Questionable** | * ≥ 5mm recession | | | **3** Pathologic pockets 4-5mm | | **Root stump** (Red) | **P** **Poor** | | | | **4** Pathologic pockets ≥6mm | | **Unsat restn due to caries** (Black) | **H** **Hopeless** | | | | \* Furcation involvement or recession ≥4mm | | **Unsat restn for other reasons** (Green) | | | | | | | **P/ap R** (Blue) | Periapical radiolucency | | | | | | **UE** (Grey) | Unerupted | | | | | | *** * Prognosis categories are based on a classification proposed by Samet & Jotkowitz (2009), where overall prognosis is the worst of periodontal, restorative, endodontic and occlusal prognoses. Anatomic, iatrogenic and patient factors modify the overall prognosis. ** Overall tooth prognosis modified downward by patient factors - poor OH, cariogenic diet, smoking, aesthetics as motivation for treatment, and high aesthetic expectations. * Overall dentition prognosis *FAIR* (Yellow) 35   #### Prognosis (Samet & Jotkowitz, 2009) **Individual Tooth Prognosis Legend:** | Restorations / Findings | Prognoses | CPITN (Periodontal Index) | | :--- | :--- | :--- | | **Comp / GIC - sat** (Green) | **G Good** | **1** Gingival bleeding after gentle probing | | **Amalgam - sat** (Yellow) | **F Fair** | **2** Supragingival or subgingival calculus | | **Caries** (Orange) | **Q Questionable** | **3** Pathologic pockets 4-5mm | | **Root stump** (Red) | **P Poor** | **4** Pathologic pockets ≥6mm | | **Unsat restn due to caries** (Black) | **H Hopeless** | **\*** Furcation involvement or recession ≥4mm | | **Unsat restn for other reasons** (Green) | | | | **P/ap R** (Blue) Periapical radiolucency | | | | **UE** (Grey) Unerupted | | | **Notes on Prognosis:** - Prognosis categories are based on a classification proposed by Samet & Jotkowitz (2009), where overall prognosis is the worst of periodontal, restorative, endodontic and occlusal prognoses. - Anatomic, iatrogenic and patient factors modify the overall prognosis. - Overall tooth prognosis modified downward by patient factors: poor OH, cariogenic diet, smoking, aesthetics as motivation for treatment, and high aesthetic expectations. **Overall Dentition Prognosis:** FAIR (Yellow) Clinical chart for individual tooth prognosis (Samet & Jotkowitz, 2009). The table displays a grid of teeth numbered 11-48. Specific cells are filled with prognoses: 'F' (Fair) and 'G' (Good). Teeth 13, 12, 32, and 33 have yellow-shaded icons indicating 'Comp / GIC - sat'. The bottom row shows the 'Overall**' prognosis as 'F' (Fair) for these four teeth. A legend below defines the color coding for restorations and findings, and the CPITN index. Text-based summary figure stating the final conclusion: 'Overall dentition prognosis FAIR', where 'FAIR' is highlighted in yellow to match the visual data. ## 2.15 Problem list * Unsatisfactory F/P due to poor occlusion & aesthetics (presenting complaint) * Lack of posterior support leading to loss of retention during function * Pt unhappy with appearance of lower middle denture tooth * Host related * N/A * Pathology * Mild generalized gingivitis on a reduced periodontium * Morphology * Class III skeletal relationship * Missing teeth Mx edentulous, Md Kennedy Cl I Mod 1 * Lack of posterior support * Negative smile arc ## 2.16 Diagnoses * Unsatisfactory F/P (presenting complaint) * Gingivitis * Mx edentulous * Md Kennedy Cl I Mod 1 * Lack of posterior support * Negative smile arc #### Problem List - **Unsatisfactory F/P (Presenting Complaint)** - Lack of posterior support leading to loss of retention during function. - Patient unhappy with appearance of lower middle denture tooth. - **Host Related** - N/A - **Pathology** - Mild generalized gingivitis on a reduced periodontium. - **Morphology** - Class III skeletal relationship. - Missing teeth: Maxilla (Mx) edentulous, Mandible (Md) Kennedy Cl I Mod 1. - Lack of posterior support. - Negative smile arc. #### Diagnoses - Unsatisfactory F/P (presenting complaint) - Gingivitis - Mx edentulous - Md Kennedy Cl I Mod 1 - Lack of posterior support - Negative smile arc <b>Patient decided on treatment option 1 remake acrylic F/P due to:</b> * Pt happy with existing F/P aside from F/ loss of retention in function * Able to improve aesthetics & occlusion * Relatively low cost of tx The image containing charts and legends is omitted.  #### Treatment Selection Patient decided on treatment option 1: remake acrylic F/P due to: - Patient happy with existing F/P aside from loss of retention in function. - Able to improve aesthetics & occlusion. - Relatively low cost of treatment. Dental chart detailing a patient's treatment plan. The chart is divided into sections for the upper and lower arches (labeled 'UPPER COMPLETE DENTURE' and 'LOWER PARTIAL DENTURE'). It lists tooth numbers (e.g., 18-28, 48-38) with corresponding prognoses ('F', 'G') and treatments ('L'). A legend section defines symbols for restorations (e.g., 'Comp / GIC - sat'), prognoses (e.g., 'Good prognosis'), and treatments (e.g., 'Adjustment'). A bottom section outlines the CPITN index for periodontal assessment. 2.18 Management plan Foundational phase • Address the presenting complaint o Explain to pt that loss of retention of F/ occurs during function due to lack of posterior support provided by F/P. Because it is an occlusal problem, both dentures will need to be replaced to address the issue. A new set of dentures will also address the aesthetic complaints. • Address lifestyle factors / OH routine (4/10/) o Diet (Evans et al, 2008) § Pt encouraged to continue balanced diet with low sugar intake, and to drink tap water regularly. o Oral hygiene and dental visits (Evans et al, 2008) § Pt encouraged to continue good OH habits for natural teeth. § For denture hygiene, recommended using a separate toothbrush to teeth and brushing the dentures with detergent & water. Pt to leave dentures out at night dry in the denture case. § Pt encouraged to continue attending recall appointments after course of tx. Emphasised dentures require maintenance as the tissues in the mouth change over time. • Scale and clean, prophylaxis paste applied (4/10/ Definitive phase • Acrylic F/P work-up (9/10 - 22/1) o Mx & Md primary alginate impressions → primary casts o Mx & Md special tray fabrication → Mx & Md alginate PVS impressions → secondary / master casts o Base & rims fabrication for facebow & bite