# CASE PORTFOLIO
DMD 4
1
CASE PORTFOLIO
DMD 4
**Contents**
**Case 1: Multi-disciplinary** ............................. 4
The patient ................................................. 5
Examination and diagnostics ............................... 9
Diagnoses and problem list .............................. 19
Prognosis .................................................. 20
Treatment options ......................................... 22
Management plan ........................................... 25
Treatment delivery ......................................... 26
**Case 2: Fixed Aesthetic** .............................. 42
The patient ................................................. 43
Examination and diagnostics ............................... 45
Diagnoses and problem list .............................. 56
Prognosis .................................................. 58
Treatment options ......................................... 60
Management plan ........................................... 64
Treatment delivery ......................................... 66
**Case 3: Removable Aesthetic** .......................... 76
The patient ................................................. 77
Examination and diagnostics ............................... 80
Diagnoses and problem list .............................. 88
Prognosis .................................................. 89
Treatment options ......................................... 92
Management plan ........................................... 95
Treatment delivery ......................................... 96
**Case 4: Fixed Occlusal Rehabilitation** ................. 100
The patient ................................................. 101
Examination and diagnostics ............................... 105
Diagnoses and problem list .............................. 114
Prognosis .................................................. 115
Treatment options ......................................... 117
2
#### Case 1: Multi-disciplinary (Page 4)
- The patient (5)
- Examination and diagnostics (9)
- Diagnoses and problem list (19)
- Prognosis (20)
- Treatment options (22)
- Management plan (25)
- Treatment delivery (26)
#### Case 2: Fixed Aesthetic (Page 42)
- The patient (43)
- Examination and diagnostics (45)
- Diagnoses and problem list (56)
- Prognosis (58)
- Treatment options (60)
- Management plan (64)
- Treatment delivery (66)
#### Case 3: Removable Aesthetic (Page 76)
- The patient (77)
- Examination and diagnostics (80)
- Diagnoses and problem list (88)
- Prognosis (89)
- Treatment options (92)
- Management plan (95)
- Treatment delivery (96)
#### Case 4: Fixed Occlusal Rehabilitation (Page 100)
- The patient (101)
- Examination and diagnostics (105)
- Diagnoses and problem list (114)
- Prognosis (115)
- Treatment options (117)
Management plan..........................................................................................120
Treatment delivery.......................................................................................121
**Case 5: Removable Occlusal Rehabilitation**...........................................129
The patient....................................................................................................130
Examination and diagnostics.......................................................................134
Diagnoses and problem list.........................................................................143
Prognosis......................................................................................................144
Treatment options.........................................................................................146
Management plan.........................................................................................148
Treatment delivery.......................................................................................149
**References**...............................................................................................158
3
- Management plan (120)
- Treatment delivery (121)
#### Case 5: Removable Occlusal Rehabilitation (Page 129)
- The patient (130)
- Examination and diagnostics (134)
- Diagnoses and problem list (143)
- Prognosis (144)
- Treatment options (146)
- Management plan (148)
- Treatment delivery (149)
#### References (Page 158)
![]()
Table of contents entry: 'Management plan' with page number 120.
![]()
Table of contents entry: 'Treatment delivery' with page number 121.
![]()
Table of contents entry: 'Case 5: Removable Occlusal Rehabilitation' with page number 129.
![]()
Table of contents entry: 'The patient' with page number 130.
![]()
Table of contents entry: 'Examination and diagnostics' with page number 134.
![]()
Table of contents entry: 'Diagnoses and problem list' with page number 143.
![]()
Table of contents entry: 'Prognosis' with page number 144.
![]()
Table of contents entry: 'Treatment options' with page number 146.
![]()
Table of contents entry: 'Management plan' with page number 148.
![]()
Table of contents entry: 'Treatment delivery' with page number 149.
![]()
Table of contents entry: 'References' with page number 158.
# CASE 1
Multi-disciplinary
4
CASE 1
Multi-disciplinary
CASE 1
Multi-disciplinary
1.1 The patient
1.1.1 Details
- 64 year-old male
1.1.2 Presenting complaint/s
- Presented in January 2019 with the following complaints:
i. “I have intermittent pain in a couple of my teeth (37, 47) and in my gums.”
ii. “There is a hole in the back of my tooth (22) and sometimes stuff gets in there and causes sensitivity.”
iii. “I think it would be benefical to have dentures because of my missing teeth.”
1.1.3 History of presenting complaint/s
- Dull, throbbing pain that lingers with minor temperature changes on lower left.
- Recent spontaneous, dull pain with minor temperature changes on lower right.
- Gingival pain and bleeding on brushing.
5
#### 1.1 The patient
##### 1.1.1 Details
- 64 year-old male
##### 1.1.2 Presenting complaint/s
- Presented in January 2019 with the following complaints:
1. “I have intermittent pain in a couple of my teeth (37, 47) and in my gums.”
2. “There is a hole in the back of my tooth (22) and sometimes stuff gets in there and causes sensitivity.”
3. “I think it would be benefical to have dentures because of my missing teeth.”
##### 1.1.3 History of presenting complaint/s
- Dull, throbbing pain that lingers with minor temperature changes on lower left.
- Recent spontaneous, dull pain with minor temperature changes on lower right.
- Gingival pain and bleeding on brushing.
![]()
Clinical photo of a patient's face (Case 1). The image shows a 64-year-old male with grey hair and glasses. His eyes are redacted with a black bar for privacy.
1.1.4 Medical history
<table>
<tr>
<th>Medical condition</th>
<th>Description</th>
<th>Dental implications (1)</th>
</tr>
<tr>
<td>Chronic obstructive pulmonary disease (COPD)</td>
<td>Respiratory condition that causes narrowing of the bronchial tubes in the lungs, making breathing difficult. Symptoms identical to asthma and include wheezing, shortness of breath, chest tightness, coughing.</td>
<td>Mouth breathing.<br>Increased risk of xerostomia.<br>Difficulty tolerating horizontal position.<br>Difficulty tolerating rubber dam.</td>
</tr>
<tr>
<td>Abdominal hernia<br>Reflux oesophagitis</td>
<td>Protrusion of organs through weakened section of abdominal wall. Associated with oesophageal reflux; regurgitation of stomach contents into oesophagus resulting in chemical insult to oesophagus from gastric acid, enzymes, bile.</td>
<td>Difficulty tolerating horizontal position.<br>Acid erosion and accelerated tooth wear.</td>
</tr>
<tr>
<td>Osteoarthritis affecting shoulders, fingers, legs, back</td>
<td>Inflammation and/or damage of joints affecting bone, cartilage, ligaments, muscles and causing pain, swelling, difficulty moving.</td>
<td>Difficulty performing adequate oral hygiene.</td>
</tr>
<tr>
<td>Stents in L & R legs</td>
<td>Tube inserted into blocked arteries in legs.</td>
<td>Difficulty with long dental appointments.</td>
</tr>
<tr>
<td>Post-traumatic stress disorder (PTSD)</td>
<td>Mental health condition triggered by a terrifying event causing flashbacks, fear, nightmares and severe anxiety.</td>
<td>Difficulty coping with changes in plans and new procedures.<br>Easily frustrated.</td>
</tr>
<tr>
<td>Previous hospitalisation</td>
<td>April 2018 – COPD and back pain<br>February 2019 – numbness in legs and back pain</td>
<td>Nil.</td>
</tr>
</table>
(1) Therapeutic Guidelines: oral and dental (2019).
<table>
<tr>
<th>Medication</th>
<th>Dosage</th>
<th>Use &amp; Mechanism of action (2, 3)</th>
<th>Dental implications (2, 3)</th>
</tr>
<tr>
<td>Breo Ellipta<br>(Fluticasone Furoate & Vilanterol)</td>
<td>100 mg / 25 mcg q.d.</td>
<td>Corticosteroid/β2 agonist.<br>Symptom relief of asthma.<br>Anti-inflammatory action and bronchodilation.</td>
<td>Increased susceptibility to:<br>(i) Dental caries – decreased salivary flow rate caused by β2-adrenergic agonist, decrease in saliva and plaque pH due to use of inhalers, fermentable carbohydrate in anti-asthma medications.<br>(ii) Dental erosion – reduction in buffering capacity and salivary flow rate due to beta-2 agonist.<br>(iii) Periodontal disease – decrease in salivary protection due to reduction in salivary flow, dehydration of alveolar mucosa due to mouth breathing, alteration of immune response, decrease in mineral bone density associated with inhaled corticosteroids.<br>(iv) Oral candidiasis – generalised immune-suppressive and anti-inflammatory effects of steroids, low salivary flow rate.</td>
</tr>
<tr>
<td>Bricanyl Turbuhaler<br>(Terbutaline Sulfate)</td>
<td>500 mcg q.d.</td>
<td>β2-agonist.<br>Symptom relief of asthma.<br>Relaxes bronchial smooth muscles.</td>
<td></td>
</tr>
<tr>
<td>Ventolin<br>(Salbutamol Sulfate)</td>
<td>100 mcg p.r.n.</td>
<td>β2-adrenergic agonist.<br>Symptom relief of asthma.<br>Relaxes bronchial smooth muscles.</td>
<td>(iv) Oral candidiasis – generalised immune-suppressive and anti-inflammatory effects of steroids, low salivary flow rate.</td>
</tr>
</table>
##### 1.1.4 Medical history
| Medical condition | Description | Dental implications |
| :--- | :--- | :--- |
| Chronic obstructive pulmonary disease (COPD) | Respiratory condition causing narrowing of bronchial tubes; symptoms include wheezing, shortness of breath, coughing. | Mouth breathing; Increased risk of xerostomia; Difficulty tolerating horizontal position or rubber dam. |
| Abdominal hernia / Reflux oesophagitis | Protrusion of organs through abdominal wall; associated with gastric acid regurgitation. | Difficulty tolerating horizontal position; Acid erosion and accelerated tooth wear. |
| Osteoarthritis | Inflammation/damage of joints (shoulders, fingers, legs, back) causing pain and swelling. | Difficulty performing adequate oral hygiene. |
| Stents in L & R legs | Tube inserted into blocked arteries. | Difficulty with long dental appointments. |
| Post-traumatic stress disorder (PTSD) | Mental health condition causing flashbacks and severe anxiety. | Difficulty coping with changes; easily frustrated. |
| Previous hospitalisation | April 2018 (COPD/back pain); Feb 2019 (numbness/back pain). | Nil. |
##### Medications
| Medication | Dosage | Use & Mechanism | Dental implications |
| :--- | :--- | :--- | :--- |
| Breo Ellipta | 100 mg / 25 mcg q.d. | Corticosteroid/β2 agonist for asthma. | Increased susceptibility to caries, erosion, periodontal disease, and oral candidiasis. |
| Bricanyl Turbuhaler | 500 mcg q.d. | β2-agonist for asthma. | Relaxes bronchial smooth muscles. |
| Ventolin | 100 mcg p.r.n. | β2-adrenergic agonist for asthma. | Oral candidiasis; low salivary flow rate. |
![]()
Table titled 'Medical history' with columns for Medical condition, Description, and Dental implications. Rows list conditions including COPD, Abdominal hernia/Reflux oesophagitis, Osteoarthritis, Stents in L & R legs, PTSD, and Previous hospitalisation with corresponding descriptions and dental implications.
![]()
Table listing medications: Breo Ellipta (Fluticasone Furoate & Vilanterol), Bricanyl Turbuhaler (Terbutaline Sulfate), and Ventolin (Salbutamol Sulfate). Columns include Dosage, Use & Mechanism of action, and Dental implications. Detailed dental implications are provided for Breo Ellipta only, covering caries, erosion, periodontal disease, and oral candidiasis.
| | | | | Management: Education, regular check-ups, good oral hygiene, caries prevention, mouth rinsing after use of inhalers, increase water intake, sugar-free gum. (4) |
| :--- | :--- | :--- | :--- | :--- |
| Esomeprazole | 20 mg tab q.d. | Proton pump inhibitor that binds to hydrogen-potassium ATPase enzyme system inhibiting stimulated and basal gastric acid production and secretion. For reflux oesophagitis. | Nil. |
| Pregabalin – ceased | 75 mg tab q.d. | Exact mechanism unknown. Used for relief of neuropathic pain and epilepsy. | Common adverse effects include dry mouth, increasing risk of dental caries. |
| Panadol (Paracetamol) | p.r.n. | Exact mechanism unknown, possibly inhibition of central prostaglandin synthesis and modulation. Used for analgesic and anti-pyretic action. | May alter perception of dental pain, affecting diagnostic procedures. |
| | | (2) Monthly Index of Medical Specialities Australia. (3) Australian Medicines Handbook. | |
| **Allergy** | **Description** | **Dental Implications** | |
| Penicillin | Anaphylactic reaction. | Penicillin contraindicated. Prescribe alternative antibiotics e.g. Clindamycin. |
| | | | |
| **Alcohol & Tobacco Use** | **Amount, Frequency & Duration** | **Dental Implications** | |
| Never smoker | N/A. | Nil. |
| Current drinker | 1-2 standard drinks per month. | Alcohol consumption raises risk of cancer including on lip and in oral cavity (5) |
| | | | |
| 7 |
#### Management of Medication Side Effects
Education, regular check-ups, good oral hygiene, caries prevention, mouth rinsing after use of inhalers, increase water intake, sugar-free gum.
| Medication | Dosage | Use & Mechanism | Dental implications |
| :--- | :--- | :--- | :--- |
| Esomeprazole | 20 mg tab q.d. | Proton pump inhibitor for reflux. | Nil. |
| Pregabalin (ceased) | 75 mg tab q.d. | For neuropathic pain/epilepsy. | Dry mouth, increasing risk of dental caries. |
| Panadol | p.r.n. | Analgesic and anti-pyretic. | May alter perception of dental pain. |
#### Allergies
- **Penicillin**: Anaphylactic reaction. Penicillin contraindicated; prescribe alternative antibiotics (e.g., Clindamycin).
#### Alcohol & Tobacco Use
- **Smoking**: Never smoker.
- **Alcohol**: Current drinker (1-2 standard drinks per month). Alcohol consumption raises risk of oral cavity cancer.
![]()
A table listing medications including Esomeprazole, Pregabalin, and Panadol. Columns include drug name, dosage/frequency, mechanism of action/usage, and dental implications. Contains specific notes on adverse effects like dry mouth or altered pain perception.
![]()
A small table titled 'Allergy' with columns for Allergy type, Description, and Dental Implications. It lists a Penicillin allergy with an anaphylactic reaction and advises prescribing alternative antibiotics like Clindamycin.
![]()
A table titled 'Alcohol & Tobacco Use' with columns for status, amount/frequency/duration, and dental implications. It indicates the patient is a current drinker (1-2 drinks/month) and notes the increased risk of oral cancer.
1.1.5 Dental history and dental attitude
* Dental history
* Attended government dental clinic in 2016 for fillings and an extraction.
* Attended free dental day in 2017 for clean and fillings and screened at OHCWA.
* Previously attempted to access regular care but been placed on long waitlists.
* History of extractions due to dental decay.
* Never worn dentures.
* Presented to student clinic for initial examination January 2019.
* Dental attitude
* Functional motivation.
* Understands and appreciates role of dental health in overall health and wellbeing.
* Highly motivated and compliant.
* Never missed an appointment.
1.1.6 Oral hygiene
* Poor oral hygiene:
* Brushes teeth two to three times daily after meals.
* Uses manual toothbrush and fluoride toothpaste.
* Uses floss pick sometimes.
* Daily salt-water rinses.
1.1.7 Social history
* Born in Melbourne and raised in Israel.
* Previously worked as an Ultra-Orthodox Jewish Rabbi and for United Nations Human Rights Commission, suffering physical and psychological injuries as a result.
* Currently retired in Perth and living alone on disability pension.
* Spends time volunteering for various causes.
8
##### 1.1.5 Dental history and dental attitude
- **Dental history**
- Attended government dental clinic in 2016 and free dental day in 2017.
- History of extractions due to dental decay.
- Never worn dentures.
- Presented to student clinic January 2019.
- **Dental attitude**
- Functional motivation.
- Understands role of dental health in overall wellbeing.
- Highly motivated and compliant; never missed an appointment.
##### 1.1.6 Oral hygiene
- **Status**: Poor oral hygiene.
- **Habits**: Brushes 2-3 times daily; uses manual toothbrush, fluoride toothpaste, and occasional floss picks; daily salt-water rinses.
##### 1.1.7 Social history
- Born in Melbourne, raised in Israel.
- Former Ultra-Orthodox Jewish Rabbi and UN Human Rights Commission worker; suffered physical/psychological injuries.
- Currently retired in Perth, living alone on disability pension; volunteers.
# 1.2 Examination and diagnostics
Date: January 2019
## 1.2.1 Extra-oral examination
| **Findings** |
| :--- |
| **Facial symmetry** | Absence of facial swelling |
| **Facial skin** | Continuous and firm |
| **Lips** | Continuous and firm texture with even colouring<br>Vermilion border present<br>Commissures continuous and intact |
| **Temporomandibular joint** | Bilateral clicking on closing<br>Bilateral clicking on lateral excursion to right<br>Absence of pain and tenderness on palpation |
| **Lymph nodes** | No sign of lymphadenopathy<br>Absence of pain and tenderness on palpation |
| **Muscles of mastication** | Absence of pain and tenderness on palpation |
| **Thyroid gland** | No obvious abnormal enlargement |
# 1.2.2 Extra-oral photographs and findings
## Dentofacial analysis
| | **Dentofacial analysis** |
| --- | --- |
| Horizontal facial proportions | Proportional facial thirds |
| Vertical facial proportions | Proportional facial fifths |
| Horizontal symmetry | Parallelism between interpupillary, intercommissural and incisal lines |
| Vertical symmetry | Mild facial asymmetry with mandible left of midline<br>Facial midline and dental midline coincide<br>Maxillary dental midline and mandibular dental midline do not coincide; mandibular dental midline deviated to left by 4-5 mm |
| Facial symmetry | Relatively symmetrical |
| Smile analysis | High smile line<br>Average smile width<br>Wide buccal corridors<br>Flat incisal/occlusal curve |
| Profile | Indications of class I skeletal relationship |
9
#### 1.2 Examination and diagnostics
Date: January 2019
##### 1.2.1 Extra-oral examination
- **Facial symmetry**: Absence of facial swelling.
- **Facial skin**: Continuous and firm.
- **Lips**: Continuous texture, even colouring, vermilion border present.
- **TMJ**: Bilateral clicking on closing and lateral excursion to right; no pain/tenderness.
- **Lymph nodes**: No lymphadenopathy; no pain/tenderness.
- **Muscles of mastication**: Absence of pain/tenderness.
- **Thyroid gland**: No obvious abnormal enlargement.
##### 1.2.2 Extra-oral findings: Dentofacial analysis
- **Proportions**: Proportional facial thirds and fifths.
- **Symmetry**: Parallelism between interpupillary and incisal lines; mild facial asymmetry with mandible left of midline.
- **Midlines**: Facial and dental midlines coincide; mandibular dental midline deviated to left by 4-5 mm.
- **Smile analysis**: High smile line, average width, wide buccal corridors, flat incisal curve.
- **Profile**: Indications of class I skeletal relationship.
![]()
Table titled '1.2.1 Extra-oral examination' listing findings for Facial symmetry, Facial skin, Lips, Temporomandibular joint, Lymph nodes, Muscles of mastication, and Thyroid gland with corresponding clinical observations.
![]()
Table titled '1.2.2 Extra-oral photographs and findings' containing a Dentofacial analysis section. It details Horizontal facial proportions, Vertical facial proportions, Horizontal symmetry, Vertical symmetry, Facial symmetry, Smile analysis, and Profile indicators.
1.2.3 Intraoral examination
<table>
<tr>
<th>Findings</th>
</tr>
<tr>
<td>Labial mucosa</td>
<td>Nil abnormalities detected</td>
</tr>
<tr>
<td>Buccal mucosa</td>
<td>Nil abnormalities detected</td>
</tr>
<tr>
<td>Buccal and labial sulci</td>
<td>Adequate depth</td>
</tr>
<tr>
<td>Frenal attachments</td>
<td>
<ul>
<li>Maxilla: labial, buccal bilaterally</li>
<li>Mandible: labial, lingual</li>
</ul>
</td>
</tr>
<tr>
<td>Hard palate</td>
<td>Prominent rugae</td>
</tr>
<tr>
<td>Soft palate</td>
<td>Nil abnormalities detected</td>
</tr>
<tr>
<td>Gingivae</td>
<td>
<ul>
<li>Thick scalloped phenotype</li>
<li>Generalised gingival inflammation</li>
<li>Generalised gingival recession and blunted papillae</li>
</ul>
</td>
</tr>
<tr>
<td>Tongue</td>
<td>Fissuring and plaque accumulation on dorsum</td>
</tr>
<tr>
<td>Floor of mouth</td>
<td>Nil abnormalities detected</td>
</tr>
</table>
10
##### 1.2.3 Intraoral examination
- **Mucosa**: Labial and buccal mucosa nil abnormalities detected.
- **Sulci**: Adequate depth.
- **Frenal attachments**: Maxillary (labial, buccal) and Mandibular (labial, lingual).
- **Palate**: Hard palate has prominent rugae; soft palate nil abnormalities.
- **Gingivae**:
- Thick scalloped phenotype.
- Generalised gingival inflammation.
- Generalised gingival recession and blunted papillae.
- **Tongue**: Fissuring and plaque accumulation on dorsum.
- **Floor of mouth**: Nil abnormalities detected.
![]()
Table titled '1.2.3 Intraoral examination' listing clinical findings for various anatomical regions: Labial mucosa, Buccal mucosa, Buccal and labial sulci, Frenal attachments (Maxilla and Mandible), Hard palate, Soft palate, Gingivae (with sub-findings: Thick scalloped phenotype, Generalised gingival inflammation, Generalised gingival recession and blunted papillae), Tongue (Fissuring and plaque accumulation on dorsum), and Floor of mouth. Most entries report nil abnormalities or adequate depth; notable findings include prominent rugae and specific gingival conditions.
![]()
Left profile photograph of an elderly male with white hair and glasses, showing facial structure from the side view.
![]()
Frontal photograph of the same elderly male subject, with eyes redacted for privacy, showing facial symmetry and features.
![]()
Frontal photograph of the subject smiling, revealing dentition and gingival condition.
![]()
Right profile photograph of the elderly male subject, showing lateral facial anatomy including nose, lips, and chin.