registration → mounted master casts o /P denture design to include lingual wire reinforcement if insufficient thickness of acrylic achievable for torsional strength  #### Management Plan: Foundational Phase - **Address the Presenting Complaint** - Explain to patient that loss of retention of F/ occurs during function due to lack of posterior support provided by F/P. - Because it is an occlusal problem, both dentures will need to be replaced to address the issue. - A new set of dentures will also address the aesthetic complaints. - **Address Lifestyle Factors / OH Routine (4/10)** - **Diet (Evans et al, 2008):** Patient encouraged to continue balanced diet with low sugar intake, and to drink tap water regularly. - **Oral Hygiene and Dental Visits (Evans et al, 2008):** - Patient encouraged to continue good OH habits for natural teeth. - For denture hygiene, recommended using a separate toothbrush and brushing the dentures with detergent & water. - Patient to leave dentures out at night dry in the denture case. - Patient encouraged to continue attending recall appointments; emphasized that dentures require maintenance as oral tissues change over time. - **Clinical Procedures** - Scale and clean, prophylaxis paste applied (4/10). #### Management Plan: Definitive Phase - **Acrylic F/P Work-up (9/10 - 22/1)** - Mx & Md primary alginate impressions → primary casts. - Mx & Md special tray fabrication → Mx & Md alginate PVS impressions → secondary / master casts. - Base & rims fabrication for facebow & bite registration → mounted master casts. - /P denture design to include lingual wire reinforcement if insufficient thickness of acrylic achievable for torsional strength. Composite diagram consisting of a clinical photograph on the left and a denture model on the right. The left panel shows an intraoral view of a maxillary arch with labels identifying anatomical landmarks: Labial vestibule, Crest of ridge, Incisive papilla, Rugae, Buccal vestibule, Hard palate, Buccal patch, Mx tuberosity, Soft palate, Alveolar ridge, Midline/suture line, and Foveae palatinae. The right panel displays a cast of an acrylic denture base with teeth, highlighting a 'Wire reinforcement' structure (labeled WW I-bar) designed to match adjacent teeth, demonstrating torsional strength features. 0 Shade selection Vita Classical shade A3.5 0 Anterior tooth try in to confirm pt happy with aesthetics, followed by posterior tooth try in to confirm satisfactory occlusion     #### Management Plan: Definitive Phase (Continued) - **Shade and Try-in** - Shade selection: Vita Classical shade A3.5. - Anterior tooth try-in to confirm patient is happy with aesthetics. - Posterior tooth try-in to confirm satisfactory occlusion. Clinical photo of an upper denture try-in showing the pink acrylic base and tooth arrangement. Anatomical diagram illustrating facial reference lines: Interpupillary Line, Camper's Line, and Occlusal Plane. Labels point to specific anatomical landmarks on a side-view skull and frontal view of a face. Clinical photo of anterior teeth try-in showing the aesthetic result with shade Vita Classical A3.5 (as per OCR context). The upper arch shows new prosthetic teeth while the lower arch shows natural teeth. Clinical photo of posterior occlusion check showing the upper and lower teeth in bite. This corresponds to the 'posterior tooth try in' step mentioned in the OCR text to confirm satisfactory occlusion. #### Initial Phase and Stabilization - **Oral Hygiene Instruction (OHI):** Comprehensive review of brushing and flossing techniques to improve periodontal health. - **Periodontal Therapy:** Full mouth debridement and scaling and root planing (SRP) to address existing periodontal concerns. - **Caries Management:** - Tooth #14: Composite restoration. - Tooth #19: Composite restoration. - Tooth #31: Composite restoration. #### Endodontic and Restorative Preparation - **Endodontic Treatment:** Root canal therapy (RCT) performed on tooth #20. - **Post and Core Build-up:** Placement of a post and core on tooth #20 to provide adequate structural support for future restoration. - **Provisionalization:** Fabrication of a long-term provisional crown for tooth #20 to assess stability and function prior to final restoration. #### Definitive Restorative Phase - **Fixed Prosthodontics:** Fabrication and delivery of a Porcelain-Fused-to-Metal (PFM) crown for tooth #20, designed with a distal rest seat to support the planned removable prosthesis. - **Removable Prosthodontics:** - Design and fabrication of a Mandibular Cast Partial Denture (CPD). - Framework try-in and adjustment. - Final delivery of the mandibular CPD to restore missing dentition and improve masticatory function. #### Maintenance and Follow-up - **Post-Insertion Care:** Evaluation of the fit, occlusion, and patient comfort following the delivery of the PFM crown and partial denture. - **Recall Schedule:** Establishment of a 6-month periodic oral examination and prophylaxis schedule to monitor oral health and the integrity of the restorations. 3. Aesthetic fixed restorative case 3.1 Presenting complaint - “I’ve had a toothache on and off for the past year in one of my upper right back teeth.” - “I’ve never liked that two of my teeth on the left hand side are stained.” 3.2 History of presenting complaint - Spontaneous dull aching sensation on/off in upper right posterior starting Feb (12mths ago). Pain is exacerbated by hot/cold food and drink. Pain lingers for about an hour. - In Feb amalgam restoration on tooth 15 was replaced with an indirect composite onlay prepared and cemented in a single visit. Pt reports toothache began after onlay was prepared and did not improve with time. - In Jun/Jul, pt’s private GDP recommended RCT for the tooth 15 but was unavailable for tx. When pt re presented to private GDP clinic, she was seen by a different GDP who believed “cracks” in the tooth were responsible for symptoms. A “sealant” was placed over the cracks, but symptoms persisted. Pt would like the toothache resolved. - Pt identified “stained” teeth as 22 and 24. Pt recalls the staining appeared some time ago. 3.3 Medical history | Conditions | Description | |---------------------|-----------------------------------------------------------------------------| | Hypertension* | Long term high blood pressure (consistently over 140/90mmHg). (Optimal blood pressure <120/80mmHg, 120/80mmHg to 139/89mmHg are in the normal to high range.) | | Lower back pain* | Due to previous back muscle injury. | | *Conditions managed by medication. 43   #### Presenting Complaint - "I’ve had a toothache on and off for the past year in one of my upper right back teeth." - "I’ve never liked that two of my teeth on the left hand side are stained." #### History of Presenting Complaint - Spontaneous dull aching sensation on/off in upper right posterior starting February (12 months ago). Pain is exacerbated by hot/cold food and drink. Pain lingers for about an hour. - In February, an amalgam restoration on tooth 15 was replaced with an indirect composite onlay prepared and cemented in a single visit. Patient reports toothache began after onlay was prepared and did not improve with time. - In June/July, the patient’s private GDP recommended RCT for tooth 15 but was unavailable for treatment. When the patient re-presented to the private GDP clinic, she was seen by a different GDP who believed “cracks” in the tooth were responsible for symptoms. A “sealant” was placed over the cracks, but symptoms persisted. Patient would like the toothache resolved. - Patient identified “stained” teeth as 22 and 24. Patient recalls the staining appeared some time ago. #### Medical History - **Hypertension:** Long term high blood pressure (consistently over 140/90mmHg). (Optimal blood pressure <120/80mmHg; 120/80mmHg to 139/89mmHg are in the normal to high range). Managed by medication. - **Lower back pain:** Due to previous back muscle injury. Managed by medication. Clinical photo series showing five views of a patient's face and smile: frontal smiling, frontal neutral, three-quarter view smiling, left profile, and right profile. The images demonstrate the aesthetic fixed restorative case context, particularly highlighting the stained teeth (identified as 22 and 24) mentioned in the presenting complaint. A table titled '3.3 Medical history' with two columns: 'Conditions' and 'Description'. It lists two conditions managed by medication: Hypertension (long term high blood pressure over 140/90mmHg) and Lower back pain (due to previous muscle injury). Includes a footnote clarifying that '*' indicates conditions managed by medication. **3.7 Extra-oral examination** | Facial appearance | Healthy, clear complexion | | --- | --- | | Facial symmetry | Symmetrical | | Thyroid gland | No noticeable enlargement or tenderness to palpation | | Muscles of mastication | No noticeable enlargement or tenderness to palpation or clenching | | TMJ | L TMJ click on opening and closing, asymptomatic | | Facial thirds | Balanced facial thirds | | Facial fifths | Balanced and symmetrical facial fifths | | Upper lip | Dry, patchy appearance consistent with solar keratosis | | Lower lip | Dry, patchy appearance consistent with solar keratosis<br>Lower lip multiple melanotic macules | | Smile analysis | On smile, 90% incisal display, 0% gingival display<br>At rest, 0% incisal display | | Profile | Straight |   #### Extra-oral Examination - **Facial appearance:** Healthy, clear complexion - **Facial symmetry:** Symmetrical - **Thyroid gland:** No noticeable enlargement or tenderness to palpation - **Muscles of mastication:** No noticeable enlargement or tenderness to palpation or clenching - **TMJ:** Left TMJ click on opening and closing, asymptomatic - **Facial thirds:** Balanced facial thirds - **Facial fifths:** Balanced and symmetrical facial fifths - **Upper lip:** Dry, patchy appearance consistent with solar keratosis - **Lower lip:** Dry, patchy appearance consistent with solar keratosis; multiple melanotic macules - **Smile analysis:** On smile, 90% incisal display, 0% gingival display. At rest, 0% incisal display - **Profile:** Straight Clinical photo set of a female patient for extra-oral examination. Left panel shows frontal view with blue horizontal lines marking facial thirds and fifths; eyes are redacted. Middle panel shows the same patient smiling to demonstrate incisal display (consistent with '90% incisal display' in table). Right panel shows lateral profile view with a blue line tracing the facial profile (consistent with 'Straight' profile in table). Eyes are redacted. Table summarizing findings from the extra-oral examination shown in the photos above. It lists items such as Facial appearance (Healthy), Facial symmetry (Symmetrical), TMJ (click on opening/closing), Smile analysis (90% incisal display on smile, 0% gingival display), and Profile (Straight). Also notes specific findings like dry/patchy lips consistent with solar keratosis and multiple melanotic macules on the lower lip. 3.10 Tooth charting  #### Tooth Charting A labeled tooth charting table titled '3.10 Tooth charting' displaying a full dental arch layout with numbered teeth positions (18-28 upper, 48-38 lower). Each tooth cell contains visual indicators for restorations and findings using colored blocks (yellow, gray, brown, red, pink) corresponding to the legend below. The legend includes categories such as 'Comp / GIC - sat', 'Amalgam - sat', 'Caries', 'Root stump', 'Unsat restn due to caries', 'NCTSL', 'RR Root remnant', 'GP ext GP extrusion', 'P/ap R Periapical radiolucency', and 'UE Unerupted'. Additionally, there is a section titled 'CPITN - Community Periodontal Index of Treatment Needs' with codes 1–4 and * indicating specific periodontal conditions like bleeding, calculus, and pocket depth. 