```html
<html><body>
<h2>1.2.4 Intraoral photographs and findings</h2>
<table border="1">
<thead><tr><th colspan="3">1.2.4 Intraoral photographs and findings</th>
</tr>
<tr>
<th colspan="2">View</th>
<th>Findings</th>
</tr>
<tr>
<td rowspan="4"><b>Maxillary occlusal</b></td>
<td>Teeth</td>
<td>Partially dentate: Kennedy-Applegate Class I (6) <br/>Incisal wear into dentine 13-23<br/>Large cavity 22D</td>
</tr>
<tr>
<td>Restorations</td>
<td>Large composite restorations 11, 14, 15<br/>Composite restorations 12, 21, 25</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Prominent rugae</td>
</tr>
<tr>
<td></td>
<td></td>
</tr>
<tr>
<td rowspan="3"><b>Mandibular occlusal</b></td>
<td>Teeth</td>
<td>Partially dentate: Kennedy-Applegate Class III Modification 1 (6)<br/>Incisal wear into dentine 33-43</td>
</tr>
<tr>
<td>Restorations</td>
<td>Large composite restorations 37, 38</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Narrow alveolar ridge 36-35 area</td>
</tr>
<tr>
<td rowspan="3">Right buccal</td>
<td>Teeth</td>
<td>Missing teeth 16, 17, 46<br/>47 intrudes into prosthetic space of opposing arch<br/>Yellow-brown bands on cervical areas of teeth*<br/>Abundant plaque</td>
</tr>
<tr>
<td>Restorations</td>
<td>Large composite restoration 47</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Marginal gingival inflammation<br/>Generalised gingival recession</td>
</tr>
<tr>
<td rowspan="3"><b>Left buccal</b></td>
<td>Teeth</td>
<td>Missing teeth 26, 27, 35, 36<br/>37 intrudes into prosthetic space of opposing arch<br/>Yellow-brown bands on cervical areas of teeth*<br/>Abundant plaque</td>
</tr>
<tr>
<td>Restorations</td>
<td>Large composite restoration 37</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Marginal gingival inflammation<br/>Generalised gingival recession</td>
</tr>
<tr>
<td rowspan="3"><b>Anterior</b></td>
<td>Teeth</td>
<td>Caries 23M<br/>Abundant plaque and calculus<br/>Deviation of mandibular dental midline to left</td>
</tr>
<tr>
<td>Restorations</td>
<td>Composite restorations 11, 21</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Marginal gingival inflammation<br/>Generalised gingival recession<br/>Blunted papilla</td>
</tr>
<tr>
<td colspan="3"><i>*Causes of discolouration may be intrinsic or extrinsic. Likely intrinsic staining caused by past use of tetracycline antibiotics.</i></td>
</tr>
</thead>
</table>
<p>11</p>
</body></html>
```
##### 1.2.4 Intraoral photographs and findings
| View | Findings |
| :--- | :--- |
| **Maxillary occlusal** | Partially dentate (Kennedy-Applegate Class I); Incisal wear into dentine 13-23; Large cavity 22D; Large composite restorations 11, 14, 15; Composite 12, 21, 25. |
| **Mandibular occlusal** | Partially dentate (Kennedy-Applegate Class III Mod 1); Incisal wear 33-43; Large composite restorations 37, 38; Narrow alveolar ridge 36-35 area. |
| **Right buccal** | Missing 16, 17, 46; 47 intrudes into prosthetic space; Yellow-brown cervical bands (likely intrinsic tetracycline staining); Abundant plaque; Large composite 47. |
| **Left buccal** | Missing 26, 27, 35, 36; 37 intrudes into prosthetic space; Yellow-brown cervical bands; Abundant plaque; Large composite 37. |
| **Anterior** | Caries 23M; Abundant plaque and calculus; Mandibular midline deviation to left; Marginal gingival inflammation and blunted papilla. |
![]()
A structured table titled '1.2.4 Intraoral photographs and findings' that organizes clinical observations into three columns: View (with subcategories including Maxillary occlusal, Mandibular occlusal, Right buccal, Left buccal, and Anterior), Teeth (detailing conditions like partial dentition, wear, missing teeth, caries, restorations, and discolouration), Restorations (listing specific composite restorations by tooth number), and Soft tissues (noting inflammation, recession, rugae, alveolar ridge issues, and papilla blunting). The table includes a footnote explaining causes of discolouration as likely intrinsic staining from tetracycline antibiotics.
1.2.5 Occlusion
| Findings |
| :--- |
| Overjet | 3 mm |
| Overbite | 2 mm |
| Canine class | LHS: Class I, RHS: Class III |
| Molar class | LHS: -, RHS: - |
| Crossbite | Absent |
| Crowding / Spacing | Nil |
| Tilting | 34, 37, 47 |
| Rotation | 22 |
| Supraeruption | 37, 47 |
| Occlusal scheme | Group function |
12
##### 1.2.5 Occlusion
- **Overjet**: 3 mm
- **Overbite**: 2 mm
- **Canine class**: LHS Class I, RHS Class III
- **Molar class**: Not applicable (-)
- **Crossbite**: Absent
- **Crowding / Spacing**: Nil
- **Tilting**: 34, 37, 47
- **Rotation**: 22
- **Supraeruption**: 37, 47
- **Occlusal scheme**: Group function
![]()
Clinical intraoral photograph showing the maxillary occlusal view (top), displaying the arrangement of upper teeth and palatal anatomy.
![]()
Clinical intraoral photograph showing the left lateral view of the dentition.
![]()
Clinical intraoral photograph showing the frontal view of the anterior dentition, illustrating the overjet and overbite measurements mentioned in the text (3 mm and 2 mm respectively).
![]()
Clinical intraoral photograph showing the right lateral view of the dentition.
![]()
Clinical intraoral photograph showing the mandibular occlusal view (bottom), displaying the arrangement of lower teeth and floor of mouth anatomy.
![]()
Structured data table titled '1.2.5 Occlusion' summarizing clinical findings: Overjet (3 mm), Overbite (2 mm), Canine class (LHS Class I, RHS Class III), Molar class (-), Crossbite (Absent), Crowding/Spacing (Nil), Tilting (34, 37, 47), Rotation (22), Supraeruption (37, 47), and Occlusal scheme (Group function).
# 1.2.6 Odontogram
# 1.2.7 Periodontal assessment
## 1.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)
<table>
<thead>
<tr>
<th colspan="3">Findings</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="2">CPITN</td>
<td>Sextant 1</td>
<td>Maximum probing depth 5 mm, generalised BOP</td>
</tr>
<tr>
<td>3</td>
<td>3</td>
<td>Sextant 2</td>
<td>Maximum probing depth 5 mm, generalised BOP</td>
</tr>
<tr>
<td>3</td>
<td>3</td>
<td>Sextant 3</td>
<td>Maximum probing depth 4 mm, generalised BOP</td>
</tr>
<tr>
<td>3</td>
<td colspan="3">Sextant 4 Maximum probing depth 5 mm, generalised BOP</td>
</tr>
<tr>
<td colspan="2">3</td>
<td>Sextant 5</td>
<td>Maximum probing depth 5 mm, generalised BOP</td>
</tr>
<tr>
<td colspan="3">Extremely tender to probing</td>
</tr>
<tr>
<td colspan="2">-</td>
<td>Sextant 6</td>
<td>Maximum probing depth 4 mm, generalised BOP</td>
</tr>
</tbody>
</table>
<table>
<thead>
<tr>
<th rowspan="2">Clinical</th>
<th>Findings</th>
</tr>
</thead>
<tbody>
<tr>
<th>Gingival tissues</th>
<td>Generalised bleeding on probing<br>No oedematous texture<br>Pink with red marginal gingival inflammation<br>Generalised gingival recession with blunted papillae<br>Thick biotype</td>
</tr>
<tr>
<th>Plaque distribution</th>
<td>Generalised plaque distribution<br>Abundant in interproximal areas</td>
</tr>
<tr>
<th>Plaque score</th>
<td>43%</td>
</tr>
<tr>
<th>Calculus distribution</th>
<td>Generalised supragingival and subgingival calculus<br>Abundant in lingual lower anterior teeth</td>
</tr>
<tr>
<th>Plaque-retentive factors</th>
<td>Restoration overhangs 11, rotated 22, distally tilted 34, mesially tilted 37</td>
</tr>
<tr>
<th>Furcation involvement</th>
<td>No</td>
</tr>
<tr>
<th>Halitosis</th>
<td>Yes</td>
</tr>
<tr>
<th>Radiographic</th>
<th>Bone levels</th>
<td>Generalised mild horizontal bone loss in maxilla and mandible</td>
</tr>
</tbody>
</table>
##### 1.2.6 Odontogram
##### 1.2.7 Periodontal assessment
###### 1.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)
- **Sextant 1**: Max PD 5 mm, generalised BOP (Score 3)
- **Sextant 2**: Max PD 5 mm, generalised BOP (Score 3)
- **Sextant 3**: Max PD 4 mm, generalised BOP (Score 3)
- **Sextant 4**: Max PD 5 mm, generalised BOP (Score 3)
- **Sextant 5**: Max PD 5 mm, generalised BOP (Score 3)
- **Sextant 6**: Max PD 4 mm, generalised BOP (Score 3)
- **Note**: Extremely tender to probing.
###### 1.2.7.2 Clinical Findings
- **Gingival tissues**: Generalised bleeding on probing; pink with red marginal inflammation; generalised recession with blunted papillae; thick biotype.
- **Plaque**: Generalised distribution; score 43%.
- **Calculus**: Generalised supragingival and subgingival; abundant on lingual lower anterior teeth.
- **Plaque-retentive factors**: Restoration overhangs (11), rotated 22, tilted 34 and 37.
- **Bone levels**: Generalised mild horizontal bone loss.
![]()
Odontogram showing tooth positions with symbols indicating restorations and caries. Top row: Teeth 5-1 (upper right), 1-5 (upper left) marked with red crosses for unsatisfactory restorations; teeth 3, 2, 1 have orange fillings for composite restorations. Bottom row: Tooth 3 has a green outline for non-carious occlusal surface loss. Right side: Teeth 1-5 (lower left), 6-8 (lower right). Tooth 7 (lower right) has an orange filling. Legend below defines symbols: orange square = Composite restoration, red cross = Unsatisfactory restoration, green outline = Non-carious occlusal surface loss, black dot = Caries.
![]()
Table titled '1.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)' with columns 'CPITN' and 'Findings'. Rows list findings for each sextant (1–6): maximum probing depth (4 or 5 mm) and generalised BOP. Sextant 5 also notes 'Extremely tender to probing'. CPITN values shown as 3 for all sextants in the grid section.
![]()
Table titled '1.2.7.2 Periodontal examination' with rows for Clinical findings: Gingival tissues (generalised bleeding on probing, oedematous texture, pink with red marginal gingival inflammation, generalised gingival recession with blunted papillae, thick biotype); Plaque distribution (generalised, abundant in interproximal areas); Plaque score (43%); Calculus distribution (generalised supragingival and subgingival calculus, abundant in lingual lower anterior teeth); Plaque-retentive factors (restoration overhangs 11, rotated 22, distally tilted 34, mesially tilted 37); Furcation involvement (No); Halitosis (Yes). Radiographic row shows bone levels: generalised mild horizontal bone loss in maxilla and mandible.
1.2.7.3 Periodontal tests
<table>
<tr>
<td>Mobility</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
</tr>
<tr>
<td>TTPalp</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
</tr>
<tr>
<td>TTP</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
</tr>
<tr>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2">47</td>
<td>15</td>
<td>14</td>
<td>13</td>
<td>12</td>
<td>11</td>
<td>21</td>
<td>22</td>
<td>23</td>
<td>24</td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
</tr>
<tr>
<td>45</td>
<td>44</td>
<td>43</td>
<td>42</td>
<td>41</td>
<td>31</td>
<td>32</td>
<td>33</td>
<td>34</td>
<td>37</td>
</tr>
<tr>
<td>TTP</td>
<td>++</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>+++</td>
<td></td>
</tr>
<tr>
<td>TTPalp</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td></td>
</tr>
<tr>
<td>Mobility</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>GI</td>
<td>GI</td>
<td>-</td>
<td>-</td>
<td>-</td>
<td>GI</td>
<td></td>
</tr>
</table>
1.2.7.4 Periodontal chart
* CPITN indicated need for periodontal chart.
* Baseline data to evaluate success of periodontal treatment.
* Periodontal assessment in consideration of removable prostheses.
###### 1.2.7.3 Periodontal tests
- **TTP (Tenderness to Percussion)**: Positive (++) on 47; Highly positive (+++) on 37.
- **Mobility**: Grade I (GI) noted on 21, 22, and 37.
- **TTPalp (Tenderness to Palpation)**: Negative (-) for all tested teeth.
###### 1.2.7.4 Periodontal chart
- CPITN indicated need for full periodontal chart.
- Baseline data established to evaluate treatment success.
- Assessment performed in consideration of removable prostheses.
![]()
Periodontal test results table. Rows are labeled Mobility, TTPalp, and TTP. Columns represent tooth numbers (e.g., 47, 15-24, 37). The TTP row shows values like '++' for tooth 47 and '+++' for tooth 37. Other cells contain '-' or 'GI'.
![]()
Buccal periodontal chart section. Includes rows for Mob, AL, Rec, PD with numerical data. Below is a graphical representation of the gum line with yellow triangles indicating pockets and red dots marking bleeding sites. A plaque index bar graph and a diagram showing tooth positions with colored squares representing plaque status are included.
![]()
Palatal periodontal chart section. Similar structure to the buccal section with Mob, AL, Rec, PD rows containing numerical data. Graphical representation of gum lines with yellow triangles and red dots. Plaque index and marginal bleeding index bars are present.
![]()
Lower buccal periodontal chart section. Contains rows for PD, Rec, AL, Mob with numerical data. Graphical representation of gum lines with yellow triangles and red dots. Plaque index and marginal bleeding index bars are included.
![]()
Lower palatal periodontal chart section. Contains rows for PD, Rec, AL, Mob with numerical data. Graphical representation of gum lines with yellow triangles and red dots. Plaque index and marginal bleeding index bars are included.
**1.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)**
Page layout description: Left side shows the hexagonal polygon chart with axes for Envir., Syst./Gen., Tooth loss, BP, BOP%, PD≥5mm, BL/Age. Center label reads Polygon surface: 32.04293. Below that: Periodontal Risk: medium, Suggested Recall Interval: 6 Months. Right side contains form fields with patient data.
**Age: 64**
**Number of teeth and implants: 21 (1 - 32)**
**Number of sites per tooth / implant: 6** ✓
**Number of BOP-pos. sites: 72 of 126**
**Number of sites with PPD≥5mm: 7**
**Number of missing teeth: 0**
**% alveolar bone loss (estimated in % or 10% per 1mm): 25 %**
**Syst./Gen.:** No ✓
**Envir.:** Non-smoker (NS) ✓
(7) Periodontal Risk Assessment for patients in Supportive Periodontal Therapy, Lang & Tonetti (2003). (8) PRA online tool.
---
**1.2.8 Pulp sensibility tests**
Pericoronal and Apical EPT Data Table:
| EPT | 20 | 22 | 15 | 73 | 37 | 56 | 0 | 36 | 36 | 67 |
|-------|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|
| CO₂ | ++ | - | + | - | - | - | - | + | + | - |
Apical Pulse Wave:
| | 47 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 37 |
|-------|----|----|----|----|----|----|----|----|----|----|----|----|
| CO₂ | - | - | + | ++ | - | - | - | - | - | ++ | ++ | +++|
| EPT | 0 | 20 | 17 | 11 | 42 | 32 | 29 | 48 | 26 | 30 | 0 | |
|-------|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|
| CO₂ | - | - | - | - | - | - | - | - | - | -- | -- | |
Page number: **15**
###### 1.2.7.5 Periodontal Risk Assessment (PRA)
- **Periodontal Risk**: Medium
- **Suggested Recall Interval**: 6 Months
- **Data Summary**:
- Age: 64
- Teeth/Implants: 21
- BOP-positive sites: 72 of 126
- Sites with PPD ≥ 5mm: 7
- Estimated Alveolar Bone Loss: 25%
- Environmental: Non-smoker
##### 1.2.8 Pulp sensibility tests
- **CO₂ Testing**:
- Positive response (+/++): 20, 15, 36, 14, 13, 24, 25, 37.
- Negative response (-): 22, 73, 37 (in specific sites), 56, 0, 47, 12, 11, 21, 22, 23.
- **EPT Testing**: Varied readings across dentition (0 to 73).
![]()
Hexagonal radar chart (spider diagram) for Periodontal Risk Assessment. Axes include 'Envir.', 'Syst./Gen.', 'Tooth loss', 'PD≥5mm', 'BOP%', and 'BL/Age'. Polygon surface area is 32.04293. Labels indicate BOP% = 57 and BL/Age = 0.39.
![]()
Table titled '1.2.8 Pulp sensibility tests' presenting Pericoronal and Apical EPT Data. Contains columns for tooth numbers and rows for EPT values and CO₂ responses with symbols like ++, -, +, etc.
**1.2.9 Radiographs**
Rationale: each radiograph taken has rationale where stated – ALARA
Note: Subscript a = amalgam, c = composite, m = metallic, p = metal-ceramic
**1.2.9.1 Orthopantogram**
Date: 3/11/2017
**Findings (9)**
| Category | Findings |
|---------------------------|--------------------------------------------------------------------------|
| Periphery and corners | Ossified stylohyoid ligaments bilaterally |
| Cortices of mandible | Continuous and even |
| | Thin rami |
| | Condyles cannot be visualised |
| Cortices of maxilla | Nil abnormalities detected |
| Zygomatic bones | Nil abnormalities detected |
| Maxillary sinuses | Nil abnormalities detected |
| Nasal cavity and palate | Nil abnormalities detected |
| Bone pattern of maxilla | Normal density and trabeculation |
| Bone pattern of mandible | Normal density and trabeculation |
| | Rectangular-shaped radiolucency R body of mandible - artefact |
| Alveolar processes | Generalised mild horizontal bone loss in maxilla and mandible |
| | No furcation involvement any teeth |
| Teeth | Missing posterior teeth 17, 16, 26, 27, 36, 35, 46 |
| | Gross carious lesion 37 |
| | Heavily restored 15, 14, 47 |
| | Mesial tilt 37, 47 |
(9) Interpretation of panoramic radiographs, Perschbacher (2012).
##### 1.2.9 Radiographs
###### 1.2.9.1 Orthopantogram (3/11/2017)
- **Periphery**: Ossified stylohyoid ligaments bilaterally.
- **Mandible**: Continuous cortices; thin rami; condyles not visualised.
- **Bone Pattern**: Normal density; rectangular radiolucency in R body (artefact).
- **Alveolar processes**: Generalised mild horizontal bone loss; no furcation involvement.
- **Teeth**:
- Missing: 17, 16, 26, 27, 36, 35, 46.
- Gross carious lesion: 37.
- Heavily restored: 15, 14, 47.
- Mesial tilt: 37, 47.
![]()
Orthopantogram radiograph dated 3/11/2017 showing a panoramic view of the maxilla and mandible. Visible findings include missing posterior teeth (17, 16, 26, 27, 36, 35, 46), gross carious lesion on tooth 37, heavily restored teeth 15, 14, 47, and mesial tilt on teeth 37 and 47. The image displays ossified stylohyoid ligaments bilaterally in the periphery and thin rami of the mandible with condyles not visualized. A rectangular-shaped radiolucency is noted in the right body of the mandible as an artefact. Generalised mild horizontal bone loss is visible in both jaws. The 'L' marker indicates the left side.
![]()
Table titled 'Findings (9)' summarizing clinical observations from the orthopantogram. Columns are 'Category' and 'Findings'. Categories include: Periphery and corners (Ossified stylohyoid ligaments bilaterally); Cortices of mandible (Continuous and even, Thin rami, Condyles cannot be visualised); Cortices of maxilla, Zygomatic bones, Maxillary sinuses, Nasal cavity and palate (Nil abnormalities detected); Bone pattern of maxilla and mandible (Normal density and trabeculation, Rectangular-shaped radiolucency R body of mandible - artefact); Alveolar processes (Generalised mild horizontal bone loss in maxilla and mandible, No furcation involvement any teeth); Teeth (Missing posterior teeth 17, 16, 26, 27, 36, 35, 46; Gross carious lesion 37; Heavily restored 15, 14, 47; Mesial tilt 37, 47). Footer cites '(9) Interpretation of panoramic radiographs, Perschbacher (2012).'.
**1.2.9.2 Bitewings**
**Bitewing – Right**
- 7/2/2019
- Rationale: Interproximal caries detection
*Findings:*
- **Caries:** 13D, 47D
- **Restorations:** 15MODc (suspicious margins), 14MODc (mesial overhang), 45Oc, 47MOc (D secondary caries)
- **Pulp:** Nil abnormalities detected
- **Periodontium:** 14D PDL space widening; Generalised crestal bone loss; Mild horizontal bone loss
- **Other:** 46 missing; 47 mesial tilt
**1.2.9.3 Periapicals**
**Periapical – 47**
- 7/3/2019
- Rationale: Check for pathology
*Findings:*
- **Caries:** 47D (deep into dentine)
- **Restorations:** 47MOc
- **Pulp:** Nil abnormalities detected
- **Periodontium:** Intact PDL space; Nil furcation involvement; Possible PA radiolucency D root
- **Other:** 46 missing; 47 mesial tilt
**Periapical – 21-25**
- 27/3/2019
- Rationale: Check for pathology
*Findings:*
- **Caries:** 21D, 22M&D, 23M
- **Restorations:** 47MOc
- **Pulp:** Nil abnormalities detected
- **Periodontium:** 21 slight PDL space widening; Nil PA radiolucency detected
- **Other:** Incisal wear anterior teeth
###### 1.2.9.2 Bitewings (7/2/2019)
- **Caries**: 13D, 47D.
- **Restorations**: 15MODc (suspicious margins), 14MODc (mesial overhang), 45Oc, 47MOc (distal secondary caries).
- **Periodontium**: 14D PDL space widening; generalised crestal bone loss.
###### 1.2.9.3 Periapicals
- **Tooth 47 (7/3/2019)**:
- Caries: 47D (deep into dentine).
- Periodontium: Possible PA radiolucency distal root.
- **Teeth 21-25 (27/3/2019)**:
- Caries: 21D, 22M&D, 23M.
- Periodontium: 21 slight PDL space widening.
- Other: Incisal wear on anterior teeth.
![]()
Table titled '1.2.9.2 Bitewings' containing a radiograph of the right side labeled 'Bitewing – Right'. The table details findings for Caries (13D, 47D), Restorations (15MODc suspicious margins, etc.), Pulp (nil abnormalities), and Periodontium (generalised crestal bone loss). Date is listed as 7/2/2019 with rationale 'interproximal caries detection'.
![]()
Table titled '1.2.9.3 Periapicals' showing a radiograph labeled 'Periapical – 47'. Findings include Caries (47D deep into dentine), Restorations (47MOc), Pulp (nil abnormalities), and Periodontium (intact PDL space). Date is 7/3/2019 with rationale 'Check for pathology'.
![]()
Table titled 'Periapical – 21-25' displaying a radiograph of anterior teeth. Findings list Caries in teeth 21, 22, 23; Restorations on 47; Pulp nil abnormalities; and slight PDL space widening on tooth 21. Date is 27/3/2019 with rationale 'Check for pathology'.
1.2.10 Caries risk assessment
1.2.10.1 Dietary assessment
- Diet is high in sugars and fermentable carbohydrates
- Coffee with 2 teaspoons of sugar four to six times daily
- Fruit juice once daily
- Bread and pasta
- Cakes, sweet biscuits, muffins
- 3-4 scoops of icecream, thickshakes, chocolate for dessert
- Frequent snacking two to three times daily
1.2.10.2 Saliva test
| | Unstimulated saliva | | | Stimulated saliva | |
|---|---|---|---|---|---|
| | Flow rate | Consistency | pH | Quantity at 5 mins | Buffering capacity |
| >60 s – low | Sticky/frothy | 5.0-5.8 | <3.5 mL – very low | 0-5 – very low |
| 30-60 s – normal | Frothy/bubbly | 6.0-6.6 | 3.5-5.0 mL – low | 6-9 – low |
| <30 s – high | Watery/clear | 6.8-7.8 | >5.0 mL – normal | 10-12 – normal |
1.2.10.3 Caries Management By Risk Assessment (CAMBRA) (10)
| | Disease indicators |
|---|---|
| | Visible caries and radiographic penetration into dentine |
| | Radiographic approximal enamel lesions |
| | White spots on smooth surfaces |
| | Restorations in last 3 years |
| | Risk factors |
| | Visible heavy plaque on teeth |
| | Frequent snacking |
| | Protective factors |
| | Lives in fluoridated community |
| | Fluoridated toothpaste at least 2x daily |
| | Adequate saliva flow |
- Caries risk:
- High
- Suggested management:
- Prescription toothpaste with 5000 ppm fluoride twice daily
- Chlorhexidine gluconate 0.12% mouthrinse once daily for 1 week
- Xylitol candies or gum four times daily
- Fluoride varnish
- 3-month recall
(10) The evidence for Caries Management by Risk Assessment, Featherstone & Chaffee (2018).
18
##### 1.2.10 Caries risk assessment
###### 1.2.10.1 Dietary assessment
- **High sugar/carb intake**: Coffee with 2 tsp sugar (4-6x daily), fruit juice, bread, pasta, cakes, ice cream, chocolate.
- **Frequency**: Snacking 2-3 times daily.
###### 1.2.10.2 Saliva test
- **Unstimulated**: Low flow rate (>60s); sticky/frothy consistency; pH 5.0-5.8.
- **Stimulated**: Low quantity (<3.5 mL); low buffering capacity.
###### 1.2.10.3 CAMBRA
- **Disease indicators**: Visible caries into dentine; restorations in last 3 years.
- **Risk factors**: Visible heavy plaque; frequent snacking.
- **Protective factors**: Fluoridated community and toothpaste; adequate flow (borderline).
- **Caries Risk**: High.
- **Management**: 5000 ppm fluoride toothpaste, CHX mouthrinse, Xylitol gum, fluoride varnish, 3-month recall.
![]()
Table titled 'Saliva test' comparing unstimulated and stimulated saliva. Columns include Flow rate, Consistency, pH for Unstimulated saliva; Quantity at 5 mins, Buffering capacity for Stimulated saliva. Rows categorize levels as low (>60s), normal (30-60s), and high (<30s) with corresponding values.
![]()
Table titled 'Caries Management By Risk Assessment (CAMBRA)' listing Disease indicators, Risk factors, and Protective factors with detailed bullet points under each category.
1.3 Diagnoses and problem list
1.3.1 Diagnoses
| | | Diagnosis |
|:---|:---|:---|
| | Caries | Multiple active carious lesions |
| **Pathological** | Restorations | Multiple unsatisfactory restorations |
| | Endodontic disease (11, 12) | 37 chronic irreversible pulpitis with primary acute apical periodontitis due to caries and broken down restoration |
| | | 47 necrotic and possibly pulple tse and infected with primary acute apical periodontitis due to caries and broken down restoration |
| | | 22 chronic reversible pulpitis and severely calcified canal with clinically normal periapical tissues due to caries and broken down restoration |
| | Periodontal disease (13) | Generalised Stage III Grade B unstable periodontitis* |
| | Non-carious tooth surface loss | Attrition of anterior teeth with possible contribution from erosion |
| **Morphological** | Malocclusion | Angle skeletal class I<br>Class III malocclusion – habitual forward posture of mandible<br>Bilateral posterior crossbite<br>Rotated 24, 26 |
| | Overbite/Overjet | 2 mm / 3 mm |
| | Missing teeth | 17-16, 26-27, 36-35, 46 |
| | Posterior impairment | Loss of posterior support<br>Multiple missing posterior teeth in maxilla and mandible<br>Mesially tilted 37, 47 |
| | Occlusal stability | Unstable |
| | Guidance system | Group function |
| **Host-related factors** | Psychosocial | Good personal presentation<br>Functional concern<br>Good dental attitude and motivated to attend appointments |
| | Habits | Poor oral hygiene<br>High sugar and fermentable carbohydrate diet with frequent snacking |
| | Socioeconomic | Financial resources available for dental care |
| | Medical | Psychological issues<br>Limited manual dexterity<br>Predominantly mouth breather |
| | Functional | Strong gag reflex |
(11) Classification, diagnosis and clinical manifestations of apical periodontitis, Abbott (2004). (12) A clinical classification of the status of the pulp and the root canal system, Abbott & Yu (2007). (13) Periodontitis: Consensus report if workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions, Papapanou et. al. (2018).
*Stage III – ≥ 5mm CAL, 25% RBL, maximum probing depth < 5mm, no furcation involvement, occlusal trauma, masticatory dysfunction, bite collapse or severe ridge defects. Grade B – BL/Age 0.39, heavy film deposits with low destruction, non-smoking, normoglycaemic. Generalised – affects >30% of teeth. Unstable – BOP > 10% and pockets 4-5mm or more.
1.3.2 Problem list
• Pulpal pathology (37, 47, 22)
• Caries (13D, 12M, 21D, 22M&D, 23M&D, 24M, 25M, 37DB, 34M, 42D, 43M, 47D)
• Unsatisfactory restorations (15MODBP, 14MODBP, 12M, 11MIDLa, 22M, 37O, 45DO, 47MOLI)
• Stage III Grade B unstable periodontitis
• Multiple missing posterior teeth – lack of posterior occlusal support and occlusal instability
• High caries risk – poor oral hygiene, limited manual dexterity, mouth breathing, psychological issues, poor dietary habits
19
#### 1.3 Diagnoses and problem list
##### 1.3.1 Diagnoses
- **Pathological**:
- Caries: Multiple active lesions.
- Endodontic: 37 chronic irreversible pulpitis; 47 necrotic; 22 chronic reversible pulpitis (calcified).
- Periodontal: Generalised Stage III Grade B unstable periodontitis.
- **Morphological**:
- Attrition of anterior teeth.
- Malocclusion: Class III (habitual forward posture); bilateral posterior crossbite.
- Missing teeth: 17-16, 26-27, 36-35, 46.
- Occlusal: Unstable; loss of posterior support.
- **Host-related**:
- Medical: PTSD, limited manual dexterity, mouth breather.
- Habits: Poor OH, high sugar diet.
##### 1.3.2 Problem list
- Pulpal pathology (37, 47, 22).
- Caries (multiple sites including 13D, 12M, 21D, 22, 23, 37, 47).
- Unsatisfactory restorations (15, 14, 11, 45).
- Unstable periodontitis.
- Lack of posterior occlusal support.
![]()
A structured table titled 'Diagnoses' with columns for categories (Pathological, Morphological, Host-related factors) and Diagnosis details. It lists specific dental conditions such as caries, endodontic disease, periodontal disease, malocclusion, and host-related factors like habits and medical issues.
![]()
A footnote table providing detailed definitions for terms used in the diagnoses section, including Stage III, Grade B, Generalised, and Unstable classifications, along with their respective criteria.
![]()
A problem list presented as a bulleted table summarizing key dental issues identified in the study, including pulpal pathology, caries, unsatisfactory restorations, periodontitis, missing teeth, and high caries risk factors.
### 1.4 Prognosis (14)
#### 1.4.1 Individual Teeth
- Row 1: Anatomic irregularities, X, X, X, X, X, X, ✓, X, X, X
- Row 2: Occlusal plane & tooth position, G, G, G, G, G, G, G, G, G, G
- Row 3: Endodontic condition, G, G, G, G, G, G, G, G, G, G
- Row 4: Restorability, F, F, F, F, F, F, Q, Q, Q, Q
- Row 5: Periodontal condition, F, G, G, G, G, G, G, G, G, G
| Periodontal condition | 15 | 14 | 13 | 12 | 11 | 11 | 21 | 22 | 23 | 24 | 25 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Restorability | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 37 |
| Periodontal condition | 47 |
### Evaluation of pathology and scale of severity
#### Periodontal condition
| Class A – Good | Class B – Fair | Class C – Questionable | Class D – Poor |
|---|---|---|---|
| 80%-100% bone support. Easily maintained. | 50%-80% bone support. Can be well maintained. | 30%-50% remaining bone support. Difficult to be well maintained. | <30% one support. Cannot be cleaned or maintained well and has evidence of active periodontal disease. |
#### Restorability
| Class A – Good | Class B – Fair | Class C – Questionable | Class D – Poor |
|---|---|---|---|
| 80%-100% remaining sound coronal tooth structure. Easily restored. | 50%-80% remaining sound coronal tooth structure. Restoration results in no infringement of biologic width, has adequate ferrule, good crown-root ratio. | 30%-50% remaining sound coronal tooth structure. Achieving adequate ferrule would compromise crown-root ratio to some extent or affect adjacent structures. | <30% sound tooth structure. Extent of lost tooth structure does not enable good ferrule to be achieved without totally compromising support of adjacent tooth structures or crown-root ratio. |
#### Endodontic condition
| Class A – Good | Class B – Fair | Class C – Questionable | Class D – Poor |
|---|---|---|---|
| Can receive straightforward primary endodontic treatment, or already has good endodontic therapy. | Failing endodontic treatment can receive predictable re-treatment, or requires a difficult primary endodontic treatment. | Failing endodontic treatment that is difficult to predictably re-treat. | Failing endodontic treatment that cannot be predictably re-treated. |
#### Occlusal plane & tooth position
| Class A – Good | Class B – Fair | Class C – Questionable | Class D – Poor |
|---|---|---|---|
| Tooth in correct occlusal plane, position, slightly deviated from ideal. | Tooth out of correct occlusal plane, can be adjusted to function within correct occlusal plane. | Tooth out of occlusal plane and requires multiple procedures to function within occlusal plane. | Tooth severely out of occlusal plane, severely tilted that after extensive treatment will exhibit reduced crown-root ratio, prevent from serving as long-term unit in arch. Position impacts health of adjacent structures. |
### Factors that result in drop of determined class
**iatrogenic compromising factors**
Perforations, extensive post preparations, minimal tooth structure thickness left after preparation, dental materials that cannot be removed, etc.
22, 37 – minimal tooth structure thickness left after preparation
#### 1.4 Prognosis
##### 1.4.1 Individual Teeth Evaluation
- **Good**: Most anterior teeth for endodontic and periodontal condition.
- **Fair/Questionable**: 15, 14, 22, 47 (Restorability and periodontal support).
- **Hopeless**: 37 (Gross carious destruction).
##### Severity Classification Criteria
- **Periodontal**: Based on bone support (Good: 80-100%; Poor: <30%).
- **Restorability**: Based on sound coronal structure (Good: 80-100%; Poor: <30%).
- **Endodontic**: Based on predictability of treatment/retreatment.
- **Occlusal**: Based on tooth position and plane alignment.
##### Iatrogenic Compromising Factors
- Minimal tooth structure thickness remaining after preparation (Teeth 22, 37).
![]()
A complex dental prognosis chart displaying individual tooth assessments. The top section is a grid with rows for 'iatrogenic compromising factors', 'Anatomic irregularities', 'Occlusal plane & tooth position', 'Endodontic condition', 'Restorability', and 'Periodontal condition'. Columns correspond to specific teeth (e.g., 15, 14, 13, etc.). Cells are marked with symbols: green dots for positive conditions, yellow dots for questionable/restorable issues, black 'x' marks for negative findings, and a checkmark for good iatrogenic factors. A colored bar below the grid identifies each tooth number, using colors Green (Good), Yellow (Questionable), Light Green (Fair), Orange (Poor), and Red (Hopeless) to visually categorize the overall status of each tooth.
![]()
A detailed classification table titled 'Evaluation of pathology and scale of severity'. It defines four classes for clinical assessment: Class A (Good), Class B (Fair), Class C (Questionable), and Class D (Poor). The table contains rows for 'Periodontal condition', 'Restorability', 'Endodontic condition', and 'Occlusal plane & tooth position'. Each cell provides specific text criteria, such as bone support percentages or descriptions of remaining tooth structure, to define the severity level.
![]()
A small summary table at the bottom titled 'Factors that result in drop of determined class'. It lists 'iatrogenic compromising factors' such as perforations and extensive post preparations. The table specifically notes that teeth 22 and 37 have minimal tooth structure thickness left after preparation.
**1.4.2 Patient-level risk factors**
| Biologic risk factors | |
|---|---|
| Medical conditions that impair immune function and healing | Nil |
| Impaired salivary flow/function | Adequate salivary flow |
| Medical condition or disability limiting oral hygiene | Poor manual dexterity |
| Other missing teeth | History of missing teeth due to caries |
| Behavioural risk factors | |
|---|---|
| Compromised or poor oral hygiene | Poor oral hygiene |
| Cariogenic diet | High carigenic diet |
| Low exposure to fluoride | Adequate exposure to fluoride |
| Parafunctional habits | No |
| Ability and willingness to adhere to long-term maintenance protocol | Yes |
| Smoking | Non-smoker |
| Financial and personal risk factors | |
|---|---|
| Motivation for treatment | Highly motivated |
| Available resources for dental care | Yes |
| Willingness to commit finances, time, and effort | Yes |
| Attitude toward losing teeth | Strong willingness to preserve existing teeth |
| Understanding of one’s condition and needed treatment | Yes |
| Aesthetic expectations | Reasonable |
| Low dental IQ | Adequate dental IQ with education |
**Key:**
- **Favourable**
- **Questionable**
- **Unfavourable**
(14) Evaluation of prognosis of individual teeth and patient-level risk factors adapted from Samet and Jotzkowitz (2009).
**1.4.3 Overall dentition**
- All teeth have sound periodontal health with exception of 37, 47 which have < 80% remaining bone support.
- 22, 47 can be predictably root treated, 37 cannot be predictably root treated due to gross carious destruction of tooth structure.
- History of extensive restoration of posterior teeth has detrimental effect on restorability of several teeth especially after restoration removal and tooth preparation.
- Prognoses: 14, 15, 47 guarded, 22 poor, 37 hopeless.
- Patient’s high sugar and high carigenic diet in combination with poor oral hygiene is unfavourable to prognosis of dentition.
- However, patient has a good attitude, is highly motivated and compliant, open to education and appears willing to commit finances, effort and time to dental treatment.
- If the patient receives no treatment for his current condition:
- Progression of active caries, pulpal disease, periodontal disease
- Further loss of teeth and edentulism
- The long-term impact of tooth loss includes:
- Loss of efficient function → speech, mastication
- Poor aesthetics → decreased self-esteem, confidence
- Poor physical and psychological health and reduction in overall quality of life
- **Poor physical and psychological health and reduction in overall quality of life**
##### 1.4.2 Patient-level risk factors
- **Biologic**: Poor manual dexterity; history of tooth loss due to caries.
- **Behavioural**: Poor oral hygiene; high cariogenic diet.
- **Personal**: Highly motivated; willing to commit finances and time; strong desire to preserve teeth.
##### 1.4.3 Overall dentition prognosis
- **Guarded**: 14, 15, 47.
- **Poor**: 22.
- **Hopeless**: 37.
- **Summary**: High sugar diet and poor OH are unfavourable. However, high patient motivation and compliance are positive indicators. Without treatment, progression to edentulism is likely, impacting quality of life and function.
![]()
Table titled '1.4.2 Patient-level risk factors' summarizing risk assessment across three categories: Biologic, Behavioural, and Financial/personal. Each row lists a specific factor (e.g., 'Medical conditions that impair immune function', 'Cariogenic diet', 'Motivation for treatment') with corresponding patient status or notes in the right column (e.g., 'Nil', 'High carigenic diet', 'Highly motivated'). A legend below indicates color coding for 'Favourable' (green), 'Questionable' (yellow), and 'Unfavourable' (red). The table is structured to compare clinical findings against established risk profiles.
The chart below details treatment options for various dental problems.
| Problem | Treatment Option 1 | Benefits 1 | Risks 1 | Decision & Rationale 1 |
| :--- | :--- | :--- | :--- | :--- |
| **Pulpal pathology: 37** | **No treatment** | • No commitment required | • Does not address presenting complaint | Option 2: |
| | **Extraction** | • Addresses presenting complaint<br>• Tooth has hopeless prognosis<br>• Minimal time and financial commitment | • Extraction complications – grossly carious and risk of crown fracture<br>• Post-extraction complications | • Risk of acute pain and infection<br>• Tooth has hopeless prognosis |
**Pulpal pathology: 47** (Patient: "Patient wishes to save tooth")
| Treatment Option 1 | Benefits 1 | Risks 1 | Decision & Rationale 1 |
| :--- | :--- | :--- | :--- |
| **Endodontic treatment** | • Addresses presenting complaint<br>• High strategic value<br>• Root canal treatment to acceptable standard possible<br>• Requires more time and financial commitment | • Does not address presenting complaint<br>• Difficult to use rubber dam due to patient's mouth breathing and anxiety<br>• Difficult access due to location and tilt<br>• Difficult restoration due to subgingival margins<br>• Questionable longevity | Option 2: |
| **Extraction** | • Addresses presenting complaint<br>• Minimal time and financial commitment | • Extraction complications<br>• Post-extraction complications<br>• Loss of tooth with high strategic value | • Patient understands risks of choosing option but willing to attempt treatment to save tooth |
**Pulpal pathology: 22** (Patient: "Patient wishes to save tooth")
| Treatment Option 1 | Benefits 1 | Risks 1 | Decision & Rationale 1 |
| :--- | :--- | :--- | :--- |
| **Endodontic treatment** | • Addresses presenting complaint<br>• Root canal treatment to acceptable standard possible<br>• Requires more time and financial commitment | • Tooth has poor prognosis<br>• Post and core required to support coronal restoration<br>• Little remaining tooth structure after preparation<br>• Possible inadequate ferrule and unrestorable<br>• Questionable longevity | Option 2: |
| **Extraction** | • Addresses presenting complaint<br>• Tooth has poor prognosis<br>• Minimal time and financial commitment | • Extraction complications<br>• Post-extraction complications<br>• Loss of anterior tooth in aesthetic region | • Patient understands risks of choosing option but willing to attempt treatment to save tooth |
**Caries: 13D, 12M, 21D, 23M&D, 24M, 25M, 34M, 42D, 43M** (Patient: "Patient wishes to keep as many teeth as possible")
| Treatment Option 1 | Benefits 1 | Risks 1 | Decision & Rationale 1 |
| :--- | :--- | :--- | :--- |
| **No treatment** | • No commitment required | • Plaque trapping, gingival inflammation<br>• Caries, pulpal involvement, infection<br>• Breakdown of tooth structure<br>• Extraction | Option 2: |
| | | | • Prevent further breakdown of tooth structure due to caries |
#### 1.5 Treatment Options and Rationale
- **Tooth 37**: Extraction chosen due to hopeless prognosis and risk of acute pain.
- **Tooth 47**: Endodontic treatment chosen. Risks include difficult access/rubber dam tolerance, but tooth has high strategic value and patient wishes to save it.
- **Tooth 22**: Endodontic treatment chosen despite poor prognosis. Risks include inadequate ferrule and questionable longevity; patient wishes to save anterior tooth.
- **Caries (Multiple)**: Removal of caries and restoration chosen to prevent further breakdown and pulpal involvement.
![]()
A comprehensive clinical decision-making table titled '1.5 Treatment options'. The table is structured with columns for 'Problem', 'Treatment Option', 'Benefits', 'Risks', and 'Decision & Rationale'. It details specific treatment pathways for four distinct dental cases: Pulpal pathology in tooth 37 (hopeless prognosis), Pulpal pathology in tooth 47 (patient wishes to save), Pulpal pathology in tooth 22 (poor prognosis), and multiple teeth affected by caries (patient wishes to keep as many teeth as possible). Each case compares options like 'No treatment', 'Extraction', or 'Endodontic treatment', listing associated benefits, risks, and the final rationale for choosing a specific option.
```html
<table border="1">
<tr>
<td rowspan="2">2</td>
<td>
<ul>
<li>Remove caries and restorations</li>
<li>Restore tooth</li>
</ul>
</td>
<td>
<ul>
<li>Minimal commitment required</li>
<li>Tooth preservation</li>
</ul>
</td>
<td>Pulpal irritation, post-operative sensitivity</td>
<td></td>
</tr>
<tr>
<td rowspan="2">Unsatisfactory restoration:
<br>15MODBP
<br>(marginal deficiencies)
<br>14MODBP
<br>(marginal deficiencies)</td>
<td>1 No treatment</td>
<td>No commitment required</td>
<td>
<ul>
<li>Tooth with old and large restoration being used as potential abutment tooth for denture</li>
<li>Risk marginal leakage</li>
<li>Plaque trapping, gingival inflammation</li>
<li>Caries, pulpal involvement, infection</li>
<li>Breakdown of tooth structure</li>
<li>Loss of denture abutment features if future restoration required and reduced denture stability and retention</li>
</ul>
</td>
<td>Option 2:
<br>• Maximise longevity and integrity of restored tooth for denture
</td>
</tr>
<tr>
<td></td>
<td>2 Remove restoration
<br>Assess restorability
<br>Restore tooth</td>
<td>Potential abutment tooth for denture – maximise longevity for denture retention</td>
<td>
<ul>
<li>Asymptomatic</li>
<li>Quality and quantity of underlying tooth structure unknown, inadequate remaining coronal tooth structure may involve extensive restorative work</li>
</ul>
</td>
<td></td>
</tr>
<tr>
<td rowspan="2">Stage III Grade B periodontitis</td>
<td>1 No treatment</td>
<td>No commitment required</td>
<td>
<ul>
<li>Does not address presenting complaint</li>
<li>Plaque and calculus accumulation</li>
<li>Deterioration of periodontal condition</li>
<li>Caries</li>
<li>Tooth loss</li>
<li>Systemic health effects</li>
</ul>
</td>
<td>Option 2:
<br>• Favour periodontal and systemic health
<br>• Reduce periodontal disease progression
<br>• Reduce risk of caries, potential for breakdown of tooth structure
<br>• Reduce risk of tooth loss
<br>• Create favourable environment for commencement and maintenance of indirect prostheses
</td>
</tr>
<tr>
<td>2 Non-surgical periodontal therapy
<br>Oral hygiene instruction</td>
<td>
<ul>
<li>Addresses presenting complaint</li>
<li>Remove plaque and calculus to promote periodontal and systemic health</li>
<li>Reduce progression of periodontal disease</li>
<li>Reduce risk of caries</li>
<li>Reduce risk of further tooth loss</li>
</ul>
</td>
<td>
<ul>
<li>Post-operative pain, bleeding, swelling, bruising, infection</li>
<li>Increased tooth sensitivity</li>
<li>Gingival recession</li>
<li>Root surface exposure dentures, likelihood of similar outcome</li>
</ul>
</td>
<td></td>
</tr>
<tr>
<td rowspan="2">Missing posterior teeth: 17-16, 26-27</td>
<td>1 No treatment – shortened dental arch</td>
<td>No commitment required</td>
<td>
<ul>
<li>Does not address presenting complaint</li>
<li>Ongoing lack of posterior occlusal support and stability</li>
</ul>
</td>
<td>Option 2:
<br>• Patient wishes to undergo occlusal rehabilitation
</td>
</tr>
<tr>
<td>2 Partial denture</td>
<td>
<ul>
<li>Addresses presenting complaint</li>
<li>Moderate time and financial commitment</li>
</ul>
</td>
<td>Patient has never worn a denture – potential discomfort, have difficulty inability to adapt to denture</td>
<td></td>
</tr>
</table>
```
#### Restorative and Periodontal Options
- **Unsatisfactory Restorations (15, 14)**: Removal and reassessment chosen to maximise longevity as potential denture abutments.
- **Periodontitis**: Non-surgical periodontal therapy and OHI chosen to reduce disease progression and create a favourable environment for prostheses.
- **Missing Posterior Teeth (Maxilla)**: Partial denture chosen to address presenting complaint and provide occlusal stability.
![]()
A structured table comparing treatment options for various dental conditions. The table is divided into sections based on condition: 'Unsatisfactory restoration', 'Stage III Grade B periodontitis', and 'Missing posterior teeth'. Each section has two rows (labeled '1' and '2') representing different treatment choices with corresponding commitments, clinical considerations, and optional alternatives.
| Missing posterior teeth: 37-36, 46 | | | |
| --- | --- | --- | --- |
| 1 | No treatment – shortened dental arch | Provide posterior occlusal support and stability
* Improve function | Long-term success relies on patient maintaining good oral hygiene |
| | | No commitment required | Does not address presenting complaint
* Ongoing lack of posterior occlusal support and stability | Option 2: Patient wishes to undergo occlusal rehabilitation |
| 2 | Partial denture | Addresses presenting complaint
* Moderate time and financial commitment | Patient has never worn a denture – potential discomfort, have difficulty inability to adapt to denture |
| | | | |
| | | 24 |
#### Missing Posterior Teeth (Mandible)
- **Option**: Partial denture.