3.11 Radiographs • OPG taken 20<sup>th</sup> Mar o 11,21 previous RCT o Heavily restored dentition o Missing tooth 36, mesially tilted 37 & 38 • 3xPAs taken 13<sup>th</sup> Feb o 16 root remnant at sinus floor, no p/ap radiolucency or clinical evidence of infection o 13 external invasive resorption Cl III o 14, 15, 24 no evidence of p/ap radiolucencies o 11 previous RCT, technically inadequate & p/ap radiolucency o 23 unsat D restoration o 24 non ideal D contact 48   #### Radiographic Findings **OPG (taken 20th March)** - 11, 21: Previous RCT - Heavily restored dentition - Missing tooth 36; mesially tilted 37 & 38 **3x PAs (taken 13th February)** - 16: Root remnant at sinus floor; no periapical radiolucency or clinical evidence of infection - 13: External invasive resorption Class III - 14, 15, 24: No evidence of periapical radiolucencies - 11: Previous RCT, technically inadequate & periapical radiolucency - 23: Unsatisfactory distal restoration - 24: Non-ideal distal contact Orthopantomogram (OPG) radiograph showing the full dentition. The image displays a 'Heavily restored dentition' with multiple radiopaque fillings visible in both arches. Key findings noted include missing tooth 36 and mesially tilted teeth 37 & 38. Previous RCTs are visible on teeth 11 and 21. Composite of three periapical radiographs (PAs) taken on Feb 13th. Left panel shows maxillary anterior region; middle panel shows posterior maxilla with sinus floor; right panel shows mandibular premolars/molars. Findings include: root remnant at sinus floor (no infection), external invasive resorption on tooth 13, inadequate previous RCT on tooth 11 with periradicular radiolucency, and unsatisfactory restoration on tooth 23. **3.14 Problem list** **15** chronic irreversible pulpitis with primary acute apical periodontitis due to tooth preparation (presenting complaint) **Discolouration** associated with **22** and **24** restoration breakdown (presenting complaint) **Host related** N/A **Pathology** Generalised mild gingivitis **11** previous root canal treatment (technically unsatisfactory) and infected root canal system and chronic apical periodontitis due to restoration breakdown (Abbott & Yu, 2007; Abbott, 2004) **13** external invasive resorption Cl III **28**O caries **23** restoration breakdown **35**Bu NCTSL **Morphology** Skeletal Cl I Stable MIP, acceptable VD, canine guidance in dynamic occlusion **16** root remnant at R sinus floor Missing **36** **M** tilted **17** & **37** **3.15 Diagnoses** Endodontically involved teeth (includes presenting complaint) Discoloured teeth (presenting complaint) Gingivitis Caries Restoration breakdown NCTSL #### Problem List **Presenting Complaints** - **15:** Chronic irreversible pulpitis with primary acute apical periodontitis due to tooth preparation. - **Discolouration:** Associated with 22 and 24 restoration breakdown. **Pathology** - Generalised mild gingivitis. - **11:** Previous root canal treatment (technically unsatisfactory), infected root canal system, and chronic apical periodontitis due to restoration breakdown. - **13:** External invasive resorption Class III. - **28:** Occlusal caries. - **23:** Restoration breakdown. - **35:** Buccal Non-Carious Cervical Tooth Surface Loss (NCTSL). **Morphology** - Skeletal Class I. - Stable MIP, acceptable VD, canine guidance in dynamic occlusion. - **16:** Root remnant at Right sinus floor. - Missing **36**. - Mesially tilted **17** & **37**. #### Diagnoses - Endodontically involved teeth (includes presenting complaint) - Discoloured teeth (presenting complaint) - Gingivitis - Caries - Restoration breakdown - NCTSL 3.17 Management plan Foundational phase * Address the presenting complaint (7/2/**BLOBBED**) * Diagnosed 15 chronic irreversible pulpitis and primary acute apical periodontitis due to tooth preparation. Pt was particularly frustrated with the symptoms associated with the toothache, as they had been ongoing for 12mths. Agreed to prioritise pulp extirpation of the tooth 15 to relieve pt's symptoms. * Expressed an understanding of pt's dissatisfaction with the appearance of her discoloured upper left teeth. However, explained to pt that oral health needs to be established first before going on to address aesthetic concerns. * Explained to pt that there are a number of dental issues that need to be addressed in addition to pt's presenting complaints, including: * Endodontically involved teeth with 2 requiring specialist referral * Caries * Restoration breakdown over time * NCTSL * Discussed treatment options and pros and cons of each choice with pt. * Referral to Endodontic specialist (7/2/**BLOBBED**) * 11 previous RCT (technically unsatisfactory) and infected RCS with chronic apical periodontitis due to unsatisfactory RCT (Abbott & Yu, 2007; Abbott, 2004). * Referral for endodontic re treatment and removal of post and core. Minimal tooth structure remaining so conservative canal preparation required. * 13 external invasive resorption Cl III. * Referral for access and removal of resorptive tissue with trichloroacetic acid (TCA).  Composite figure containing two dental radiographs (periapical X-rays) of the upper left quadrant. The image is associated with the management plan for teeth 11 and 13. Left panel shows tooth 11 with a post-core and signs of periapical pathology; right panel shows tooth 13 with a large restoration and evidence of external resorption. • Tooth 15 RCT (14/2/ - 7/8/ ) o Dx: 15 chronic irreversible pulpitis and chronic apical periodontitis due to tooth preparation (Abbott & Yu, 2007; Abbott, 2004). o Pt opted for RCT over extraction as she was eager to keep the tooth 15. Pt aware a course of tx is required and final restoration will likely be a crown. o Investigation (14/2/ ) § Indirect composite restoration, tooth deemed suitable for restoration & requires a full crown. § Located 2 canals Bu and Li. o Canal preparation (10/4/ ) o Dressing change (12/7/ ) with Pulpdent medicament o RCF (7/8/ ) via lateral condensation with GP + AH26   Clinical photo showing two views of Tooth 15: a periapical radiograph (left) displaying the tooth structure and surrounding bone, and an intraoral clinical photo (right) showing the prepared tooth with a rubber dam in place. This corresponds to the diagnosis of chronic irreversible pulpitis and apical periodontitis due to tooth preparation. Close-up clinical photo of Tooth 15 showing an indirect composite restoration with a white core build-up material visible inside the occlusal cavity. The text context indicates this was deemed suitable for full crown restoration. - **Counselling on required changes in lifestyle factors / OH routine (7/2/)** - o **Diet** (Evans et al, 2008) - Pt encouraged to continue eating balanced diet and eating three meals per day regularly. - Pt encouraged to be wary of exposures to sugar during the day through dried fruit and sugar added to tea and coffee. Advised pt to drink water after sugar exposures and give teeth 2hr break for remineralisation to occur. - o **Oral hygiene and dental visits** (Evans et al, 2008) - Pt encouraged to continue good OH habits. Encouraged pt to focus on using large interdental brushes to clean area of missing 36. - Pt encouraged