- **Rationale**: Patient wishes to undergo occlusal rehabilitation to improve function and provide posterior support.
- **Risks**: Potential discomfort or difficulty adapting as a first-time denture wearer.
![]()
A clinical decision table comparing treatment options for a patient with missing posterior teeth (37-36, 46). The table is structured into columns detailing the condition, option number, specific treatment plan, benefits/risks, and a final summary. Row 1 covers 'No treatment – shortened dental arch', highlighting benefits like improved function but noting it does not address the presenting complaint. Row 2 covers 'Partial denture', noting it addresses the complaint but carries risks of discomfort due to inexperience. A final column summarizes Option 2 as the choice if the patient wishes to undergo occlusal rehabilitation.
## 1.6 Management plan
<table>
<tr>
<td>Systemic phase</td>
<td>Dietary counselling</td>
</tr>
<tr>
<td>Emergency phase</td>
<td>Not applicable</td>
</tr>
<tr>
<td rowspan="8">Control phase<br><em>Eliminate pain, infection, inflammation</em></td>
<td>Patient education and consent to treatment</td>
</tr>
<tr>
<td>Hygienic phase of periodontal therapy:<br>Supragingival scale and subgingival debridement<br>Fluoride application<br>Oral hygiene instruction</td>
</tr>
<tr>
<td>Caries control and replacement of unsatisfactory restorations:<br>13D, 12M, 21D, 23M&amp;D, 24M, 25M, 34M, 42D, 43M</td>
</tr>
<tr>
<td>Recontouring of existing restorations:<br>11MIDLa, 45DO</td>
</tr>
<tr>
<td>Extraction of teeth with hopeless prognosis: 37</td>
</tr>
<tr>
<td>Endodontic treatment:</td>
</tr>
<tr>
<td>22 tooth investigation</td>
</tr>
<tr>
<td>47 tooth investigation</td>
</tr>
<tr>
<td rowspan="5">Holding phase<br><em>Preserve residual dentition</em></td>
<td>Periodontal review 6 weeks after periodontal treatment</td>
</tr>
<tr>
<td>Assess response to periodontal therapy and oral hygiene compliance</td>
</tr>
<tr>
<td>Endodontic review:</td>
</tr>
<tr>
<td>22 review and root filling if asymptomatic</td>
</tr>
<tr>
<td>47 review and root filling if asymptomatic</td>
</tr>
<tr>
<td rowspan="6">Reconstructive phase<br><em>Replace lost tissue and stabilise occlusion</em></td>
<td>22 cast post-core and crown</td>
</tr>
<tr>
<td>47 survey crown</td>
</tr>
<tr>
<td>14 onlay</td>
</tr>
<tr>
<td>15 onlay</td>
</tr>
<tr>
<td>Co-Cr maxillary partial denture</td>
</tr>
<tr>
<td>Co-Cr mandibular partial denture</td>
</tr>
<tr>
<td rowspan="4">Maintenance phase<br><em>Prevention of further breakdown</em></td>
<td>Partial denture post-insert review</td>
</tr>
<tr>
<td>Recall exam</td>
</tr>
<tr>
<td>3 monthly periodontal review</td>
</tr>
<tr>
<td>Reinforce oral and denture hygiene</td>
</tr>
</table>
25
#### 1.6 Management plan
- **Systemic phase**: Dietary counselling.
- **Control phase**:
- Periodontal debridement and OHI.
- Caries control (13, 12, 21, 23, 24, 25, 34, 42, 43).
- Extraction of 37.
- Endodontic investigation of 22 and 47.
- **Holding phase**: Periodontal review (6 weeks); endodontic obturation if asymptomatic.
- **Reconstructive phase**:
- 22 cast post-core and crown.
- 47 survey crown.
- 14, 15 onlays.
- Maxillary and mandibular Co-Cr partial dentures.
- **Maintenance phase**: 3-monthly periodontal review; reinforce hygiene.
![]()
A structured table outlining a dental management plan divided into five phases: Systemic phase (Dietary counselling), Emergency phase (Not applicable), Control phase (Eliminate pain, infection, inflammation - includes patient education, periodontal therapy, caries control, restorations, extractions, and endodontic investigations), Holding phase (Preserve residual dentition - includes reviews and root fillings), Reconstructive phase (Replace lost tissue and stabilise occlusion - includes crowns, onlays, and partial dentures), and Maintenance phase (Prevention of further breakdown - includes post-insert review and hygiene reinforcement). The table organizes clinical interventions by treatment stage.
**1.7 Treatment delivery**
**1.7.1 Treatment delivery**
Date: January 2019 – October 2020
(Left Column: 2019 and right column 2020)
| Date | Treatment |
|--------|-------------------------------------------------------------------------------------------------------------------------------------------|
| January | Comprehensive exam <br> Patient education and consent to treatment <br> Dietary counselling |
| February | Initial periodontal charting |
| March | Hygienic phase of periodontal therapy <br> Fluoride application <br> Oral hygiene instruction |
| April | 47 tooth investigation |
| May | Caries control and replacement of unsatisfactory restorations commenced <br> 47 working length and canal preparation <br> Review periodontal charting |
| June | - |
| July | Caries control and replacement of unsatisfactory restorations continued <br> 37 extraction |
| August | Caries control and replacement of unsatisfactory restorations completed <br> 47 obturation |
| September | 22 tooth investigation, working length, canal preparation |
| October | 47 direct post and core build-up <br> 15 onlay preparation |
| Date | Treatment |
|--------|-------------------------------------------------------------------------------------------------------------------------------------------|
| January | Recall exam <br> Supragingival scale and clean <br> Reinforce oral hygiene instruction <br> 22 obturation |
| February | 22 post space preparation and post space impression <br> 22 cast post-core cementation <br> 22 crown preparation |
| March | 14 onlay preparation <br> 47 survey crown preparation |
| April | - |
| May | - |
| June | - |
| July | Recall exam <br> Supragingival scale and clean <br> Reinforce oral hygiene instruction |
| August | 14, 15, 22, 47 onlay and crown final impressions <br> 14, 15 onlay cementation <br> 22 crown cementation <br> 47 survey crown cementation <br> Mouth preparation for maxillary and mandibular partial dentures <br> CoCr maxillary and mandibular partial denture final impressions <br> MMR |
| September | CoCr maxillary and mandibular framework try-in <br> MMR |
| October | CoCr maxillary and mandibular partial denture post-insert review <br> Reinforce oral hygiene instruction |
Page number: 26
#### 1.7 Treatment delivery
- **2019 Timeline**:
- Jan-Mar: Exam, OHI, Periodontal therapy.
- Apr-Aug: 47 endodontic treatment; 37 extraction; Caries control.
- Sep-Oct: 22 endodontic investigation; 15 onlay preparation.
- **2020 Timeline**:
- Jan-Feb: 22 obturation and cast post-core.
- Mar-Jul: 47 survey crown and 14 onlay prep; Recall clean.
- Aug-Oct: Final impressions and cementation of all indirect restorations; Co-Cr partial denture fabrication and insertion.
![]()
Table detailing 'Treatment delivery' for the year 2019. Columns are 'Date' and 'Treatment'. Rows list specific dental procedures chronologically from January to October, including comprehensive exams, periodontal charting, caries control, tooth investigations (specifically teeth 47, 37, 22), extractions, obturations, and post/core build-ups.
![]()
Table detailing 'Treatment delivery' for the year 2020. Columns are 'Date' and 'Treatment'. Rows list specific dental procedures chronologically from January to October, including recall exams, scaling/cleaning, obturation of tooth 22, crown preparations for teeth 14, 15, 22, 47, cementation of onlays and crowns, mouth preparation for partial dentures, framework try-in, and final reviews.
Diagnostics:
Patient education and consent to treatment:
- Major problem is caries and poor oral hygiene.
- Educated patient on aetiology of caries i.e. tooth, bacteria, diet, time.
- Dietary counselling and encouraged patient to keep a food diary.
- Discussed patient’s goals, treatment options and proposed treatment plan.
- Discussed expectations in terms of financial and time commitment required, stages of treatment and milestones, patient’s and clinician’s responsibilities.
- Patient accepted treatment plan.
Initial periodontal chart (February 2019):
- Plaque score 100%.
- Bleeding on probing 68/126 sites (57%).
- Periodontal probing depth ≥ 4 mm 30/126 sites (24%).
- Grade I mobility 31, 32, 37.
- Extreme gingival pain.
- Oral hygiene extremely poor; instruction to use interproximal brushes and electric toothbrush.
- First round periodontal debridement completed; gingival sensitivity and bleeding during treatment.
#### Treatment Details: Diagnostics and Initial Phase
- **Education**: Focused on caries aetiology and dietary habits (food diary). Patient accepted the staged treatment plan.
- **Initial Periodontal Therapy (Feb 2019)**:
- Plaque score: 100%.
- BOP: 57%.
- PPD ≥ 4mm: 24%.
- Status: Extreme gingival pain and poor hygiene. First round debridement completed.
![]()
Clinical figure showing three views of a dental study model (upper and lower jaws) with red wax highlighting severe caries lesions on the posterior teeth. Images include lateral view from left, frontal occlusal view, and lateral view from right.
![]()
Initial periodontal chart (February 2019) displaying four quadrants of periodontal measurements including Probing Depth (PD), Recession (Rec), Attachment Level (AL), Mobility (Mob), Plaque Index, Bleeding on Probing Index, and Marginal Bleeding Index for each tooth site. The chart shows extensive bleeding and moderate to deep probing depths consistent with the text summary.
Review periodontal chart (May 2019):
• Plaque score 43% (reduced to 21% by September 2019) ↓
• Bleeding on probing 24/126 sites (20%)
• Periodontal probing depth ≥4 mm 0/36 sites (0%) ↓
• No mobility 31, 32, 37 ↓
• Periodontal diagnosis revised from Generalised Stage III Grade B unstable periodontitis to Generalised Stage III Grade B periodontitis currently in remission.
• Oral hygiene improved; patient reported nil gingival pain or bleeding on brushing and nil halitosis
• Caries control and replacement of unsatisfactory restorations:
- Carious teeth and unsatisfactory restorations treated over multiple appointments.
- Patient started using electric toothbrush after every meal, Modified Bass technique, Neutraflur 5000 toothpaste, Neutraflur 220 mouthwash and interdental brushes.
- Food diary recorded; halved coffee consumption and substituted sugar with Stevia, eliminated fruit juices, reduced fermentable carbohydrate intake, increased fruit, vegetable, eggs, cheese and dairy intake, reduced snacking from four times to once daily. However, was consuming high sugar diet shakes.
• 37 extraction:
- Symptomatic, unrestorable due to extensive subgingival caries.
- Uncomplicated extraction in emergency clinic.
#### Treatment Details: Control Phase Progress
- **Periodontal Review (May 2019)**:
- Plaque score reduced to 43% (later 21%).
- BOP reduced to 20%.
- PPD ≥ 4mm: 0%.
- Status: Remission; nil pain or halitosis.
- **Caries Control**: Switched to electric toothbrush and Neutraflur 5000. Dietary changes included substituting sugar with Stevia and reducing snacking.
- **37 Extraction**: Completed as tooth was symptomatic and unrestorable.
![]()
Periodontal chart (Buccal) for May 2019. Displays periodontal measurements including Mobility (Mob), Attachment Level (AL), Recession (Rec), and Probing Depth (PD). Includes Plaque Index, Bleeding On Probing Index, and a visual representation of tooth positions with colored markers indicating plaque (yellow), bleeding (red), and recession levels.
![]()
Periodontal chart (Palatal) for May 2019. Similar structure to the Buccal chart, displaying Mob, AL, Rec, PD, Plaque Index, and Bleeding On Probing Index data points across different teeth locations.
![]()
Lower section of the Buccal periodontal chart. Shows additional rows for PD, Rec, AL, and Mob values, along with a graphical representation of tooth alignment and periodontal status using color-coded indicators.
![]()
Lower section of the Palatal periodontal chart. Mirrors the structure of the lower Buccal chart, providing detailed periodontal measurements and graphical representations for the palatal side of the dentition.
![]()
Clinical photograph showing an extracted tooth on a white background. The tooth appears to be a molar or premolar with visible root structures and some residual tissue attached. This image corresponds to the '37 extraction' mentioned in the text as symptomatic and unrestorable due to extensive subgingival caries.
- 47 endodontic treatment (April 2019 – September 2019):
- Periapical radiographs from left to right: pre-operative (7/3/2019), tooth investigation (13/5/2019), working length (16/5/2019), master GP (30/8/2019), apical third (30/8/2019), post-operative (5/9/2019).
- 47 definitive restoration:
- Stainless steel direct post and amalgam Nayyar core build-up.
*Direct post placed into distal canal as posts should be placed in the largest and straightest canal to avoid weakening the root too much during post space preparation and root perforation in curved canals. (15) Amalgam Nayyar core technique is a viable method for restoring endodontically treated posterior teeth. (16) For technique to be successful (i) size of remaining pulp chamber should be of sufficient width and depth to provide adequate bulk of amalgam and for retention (ii) adequate dentin thickness in area of pulp chamber is required for rigidity and strength. May be completed at the end of obturation appointment. (16) Amalgam as core material used successfully for many years, high strength, low solubility, coefficient of thermal expansion similar to tooth substance, however, requires prolonged setting time and difficult to prepare immediately after placement, not aesthetic, concerns of toxicity. (15)*
29
#### Treatment Details: Tooth 47 Endodontics and Core
- **Endodontic Treatment**: Completed April–September 2019.
- **Definitive Restoration**: Stainless steel direct post (distal canal) and amalgam Nayyar core build-up.
- **Rationale**: Amalgam Nayyar core is viable for posterior teeth with sufficient pulp chamber depth; post placed in the straightest canal to avoid perforation.
![]()
Grid of six periapical radiographs showing endodontic treatment progression for tooth 47. Labeled panels (top row left to right): pre-operative (7/3/2019), tooth investigation (13/5/2019), working length (16/5/2019). Bottom row: master GP (30/8/2019), apical third (30/8/2019), post-operative (5/9/2019). Radiographs show root canal anatomy and instrument placement.
![]()
Clinical intraoral photograph of definitive restoration on tooth 47. Shows stainless steel direct post in distal canal with amalgam Nayyar core build-up over pulp chamber area. Text describes technique requirements including sufficient bulk and dentin thickness for retention and rigidity.
- Survey crown preparation.
**Tooth prepared for zirconia survey crown. Zirconia was chosen for 47 due to its superior mechanical properties. As a posterior abutment, aesthetics is not an important factor as strength. There is clinical evidence that zirconia is a good choice for posterior single unit restorations. (17)** Provisionally restored with Luxatemp crown cemented with TempoCem.
- Final impressions taken using PVS and poured in die-stone.
- 22 endodontic treatment (May 2019 – January 2020):
- Periapical radiographs from left to right: pre-operative (27/3/2019), tooth investigation and working length (5/9/2019), master GP (30/1/2020), apical third (30/1/2020), post-operative (30/1/2020).
- Canal was calcified and difficult to access, assistance from Endodontist required.
- Tooth was temporised with GIC dome restoration as patient was not concerned about gap, note the minimal tooth structure remaining.
30
#### Treatment Details: Tooth 47 Survey Crown and 22 Endodontics
- **47 Survey Crown**: Prepared for zirconia due to superior strength for a posterior abutment.
- **22 Endodontic Treatment**: Completed May 2019–January 2020. Canal was severely calcified, requiring endodontist assistance. Temporised with GIC dome.
![]()
Clinical photos showing survey crown preparation. Three images display the tooth prepared for a zirconia survey crown, with visible metallic restoration and surrounding gum tissue.
![]()
Photos of final impressions taken using PVS (polyvinyl siloxane) material. Two images show the yellow impression tray containing the dental impression, followed by the poured die-stone model revealing the prepared tooth structure.
![]()
Series of five periapical radiographs documenting endodontic treatment progression from pre-operative to post-operative stages, with dates labeled for each stage.
![]()
Clinical photos showing temporary restoration with GIC dome. Three images display the tooth temporized with glass ionomer cement, highlighting minimal remaining tooth structure and the gap between teeth.
- 22 definitive restoration:
- Cast gold direct post-core.
*Post should only be used when there is insufficient tooth substance remaining to* *support final restoration as preparation of post space and placement of post can* *weaken the root and lead to root fracture and treatment failure. (15) If an* *anterior tooth must be prepared to receive a crown after endodontic treatment* *because a good amount of tooth structure was lost, a post may be necessary to* *retain the core to the tooth can resist functional forces. (15) Cast post and cores* *have been used for decades, have reported success rate of 90.6%, cast gold alloy* *(type III/IV) is inert with modulus of elasticity and coefficient of thermal* *expansion similar to those of enamel with good compressive strength to* *withstand normal occlusal forces. (15) Disadvantages are multiple appointments* *required and aesthetics as metal shade shows through newer ceramics, however* *this can be overcome with porcelain-fused to metal crowns. Post design: parallel* *(more retentive, no wedging effect), passive (transfer less stress to root) post.* *Post length: extend to half the length of root supported by bone with* *preservation of 3-6 mm apical gutta percha. Post width: not exceed one third of* *root width.*
- Post space preparation completed to adequate length, note transportation of
canal evident from radiograph.
- Post space impression taken using PVS and poured in die stone.
- Cast gold post-core fabricated.
31
#### Treatment Details: Tooth 22 Cast Post-Core
- **Rationale**: Post used due to insufficient tooth substance to support a crown. Cast gold (Type III/IV) chosen for its modulus of elasticity similar to enamel.
- **Design**: Parallel, passive post; length extended to half the bone-supported root length with 3-6 mm apical seal preserved.
- **Procedure**: Post space preparation and PVS impression for fabrication.
![]()
Radiograph showing post space preparation completed to adequate length. Note transportation of canal evident in the root structure.
![]()
Clinical photo showing Post space impression taken using PVS and poured in die stone. Left panel shows the tray with impression material; right panel shows the poured die stone model.
![]()
Photo showing Cast gold post-core fabricated. Left panel displays the cast gold post; right panel shows the post seated in the die stone model.
- Cemented with Panavia, marginal deficiency of 0.5 mm filled with cement. Zinc phosphate has longest history of success, extended working time, compatible with zinc oxide eugenol contained in most root canal sealers, easier to remove, lower risk of root fracture compared with post bonded with resin-based cement. Resin-based cement has potential to bond to dentine, improved post retention, decreased microleakage, higher fracture resistance, similar modulus of elasticity to that of dentine, however, difficult to remove in case of endodontic failure. (15)
- Crown preparation and provisional restoration with polycarbonate shell-lined with PEMA and cemented with IRM. Tooth prepared for zirconia crown. Generally, glass-based ceramics such as lithium disilicate is chosen for anterior crowns. With new materials on the market, for a single anterior tooth, all ceramics have sufficient longevity based on clinical trial data, so the choice can be made on aesthetic capability alone. (18) In this case, 22 had a cast post-core to support the coronal restoration. The colour of the metal would show through a glass-based ceramic; hence zirconia was chosen as a safer option. Zirconia aesthetics have improved over the years and is available in different translucencies. Use of an opaque cement may also be beneficial to mask the metallic shade under the crowns. Metal-ceramic crowns are another available option which allows more control over the aesthetic outcome. However, due to financial reasons zirconia was chosen.
- Final impressions taken using PVS and poured in die-stone.
32
#### Treatment Details: Tooth 22 Crown
- **Cementation**: Post cemented with Panavia.
- **Crown Choice**: Zirconia chosen over lithium disilicate to mask the underlying metal cast post-core. Zirconia provides high strength and improved aesthetics with opaque cements to block metallic shades.
![]()
Clinical photo showing a tooth with a cast post-core restoration. The gold-colored metal structure is visible within the prepared tooth, demonstrating the 'cast post-core to support the coronal restoration' mentioned in the text.
![]()
Clinical photo of a crown preparation and provisional restoration. The image shows a temporary restoration (likely polycarbonate shell-lined with PEMA) cemented onto the prepared tooth, consistent with the text describing the step before final zirconia crown placement.
![]()
Radiograph (X-ray) showing the internal structure of the root canal treatment and post-core. This visual confirms the presence of the post and core material inside the tooth, which supports the choice of zirconia over glass-based ceramics due to metal visibility concerns.
![]()
Clinical photo of the anterior teeth after crown preparation or during the stage of choosing the final material. It shows the prepared tooth stumps and adjacent natural teeth, illustrating the context for selecting zirconia based on aesthetic capability versus financial reasons.
![]()
Procedure image showing a yellow PVS (polyvinyl siloxane) impression material being used to take an impression of the prepared teeth. This corresponds to the text stating 'Final impressions taken using PVS'.
![]()
Procedure image showing the poured die-stone model created from the PVS impression. This represents the second part of the process described: 'poured in die-stone', which is essential for fabricating the final zirconia crown.
- 15 & 14 definitive restorations:
- Large MOD composite restorations removed and remaining tooth structure reassessed.
- Cracks found in tooth 15; buccal and palatal walls reduced for cuspal coverage to prevent failure of tooth by cuspal flexure.
- Both teeth prepared for onlays.
- Teeth prepared for Emax onlays to prevent cuspal flexure and failure. IPS Emax is a glass ceramic containing approximately 70% crystalline lithium disilicate in a glass matrix. Available as ingots to be used according to heat-pressing procedure or blue state blocks to be used for CAD-CAM manufacturing. Flexural strength of approximately 500 MPa. Indications for veneers, inlays, onlays, crowns. A study analysing survival and success rates of IPS Emax for all ceramic restorations found for full coverage crowns, 5-year survival was 94.90% with causes of failure including fracture of the restoration, apical osteitis, loss of retention, hypersensitivity, pre-prosthetic core fracture. (19) A clinical study examining 10-year survival of pressed lithium disilicate glass-ceramic full coverage restorations found that these restorations survived successfully over 10.4 year period with overall failure rate of below 0.2% per year. (20) Another clinical study examining 10.9-year survival of pressed lithium disilicate glass-ceramic partial coverage restorations found 98.3% survival at 9.8 years, with failure occurring in the molar region. (21) There is good evidence for lithium disilicate restoration longevity to justify its use.
- Both teeth provisionally restored with stainless steel bands and IRM.
33
#### Treatment Details: Teeth 14 & 15 Onlays
- **Findings**: Cracks found in 15; required cuspal coverage.
- **Material**: IPS Emax (lithium disilicate) chosen for high flexural strength (500 MPa) and proven 10-year survival rates for partial coverage restorations.
- **Preparation**: Teeth prepared for onlays and provisionally restored with stainless steel bands and IRM.
![]()
Clinical photo showing tooth preparation with a large MOD composite restoration removed and remaining tooth structure reassessed. The image demonstrates the exposed dentin and enamel after removal of previous restorations.
![]()
Clinical photo illustrating cracks found in tooth 15, with buccal and palatal walls reduced for cuspal coverage to prevent failure by cuspal flexure. The illuminated view highlights the crack lines on the prepared tooth surface.
![]()
Clinical photo showing both teeth (15 & 14) prepared for Emax onlays. The images display the final tooth preparations with smooth contours and adequate reduction for lithium disilicate ceramic restorations to prevent cuspal flexure and failure.
![]()
Clinical photo showing both teeth provisionally restored with stainless steel bands and IRM (intermediate restoration material). The provisional restoration provides temporary protection while awaiting definitive IPS Emax onlay fabrication.
Final impressions taken using PVS and poured in die-stone.
Cementation of definitive 14, 15, 22, 47:
- 14 & 15 cemented with Variolink.
- 22 cemented with Panavia.
- 47 cemented with Permacem.
34
#### Final Cementation
- **14 & 15**: Cemented with Variolink.
- **22**: Cemented with Panavia.
- **47**: Cemented with Permacem.
![]()
Clinical photo showing a final dental impression in PVS material with die-stone casts visible inside the tray.
![]()
Intraoral clinical photo of maxillary anterior teeth after cementation of definitive crowns on teeth 14 and 15 (Variolink) and tooth 22 (Panavia).
![]()
Intraoral clinical photo of mandibular anterior teeth after cementation of definitive crown on tooth 47 (Permacem).
![]()
Lateral intraoral view showing cemented crowns on upper right quadrant (teeth 14, 15) and adjacent natural teeth.
![]()
Lateral intraoral view showing cemented crowns on lower left quadrant (tooth 47) and adjacent natural teeth.
- CoCr maxillary and mandibular removable prostheses design:
- Diagnostic models mounted and surveyed.
- Preliminary CoCr maxillary and mandibular dentures designed.
A cobalt-chrome denture was selected over acrylic.
<table>
<tr>
<th>Advantages</th>
<th>Disadvantages</th>
</tr>
<tr>
<td>Accurate adaptation to tissues for comfort</td>
<td>Expensive</td>
</tr>
<tr>
<td>Easily cleaned and favourable to tissue health</td>
<td>Difficult to adjust and reline</td>
</tr>
<tr>
<td>Thermal conductivity</td>
<td>Cannot add tooth on as easily as acrylic</td>
</tr>
<tr>
<td>Low specific gravity i.e. low weight and bulk for comfort and adaptation</td>
<td></td>
</tr>
<tr>
<td>Higher strength and resistance to fracture</td>
<td></td>
</tr>
</table>
McCracken’s Removable Partial Prosthodontics (6)
- Mouth preparation:
- Rest seats 15M, 14M, 47M (incorporated into indirect restorations)
- Rest seats 24M, 25M, 33P, 45D
- Guide planes 15D, 47M (incorporated into indirect restorations)
- Guide planes 25D, 34D
- Final impressions:
- Maxillary and mandibular final impressions taken using PVS and poured in die stone.
- MMR:
- Master models mounted.
- Maxillary and mandibular CoCr frameworks fabricated.
35
#### Removable Prostheses Design
- **Material**: Cobalt-chrome (CoCr) selected over acrylic for accurate adaptation, thermal conductivity, and higher strength.
- **Mouth Preparation**:
- Rest seats: 15M, 14M, 47M (in restorations); 24M, 25M, 33P, 45D.
- Guide planes: 15D, 47M (in restorations); 25D, 34D.
- **Process**: Final PVS impressions taken; master models mounted for framework fabrication.
![]()
Clinical photos of diagnostic models and preliminary CoCr dentures. Top row shows maxillary diagnostic models mounted and surveyed, with one hand holding a model showing the occlusal view. Bottom row shows mandibular diagnostic models and frameworks from multiple angles.
![]()
Comparison table of Cobalt-Chrome (CoCr) denture advantages and disadvantages based on McCracken's Removable Partial Prosthodontics. Advantages include accurate adaptation to tissues, ease of cleaning, thermal conductivity, low specific gravity, and higher strength. Disadvantages include cost, difficulty in adjustment/relining, and inability to add teeth as easily as acrylic.
![]()
Clinical photo of final impressions taken using PVS material and poured in die stone. Shows a yellowish impression tray filled with blue-colored PVS material on the left, and a pinkish-red impression tray on the right.
![]()
Clinical photo of final impressions taken using PVS material and poured in die stone. Shows a pinkish-red impression tray with blue-colored PVS material filling the spaces between teeth.
- CoCr framework try-in:
- Maxillary framework did not seat passively even with minimal adjustment.
- Clinical decision to re-take maxillary final impression to fabricate new CoCr framework.
- Second maxillary framework did not seat passively but was better than first, clinical decision to accept second framework.
- Mandibular framework fitted and seated correctly.
- Wax rims added to metal framework and MMR taken to mount models and set teeth.
- CoCr framework with denture teeth try-in:
- Aesthetics satisfactory.
- Phonetics satisfactory.
- Occlusion satisfactory.
- Sent to lab for final processing.
- Maxillary and mandibular partial denture insert:
- Maxillary partial denture did not seat passively without additional finger pressure, however with clasp adjustment, seating and stability was satisfactory and found acceptable to patient.
- Patient very happy with final outcome.
*In determining whether provision of removable partial denture is justified – shortened dental arch (minimum of four occlusal units which provide functional satisfaction) (22) was considered, and current literature shows that to assure optimal function throughout life an individual should have natural dentition of not less than 20 teeth. (23) Wearing of CoCr removable partial dentures has been shown to be related to higher prevalence of plaque, gingivitis, gingival recession and root caries. (24) In a study, usage of CoCr removable partial dentures has been found to decline with time and half of the dentures had been discarded or replaced 5-6 years after insertion, with reasons being general dissatisfaction with dentures due to comfort, fit, chewing ability, food trapping and appearance. In the same study, status of CoCr removable partial dentures that had constantly been used for 5-6 years by patients was good and demonstrated fair to good cleanliness, stability and retention with no defect of any sort. (25)*
36
#### Framework Try-in and Insertion
- **Maxillary**: First framework failed to seat; second framework accepted after re-impression.
- **Mandibular**: Seated correctly.
- **Try-in**: Aesthetics, phonetics, and occlusion found satisfactory.
- **Insertion**: Maxillary denture required clasp adjustment for passive seating. Patient reported high satisfaction and improved bite stability.
- **Clinical Note**: Shortened dental arch concepts were considered, but dentures were provided to meet the patient's functional goals.
![]()
Clinical photo showing two dental study models side-by-side. The left image displays a maxillary cast with a CoCr framework try-in labeled 'TASSIE-6', demonstrating the metal structure on pink gingival tissue. The right image shows a mandibular cast with a CoCr framework try-in labeled 'Tassie'. These images visually demonstrate the fit and seating of the frameworks described in the text section above them.
Despite the evidence and the patient having 21 teeth after control phase, patient chose to have removable partial dentures with knowledge that success depends highly on patient's ability to adapt to prostheses, oral and denture hygiene in addition to regular dental visits for periodontal maintenance and review of prostheses.
Despite having 21 teeth after the control phase, the patient chose removable partial dentures. Success depends on adaptation, hygiene, and regular maintenance.
**1.7.2** Before and after photographs
Date: January 2019 – October 2020
1. Diagnostic phase
January 2019
**Pre-treatment**
2. Control phase
May 2019
**Initial phase periodontal therapy completed**
**Caries control in progress**
**Endodontic treatment 47 in progress**
3. Control phase
August 2019
**Extraction 37 completed**
**Caries control in progress**
**Endodontic treatment 22 & 47 in progress**
**Periodontal status maintained**
4. Control phase
September 2019
**Caries control completed**
**Endodontic treatment 47 completed**
**Endodontic treatment 22 in progress**
**Periodontal status maintained**
---
38
##### 1.7.2 Before and after photographs
1. **Diagnostic phase (Jan 2019)**: Pre-treatment status.
2. **Control phase (May 2019)**: Periodontal therapy completed; caries control and 47 endodontics in progress.
3. **Control phase (Aug 2019)**: 37 extraction completed; endodontics for 22 and 47 in progress.
4. **Control phase (Sep 2019)**: Caries control and 47 endodontics completed.
![]()
Clinical figure showing a series of before-and-after intraoral photographs documenting the progression of dental treatment from January 2019 to September 2019. The figure is organized into four rows, each representing a distinct phase: Diagnostic phase (January 2019) with 'Pre-treatment' image; Control phase (May 2019) showing completed periodontal therapy and ongoing caries/endodontic control; Control phase (August 2019) showing extraction site healing and continued endodontic treatment; and Control phase (September 2019) showing completion of caries and endodontic treatments for teeth 47 and 22. Each photo is accompanied by descriptive text detailing clinical status.
**Reconstructive phase**
October 2019
Direct post and core 47 completed
Endodontic treatment 22 in progress with new provisional restoration
Tooth preparation 15 in progress
Periodontal status maintained
**Holding phase**
March 2020
Endodontic treatment 22 completed
Cast post-core 22 completed
Crown preparation 14, 15, 22 & 47 in progress
Periodontal status maintained
**Reconstructive phase**
August 2020
Indirect fixed restorations 14, 15, 22 47 completed
Periodontal status maintained
**Reconstructive phase**
October 2020
Removable prostheses inserted
Periodontal status maintained
39
##### Treatment Progression Photographs
- **Reconstructive (Oct 2019)**: 47 post/core completed; 15 preparation started.
- **Holding (Mar 2020)**: 22 endodontics and cast post-core completed; crown preparations in progress.
- **Reconstructive (Aug 2020)**: All indirect fixed restorations (14, 15, 22, 47) completed.
- **Reconstructive (Oct 2020)**: Removable prostheses inserted; periodontal status maintained.
![]()
Clinical photo of teeth during the 'Reconstructive phase' in October 2019. Shows upper and lower anterior teeth with a metal post visible in tooth 47 (lower right). Text below indicates direct post/core 47 completed, endodontic treatment 22 in progress, and tooth preparation 15 in progress.
![]()
Clinical photo of teeth during the 'Holding phase' in March 2020. Shows upper and lower anterior teeth with a metal post visible in tooth 47. Text below notes endodontic treatment 22 completed, cast post-core 22 completed, and crown preparation for teeth 14, 15, 22 & 47 in progress.
![]()
Clinical photo of teeth during the 'Reconstructive phase' in August 2020. Shows upper and lower anterior teeth with indirect fixed restorations on teeth 14, 15, 22 & 47. Text confirms these restorations are completed and periodontal status is maintained.
![]()
Clinical photo of teeth during the 'Reconstructive phase' in October 2020. Shows upper and lower anterior teeth with removable prostheses inserted (visible as metal clasps on the sides). Text indicates removable prostheses inserted and periodontal status maintained.
**1.7.3** Patient response to treatment
- Patient was very satisfied with overall outcome of treatment.
- “I did not believe this day would come where I would get my dentures!”
- “I feel more stable (bite).”
**Resolution of presenting complaints:**
i. “I have intermittent pain in a couple of my teeth (37, 47) and in my gums.”
√ 37 pain resolved after extraction.
√ 47 pain resolved after endodontic treatment and definitive restoration.
√ Gingival pain resolved after periodontal treatment.
ii. “There is a hole in the back of my tooth (22) and sometimes stuff gets in there and causes sensitivity – it’s been there for a long time me.”
√ 22 sensitivity resolved after endodontic treatment and definitive restoration.
iii. “I think it would be beneficial to have dentures because of my missing teeth.”
√ Maxillary and mandibular Co-Cr partial dentures inserted.
- Patient changed lifestyle and followed overall management plan in order to achieve health goals e.g. diet, exercise, mental health, dental work.
- Changes to lifestyle complemented dental goals.
- Patient was highly compliant with dental advice and instructions – oral hygiene occasionally regressed to old habits but with gentle reminders patient was able to stay on track.
- Patient has never missed an appointment without notice and will continue to attend OHCWA for maintenance.
##### 1.7.3 Patient response to treatment
- **Outcome**: Patient very satisfied; felt bite was more stable.
- **Complaint Resolution**:
- 37/47 pain and gingival pain resolved.
- 22 sensitivity and "hole" resolved.
- Missing teeth addressed with Co-Cr dentures.
- **Compliance**: Patient successfully changed lifestyle (diet/exercise) and remained highly compliant with oral hygiene instructions.
![]()
Clinical photo of a male patient with grey hair and beard, smiling to show his teeth after treatment.
![]()
Clinical photo of the same male patient from a slightly different angle, showing his smile and dentures.
### 1.7.4 Reflection
<table>
<thead>
<tr>
<th></th>
<th>Challenges</th>
<th>Management</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="4">Patient-related</td>
<td>Medication</td>
<td><ul><li>Patient did not take medication to control leg spasms because he thought it would interfere with dental treatment.<ul><li>Emphasized to patient importance of taking medication as prescribed by general medical practitioner.</li><li>Informed patient is he has any concerns about medication and dental treatment to check with general medical practitioner.</li><li>Xylocaine spray</li></ul></li></ul></td>
</tr>
<tr>
<td>Back pain</td>
<td><ul><li>Patient had back pain from sitting in dental chair for extended periods.<ul><li>Frequent breaks during appointments to stretch.</li><li>Use of cushioning to support neck and back in dental chair.</li></ul></li></ul></td>
</tr>
<tr>
<td>Rubber dam</td>
<td><ul><li>As a mouth breather, patient found it difficult to tolerate rubber dam.<ul><li>Gentle encouragement, education on importance of use and frequent use allowed patient to adjust and tolerate it.</li></ul></li></ul></td>
</tr>
<tr>
<td>Post-traumatic stress disorder</td>
<td><ul><li>Common symptom of PTSD is anxiety.<ul><li>Managed by preventing stressing patient during dental appointments and constant reassurance.</li></ul></li></ul></td>
</tr>
<tr>
<td rowspan="6">Clinical</td>
<td>Rubber dam placement</td>
<td><ul><li>Rubber dam leakage during 47 working length appointment.<ul><li>Patient panicked.</li><li>Rubber dam removed promptly, patient allowed to rinse, reassured patient, canals re-irrigated and re-medicated.</li><li>Thoroughly check rubber dam adaptation prior to commencing treatment and use oraseal If necessary to cover gaps.</li></ul></li></ul></td>
</tr>
<tr>
<td>Subgingival restorations</td>
<td><ul><li>Cavity preparations some teeth were subgingival.<ul><li>Place GIC temporarily and wait for gingival tissues to heal prior to placing composite.</li><li>Healthy gingiva easier to control moisture.</li><li>Use retraction cord.</li></ul></li></ul></td>
</tr>
<tr>
<td>Shade matching</td>
<td><ul><li>Difficulty matching shade of tetracycline stained teeth.<ul><li>Accept differences in shades and provide explanation to patient.</li></ul></li></ul></td>
</tr>
<tr>
<td>Post space preparation</td>
<td><ul><li>Transportation of canal<ul><li>Stop preparation</li></ul></li></ul></td>
</tr>
<tr>
<td>Cast post-core</td>
<td><ul><li>Poor marginal fit<ul><li>Accept gap and fill with cement</li><li>Re-take post space impression with Duralay or PVS</li></ul></li></ul></td>
</tr>
<tr>
<td>CoCr framework</td>
<td><ul><li>Framework did not seat passively<ul><li>Likely an issue with impression as patient has strong gag reflex</li></ul></li></ul></td>
</tr>
</tbody>
</table>
41
##### 1.7.4 Reflection
| Category | Challenges | Management |
| :--- | :--- | :--- |
| **Patient-related** | Medication/Leg spasms | Emphasized importance of prescribed meds; used Xylocaine spray. |
| | Back pain | Frequent breaks and cushioning. |
| | Rubber dam | Managed mouth breathing with education and gradual adjustment. |
| | PTSD | Anxiety managed with reassurance and stress prevention. |
| **Clinical** | Rubber dam leakage | Prompt removal, irrigation, and use of Oraseal. |
| | Subgingival margins | Temporary GIC and retraction cord used. |
| | Shade matching | Tetracycline staining made matching difficult; patient informed of limitations. |
| | Post space | Canal transportation occurred; preparation stopped. |
| | Framework fit | Maxillary framework required re-impression due to gag reflex issues. |
![]()
A comprehensive summary table titled '1.7.4 Reflection' organized into three columns: 'Patient-related', 'Clinical', and 'Management'. The first column categorizes challenges into 'Patient-related' (Medication, Back pain, Rubber dam, Post-traumatic stress disorder) and 'Clinical' (Rubber dam placement, Subgingival restorations, Shade matching, Post space preparation, Cast post-core, CoCr framework). The second column lists specific clinical or patient challenges. The third column details management strategies for each challenge, such as using Xylocaine spray for leg spasms, cushioning for back pain, gentle encouragement for rubber dam tolerance, managing anxiety for PTSD, removing and re-irrigating canals for rubber dam leakage, placing GIC temporarily for subgingival restorations, accepting shade differences for tetracycline stains, stopping preparation to prevent canal transportation, filling gaps with cement for poor marginal fit, and checking impressions for gag reflex issues.
CASE 2
Fixed Aesthetic
42
CASE 2
Fixed Aesthetic
CASE 2
Fixed Aesthetic
2.1.1 Details
• 61 year-old female
2.1.2 Presenting complaint/s
• Patient presented to student clinic in May 2019 with the following complaints:
i. “I don’t smile anymore because my front teeth are so bad. The front tooth (21) is brown, they're all mismatched. I want the teeth (13-21) to look the same colour because when I smile, I'm self-conscious.”
ii. “My crown (11) has fallen off and been stuck on again – I'm afraid it will fall off again.”
iii. “I had some sensitivity last week when eating sweet foods (47).”
2.1.3 History of presenting complaint/s
• Upper anterior crowns (11, 12) were inserted 20-30 years ago. 11 crown de-bonded and was re-cemented 7 years ago.
• Noticed occasional sensitivity on lower right-hand side after eating sweet foods. Happened about a week ago. No sensitivity to thermal stimuli. Did not cause patient to wake at night. Relieved by ibuprofen.
43
#### Patient Details
- 61 year-old female
#### Presenting Complaints
Patient presented to student clinic in May 2019 with the following complaints:
1. "I don’t smile anymore because my front teeth are so bad. The front tooth (21) is brown, they're all mismatched. I want the teeth (13-21) to look the same colour because when I smile, I'm self-conscious."
2. "My crown (11) has fallen off and been stuck on again – I'm afraid it will fall off again."
3. "I had some sensitivity last week when eating sweet foods (47)."
#### History of Presenting Complaints
- **Upper Anterior Crowns (11, 12):** Inserted 20-30 years ago. The 11 crown de-bonded and was re-cemented 7 years ago.
- **Lower Right Sensitivity:** Occasional sensitivity noticed after eating sweet foods about a week ago. No sensitivity to thermal stimuli. Did not cause patient to wake at night. Relieved by ibuprofen.
![]()
Clinical facial photograph of a 61-year-old female patient with dark hair and bangs. The eyes are obscured by a black rectangle for privacy. The image serves as the visual subject for Case 2 (Fixed Aesthetic) documentation.
**2.1.4 Medical history**
<table>
<thead>
<tr>
<th>
Medical condition
</th>
<th>
Description
</th>
<th>
Dental implications (1)
</th>
</tr>
</thead>
<tbody>
<tr>
<td>
History of asthma attack a few years ago
</td>
<td>
Wheezing, coughing, chest tightness or shortness of breath. Often waking at night with asthma symptoms. Becomes a medical emergency when symptoms worsen rapidly, speaking becomes difficult, lips look blue or there is little relief from reliever inhaler.
</td>
<td>
Asthma attack in dental chair. Sit person upright, reassure. Give 4 puffs blue/grey reliever every 4 minutes. If symptoms do not improve call 000 immediately.
</td>
</tr>
</tbody>
</table>
(1) Therapeutic Guidelines: oral and dental (2019).
<table>
<thead>
<tr>
<th>
Medication
</th>
<th>
Dosage
</th>
<th>
Use &amp; Mechanism of action
</th>
<th>
Dental implications
</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="4">
Not currently taking any medication/s
</td>
</tr>
</tbody>
</table>
<table>
<thead>
<tr>
<th>
Allergy
</th>
<th>
Description
</th>
<th>
Dental implications
</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="3">
No known allergies
</td>
</tr>
</tbody>
</table>
<table>
<thead>
<tr>
<th>
Alcohol &amp; Tobacco Use
</th>
<th>
Amount, Frequency &amp; Duration
</th>
<th>
Dental implications
</th>
</tr>
</thead>
<tbody>
<tr>
<td>
Former smoker in twenties
</td>
<td>
5-6 cigarettes a day for 4 years (1 pack year). Quit and has not smoked since.
</td>
<td>
Among former smokers, time since quitting is statistically significantly protective against periodontal disease. (26)
</td>
</tr>
<tr>
<td>
Current drinker
</td>
<td>
1 glass of wine – 1.5 standard drinks a fortnight.
</td>
<td>
Alcohol consumption raises risk of cancer including on lip and in oral cavity. (5)
</td>
</tr>
</tbody>
</table>
**2.1.5 Dental history and dental attitude**
* Dental history
- Attended dentist in Ireland once every six months for routine examinations, cleans and restorations as required. Last attended 2018.
- History of extractions and orthodontic treatment in teenage years.
- History of endodontic treatment 11, 12 due to dental infection.
- No history of trauma.
- Attended OHCWA screening clinic February 2019. Presented to student clinic for initial examination May 2019.
* Dental attitude
- Aesthetic motivation.
- Apprehensive to radiation exposure.
- Strong gag reflex.
- Lack of trust in student clinicians.
- Never missed an appointment.
44
#### Medical History
| Medical Condition | Description | Dental Implications |
| :--- | :--- | :--- |
| History of asthma attack | Wheezing, coughing, chest tightness or shortness of breath. Often waking at night. Emergency if symptoms worsen rapidly or lips look blue. | Risk of attack in chair. Sit upright, reassure. Give 4 puffs blue/grey reliever every 4 minutes. Call 000 if no improvement. |
- **Medications:** Not currently taking any medication/s.
- **Allergies:** No known allergies.
#### Alcohol & Tobacco Use
| Usage | Amount, Frequency & Duration | Dental Implications |
| :--- | :--- | :--- |
| Former smoker | 5-6 cigarettes/day for 4 years (1 pack year). Quit in twenties. | Time since quitting is protective against periodontal disease. |
| Current drinker | 1 glass of wine (1.5 standard drinks) a fortnight. | Alcohol consumption raises risk of oral cavity cancer. |
#### Dental History and Attitude
**Dental History**
- Routine examinations and cleans every six months in Ireland; last attended 2018.
- History of extractions and orthodontic treatment in teenage years.
- History of endodontic treatment (11, 12) due to dental infection.
- No history of trauma.
- Attended OHCWA screening February 2019; initial examination May 2019.
**Dental Attitude**
- Aesthetic motivation.
- Apprehensive to radiation exposure.
- Strong gag reflex.
- Initial lack of trust in student clinicians.
- Reliable attendance (never missed an appointment).
![]()
Table titled 'Medical history' with columns: Medical condition, Description, Dental implications (1). Row content: History of asthma attack a few years ago; Wheezing, coughing, chest tightness or shortness of breath. Often waking at night with asthma symptoms. Becomes a medical emergency when symptoms worsen rapidly, speaking becomes difficult, lips look blue or there is little relief from reliever inhaler.; Asthma attack in dental chair. Sit person upright, reassure. Give 4 puffs blue/grey reliever every 4 minutes. If symptoms do not improve call 000 immediately.
![]()
Table with columns: Medication, Dosage, Use & Mechanism of action, Dental implications. Content: Not currently taking any medication/s.
![]()
Table with columns: Allergy, Description, Dental implications. Content: No known allergies.
![]()
Table titled 'Alcohol & Tobacco Use' with columns: Alcohol & Tobacco Use, Amount, Frequency & Duration, Dental implications. Rows include: Former smoker in twenties; 5-6 cigarettes a day for 4 years (1 pack year). Quit and has not smoked since.; Among former smokers, time since quitting is statistically significantly protective against periodontal disease. (26); Current drinker; 1 glass of wine – 1.5 standard drinks a fortnight.; Alcohol consumption raises risk of cancer including on lip and in oral cavity. (5).
**2.1.6 Oral hygiene**
* Fair oral hygiene
* Brushes teeth twice daily, morning and night.
* Uses electric toothbrush and pea-sized amount of fluoride toothpaste.
* Uses floss once a week.
* Does not use any other cleaning adjuncts.
**2.1.7 Social history**
* Born and raised in Ireland, moved to Australia in November 2018.
* Currently lives alone and works in aged care.
* Two children; son (researcher living in Sydney) and daughter (doctor living in Perth).
* Enjoys playing competitive golf every Tuesday.