to continue attending recall appointments after course of tx. Emphasised restorations require maintenance, and detecting and addressing issues early is essential to prolonging the lifespan of teeth with minimal tooth structure remaining. - Scale and clean, **prophylaxis paste** applied (19/4/) - **Restorations (23/4/ - 30/4/)** - 28 O GIC (Fuji VII) restoration. - 22 M composite restoration. - 23 **DPal** composite restoration. - 35 Bu GIC (Fuji IX) restoration. - 13 **Pal** composite restoration (completed by Endodontic specialist). Definitive phase **Tooth** 15 full ceramic (**lithium disilicate**) crown (9/8/ - 22/3/) o Pt desired an aesthetic restoration, and there were no **occlusal** contraindications to the use of ceramic, hence a full ceramic crown was selected. o In this case, IPS e.Max **lithium disilicate** was chosen. Monolithic full crowns in this material have been shown to provide excellent longevity when placed in anterior and posterior teeth. A 10.4 year clinical study reported a 0.2% per year failure rate primarily confined to molar teeth (Malament et al, 2019). The crown was cemented using a resin cement system (**Variolink DC**). o Alternative ceramic material options include leucite based ceramics, glass infiltrated alumina and **zirconia**, or **zirconia**.  Clinical intraoral photograph showing dental restorations. The image displays a 'before' and 'after' comparison of teeth with composite and GIC (glass ionomer cement) fillings. Visible are teeth labeled in the OCR context as 28, 22, 23, 35, and 13, featuring materials like Fuji VII, Fuji IX, and IPS e.Max lithium disilicate.  Table listing medications and supplements including Sertraline (Zoloft), Paracetamol (Panadol Osteo), Amitriptyline (Endep), and Fish oil & magnesium supplements. Columns detail dosage, indications/mechanisms of action, and evidence for inducing xerostomia. # 4.7 Extra-oral examination | Facial appearance | Healthy, clear complexion | | Facial symmetry | Symmetrical | | Thyroid gland | No noticeable enlargement or tenderness to palpation | | Muscles of mastication | No noticeable enlargement or tenderness to palpation or clenching | | TMJ | Crepitus of L and R TMJ, R TMJ click on closing, asymptomatic | | Facial thirds | Balanced thirds | | Facial fifths | Balanced and symmetrical facial fifths | | Upper lip | Distinct vermilion border, smooth vermilion, healthy appearance | | Lower lip | Distinct vermilion border, smooth vermilion, healthy appearance | | Smile analysis | On smile, 70% incisal display, 0% gingival display<br>At rest, 0% incisal display | | Profile | Concave |   Clinical extra-oral examination photos of a patient showing three views: frontal with neutral expression (left), frontal smiling (middle), and lateral profile (right). Annotations include blue horizontal lines on the first image for facial third/fifth analysis and a blue vertical line on the profile image indicating facial convexity/concavity assessment. Eyes are redacted. Structured clinical documentation table titled '4.7 Extra-oral examination'. Contains rows for: Facial appearance (Healthy, clear complexion), Facial symmetry (Symmetrical), Thyroid gland (No enlargement/tenderness), Muscles of mastication (No enlargement/tenderness/clenching), TMJ (Crepitus L/R, click R on closing, asymptomatic), Facial thirds (Balanced), Facial fifths (Balanced/symmetrical), Upper lip (Distinct vermilion border, smooth/healthy), Lower lip (Distinct vermilion border, smooth/healthy), Smile analysis (70% incisal display on smile, 0% gingival display; 0% incisal at rest), Profile (Concave). **4.11 Tooth charting** **66**  Tooth charting diagram displaying a full dentition layout with tooth numbers (1–32) and symbolic representations of restorations, caries, and other findings using color-coded blocks. Includes rows for CO₂, Mob, TTP, P/ap R, and Peg indicators. Features labeled legend sections for 'Restorations / findings' and 'CPITN - Community Periodontal Index of Treatment Needs', with specific color codes for conditions such as amalgam, caries, root stump, NCTSL, unerupted teeth, and cracks. CPITN scale includes numeric ratings (1–4, *) corresponding to gingival bleeding, calculus, pathologic pockets, and furcation involvement. # 4.12 Radiographs ## **OPG taken 20**<sup>th</sup> **April** (Redacted) * Missing Mx teeth ## **2x BWs taken 2**<sup>7</sup><sup>th</sup> **July** (Redacted) * 36 M secondary caries ## **3x PAs taken 2**<sup>7</sup><sup>th</sup> **July** (Redacted) * Mild levels of horizontal bone loss * Mesially tilted 28 ---    Orthopantomogram (OPG) taken on 20th April showing the maxillary and mandibular dentition. Notable findings include missing maxillary teeth as indicated in the OCR text. Two Bitewing radiographs (BWs) taken on 27th July displaying secondary caries at tooth #36. Three Periapical radiographs (PAs) taken on 27th July showing mild horizontal bone loss and a mesially tilted tooth #28. 70 **4.15 Problem list** * Extended use of temporary acrylic P/ (presenting complaint) * Host related * Depression managed by medication * Primary caretaker for father with dementia * Frequent intake of sugary foods * Pathology * Mild generalized gingivitis * Caries 18, 36, 38, 48 * Restoration breakdown 46, 47 * NCTSL 14, 24, 44 * Denture stomatitis of the anterior hard palate * Morphology * Skeletal CI III * Missing teeth 21, 16, 15, 26, 27 * Mx Kennedy CI III Mod 2 * Hypercementosis 46 **4.16 Diagnoses** * Extended use of temporary acrylic P/ (presenting complaint) * Gingivitis * Caries * Restoration breakdown * Mx Kennedy CI III Mod 2 # 4.18 Management plan ## Foundational phase * **Address the presenting complaint** * Advised pt that a foundation of oral health needs to be established first before making the CrCo P/. Pt’s acrylic P/ is technically satisfactory and can be safely used to maintain aesthetics while oral health is established. * **Counselling on required changes in lifestyle factors / OH routine (12/7/)** * **Diet (Evans et al, 2008)** * Continue 3 meals/day of a balanced and healthy diet. * Try to cut down on sugary biscuits between meals. After snacking, have a glass of tap water and try to give teeth a 2hr break to remineralise. * Start drinking tap water regularly aim for 2L/day. * **Oral hygiene and dental visits (Evans et al, 2008)** * Pt encouraged