* Thinking of moving to Sydney in future.
**2.2 Examination and diagnostics**
Date: May 2019
**2.2.1 Extra-oral examination**
| | Findings |
| :--- | :--- |
| Facial symmetry | Absence of facial swelling |
| Facial skin | Dry, peeling skin and hyperpigmentation |
| Lips | Dry, cracked lips and indistinct vermilion border* |
| Temporomandibular joint | Minor crepitus on opening and closing bilaterally<br>Absence of clicking and crepitus in excursion bilaterally<br>Absence of pain and tenderness on palpation |
| Lymph nodes | No sign of lymphadenopathy<br>Absence of pain and tenderness on palpation |
| Muscles of mastication | Absence of pain and tenderness on palpation |
| Thyroid gland | No obvious abnormal enlargement |
*Consultation with Oral Medicine – confirmed actinic cheilitis.*
**2.2.2 Extra-oral photographs and findings**
| | Dentofacial analysis |
| :--- | :--- |
| Horizontal facial proportions | Elongated lower facial third<br>Elongated philtrum |
| Vertical facial proportions | Proportional facial fifths |
| Horizontal symmetry | Incisal plane lacks parallelism with ophric and interpupillary lines<br>Incisal plane cants slightly downward to right |
| Vertical symmetry | Facial midline and dental midline do not coincide* |
| Facial symmetry | Relatively symmetrical |
| Smile analysis | Low smile line**<br>Extra wide smile width<br>Normal buccal corridors<br>Flat incisal/occlusal curve |
| Profile | Convex – indicative of class II skeletal profile |
*Midline discrepancy not detectable at conversational distance. A study on midline deviations among different facial types concluded overall threshold for acceptability of midline deviation 2.92 ± 1.10 mm. {27}<br/>
**Patient is not smiling normally.
#### Oral Hygiene
- **Status:** Fair oral hygiene.
- **Routine:** Brushes twice daily (morning/night) with an electric toothbrush and fluoride toothpaste.
- **Adjuncts:** Uses floss once a week; no other cleaning adjuncts.
#### Social History
- Born and raised in Ireland; moved to Australia in November 2018.
- Lives alone; works in aged care.
- Two children: a son in Sydney and a daughter in Perth.
- Enjoys competitive golf on Tuesdays.
- Considering a future move to Sydney.
#### Extra-Oral Examination
| Feature | Findings |
| :--- | :--- |
| Facial symmetry | Absence of facial swelling; relatively symmetrical |
| Facial skin | Dry, peeling skin and hyperpigmentation |
| Lips | Dry, cracked lips and indistinct vermilion border (Confirmed actinic cheilitis) |
| TMJ | Minor bilateral crepitus on opening/closing; no pain or tenderness |
| Lymph nodes | No lymphadenopathy; no pain or tenderness |
| Muscles | Absence of pain or tenderness on palpation |
| Thyroid | No obvious abnormal enlargement |
#### Dentofacial Analysis
- **Horizontal Proportions:** Elongated lower facial third and philtrum.
- **Vertical Proportions:** Proportional facial fifths.
- **Horizontal Symmetry:** Incisal plane lacks parallelism with interpupillary lines; cants slightly downward to the right.
- **Vertical Symmetry:** Facial and dental midlines do not coincide (discrepancy not detectable at conversational distance).
- **Smile Analysis:** Low smile line (not smiling normally), extra wide smile width, normal buccal corridors, flat incisal/occlusal curve.
- **Profile:** Convex (indicative of Class II skeletal profile).
![]()
Table titled 'Extra-oral examination' listing findings for various anatomical regions: Facial symmetry (Absence of facial swelling), Facial skin (Dry, peeling skin and hyperpigmentation), Lips (Dry, cracked lips and indistinct vermilion border*), Temporomandibular joint (Minor crepitus on opening and closing bilaterally; Absence of clicking and crepitus in excursion bilaterally; Absence of pain and tenderness on palpation), Lymph nodes (No sign of lymphadenopathy; Absence of pain and tenderness on palpation), Muscles of mastication (Absence of pain and tenderness on palpation), and Thyroid gland (No obvious abnormal enlargement). A footnote indicates consultation with Oral Medicine confirmed actinic cheilitis.
![]()
Table titled 'Extra-oral photographs and findings' presenting dentofacial analysis. It includes categories such as Horizontal facial proportions (Elongated lower facial third; Elongated philtrum), Vertical facial proportions (Proportional facial fifths), Horizontal symmetry (Incisal plane lacks parallelism with ophric and interpupillary lines; Incisal plane cants slightly downward to right), Vertical symmetry (Facial midline and dental midline do not coincide*), Smile analysis (Low smile line**; Extra wide smile width; Normal buccal corridors; Flat incisal/occlusal curve), and Profile (Convex – indicative of class II skeletal profile). Footnotes explain the midline discrepancy threshold and note that the patient is not smiling normally.
2.2.3 Intraoral examination
<table>
<thead>
<tr>
<th></th>
<th>Findings</th>
</tr>
</thead>
<tbody>
<tr>
<td>Labial mucosa</td>
<td>No abnormalities detected</td>
</tr>
<tr>
<td>Buccal mucosa</td>
<td>Bilateral, symmetrical horizontal white lines level with occlusal plane (asymptomatic)*</td>
</tr>
<tr>
<td>Hard palate</td>
<td>No abnormalities detected</td>
</tr>
<tr>
<td>Soft palate</td>
<td>No abnormalities detected</td>
</tr>
<tr>
<td>Gingivae</td>
<td>Approximately 5 mm x 3 mm soft, round, slate grey macule on area buccal of 45 (asymptomatic)**</td>
</tr>
<tr>
<td>Tongue</td>
<td>No abnormalities detected</td>
</tr>
<tr>
<td>Floor of mouth</td>
<td>Bilateral lingual tori</td>
</tr>
</tbody>
</table>
*Consultation with Oral Medicine and monitoring – confirmed frictional hyperkeratosis. Ddx leukoedema, oral lichen planus.
**Consultation with Oral Medicine and radiographic finding – confirmed amalgam tattoo. Ddx melanotic macule, oral nevi.
46
#### Intraoral Examination
| Site | Findings |
| :--- | :--- |
| Labial mucosa | No abnormalities detected |
| Buccal mucosa | Bilateral, symmetrical horizontal white lines level with occlusal plane (Confirmed frictional hyperkeratosis) |
| Hard/Soft palate | No abnormalities detected |
| Gingivae | 5 mm x 3 mm soft, slate grey macule buccal of 45 (Confirmed amalgam tattoo) |
| Tongue | No abnormalities detected |
| Floor of mouth | Bilateral lingual tori |
![]()
Clinical examination table titled '2.2.3 Intraoral examination' listing findings for labial mucosa (no abnormalities), buccal mucosa (bilateral symmetrical horizontal white lines level with occlusal plane, asymptomatic*), hard palate (no abnormalities), soft palate (no abnormalities), gingivae (5 mm x 3 mm soft round slate grey macule on area buccal of 45, asymptomatic**), tongue (no abnormalities), and floor of mouth (bilateral lingual tori). Footnotes indicate consultation results: *confirmed frictional hyperkeratosis; **confirmed amalgam tattoo.
![]()
Frontal facial photograph annotated with vertical red lines labeled 'Vertical facial fifths' and horizontal blue lines labeled 'Horizontal facial thirds', used to assess facial proportions.
![]()
Frontal facial photograph annotated with yellow anatomical reference lines including dental midline, facial midline, ophriac line, interpupillary line, commissural line, and incisal plane.
![]()
Lateral facial profile photograph annotated with green cephalometric points GL (glabella), SN (subnasale), PG (posterior gnathion) and a connecting line indicating the aesthetic facial profile.
![]()
Lateral facial profile photograph annotated with blue horizontal lines dividing the face into upper, middle, and lower facial thirds.
<table>
<tr>
<th colspan="3">
2.2.4 Intraoral photographs and findings
</th>
</tr>
<tr>
<th>View</th>
<th>Teeth</th>
<th>Findings</th>
</tr>
<tr>
<td rowspan="3">Maxillary occlusal</td>
<td>Teeth</td>
<td>Heavily restored dentition<br/>
Missing premolars 14, 24*<br/>
Non-carious tooth surface loss 33I<br/>
Brown discolouration 13, 21**<br/>
Calculus on buccal of upper posterior teeth
</td>
</tr>
<tr>
<td>Restorations</td>
<td>Metallic crown 17<br/>
Amalgam restorations 16, 15, 25, 26, 27<br/>
Metal-ceramic crown 12 (visible labial margin)<br/>
Metal-ceramic crown 11 (MI fractured, repaired?)<br/>
Composite restorations 21, 22
</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Lip mucosa appears dry and fragile<br/>
</td>
</tr>
<tr>
<td>Mandibular occlusal</td>
<td>Teeth</td>
<td>Heavily restored dentition<br/>
Missing premolars 34, 44*<br/>
Non-carious tooth surface loss 32I<br/>
Buccal malposition 33 outside occlusal arch<br/>
Calculus on lingual of lower anterior teeth
</td>
</tr>
<tr>
<td rowspan="3">Right buccal</td>
<td>Restorations</td>
<td>Amalgam restorations 47 (broken ML), 36, 37<br/>
Metallic crown 46<br/>
Composite restoration 45 (leakage)<br/>
GIC restoration 35<br/>
</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>-<br/>
</td>
</tr>
<tr>
<td>Teeth</td>
<td>White-brown opacities 16B, 47B<br/>
Enamel infractions 13B<br/>
Distally inclined long axis 12<br/>
Calculus on buccal of upper posterior teeth
</td>
</tr>
<tr>
<td>Restorations</td>
<td>Metallic crown 17<br/>
Metal-ceramic crown 12 (triangular shape, long mesial outline, straight distal outline with rounded corner, rounded incisal edge, poor colour-white hue, high value)<br/>
Composite restoration 45 (leakage)<br/>
Metallic crown 46
</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Gingival recession at 12<br/>
Gingival zenith 12 at equal height to that of 13, 11<br/>
Loss of interdental papilla 12M<br/>
Mild marginal gingival inflammation
</td>
</tr>
<tr>
<td>Left buccal</td>
<td>Teeth</td>
<td>Distally inclined long axis 22<br/>
Long and straight mesial outline 22<br/>
White-brown opacities 26B, 27B, 37B, 36B<br/>
Brown-grey discolouration 27<br/>
Buccal malposition 33 outside occlusal arch
</td>
</tr>
<tr>
<td rowspan="3">Anterior</td>
<td>Restorations</td>
<td>Composite restoration 22 (translucent, poor contour at gingival margin)<br/>
Amalgam restoration 36<br/>
</td>
</tr>
<tr>
<td>Soft tissues</td>
<td>Gingival zenith 22 flat and coronal to that of 23<br/>
Loss of interdental papilla 22M, 33M<br/>
Mild marginal gingival inflammation
</td>
</tr>
<tr>
<td>Teeth</td>
<td>Disharmonious, asymmetric, unaesthetic anterior teeth (11, 21 different colour, shape, size)<br/>
Brown discolouration, white-brown opacities 13<br/>
Brown discolouration, high W:L (square) shape 21<br/>
Long and straight mesial outline 22<br/>
Incisal plane cants slightly downward to right<br/>
Maxillary midline not coincident with mandibular midline (mandibular midline deviates 3.5 mm to the right of maxillary midline)***
</td>
</tr>
</table>
#### Intraoral Findings by View
**Maxillary Occlusal**
- **Teeth:** Heavily restored; missing 14, 24; non-carious tooth surface loss 33I; brown discolouration 13, 21; buccal calculus on posterior teeth.
- **Restorations:** Metallic crown 17; Amalgam 16, 15, 25, 26, 27; Metal-ceramic crown 12 (visible margin) and 11 (fractured/repaired); Composite 21, 22.
**Mandibular Occlusal**
- **Teeth:** Heavily restored; missing 34, 44; non-carious tooth surface loss 32I; 33 malposed buccally; lingual calculus on anterior teeth.
- **Restorations:** Amalgam 47 (broken ML), 36, 37; Metallic crown 46; Composite 45 (leakage); GIC 35.
**Right Buccal**
- **Teeth:** White-brown opacities 16B, 47B; enamel infractions 13B; 12 distally inclined.
- **Restorations:** Metallic crown 17, 46; Metal-ceramic crown 12 (poor colour, high value); Composite 45 (leakage).
- **Soft Tissues:** Gingival recession at 12; mild marginal inflammation.
**Left Buccal**
- **Teeth:** 22 distally inclined with long/straight mesial outline; white-brown opacities 26B, 27B, 37B, 36B; brown-grey discolouration 27.
- **Restorations:** Composite 22 (translucent, poor contour); Amalgam 36.
- **Soft Tissues:** Gingival zenith 22 flat/coronal; loss of interdental papilla 22M, 33M.
**Anterior**
- **Teeth:** Asymmetric, unaesthetic (11, 21 differ in colour/shape/size); 13 brown discolouration; 21 square shape; incisal plane cant; mandibular midline deviates 3.5 mm right of maxillary midline.
![]()
A structured clinical findings table titled '2.2.4 Intraoral photographs and findings', organized into three main columns: View, Teeth, and Findings. The table categorizes dental observations by anatomical view (Maxillary occlusal, Mandibular occlusal, Right buccal, Left buccal, Anterior), detailing specific tooth conditions such as restorations (metallic crowns, amalgam, composite), soft tissue states (gingival recession, inflammation), and structural anomalies (malposition, discolouration). Each row corresponds to a specific dental finding with precise annotations like 'Missing premolars 14, 24*', 'Buccal malposition 33 outside occlusal arch', and 'Gingival zenith 12 at equal height to that of 13, 11'. The layout uses clear borders and consistent formatting for readability.
**Restorations**
Metal-ceramic crown 12 (visible margins, incisal edge in line with 11, poor colour-white hue, high value)
Metal-ceramic crown 11 (square shape, poor colour-white hue, high value)
Composite restoration 21 (poor contour at gingival margin)
Composite restoration 22 (translucent, poor contour at mesial gingival margin)
Composite restoration 45 (leakage)
Incisal embrasures asymmetric (larger embrasures on left than right)
**Soft tissues**
Slate grey macule on area buccal of 45
Gingival recession at 12
Gingival zenith 13-23 non-ideal****
Loss of interdental papilla 12-22
Gingival discolouration 12-11
Mild marginal gingival inflammation
*Patient has history of extractions and orthodontic treatment to correct malocclusion. Rounded/oval occlusal outline rather than angular/hexagonal of maxillary premolars suggest US present. Appearance of three distinct cusps characteristic of square-shaped three cusp-type in mandibular premolars suggests LS present. [28]
**Causes of discolouration may be intrinsic or extrinsic. Possibly extrinsic staining caused by tea/coffee consumption.
***Relatively common problem at finishing stage of orthodontic treatment is discrepancy in midlines of dental arches, resulting from pre-existing midline discrepancy or asymmetric closure of spaces within the arch. Minor discrepancies at finishing stage are no great problem, but quite difficult to correct large discrepancies after closure of spaces and occlusal relationships have been nearly established. [29]
****Aesthetic gingival shape elliptical for maxillary central incisors and canines with gingival zenith distal to long axis of these teeth, and semi-circular for lateral incisors. Gingival zenith of maxillary central incisors and canines should be apical to that of lateral incisors for aesthetics. [30]
48
#### Restoration and Soft Tissue Summary
**Restorations**
- **12 Crown:** Metal-ceramic; visible margins, poor colour (white hue, high value).
- **11 Crown:** Metal-ceramic; square shape, poor colour (white hue, high value).
- **21 & 22 Composites:** Poor contour at gingival margins; 22 is translucent.
- **45 Composite:** Evidence of leakage.
- **Embrasures:** Asymmetric incisal embrasures (larger on left).
**Soft Tissues**
- **Pigmentation:** Slate grey macule buccal of 45 (Amalgam tattoo).
- **Gingival Health:** Mild marginal inflammation; recession at 12; loss of interdental papilla 12-22.
- **Aesthetics:** Non-ideal gingival zenith 13-23; gingival discolouration 12-11.
**Clinical Notes**
- Missing premolars are consistent with a history of orthodontic extractions.
- Discolouration of 13 and 21 may be intrinsic or extrinsic (possibly tea/coffee).
- Midline discrepancy (3.5 mm) is likely a result of previous orthodontic space closure.
- Aesthetic gingival zenith for central incisors and canines should be distal to the long axis and apical to the lateral incisors.
![]()
A structured table with two primary rows labeled 'Restorations' and 'Soft tissues'. Under 'Restorations', it lists clinical findings for teeth 11, 12 (metal-ceramic crowns), and 21, 22, 45 (composite restorations), noting specific defects like poor colour, leakage, and asymmetry. Under 'Soft tissues', it documents a slate grey macule on tooth 45, gingival recession at 12, non-ideal zeniths in 13-23, loss of interdental papilla in 12-22, discolouration in 12-11, and mild marginal inflammation.
**2.2.5 Occlusion**
| Findings |
|----------|
| Overjet | 3 mm |
| Overbite | 2 mm |
| Canine class | LHS: Class II, RHS: Class I |
| Molar class | LHS: Class II, RHS: ½ Class II |
| Crossbite | Absent |
| Crowding / Spacing | Lower anterior crowding, 33 malposed buccally |
| Rotation | Absent |
| Supraeruption | Absent |
| Occlusal scheme | Canine guidance |
49
#### Occlusal Analysis
- **Overjet:** 3 mm
- **Overbite:** 2 mm
- **Canine Class:** Class I (Right), Class II (Left)
- **Molar Class:** ½ Class II (Right), Class II (Left)
- **Crossbite:** Absent
- **Crowding/Spacing:** Lower anterior crowding; 33 malposed buccally
- **Rotation/Supraeruption:** Absent
- **Occlusal Scheme:** Canine guidance
![]()
Clinical photo set of five intraoral views showing the patient's dentition and occlusion. Includes: (top) maxillary arch view revealing multiple amalgam restorations; (middle left) buccal view of posterior teeth with metallic fillings; (middle center) frontal view displaying anterior crowding and malpositioned lower incisors (tooth #33); (middle right) lateral view of posterior occlusion; (bottom) mandibular arch view showing a prominent gold crown on the left canine and other restorations. These images visually demonstrate the findings listed in the table below, including Class II molar/canine relationships and lower anterior crowding.
![]()
A structured clinical findings table titled 'Findings' under section '2.2.5 Occlusion'. It lists nine diagnostic parameters for the patient's occlusion: Overjet (3 mm), Overbite (2 mm), Canine class (LHS: Class II, RHS: Class I), Molar class (LHS: Class II, RHS: ½ Class II), Crossbite (Absent), Crowding / Spacing (Lower anterior crowding, 33 malposed buccally), Rotation (Absent), Supraeruption (Absent), and Occlusal scheme (Canine guidance). This table quantifies the visual evidence presented in the accompanying photos.
### 2.2.6 Odontogram
#### Key Findings:
- **Sextant 1**: Missing tooth (marked by 'x'), root canal treated (RCT).
- **Sextant 2**: Missing tooth (marked by 'x'), amalgam restoration, unsatisfactory restoration.
- **Sextant 3**: Missing tooth (marked by 'x'), metal-ceramic crown, enamel infraction.
- **Sextant 4**: Missing teeth (marked by 'x'), non-carious tooth surface loss.
- **Sextant 5**: Missing teeth (marked by 'x'), amalgam restoration, composite restoration.
- **Sextant 6**: Missing teeth (marked by 'x'), amalgam restoration, unsatisfactory restoration.
- **Sextant 7**: Missing tooth (marked by 'x'), amalgam restoration, glass-ionomer cement restoration.
- **Sextant 8**: Missing tooth (marked by 'x'), amalgam restoration.
Poden
### 2.2.7 Periodontal Assessment
#### 2.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)
| CPITN | Sextant 1 | Sextant 2 | Sextant 3 | Sextant 4 | Sextant 5 | Sextant 6 |
|-------|-----------|-----------|-----------|-----------|-----------|-----------|
| | 3 | 2 | 2 | 2 | 2 | 2 |
**Findings:**
- **Sextant 1**: 17MB 5mm pocket likely due to over-contoured crown, generalized BOP, plaque, calculus.
- **Sextant 2**: Generalized BOP, plaque, calculus.
- **Sextant 3**: Generalized BOP, plaque, calculus.
- **Sextant 4**: Generalized BOP, plaque, calculus.
- **Sextant 5**: Generalized BOP, plaque, calculus.
- **Sextant 6**: Generalized BOP, plaque, calculus.
#### 2.2.7.2 Periodontal Examination
**Clinical:**
- **Gingival Tissues**: Light pink, oedematous, blunted papillae, medium biotype.
- **Plaque Distribution**: Generalized plaque distribution abundant in interproximal areas.
- **Plaque Score**: 70%.
- **Calculus Distribution**: Generalized calculus, abundant on buccal upper posterior teeth and lingual lower anterior teeth.
- **Plaque-Retentive Factors**: Restorations overhang 16, 15, 21, 22, 37, 45, 46, 47, open contact 36, over-contoured crown 17, lower anterior crowding, buccal malposition 33.
- **Furcation Involvement**: No.
- **Halitosis**: No.
**Radiographic:**
- **Bone Levels**: Generalized mild horizontal bone loss in maxilla and mandible.
#### Odontogram Key Findings
- **Missing Teeth:** 14, 24, 34, 44.
- **Endodontics:** Root canal treated (RCT) teeth at 11, 12, 36.
- **Restorations:** Heavily restored with amalgam, composite, and metal-ceramic crowns; several unsatisfactory restorations noted.
- **Tooth Surface Loss:** Non-carious loss observed in anterior regions.
#### Periodontal Assessment
**Community Index of Periodontal Treatment Needs (CPITN)**
- **Sextant 1:** Score 3 (5mm pocket at 17MB likely due to over-contoured crown).
- **Sextants 2-6:** Score 2 (Generalized bleeding on probing (BOP), plaque, and calculus).
**Clinical Findings**
- **Gingiva:** Light pink, oedematous, blunted papillae, medium biotype.
- **Plaque/Calculus:** 70% plaque score; abundant interproximal plaque; generalized calculus (heavy on upper posterior buccal and lower anterior lingual).
- **Plaque-Retentive Factors:** Overhanging restorations (16, 15, 21, 22, 37, 45, 46, 47), open contact (36), over-contoured crown (17), crowding, and malposition (33).
- **Radiographic:** Generalized mild horizontal bone loss.
![]()
Odontogram diagram illustrating dental status across four quadrants. The legend indicates: Amalgam restoration (grey), Metallic crown (yellow), Metal-ceramic crown (blue), Composite restoration (orange), Glass-ionomer cement restoration (purple), Non-carious tooth surface loss (white outline), Enamel infraction (hatched lines), Cracked tooth (asterisk), Caries (black dot), RCT (box with text 'RCT'), and Unsatisfactory restoration (red cross). Specific findings per sextant include: Sextant 1 has an amalgam restoration; Sextant 2 has a metallic crown with an unsatisfactory restoration; Sextant 3 shows enamel infraction and RCT; Sextant 4 displays non-carious tooth surface loss and caries; Sextant 5 has a composite restoration; Sextant 6 shows amalgam restoration and RCT; Sextant 7 has a glass-ionomer cement restoration; Sextant 8 shows amalgam restoration.
![]()
Table presenting the Community Index of Periodontal Treatment Needs (CPITN) for six sextants. Columns are labeled CPITN, Sextant 1 through Sextant 6. Rows list specific findings for each sextant. Notable values include CPITN scores of 3 for Sextant 1 and 2 for others. Findings describe conditions such as '17MB 5 mm pocket likely due to over-contoured crown' for Sextant 1, and 'Generalised BOP, plaque, calculus' for all other listed sextants.
![]()
Table summarizing periodontal examination findings divided into Clinical and Radiographic sections. Clinical details include gingival tissues description ('Light pink, oedematous...'), plaque score ('70%'), calculus distribution, plaque-retentive factors (listing specific teeth like 16, 15, 21, etc.), furcation involvement ('No'), and halitosis ('No'). Radiographic section notes bone levels showing 'Generalised mild horizontal bone loss in maxilla and mandible'.
**2.2.7.3 Periodontal tests**<br>
<table>
<thead>
<tr><th>Mobility</th><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr>
<tr><th>TTPalp</th><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr>
<tr><th>TTP</th><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr>
</thead>
<tbody>
<tr>
<td>&nbsp;</td>
<td>18</td>
<td>17</td>
<td>16</td>
<td>15</td>
<td>14</td>
<td>13</td>
<td>12</td>
<td>11</td>
<td>21</td>
<td>22</td>
<td>23</td>
<td>24</td>
<td>25</td>
<td>26</td>
<td>27</td>
<td>28</td>
</tr>
<tr>
<td>&nbsp;</td>
<td>48</td>
<td>47</td>
<td>46</td>
<td>45</td>
<td>44</td>
<td>43</td>
<td>42</td>
<td>41</td>
<td>31</td>
<td>32</td>
<td>33</td>
<td>34</td>
<td>35</td>
<td>36</td>
<td>37</td>
<td>38</td>
</tr>
<tr>
<td>TTP</td>
<td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr>
<tr>
<td>TTPalp</td>
<td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr>
<tr>
<td>Mobility</td>
<td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr>
</tbody>
</table><br>
**2.2.7.4 Periodontal chart**
* Local pocketing at one site and general risk assessment did not warrant full periodontal chart.<br>
**2.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)**<br>
<img>
Age: 61
Number of teeth and Implants: 24 (1 - 32)
Number of sites per tooth / implant: 6
Number of BOP-pos. sites: 99 of 144
Number of sites with PPD≥6mm: 1
Number of missing teeth: 4
% alveolar bone loss (estimated in % or 10% per 1mm): 25 %
Syst./Gen.: Yes No
Envir.: Non-smoker (NS); **Former smoker (FS)**; Occasional smoker (OS); Smoker (S); Heavy smoker (HS)<br>
Polygon surface: 21.65063
**Periodontal Risk: medium**
Suggested Recall Interval: 6 Months<br>
**2.2.8 Pulp sensibility tests**
<table>
<thead>
<tr><th>EPT</th><td>38</td><td>47</td><td>56</td><td>42</td><td>20</td><td>0</td><td>0</td><td>32</td><td>26</td><td>27</td><td>22</td><td>28</td><td>34</td><td>33</td></tr>
<tr><th>CO₂</th><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>-</td><td>-</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td></tr>
<tr><td>&nbsp;</td>
<td>18</td><td>17</td><td>16</td><td>15</td><td>14</td><td>13</td><td>12</td><td>11</td><td>21</td><td>22</td><td>23</td><td>24</td><td>25</td><td>26</td><td>27</td><td>28</td>
</tr>
<tr><td>&nbsp;</td>
<td>48</td><td>47</td><td>46</td><td>45</td><td>44</td><td>43</td><td>42</td><td>41</td><td>31</td><td>32</td><td>33</td><td>34</td><td>35</td><td>36</td><td>37</td><td>38</td>
</tr>
<tr>
<th>CO₂</th><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>++</td><td>+</td><td>+</td><td>+</td><td>-</td><td>+</td><td>+</td></tr>
<tr><th>EPT</th><td>34</td><td>30</td><td>44</td><td>29</td><td>27</td><td>19</td><td>4</td><td>14</td><td>7</td><td>27</td><td>34</td><td>0</td><td>26</td><td>48</td></tr>
</tbody>
</table>
#### Periodontal and Pulp Testing
**Periodontal Tests**
- **Mobility/TTP/TTPalp:** Negative (-) for all teeth 18-28 and 48-38.
**Periodontal Risk Assessment (PRA)**
- **Age:** 61
- **Teeth Present:** 24
- **BOP Sites:** 99 of 144
- **Deep Pockets:** 1 site with PPD ≥ 6mm
- **Bone Loss:** Estimated 25%
- **Environmental:** Former smoker
- **Overall Risk:** Medium
- **Recall Interval:** 6 Months
**Pulp Sensibility Tests (CO₂ and EPT)**
- **Non-Responsive (-):** 12, 11, 36 (All previously root canal treated).
- **Responsive (+):** All other teeth tested (18-13, 21-28, 48-37, 35-31, 41-45) responded normally to CO₂ and EPT.
![]()
Table of Periodontal tests for teeth numbered 18-28 (top row) and 48-38 (bottom row). Columns show Mobility (-), TTPalp (-), and TTP (-) results.
![]()
Periodontal Risk Assessment (PRA) visual. Includes a radar chart showing BOP% = 69, PD≥5mm, Tooth loss, BL/Age = 0.41, Syst./Gen., and Envir. axes. Adjacent input fields show Age: 61, Number of teeth/Implants: 24, Sites per tooth: 6, BOP-pos sites: 99/144, PPD≥6mm sites: 1, Missing teeth: 4, Bone loss: 25%, and Former smoker selected. Summary text indicates Polygon surface: 21.65063, Periodontal Risk: medium, Suggested Recall Interval: 6 Months.
![]()
Table of Pulp sensibility tests for teeth numbered 18-28 (top row) and 48-38 (bottom row). Columns show EPT values, CO₂ responses (+/-), and repeated EPT values in the bottom section with varying intensities (e.g., ++).
2.2.9 Radiographs
Rationale: each radiograph taken has rationale where stated – ALARA
Note: Subscript a = amalgam, c = composite, m = metallic, p = metal-ceramic
2.2.9.1 Orthopantogram
Date: 25/2/2019
<table border="1">
<tr>
<th colspan="2">Findings (9)</th>
</tr>
<tr>
<td>Periphery and corners</td>
<td>Nil abnormalities detected<br><i>Inferior rim of orbits (1) Articular processes of temporal bones (2) Cervical spine (3a) Superimposition of cervical spine (3b) Styloid processes (not identified) Pharynx (not identified) Hyoid bone (4) External acoustic meatuses (5)</i></td>
</tr>
<tr>
<td>Cortices of mandible</td>
<td>Continuous and even<br><i>Anterior and posterior rami (6) Coronoid processes (7) Condyles (8) Inferior borders of mandible (9)</i></td>
</tr>
<tr>
<td>Cortices of maxilla</td>
<td>Nil abnormalities detected<br><i>Posterior walls of maxillary sinuses (10) Medial walls of maxillary sinuses (11) Floor of maxillary sinuses (12) Zygomatic processes of maxillae (13) Pterygomaxillary fissures (14) Lateral pterygoid plate (15)</i></td>
</tr>
<tr>
<td>Zygomatic bones</td>
<td>Nil abnormalities detected<br><i>Zygomatic bone (16)</i></td>
</tr>
<tr>
<td>Maxillary sinuses</td>
<td>Internal density of sinuses: Radiopaque shadow within sinuses – superimposition of inferior nasal conchae and zygomatic buttresses</td>
</tr>
<tr>
<td>Nasal cavity and palate</td>
<td>Nil abnormalities detected<br><i>Floor of nose/hard palate (17) Nasal conchae (18) Anterior nasal spine (19) Soft palate (20)</i></td>
</tr>
<tr>
<td>Bone pattern of maxilla</td>
<td>Normal density and trabeculation</td>
</tr>
<tr>
<td>Bone pattern of mandible</td>
<td>Normal density and trabeculation<br>Two radiopaque spots on right body of mandible superimposed over 45 – amalgam tattoos<br><i>Inferior alveolar nerve canals (21) Mandibular foramina (not identified) Mental foramina (22) External oblique ridges (23)</i></td>
</tr>
<tr>
<td>Alveolar processes</td>
<td>Generalised mild horizontal bone loss in maxilla and mandible<br>No furcation involvement any teeth</td>
</tr>
<tr>
<td>Teeth</td>
<td>Heavily restored dentition<br>Endodontically treated teeth – 12, 11, 36<br>One premolar missing in each quadrant<br>Third molars present in each quadrant</td>
</tr>
</table>
Interpretation of panoramic radiographs, Perschbacher (2012). (9)
52
#### Radiographic Findings: Orthopantogram (OPG)
- **General Structures:** No abnormalities detected in the facial symmetry, mandible/maxilla cortices, zygomatic bones, or nasal cavity.
- **Maxillary Sinuses:** Radiopaque shadows noted, attributed to superimposition of nasal conchae.
- **Mandible:** Two radiopaque spots on the right body superimposed over 45, consistent with amalgam tattoos.
- **Alveolar Bone:** Generalized mild horizontal bone loss; no furcation involvement.
- **Dentition:**
- Heavily restored.
- Endodontically treated: 12, 11, 36.
- Missing: One premolar in each quadrant (14, 24, 34, 44).
- Third molars: Present in all quadrants.
![]()
Orthopantogram radiograph (dated 25/2/2019) showing the maxilla and mandible. The image is annotated with yellow arrows pointing to specific anatomical landmarks identified in the findings table: inferior rim of orbits (1), articular processes of temporal bones (2), cervical spine (3a), styloid processes (not identified) (3b), pharynx (not identified), hyoid bone (4), external acoustic meatuses (5), anterior and posterior rami (6), coronoid processes (7), condyles (8), inferior borders of mandible (9), posterior walls of maxillary sinuses (10), medial walls of maxillary sinuses (11), floor of maxillary sinuses (12), zygomatic processes of maxillae (13), pterygomaxillary fissures (14), lateral pterygoid plate (15), zygomatic bone (16), floor of nose/hard palate (17), nasal conchae (18), anterior nasal spine (19), soft palate (20), inferior alveolar nerve canals (21), mental foramina (22), and external oblique ridges (23).
![]()
Table titled 'Findings (9)' summarizing the interpretation of the orthopantogram. It lists anatomical regions (Periphery and corners, Cortices of mandible, Cortices of maxilla, Zygomatic bones, Maxillary sinuses, Nasal cavity and palate, Bone pattern of maxilla, Bone pattern of mandible, Alveolar processes, Teeth) and corresponding observations such as normal density, amalgam tattoos, mild horizontal bone loss, and endodontically treated teeth.
## 2.2.9.2 Bitewings
<table>
<tr>
<th colspan="2">Bitewing – Left</th>
<th colspan="2">Findings</th>
</tr>
<tr></tr>
<tr>
<td rowspan="4"><img style="width:100px;height:100px;" src="https://en.wikipedia.org/upload/resize_cache/visw/665/315_468.png"/></td>
<td>Caries</td>
<td colspan="2">36D (secondary caries)</td>
</tr>
<tr>
<td>Restorations</td>
<td colspan="2">25Oc, 26Oc, 27Oc, 28Oc, 38Oc, 37MOs (M overhang), 36MODs (M uneven, M open contact)</td>
</tr>
<tr>
<td>Pulp</td>
<td colspan="2">36 RCT (RCF radiographically deficient)</td>
</tr>
<tr>
<td>Periodontium</td>
<td colspan="2">25M PDL widening</td>
</tr>
<tr>
<td>Date: 7/5/2019<br/>Rationale: Examine interproximal areas of teeth</td>
<td>Other</td>
<td colspan="2">Calculus, overlap between 26D & 27M, 27D & 28M, 38M & 37D</td>
</tr>
<tr></tr>
<tr>
<th colspan="2">Bitewing – Right</th>
<th colspan="2">Findings</th>
</tr>
<tr></tr>
<tr>
<td rowspan="5"><img style="width:100px;height:100px;" src="https://en.wikipedia.org/upload/resize_cache/visw/665/315_477.png"/></td>
<td>Caries</td>
<td colspan="2">17M (?)*, 47M (secondary caries)</td>
</tr>
<tr>
<td>Restorations</td>
<td colspan="2">¹µ, 17 crown (over-contoured), 16Oc & MOs (M overhang), 15MODs (M overhang), 45MODs (M overhang), 46 pinned core & crown (M&D overhangs), 47MOs (M overhang), 48Oc</td>
</tr>
<tr>
<td>Pulp</td>
<td colspan="2">46 (retention pins extend close to pulp horns), 47 (history of pulp capping?)</td>
</tr>
<tr>
<td>Periodontium</td>
<td colspan="2">15D slight PDL widening</td>
</tr>
<tr>
<td>Date: 7/5/2019<br/>Rationale: Examine interproximal areas of teeth</td>
<td>Other</td>
<td colspan="2">Calculus, overlap between 47D & 48M, radiopacities superimposed over 45 (amalgam tattoos), radiographic artifact superimposed over 48</td>
</tr>
</table>
*Clinically confirmed non-carious.
## 2.2.9.3 Periapicals
<table>
<tr>
<th colspan="2">Periapical – 11-12</th>
<th colspan="2">Findings</th>
</tr>
<tr></tr>
<tr>
<td rowspan="5"><img style="width:100px;height:100px;" src="https://en.wikipedia.org/upload/resize_cache/visw/665/315_484.png"/></td>
<td>Caries</td>
<td colspan="2">21M (secondary caries)</td>
</tr>
<tr>
<td>Restorations</td>
<td colspan="2">12 cast post-core and crown (post-core wide in relation to root width, gap between post and apical RCF)<br/>11 post-core and crown (post long axis not parallel to root long axis, inadequate length, gap between post and apical RCF, margins questionable)<br/>21MOs</td>
</tr>
<tr>
<td>Pulp</td>
<td colspan="2">12 RCT (RCF radiographically deficient but satisfactory)<br/>11 RCT (RCF radiographically short of apex and deficient)</td>
</tr>
<tr>
<td>Periodontium</td>
<td colspan="2">Intact PDL & lamina dura 12, 11, nil PA radiolucency 12, 11</td>
</tr>
<tr>
<td>Date: 7/5/2019<br/>Rationale: Check RCT'd teeth and for pathology before fixed prosthodontics</td>
<td>Other</td>
<td colspan="2">12 blunted root apex*</td>
</tr>
</table>
*External apical root resorption, undesirable complication of orthodontic treatment. (31)
#### Bitewing Radiographs
**Left Bitewing**
- **Caries:** Secondary caries at 36D.
- **Restorations:** Multiple occlusal amalgams; 37MO overhang; 36MOD open contact and uneven contour.
- **Pulp:** 36 RCT is radiographically deficient.
- **Periodontium:** PDL widening at 25M.
- **Other:** Calculus; interproximal overlaps.
**Right Bitewing**
- **Caries:** Secondary caries at 47M.
- **Restorations:** 17 over-contoured crown; multiple amalgams with mesial overhangs (16, 15, 45, 47); 46 crown with M&D overhangs.
- **Pulp:** 46 retention pins near pulp; 47 possible history of pulp capping.
- **Other:** Amalgam tattoos at 45; calculus.
#### Periapical Radiographs
**Teeth 11-12**
- **Caries:** Secondary caries at 21M.
- **Restorations:**
- 12: Cast post-core (wide) and crown; gap between post and RCF.
- 11: Post-core and crown; post not parallel to root, inadequate length, gap between post and RCF.
- **Pulp:** 12 RCT deficient but satisfactory; 11 RCT short and deficient.
- **Periodontium:** Intact PDL; no periapical radiolucency.
- **Other:** 12 blunted root apex (external apical resorption from previous ortho).
![]()
Bitewing radiograph of the left side showing teeth and dental work. Caption: 'Date: 7/5/2019', 'Rationale: Examine interproximal areas of teeth'.
![]()
Bitewing radiograph of the right side showing teeth and dental work. Caption: 'Date: 7/5/2019', 'Rationale: Examine interproximal areas of teeth'.
![]()
Periapical radiograph focusing on teeth 11-12 showing root canals and restorations. Caption: 'Date: 7/5/2019', 'Rationale: Check RCT'd teeth and for pathology before fixed prosthodontics'.
**Periapical – 21-22**
**Findings**
Caries - 21 M&D (secondary caries), 22M?
Restorations - 21 Mξ&Dξ (M overhang), 22M
Pulp - Nil abnormalities detected
Periodontium - Intact PDL & lamina dura 21, 22, nil PA radiolucency 21, 22
Other -
*Clinically confirmed non-carious.*
**Periapical – Quadrant 3**
**Findings**
Caries - 36D (secondary caries)
Restorations - 38Oξ, 37MOξ (M overhang), 36MODξ (M uneven, M open contact)
Pulp - 36 RCT (RCF radiographically deficient), radiopaque liner in pulp chamber
Periodontium - Intact PDL & lamina dura35, 36, 37, PA radiolucency 36?*, nil PA radiolucency 35, 37
Other - Calculus, overlap between 38M & 37D
*Consultation with Endodontist – as tooth asymptomatic for many years likely that radiolucency is scar tissue.*
**Periapical – Quadrant 4**
**Findings**
Caries - 46M (secondary caries), 47M (secondary caries)
Restorations - 45MODξ (M overhang), 46 pinned core & crown (M&D overhangs), 47MOξ (M overhang), 48Oξ
Pulp - 46 (retention pins extend close to pulp horns), 47 (history of pulp capping?)
Periodontium - Intact PDL & lamina dura 45, 46, 47, nil PA radiolucency 45, 46, 47
Other - Calculus, overlap between 47D & 48M, radiopacities superimposed over 45 (amalgam tattoos)
#### Periapical Radiographs (Continued)
**Teeth 21-22**
- **Caries:** Secondary caries at 21 M&D.
- **Restorations:** 21 M&D composites (M overhang); 22M composite.
- **Periodontium:** Intact PDL and lamina dura; no periapical radiolucency.
**Quadrant 3**
- **Caries:** Secondary caries at 36D.
- **Restorations:** 37MO overhang; 36MOD uneven with open contact.
- **Pulp:** 36 RCT radiographically deficient; radiopaque liner present.
- **Periodontium:** Possible PA radiolucency at 36 (Endodontist consultation suggests scar tissue as tooth is asymptomatic).
**Quadrant 4**
- **Caries:** Secondary caries at 46M and 47M.
- **Restorations:** 45MOD overhang; 46 crown with M&D overhangs; 47MO overhang.
- **Pulp:** 46 retention pins near pulp; 47 possible pulp capping.
- **Periodontium:** Intact PDL; no periapical radiolucency.
![]()
Clinical table titled 'Periapical – 21-22' containing an X-ray image of teeth 21 and 22 with a date of 30/5/2019. The findings section lists caries (secondary caries on M&D), restorations (M overhangs), pulp status (nil abnormalities), periodontium (intact PDL & lamina dura), and notes on radiolucency.
![]()
Clinical table titled 'Periapical – Quadrant 3' containing an X-ray image of lower left teeth with a date of 7/5/2019. Findings include secondary caries on tooth 36D, multiple restorations with noted overhangs, RCT on tooth 36 with deficient radiopaque liner, intact periodontium, and calculus overlap between 38M & 37D.
![]()
Clinical table titled 'Periapical – Quadrant 4' containing an X-ray image of lower right teeth with a date of 7/5/2019. Findings include secondary caries on 46M and 47M, complex restorations including pinned core/crown on 46 with overhangs, retention pins close to pulp horns on 46, intact periodontium, and amalgam tattoos superimposed over 45.
• Cawies risk assessment
2.2.10.1 Dietary assessment
• Generally, diet is: Low sugar - Low acid - Moderate sterilable carbohydrates
- Limited snacking frequency
- Lacking dairy
2.2.10.2 Saliva test
\begin{tabular}{|l|l|l|l|l|}
\hline
\multicolumn{3}{|c|}{Unstimulated saliva} & \multicolumn{2}{|c|}{Stimulated saliva} \\
\hline
Flow rate & Consistency & pH & Quantity at 5 mins & Buffering capacity \\
\hline
>60 s - low & Sticky/frothy & 5.0-5.8 & <3.5 mL - very low & 0-5 - very low \\
\hline
30-60 s - normal & Frothy/bubbly & 6.0-6.6 & 3.5-5.0 mL - low & 6-9 - low \\
\hline
<30 s - high & Watery/clear & 6.8-7.8 & >5.0 mL - normal & 10-12 - normal \\
\hline
\end{tabular}
2.2.10.3 Caries Management By Risk Assessment (CAMBRA)
\begin{tabular}{|l|l|}
\hline
Disease indicators & Visible cavities or radiographic penetration of the dentine Radiographic approximal enamel lesions (not in dentine) \\
\hline
Risk factors & Visible heavy plaque on teeth \\
\hline
Protective factors & Lives/works/school in fluoridated community Fluoride toothpaste (1000 ppm+) at least once daily Adequate saliva flow (>1.0 mL/min stimulated) \\
\hline
\end{tabular}
- Caries risk: Moderate
- Suggested management:
- OTC tootpaper with 1000 ppm fluoride, 2x daily
- OTC fluoride rinse (0.05% NaF), 1x daily
- Xylitoll candies or gums, 4x daily
(10) Caries Management by Risk Assessment, Featherstone 4 Chaffee (2018).
#### Caries Risk Assessment
**Dietary Assessment**
- Low sugar and low acid intake.
- Moderate fermentable carbohydrates.
- Limited snacking frequency.
- Lacking dairy products.
**Saliva Testing**
- **Unstimulated:** Normal flow (30-60s), frothy/bubbly consistency, pH 6.0-6.6.
- **Stimulated:** Normal quantity (>5.0 mL at 5 mins), normal buffering capacity (10-12).
**CAMBRA (Caries Management By Risk Assessment)**
- **Disease Indicators:** Visible cavities and radiographic penetration into dentine.
- **Risk Factors:** Visible heavy plaque.
- **Protective Factors:** Fluoridated community, fluoride toothpaste 2x daily, adequate saliva flow.
- **Overall Risk:** Moderate.
**Management Plan**
- 1000 ppm fluoride toothpaste, 2x daily.
- 0.05% NaF rinse, 1x daily.
- Xylitol candies or gums, 4x daily.
![]()
A table titled 'Saliva test' comparing Unstimulated saliva and Stimulated saliva. It includes columns for Flow rate, Consistency, pH, Quantity at 5 mins, and Buffering capacity with corresponding values and classifications (e.g., >60 s - low, Sticky/frothy, 5.0-5.8, <3.5 mL - very low, 0-5 - very low).
![]()
A table titled 'Caries Management By Risk Assessment (CAMBRA)' listing Disease indicators (Visible cavities or radiographic penetration of the dentine, Radiographic approximal enamel lesions), Risk factors (Visible heavy plaque on teeth), and Protective factors (Lives/works/school in fluoridated community, Fluoride toothpaste 1000 ppm+ at least once daily, Adequate saliva flow >1.0 mL/min stimulated).