to continue toothbrushing 2x/day with a fluoride toothpaste. Advised pt to switch to a different toothbrush to clean P/ and use detergent and water. * Scale and clean, prophylaxis paste (27/7/) * **Restorations (1/8/- 4/9)** * 18 O amalgam restoration. * 38 O amalgam restoration. * 48 O amalgam restoration. * 14 Bu, 24 Bu, 44 Bu composite restorations. ## Definitive phase * **Replacement of Md amalg restorations 36, 46, 47 with ceramic onlays** * Pt desired an aesthetic restoration, and there were no occlusal contraindications to the use of ceramic or an indirect composite. * In this case, indirect composite (Enamic) was selected for the onlay, as it is the preferred material for onlays at the UWA Dental School. While there is some positive evidence for the longevity of indirect composites, the consensus in the literature is that gaps in clinical evidence exist for the justification of resin composites compared with ceramics when restoring teeth with onlays and overlays (Miromoto, 2016). However, advantages of using indirect composite include greater flexibility to make adjustments following insertion, restorations are relatively easy to repair, and reduced expense when compared to ceramic onlays. The onlay was cemented using a resin cement system (Variolink DC). • 1wk review (19/3/) o Post insert review of CrCo P/. Pt very happy with P/ and reports no problems. o S+C with ultrasonic, prophylaxis paste applied. • 3mth review (5/6/) o Periodic examination and review of CrCo P/. Examination consistent with dental health. 36, 46, 47 remain asymptomatic and positive to CO₂ test. o Denture hygiene instruction reinforced. Scale and clean performed. o 2xBWs taken to screen for interproximal caries (as last set taken 1yr ago and pt is high caries risk) and assess indirect restorations 36, 46 and 47.   Clinical intraoral photo collage showing post-insertion review of a CrCo partial denture. Top center image shows maxillary arch with metal framework and clasps in place. Bottom center shows mandibular arch. Left and right side images show lateral views of the dentition. Context from OCR: Pt very happy with P/ and reports no problems. Bitewing radiograph (BWs) taken to screen for interproximal caries. Two panels labeled 'a' and 'e'. Shows posterior teeth with visible restorations and interproximal areas. Context from OCR: 2xBWs taken to screen for interproximal caries as last set taken 1yr ago and pt is high caries risk and assess indirect restorations 36, 46 and 47. | | | | | | :--- | :--- | :--- | :--- | | | | | myocardium and cardiac conducting system via L-type calcium channels. Act on coronary arteriolar smooth muscle to reduce vascular resistance and myocardial oxygen requirements, relieving angina symptoms (AMH, 2019). | | **Atorvastatin** (Lorstat) | **20mg tablet**<br>**1x/day** | • For hypercholesterolaemia.<br>• Statin. Competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (a rate-limiting enzyme in cholesterol synthesis). Increase hepatic cholesterol uptake from blood, reduce concentrations of total cholesterol, LDL and triglyceride, and produce a small increase in HDL concentrations (AMH, 2019). | - | | Propranolol | 40mg 1x/day<br>orally | • For essential tremors.<br>• Competitively block β receptors in peripheral vasculature to reduce tremors (AMH, 2019). | - | | **Paracetamol** (Panamax) | **500mg 1-2x/day**<br>**orally** | • For osteoarthritis.<br>• Mode of action not fully determined - may include inhibition of central prostaglandin synthesis & modulation of inhibitory descending serotonergic pathways (AMH, 2019). | • May affect perception of dental pain if taken recently. | | **Sertraline** (Zoloft) | **100mg tablet**<br>**orally 1x/day** | • For depression.<br>• Selective serotonin reuptake intake (SSRI) selectively inhibit the presynaptic uptake of serotonin (5-hydroxytryptamine) (AMH, 2019). | • Strong evidence for inducing xerostomia (Wolff et al, 2016). | | **Esomeprazole** (Nexium) | **20mg tablet orally**<br>**1x/day, as required** | • For acid reflux.<br>• Proton pump inhibitor. Bind to hydrogen/potassium ATPase proton pump, inhibiting both stimulated and basal acid secretion (AMH, 2019). | • Chronic regurgitation<br>of gastric contents (pH as low<br>as 1) can cause dental<br>erosion. | 80  A comprehensive pharmaceutical reference table comparing five medications. Columns include Drug Name (e.g., Atorvastatin/Lorstat, Propranolol), Dosage and Route, Mode of Action/Indication, and Side Effects/Notes. Key details extracted: Atorvastatin is a statin for hypercholesterolaemia; Paracetamol may affect dental pain perception; Sertraline causes xerostomia; Esomeprazole causes dental erosion via gastric regurgitation. **5.7 Extra-oral examination** | **Facial appearance** | Healthy, clear complexion | | **Facial symmetry** | Symmetrical | | **Thyroid gland** | No noticeable enlargement or tenderness to palpation | | **Muscles of mastication** | No noticeable enlargement or tenderness to palpation or clenching | | **TMJ** | Bilateral crepitus, asymptomatic | | **Facial thirds** | Elongated lower third of face | | **Facial fifths** | Balanced and symmetrical facial fifths | | **Upper lip** | Distinct vermilion border, smooth vermilion, healthy appearance | | **Lower lip** | Distinct vermilion border, smooth vermilion, healthy appearance | | **Smile analysis** | On smile, 80% incisal display, 0% gingival display | | | At rest, 0% incisal display | | **Profile** | Convex | 82   Clinical extra-oral examination photos of an elderly male patient showing frontal view with relaxed and smiling expressions, and a right lateral profile view. The images include annotations: blue horizontal lines on the frontal views indicate facial thirds, and a vertical blue line on the profile indicates the nasolabial plane or midline reference. Structured table summarizing extra-oral examination findings for 'Facial appearance', 'Facial symmetry', 'Thyroid gland', 'Muscles of mastication', 'TMJ', 'Facial thirds', 'Facial fifths', 'Upper lip', 'Lower lip', 'Smile analysis', and 'Profile'. Includes clinical observations such as 'Healthy, clear complexion', 'Elongated lower third of face', 'Bilateral crepitus, asymptomatic', and smile metrics (80% incisal display). # 5.12 Radiographs - OPG taken 3rd July - Heavily restored dentition, multiple carious lesions, calculus, radiographic evidence of bone loss - Impacted 23 - 34 incomplete RCT - 8x PAs taken 8th March 86   OPG radiograph taken on 3rd July showing heavily restored dentition with multiple carious lesions, calculus, and radiographic evidence of bone loss. Impacted tooth 23 is visible in the lower left quadrant. Tooth 34 shows incomplete root canal treatment (RCT). The image includes an 'L' marker indicating the left side. Eight periapical (PA) radiographs taken on 8th March, arranged in two rows of four. Each PA image shows different quadrants or teeth groups with varying degrees of restoration, caries, and bone levels. Some images display endodontic treatments and impacted teeth. Labels such as 'a', 'b', 'c' appear on some films for identification. # 5.13 Caries risk assessment (Evans et al, 2008) - **Diet assessment** (Usual 24h snacking questionnaire) - Breakfast toast & eggs with coffee - Lunch bread roll with cheese & luncheon meat - Dinner fish or chicken with vegetables - Occasionally savory biscuits - Drinks lemon and barley water with ¹⁄₄ tsp Stevia - **Plaque score** - 56% (45/80) - **Saliva assessment -** ## Resting saliva | Hydration | Viscosity | pH | |---|---|---| | >60s | Sticky/stringy | 5.0-5.8 | | 30-60s | Frothy/bubbly | 6.0-6.6 | | <30s | Watery/clear | 6.8-7.8 | ## Stimulated saliva | Quantity | pH | Buffering | |---|---|---| | <3.5mL | 5.0-5.8 | 0-5pt | | 3.5-5.0mL | 6.0-6.6 | 6-9pt | | >5.0mL | 6.8-7.8 | 10-12pt | - **Clinical examination / radiographic assessment -** - Multiple untreated frank cavities - Multiple restorations with secondary caries - Radiographic bone loss - **Caries risk:** **HIGH**    Plaque score visual chart showing a grid of teeth numbered 1-8. Yellow X marks indicate plaque presence on specific teeth (teeth 7, 6, 5, 4, 3, 2, 1, 1, 2, 3, 4, 5, 6, 7, 8), totaling 45 out of 80 scored areas, corresponding to the text '56% (45/80)'. Table titled 'Resting saliva' with three columns: Hydration (>60s, 30-60s, <30s), Viscosity (Sticky/stringy, Frothy/bubbly, Watery/clear), and pH (5.0-5.8, 6.0-6.6, 6.8-7.8). Table titled 'Stimulated saliva' with three columns: Quantity (<3.5mL, 3.5-5.0mL, >5.0mL), pH (5.0-5.8, 6.0-6.6, 6.8-7.8), and Buffering (0-5pt, 6-9pt, 10-12pt). 5.14 **_**Periodontal risk assessment (Lang & Tonetti, 2003)** Age | **85** ---|:---: Number of teeth and implants | **20** (1 - 32) Number of sites per tooth / implant | *2* | o *4* | **o 6** Number of BOP-pos. sites | **63** of **120** Number of sites with PPD≥5mm | **8** Number of missing teeth | **8** % Alveolar bone loss (estimated in % or 10% per 1mm) | **60** % Syst./Gen. | **o Yes** | o No Envir. | o **Non smoker (NS)** | o Former smoker (FS) | o Occasional smoker (OS) | o Smoker (S) | o Heavy smoker (HS) Polygon surface: **84.0044** periodontal Risk: **high** Suggested Recall interval: **3** Months * Periodontal risk: **HIGH** 88   A radar chart (spider diagram) visualizing a periodontal risk assessment. The axes are labeled 'Envir.', 'PD≥5mm', 'Tooth loss', and 'Syst./Gen.'. A shaded polygon represents the patient's data points on these axes. Specific values are annotated around the chart: 'BOP% = 53%' at the top vertex and 'BL/Age = 0.70588' at the bottom vertex. A data entry table containing patient parameters for the risk assessment. Fields include Age (85), Number of teeth and implants (20), Number of sites per tooth/implant (selected as 6), Number of BOP-pos. sites (63 of 120), Number of sites with PPD≥5mm (8), Number of missing teeth (8), % Alveolar bone loss (60%), Syst./Gen. (Yes), and Envir. (Non smoker). 5.15 Prognosis (Samet & Jotkowitz, 2009) Individual tooth prognosis - * Prognosis categories are based on a classification proposed by Samet & Jotkowitz (2009), where overall prognosis is the worst of periodontal, restorative, endodontic and occlusal prognoses. Anatomic, iatrogenic and patient factors modify the overall prognosis. ** Overall tooth prognosis modified downward by patient factors - poor OH, cariogenic diet, smoking, aesthetics as motivation for treatment, and high aesthetic expectations. • Overall dentition prognosis **QUESTIONABLE TO POOR**  A comprehensive dental prognostic chart titled 'Individual tooth prognosis' based on Samet & Jotkowitz (2009). The chart displays a grid of tooth positions (e.g., 11-28, 31-38, 41-48) with columns for Periodontal, Restorative, Endodontic, and Occlusal prognoses. Specific teeth are marked with colored squares indicating their status: red for Poor (P), orange for Questionable (Q), yellow for Fair (F), green for Good (G), and black for Hopeless (H). Visual representations of restorations (amalgam, composite, caries, root stumps) are shown as icons within the tooth slots. A legend at the bottom defines the color coding for prognoses and symbols for findings like unerupted teeth or cracks. ### 5.16 Problem list - Frank cavitation of 12, 13, 14, 24, 25, 33, 36, 37, 42, 47 (presenting complaint) - Poor smile aesthetics due to missing anterior teeth 11, 21, 22 (presenting complaint) - Host related - Metastasis of prostate cancer to lower vertebrae - Essential tremors - Major depression - Well controlled T2DM - Osteoarthritis - Hypertension - Pathology - Moderate to severe generalized chronic periodontitis modified by diabetes (AAPD, 1999) / Periodontitis Stage IV Grade B modified by diabetes (Papapanou et al, 2017) - 34 incomplete root canal treatment with no signs of infection with clinically normal periapical tissues (Abbott & Yu, 2007; Abbott, 2004) - Morphology - Missing teeth 26, 31, 41, 43, 45, 46 - Mx Kennedy Cl III Mod 1 - Md Kennedy Cl III - Drifting of teeth - Problematic spacing - Anterior open bite - Fibrous hyperplasia of hard palate (gingival overgrowth associated with amlodipine use?) ### 5.17 Diagnoses - Caries (presenting complaint) - Poor smile aesthetics (presenting complaint) - Restoration breakdown - Periodontitis - Incomplete endodontic treatment - Mx Kennedy Cl III Mod 1 - Md Kennedy Cl III 5.19 **Management plan** **Foundational phase** • **Address the presenting complaint** o Express an understanding of the patient’s situation and aims of dental treatment. Explained we will need to establish a foundation of oral health before proceeding to fabrication of acrylic P/ . • **Counselling on required changes in lifestyle factors / OH routine** (7/3/ [Date Restriction]) o **Diet** (Evans et al, 2008) § Reduce intake of sugary drinks since frequent exposure increases caries risk. Try to limit sugary drinks to mealtimes and have a glass of water afterwards. o **Oral hygiene and dental visits** (Evans et al, 2008) § Toothbrushing 2x/day in the morning and at night using Neutrafluor 5000 Plus toothpaste. § Floss or use interdental brushes 1x/day at night before brushing. § Attend scheduled dental appointments where possible. We will arrange dental appointments to fit around pt’s medical appointments. • **Scaling and root debridement** (15/3/ [Date Restriction] - 19/3/ [Date Restriction]) under LA over two visits. Fluoride varnish (5% NaF Duraphat) applied to all carious lesions. • **Restorations** (20/3/ [Date Restriction] - 25/10/ [Date Restriction]) o 47 **MOBu** Equia Forte restoration. o 37 **DOBu** Equia Forte restoration. o 36 **Bu** Equia Forte restoration & resin fissure seal. o 24 **DOBu** Equia Forte restoration. o 25 **MBu** Equia Forte restoration. o 13 **DBu** composite restoration. o 14 **MBu** composite restoration. o 33 **DLiBu** composite restoration. o 42 **M&D** composite restorations. o 12 **MIncLaD** composite restoration.  Clinical intraoral photograph showing the anterior and premolar region of a patient's mouth. The image displays significant dental pathology including multiple missing teeth, exposed root stumps with severe discoloration, and generalized gingival inflammation. This visual corresponds to the 'Foundational phase' described in the text, illustrating the need for scaling, root debridement, and restorative work on teeth such as 47, 37, and others listed in the management plan. [^1]: Original PDF page 1: [[Sample portfolio 1.pdf#page=1|Sample portfolio 1, p.1]] [^2]: Original PDF page 2: [[Sample portfolio 1.pdf#page=2|Sample portfolio 1, p.2]] [^3]: Original PDF page 3: [[Sample portfolio 1.pdf#page=3|Sample portfolio 1, p.3]] [^4]: Original PDF page 4: [[Sample portfolio 1.pdf#page=4|Sample portfolio 1, p.4]] [^5]: Original PDF page 5: [[Sample portfolio 1.pdf#page=5|Sample portfolio 1, p.5]] [^6]: Original PDF page 6: [[Sample portfolio 1.pdf#page=6|Sample portfolio 1, p.6]] [^7]: Original PDF page 7: [[Sample portfolio 1.pdf#page=7|Sample portfolio 1, p.7]] [^8]: Original PDF page 8: [[Sample portfolio 1.pdf#page=8|Sample portfolio 1, p.8]] [^9]: Original PDF page 9: [[Sample portfolio 1.pdf#page=9|Sample portfolio 1, p.9]] [^10]: Original PDF page 10: [[Sample portfolio 1.pdf#page=10|Sample portfolio 1, p.10]] [^11]: Original PDF page 11: [[Sample portfolio 1.pdf#page=11|Sample portfolio 1, p.11]] [^12]: Original PDF page 12: [[Sample portfolio 1.pdf#page=12|Sample portfolio 1, p.12]] [^13]: Original PDF page 13: [[Sample portfolio 1.pdf#page=13|Sample portfolio 1, p.13]] [^14]: Original PDF page 14: [[Sample portfolio 1.pdf#page=14|Sample portfolio 1, p.14]] [^15]: Original PDF page 15: [[Sample portfolio 1.pdf#page=15|Sample portfolio 1, p.15]] [^16]: Original PDF page 16: [[Sample portfolio 1.pdf#page=16|Sample portfolio 1, p.16]] [^17]: Original PDF page 17: [[Sample portfolio 1.pdf#page=17|Sample portfolio 1, p.17]] [^18]: Original PDF page 18: [[Sample portfolio 1.pdf#page=18|Sample portfolio 1, p.18]] [^19]: Original PDF page 19: [[Sample portfolio 1.pdf#page=19|Sample portfolio 1, p.19]] [^20]: Original PDF page 20: [[Sample portfolio 1.pdf#page=20|Sample portfolio 1, p.20]] [^21]: Original PDF page 21: [[Sample portfolio 1.pdf#page=21|Sample portfolio 1, p.21]] [^22]: Original PDF page 22: [[Sample portfolio 1.pdf#page=22|Sample portfolio 1, p.22]] [^23]: Original PDF page 23: [[Sample portfolio 1.pdf#page=23|Sample portfolio 1, p.23]] [^24]: Original PDF page 24: [[Sample portfolio 1.pdf#page=24|Sample portfolio 1, p.24]] [^25]: Original PDF page 25: [[Sample portfolio 1.pdf#page=25|Sample portfolio 1, p.25]] [^26]: Original PDF page 26: [[Sample portfolio 1.pdf#page=26|Sample portfolio 1, p.26]] [^27]: Original PDF page 27: [[Sample portfolio 1.pdf#page=27|Sample portfolio 1, p.27]] [^28]: Original PDF page 28: [[Sample portfolio 1.pdf#page=28|Sample portfolio 1, p.28]] [^29]: Original PDF page 29: [[Sample portfolio 1.pdf#page=29|Sample portfolio 1, p.29]] [^30]: Original PDF page 30: [[Sample portfolio 1.pdf#page=30|Sample portfolio 1, p.30]] [^31]: Original PDF page 31: [[Sample portfolio 1.pdf#page=31|Sample portfolio 1, p.31]] [^32]: Original PDF page 32: [[Sample portfolio 1.pdf#page=32|Sample portfolio 1, p.32]] [^33]: Original PDF page 33: [[Sample portfolio 1.pdf#page=33|Sample portfolio 1, p.33]] [^34]: Original PDF page 34: [[Sample portfolio 1.pdf#page=34|Sample portfolio 1, p.34]] [^35]: Original PDF page 35: [[Sample portfolio 1.pdf#page=35|Sample portfolio 1, p.35]] [^36]: Original PDF page 36: [[Sample portfolio 1.pdf#page=36|Sample portfolio 1, p.36]] [^37]: Original PDF page 37: [[Sample portfolio 1.pdf#page=37|Sample portfolio 1, p.37]] [^38]: Original PDF page 38: [[Sample portfolio 1.pdf#page=38|Sample portfolio 1, p.38]] [^39]: Original PDF page 39: [[Sample portfolio 1.pdf#page=39|Sample portfolio 1, p.39]] [^40]: Original PDF page 40: [[Sample portfolio 1.pdf#page=40|Sample portfolio 1, p.40]] [^41]: Original PDF page 41: [[Sample portfolio 1.pdf#page=41|Sample portfolio 1, p.41]] [^42]: Original PDF page 42: [[Sample portfolio 1.pdf#page=42|Sample portfolio 1, p.42]] [^43]: Original PDF page 43: [[Sample portfolio 1.pdf#page=43|Sample portfolio 1, p.43]] [^44]: Original PDF page 44: [[Sample portfolio 1.pdf#page=44|Sample portfolio 1, p.44]] [^45]: Original PDF page 45: [[Sample portfolio 1.pdf#page=45|Sample portfolio 1, p.45]] [^46]: Original PDF page 46: [[Sample portfolio 1.pdf#page=46|Sample portfolio 1, p.46]] [^47]: Original PDF page 47: [[Sample portfolio 1.pdf#page=47|Sample portfolio 1, p.47]] [^48]: Original PDF page 48: [[Sample portfolio 1.pdf#page=48|Sample portfolio 1, p.48]] [^49]: Original PDF page 49: [[Sample portfolio 1.pdf#page=49|Sample portfolio 1, p.49]] [^50]: Original PDF page 50: [[Sample portfolio 1.pdf#page=50|Sample portfolio 1, p.50]] [^51]: Original PDF page 51: [[Sample portfolio 1.pdf#page=51|Sample portfolio 1, p.51]] [^52]: Original PDF page 52: [[Sample portfolio 1.pdf#page=52|Sample portfolio 1, p.52]] [^53]: Original PDF page 53: [[Sample portfolio 1.pdf#page=53|Sample portfolio 1, p.53]]