**Table 1: Diagnoses and problem list**
| Category | Diagnosis | Details |
|----------|-----------|---------|
| Pathological | Caries | Multiple teeth with secondary caries |
| | Restorations | Heavily restored dentition – RCT, crowns, large amalgam restorations, composite restorations, several unsatisfactory |
| | Endodontic disease (11, 12) | 47 chronic reversible pulpitis and clinically normal periapical tissues due to broken down restoration and secondary caries<br>36 previous endodontic treatment with no signs of infection and clinically normal periapical tissues<br>12 previous endodontic treatment with no signs of infection and clinically normal periapical tissues<br>11 previous endodontic treatment with no signs of infection and clinically normal periapical tissues |
| | Periodontal disease (13) | Generalised Stage II Grade B unstable periodontitis* |
| | Oral medicine | Actinic cheilitis<br>Bilateral frictional keratosis of buccal mucosa<br>Amalgam tattoo buccal gingiva 45 |
| Morphological | Non-carious tooth surface loss | 13I, 23I, 321 |
| | Cracked teeth | 27, 36, 47 |
| | Angle class | Indications Angle skeletal class II |
| | Malocclusion | Class II malocclusion, lower anterior crowding |
| | Overbite/Overjet | 2 mm / 3 mm |
| | Missing teeth | 14, 24, 34, 44 |
| | Aesthetic harmony | Incisal plane cant<br>Facial midline and dental midline discrepancy<br>Maxillary midline and mandibular midline discrepancy<br>High smile line, extra wide smile, flat incisal curve<br>Poor pink aesthetics<br>Disharmony of anterior teeth 13-23 |
| | Occlusal stability | Stable occlusion |
| | Guidance system | Canine guidance |
| Host-related factors | Psychosocial | Excellent personal presentation<br>High aesthetic concern<br>Slight skepticism towards dental treatment and radiation<br>Good oral hygiene compliance<br>Good dental attitude and motivated to attend appointments |
| | Habits | Fair oral hygiene<br>Low sugar, low acid, moderate fermentable carbohydrate diet |
| | Socioeconomic | Uncertainty regarding possible relocation to Sydney<br>Employed and willing to use financial resources for dental care |
| | Medical | Medically fit and healthy |
| | Functional | Strong gag reflex |
*(11) Classification, diagnosis and clinical manifestations of apical periodontitis, Abbott (2004). (12) A clinical classification of the status of the pulp and the root canal system, Abbott & Yu (2007). (13) Periodontitis: Consensus report if workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions, Papapanou et al. (2018).*
*Stage II – RBL 15%-33%, no tooth loss due to periodontitis, max probing depth ≤ 5 mm, mostly horizontal bone loss. Generalised – bone loss affects all teeth. Grade B – %BL/age 0.25-1.0, however heavy biofilm deposits with low levels of destruction, non-smoker, normoglycaemic. Unstable - probing depth ≥5 mm, however limited to one site. (13)*
#### Diagnoses and Problem List
**Pathological**
- **Caries:** Multiple teeth with secondary caries.
- **Restorations:** Heavily restored dentition; several unsatisfactory restorations.
- **Endodontic:** 47 chronic reversible pulpitis; 36, 12, 11 previous RCT with normal periapical tissues.
- **Periodontal:** Generalised Stage II Grade B unstable periodontitis.
- **Oral Medicine:** Actinic cheilitis; bilateral frictional keratosis; amalgam tattoo at 45.
**Morphological & Aesthetic**
- **Tooth Loss:** Non-carious surface loss (13I, 23I, 32I); missing 14, 24, 34, 44.
- **Cracked Teeth:** 27, 36, 47.
- **Malocclusion:** Class II profile; lower anterior crowding; midline discrepancies.
- **Aesthetics:** Incisal plane cant; disharmony of 13-23; poor pink aesthetics (gingival recession/discolouration).
**Host-Related Factors**
- **Psychosocial:** High aesthetic concern; slight skepticism of radiation/treatment; good compliance.
- **Medical/Functional:** Medically fit; strong gag reflex.
- **Socioeconomic:** Employed; potential relocation to Sydney.
![]()
A detailed table titled 'Diagnoses and problem list' with sub-sections for Pathological, Morphological, and Host-related factors. The table lists various dental conditions and patient details such as caries, restorations, endodontic disease, periodontal disease, oral medicine issues, non-carious tooth surface loss, cracked teeth, angle class, malocclusion, overbite/overjet, missing teeth, aesthetic harmony, occlusal stability, guidance system, psychosocial aspects, habits, socioeconomic status, medical condition, and functional reflexes. Each row provides specific diagnoses or observations related to the category.
2.3.2 Problem list
* Pulpal pathology: 47
* Secondary caries: 21M&D, 36D, 45MO, 46M, 47M
* Heavily restored dentition with several unsatisfactory restorations
* Over-contoured: 17 crown
* Overhangs: 16M, 15M, 21M, 22M, 37M, 45M, 46M&D, 47M
* Open contact: 36M
* Poor aesthetics: 12 crown, 11 crown, 21M&D, 22M
* Poor aesthetics
* Asymmetry of anterior teeth 13-23
* Discoloured teeth: 13, 21
* Non-ideal colour: 12, 11, 21, 22
* Non-ideal size, shape, contours: 12, 21, 22
* Asymmetry of incisal embrasures: larger on left than right
* Pink aesthetic: high smile line, 12 gingival recession, loss of interdental papillae, non-ideal gingival zenith height and symmetry, gingival discolouration 12-11
* Cracked teeth: 27, 36, 47
* Asymptomatic endodontically treated teeth with questionable RCF: 12, 11, 36
* Generalised Stage II Grade B unstable periodontitis
* Actinic cheilitis
* Strong gag reflex
* Uncertainty regarding possible relocation to Sydney
57
#### Detailed Problem List
- **Pulpal/Caries:** 47 pathology; secondary caries at 21, 36, 45, 46, 47.
- **Unsatisfactory Restorations:**
- Over-contoured: 17 crown.
- Overhangs: 16, 15, 21, 22, 37, 45, 46, 47.
- Open contact: 36M.
- **Aesthetic Deficits:**
- Asymmetry and discolouration of 13-23.
- Non-ideal size/shape/contour of 12, 21, 22.
- Pink aesthetics: High smile line, recession at 12, loss of papillae, gingival discolouration.
- **Structural/Endodontic:** Cracked teeth (27, 36, 47); questionable RCF in asymptomatic teeth (12, 11, 36).
- **Periodontal:** Generalised Stage II Grade B unstable periodontitis.
- **Other:** Actinic cheilitis; strong gag reflex; relocation uncertainty.
**2.4 Prognosis (14)**
**2.4.1 Individual teeth**
```html
<table border="1" cellspacing="0">
<tr>
<th>
Patient number
</th>
<th>
Periodontal condition
</th>
<th>
Restorability
</th>
<th>
Endodontic condition
</th>
<th>
Occlusal plane & tooth position
</th>
<th>
Anatomical irregularities
</th>
<th>
Iatrogenic factors
</th>
</tr>
<tr>
<td>
18
</td>
<td>
Excellent
</td>
<td>
Good
</td>
<td>
Good
</td>
<td>
Excellent
</td>
<td>
Poor
</td>
<td>
Excellent
</td>
</tr>
<tr>
<td>
17
</td>
<td>
Excellent
</td>
<td>
Good
</td>
<td>
Good
</td>
<td>
Excellent
</td>
<td>
Fair
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
16
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Good
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
15
</td>
<td>
Questionable
</td>
<td>
Poor
</td>
<td>
Good
</td>
<td>
Fair
</td>
<td>
Poor
</td>
<td>
Poor
</td>
</tr>
<tr>
<td>
48
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Questionable
</td>
<td>
Fair
</td>
<td>
Excellent
</td>
<td>
Excellent
</td>
</tr>
<tr>
<td>
47
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Questionable
</td>
<td>
Fair
</td>
<td>
Excellent
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
46
</td>
<td>
Poor
</td>
<td>
Questionable
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Excellent
</td>
<td>
Poor
</td>
</tr>
<tr>
<td>
45
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Poor
</td>
</tr>
<tr>
<td>
13
</td>
<td>
Excellent
</td>
<td>
Good
</td>
<td>
Good
</td>
<td>
Excellent
</td>
<td>
Excellent
</td>
<td>
Excellent
</td>
</tr>
<tr>
<td>
12
</td>
<td>
Excellent
</td>
<td>
Good
</td>
<td>
Good
</td>
<td>
Excellent
</td>
<td>
Fair
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
11
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Good
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Fair
</td>
</tr>
<tr>
<td>
21
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Good
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Fair
</td>
</tr>
<tr>
<td>
22
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Good
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
23
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Good
</td>
<td>
Poor
</td>
<td>
Poor
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
25
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Good
</td>
</tr>
<tr>
<td>
26
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Poor
</td>
</tr>
<tr>
<td>
27
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Poor
</td>
</tr>
<tr>
<td>
28
</td>
<td>
Fair
</td>
<td>
Questionable
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Fair
</td>
<td>
Fair
</td>
</tr>
<tr>
<td>
Key:
</td>
<td>
**Good**: Green
</td>
<td>
**Fair**: Yellow
</td>
<td>
**Questionable**: Amber
</td>
<td>
**Poor**: Red
</td>
<td>
**Hopeless**: Black
</td>
<td>
**Excellent**: Dark Green
</td>
</tr>
</table>
```
**Evaluation of pathology and scale of severity**
| Class | A - Good | B - Fair | C - Questionable |
|---|---|---|---|
| Periodontal condition | 80%-100% bone support. Easily maintained. | 50%-80% bone support. Can be well maintained. | 30%-50% remaining bone support. Difficult to be well maintained. |
| Restorability | 80%-100% remaining sound coronal tooth structure. Easily restored. | 50%-80% remaining sound coronal tooth structure. Restoration results in no infringement of biologic width, has adequate ferrule, good crown-root ratio. | 30%-50% remaining sound coronal tooth structure. Achieving adequate ferrule would compromise crown-root ratio to some extent or affect adjacent structures. |
| Endodontic condition | Can receive straightforward primary endodontic treatment, or already has good endodontic therapy. | Failing endodontic treatment can receive predictable re-treatment, or requires a difficult primary endodontic treatment. | Failing endodontic treatment that is difficult to predictably re-treat. |
| Occlusal plane & tooth position | Tooth in correct occlusal plane, position, slightly deviated from ideal. | Tooth out of correct occlusal plane, can be adjusted to function within correct occlusal plane. | Tooth out of occlusal plane and requires multiple procedures to function within occlusal plane. |
**Factors that result in drop of determined class**
| Iatrogenic compromising factors | Perforations, extensive post preparations, minimal tooth structure thickness left after preparation, dental materials that cannot be removed, etc. 12 – extensive post space preparation 27, 36, 47 – cracked teeth from large amalgam restorations | | |
|---|---|---|---|
**58**
#### Individual Tooth Prognosis
| Tooth | Periodontal | Restorability | Endodontic | Position | Iatrogenic |
| :--- | :--- | :--- | :--- | :--- | :--- |
| 18, 13 | Excellent | Good | Good | Excellent | Excellent |
| 17, 12 | Excellent | Good | Good | Excellent | Good |
| 16 | Fair | Questionable | Good | Poor | Good |
| 15, 45 | Questionable | Poor | Good/Poor | Fair/Poor | Poor |
| 48, 47 | Fair | Questionable | Questionable | Fair | Exc./Good |
| 46 | Poor | Questionable | Poor | Poor | Poor |
| 11, 21 | Fair | Questionable | Good | Poor | Fair |
| 22, 23 | Fair | Questionable | Good | Poor | Good |
| 25-28 | Fair | Questionable | Fair | Fair | Good/Poor |
**Prognosis Criteria**
- **Good:** 80-100% bone support/structure; easily maintained/restored.
- **Fair:** 50-80% bone support/structure; predictable re-treatment possible.
- **Questionable:** 30-50% bone support/structure; difficult to maintain or restore.
- **Poor:** Significant loss of support or structure; complex procedures required.
- **Iatrogenic Factors:** Extensive post preps (12) and cracked teeth (27, 36, 47) reduce the determined class.
![]()
Table titled '2.4 Prognosis (14) - 2.4.1 Individual teeth' showing prognosis ratings for multiple patient teeth (numbered 18-48). Rows include: iatrogenic compromising factors, anatomic irregularities, occlusal plane & tooth position, endodontic condition, restorability, and periodontal condition. Columns are color-coded by severity: green dots = Good, yellow dots = Questionable, red squares = Hopeless, black squares = Poor.
![]()
Second table in the same section, mirroring the structure of the first but with different data rows for another set of patients. Same row/column categories and color coding apply.
![]()
Key legend table explaining the color codes used in the prognosis tables: Green square = Good, Yellow square = Questionable, Red square = Hopeless, Light green square = Fair, Orange square = Poor.
![]()
Detailed evaluation table titled 'Evaluation of pathology and scale of severity', subdivided into three classes: Class A – Good, Class B – Fair, Class C – Questionable. Each class has descriptive criteria for five parameters: Periodontal condition, Restorability, Endodontic condition, Occlusal plane & tooth position, and Iatrogenic compromising factors.
2.4.2 Patient-level risk factors
| | |
|---|---|
| **Biologic risk factors** | |
| Medical conditions that impair immune function and healing | • Nil |
| Impaired salivary flow/function | • Adequate salivary flow |
| Medical condition or disability limiting oral hygiene | • Nil |
| Other missing teeth | • No missing teeth due to periodontal disease or caries |
| **Behavioural risk factors** | |
| Compromised or poor oral hygiene | • Fair oral hygiene |
| Cariogenic diet | • Low cariogenic diet |
| Low exposure to fluoride | • Adequate exposure to fluoride |
| Parafunctional habits | • No |
| Ability and willingness to adhere to long-term maintenance protocol | • Yes |
| Smoking | • Has not smoked in last 40 years |
| **Financial and personal risk factors** | |
| Motivation for treatment | • Highly motivated |
| Available resources for dental care | • Currently employed |
| Willingness to commit finances, time, and effort | • Willing to commit finances, time and effort (length of time uncertain) |
| Attitude toward losing teeth | • Strong willingness to preserve existing teeth |
| Understanding of one’s condition and needed treatment | • Yes |
| Aesthetic expectations | • Reasonable |
| Low dental IQ | • Adequate dental IQ |
Key:
**Green:** Favourable
**Yellow:** Questionable
**Red:** Unfavourable
(14) Evaluation of prognosis of individual teeth and patient-level risk factors adapted from Samet and Jotkowitz (2009).
2.4.3 Overall dentition
- All teeth are in the correct occlusal plane and majority of teeth have sound periodontal and pulp health.
- History of extensive restoration of posterior teeth has detrimental effect on restorability and prognosis.
- Patient’s unremarkable medical history, low cariogenic, low acid diet and ability to maintain good oral hygiene is favourable to prognosis of dentition.
- Patient has high aesthetic motivation and is willing to commit finances, effort and time to treatment.
- Factors that may affect treatment include patient’s uncertainty in future plans, slight skepticism towards dental treatment and apprehension to radiation.
- If patient receives no treatment for current condition:
- Progression of carious disease process, potential to cause pulpal involvement and consequently infection, pain and tooth loss with no intervention.
- Longstanding poor aesthetic condition of teeth and soft tissues and likely further deterioration without treatment could potentially further decrease patient’s confidence, self-esteem and quality of life.
- Discussion of diagnoses and prognoses of dentition with patient led patient to decide on and commit to treatment.
#### Patient-Level Risk Factors
- **Favourable (Green):** Adequate salivary flow, low cariogenic diet, fluoride exposure, non-smoker (40 years), high motivation, adequate dental IQ.
- **Questionable (Yellow):** Fair oral hygiene, willingness to commit finances (uncertain timeframe), aesthetic expectations.
- **Unfavourable (Red):** None identified.
#### Overall Dentition Prognosis
- **Positive Factors:** Correct occlusal plane for most teeth; sound periodontal/pulp health for majority; good medical history and diet.
- **Negative Factors:** History of extensive posterior restorations; uncertainty regarding relocation; apprehension toward radiation.
- **Risk of No Treatment:** Progression of caries leading to pain/infection; deterioration of aesthetics impacting quality of life.
![]()
A structured table titled '2.4.2 Patient-level risk factors' adapted from Samet and Jotkowitz (2009). The table categorizes risk factors into three sections: Biologic, Behavioural, and Financial/personal. Each row lists a specific factor (e.g., Medical conditions, Oral hygiene) with corresponding patient status values (e.g., Nil, Fair oral hygiene, Highly motivated). A column of colored dots indicates the prognostic value of each factor.
![]()
A color-coded legend key located below the main table. It defines the meaning of the colored indicators used in the table above: Green represents 'Favourable', Yellow represents 'Questionable', and Red represents 'Unfavourable'. This is essential for interpreting the patient's risk profile.
2.5 Treatment options
| **Problem** | **Treatment Option** | **Benefits** | **Risks** | **Decision & Rationale** |
| ----------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------- | ------------------------------------- | -------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------ |
| **Tooth 47**:<br>- **Pulpal pathology**<br>- Unsat. restoration ($MO_4$; ML fracture, M<br>secondary caries, M overhang)<br>- Cracked tooth | 1 **No treatment** | No commitment required | - Does not address presenting complaint<br>- Ongoing symptoms<br>- Plaque trapping, gingival inflammation<br>- Crack progression<br>- Caries, pulpal involvement, infection<br>- Breakdown of tooth structure<br>- Extraction | **Option 2**:<br>- Addresses presenting complaint<br>- Eliminate factor in gingival inflammation<br>- Eliminate cause of pulpal inflammation<br>- Prevent further breakdown of tooth structure due to caries and cracking<br>- Further deterioration of tooth may involve extensive/invasive treatment in future to save tooth or render tooth unrestorable |
| | 2 Remove caries and restoration<br>Endodontic assessment<br>Assess restorability<br>Temporise and monitor<br>Restore | Eliminate cause of symptoms<br>Tooth preservation | - Pulpal irritation, post-operative sensitivity<br>- Following crack extensions could render tooth unrestorable and indicate tooth for extraction | |
| **Tooth 46**:<br>- Unsat. restoration (crown$M_{m}$; M secondary<br>caries, M&D overhang) | 1 **No treatment** | No commitment required | - Plaque trapping, gingival inflammation<br>- Caries, pulpal involvement, infection<br>- Breakdown of tooth structure | **Option 2**:<br>- Eliminate factor in gingival inflammation<br>- Prevent further breakdown of tooth structure due to caries |
| | 2 Remove caries and restoration<br>Assess restorability<br>Restore | Eliminate plaque trap for gingival healing<br>Eliminate caries<br>Tooth preservation | - Pulpal irritation, post-operative sensitivity<br>- Quality and quantity of underlying tooth structure unknown, inadequate remaining coronal tooth structure may involve extensive restorative work | |
| **Tooth 45**:<br>- Unsat. restoration ($MO_2$; MO secondary<br>caries, M overhang) | 1 **No treatment** | No commitment required | - Plaque trapping, gingival inflammation<br>- Caries, pulpal involvement, infection<br>- Breakdown of tooth structure | **Option 2**:<br>- Eliminate factor in gingival inflammation<br>- Prevent further breakdown of tooth structure due to caries |
| | 2 Remove caries and restoration<br>Restore | Eliminate plaque trap for gingival healing<br>Eliminate caries<br>Tooth preservation | - Pulpal irritation, post-operative sensitivity | |
| **Tooth 36**:<br>- Unsat. restoration ($MOD_2$; D secondary<br>caries, M open contact, M uneven contour)<br>- Cracked tooth<br>- Questionable RCT | 1 **No treatment** | No commitment required | - Plaque and food trapping, gingival inflammation<br>- Crack progression<br>- Caries, pulpal involvement, infection<br>- Breakdown of tooth structure<br>- Extraction | **Option 3**:<br>- Eliminate factor in gingival inflammation<br>- Prevent further breakdown of tooth structure due to caries<br>- Asymptomatic, however further deterioration of tooth |
60
#### Treatment Options: Posterior Teeth
**Tooth 47 (Pulpal pathology, cracked, secondary caries)**
- **Option 1:** No treatment (Risk of pain, infection, extraction).
- **Option 2 (Selected):** Remove caries/restoration, assess restorability, temporise, and restore. Addresses symptoms and prevents further breakdown.
**Tooth 46 (Secondary caries, overhangs)**
- **Option 1:** No treatment (Risk of caries progression and inflammation).
- **Option 2 (Selected):** Remove caries/restoration, assess, and restore. Eliminates plaque traps and caries.
**Tooth 45 (Secondary caries, overhang)**
- **Option 1:** No treatment.
- **Option 2 (Selected):** Remove caries and restore. Eliminates plaque trap and caries.
**Tooth 36 (Secondary caries, cracked, questionable RCT)**
- **Option 1:** No treatment.
- **Option 3 (Selected):** Endodontic assessment, assess restorability, endodontic re-treatment, and restore. Provides the most predictable outcome for an extensively damaged tooth.
![]()
A structured table titled '2.5 Treatment options' detailing clinical decision-making for four specific teeth (47, 46, 45, and 36). The table is organized into five columns: Problem, Treatment Option, Benefits, Risks, and Decision & Rationale. It presents a comparison between 'No treatment' and active intervention strategies for each tooth, outlining the associated medical benefits, potential risks (such as infection or extraction), and the rationale for selecting one option over another.
<table>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Endodontic assessment</li><li>Assess restorability</li><li>No endodontic re-treatment</li><li>Restore</li></ul></td>
<td><ul><li>Less commitment required than option 3</li><li>Eliminate plaque trap and food trap for gingival healing</li><li>Eliminate caries</li><li>Tooth preservation</li></ul></td>
<td><ul><li>Less predictable treatment outcome</li><li>Inadequate remaining coronal tooth structure may involve extensive restorative work</li><li>Following crack extensions could render tooth unrestorable and indicate tooth for extraction</li></ul></td>
<td>may involve extensive/invasive treatment in future to save tooth or render tooth unrestorable<li>Quality of RCT controlled resulting in more predictable treatment outcome</li></td>
</tr>
<tr>
<td></td>
<td>3</td>
<td><ul><li>Endodontic assessment</li><li>Assess restorability</li><li>Endodontic re-treatment</li><li>Restore</li></ul></td>
<td><ul><li>Eliminate plaque and food trap for gingival healing</li><li>Eliminate caries</li><li>Tooth preservation</li><li>More predictable treatment outcome</li></ul></td>
<td><ul><li>More commitment required than option 2</li><li>Inadequate remaining coronal tooth structure may involve extensive restorative work</li><li>Following crack extensions could render tooth unrestorable and indicate tooth for extraction</li></ul></td>
<td></td>
</tr>
<tr>
<td>Tooth 37:<br>- Unsat. restoration (MOa; M overhang)</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Plaque trapping, gingival inflammation</li><li>Caries, pulpal involvement, infection</li><li>Breakdown of tooth structure</li></ul></td>
<td>Option 2:<ul><li>Eliminate factor in gingival inflammation</li><li>Reduce risk of caries</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Polish restoration</li></ul></td>
<td><ul><li>Eliminate plaque trap for gingival healing</li><li>Conservative</li></ul></td>
<td><ul><li>Over-polishing could result in open contact</li></ul></td>
<td></td>
</tr>
<tr>
<td>Tooth 27:<br>- Cracked tooth</td>
<td>1</td>
<td><ul><li>No treatment and monitor for symptoms or further breakdown</li></ul></td>
<td><ul><li>No commitment required</li><li>Conservative</li></ul></td>
<td><ul><li>Crack progression</li><li>Caries, pulpal involvement, infection</li><li>Breakdown of tooth structure</li><li>Extraction</li></ul></td>
<td>Option 1:<ul><li>Asymptomatic</li><li>Crack investigation could lead to inability to restore tooth</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Restore</li></ul></td>
<td><ul><li>Early intervention may prevent crack progression, caries, pulpal involvement, infection, catastrophic tooth fracture</li></ul></td>
<td><ul><li>Following crack extensions could render tooth unrestorable and indicate tooth for extraction</li><li>Inadequate remaining coronal tooth structure may involve extensive restorative work</li></ul></td>
<td></td>
</tr>
<tr>
<td>Tooth 22:<br>- Unsat. restoration (Mc; M overhang, poor aesthetics)</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="3">Option 3.<ul><li>Recontour first to resolve inflammation</li><li>Addresses presenting complaint</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Recontour restoration</li></ul></td>
<td><ul><li>Conservative</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
</tr>
<tr>
<td></td>
<td>3</td>
<td><ul><li>Restore</li></ul></td>
<td><ul><li>Addresses presenting complaint</li></ul></td>
<td><ul><li>Pulpal irritation, post-operative sensitivity</li></ul></td>
</tr>
</table>
#### Treatment Options (Continued)
**Tooth 37 (Overhang)**
- **Option 1:** No treatment.
- **Option 2 (Selected):** Polish restoration to eliminate plaque trap conservatively.
**Tooth 27 (Cracked tooth)**
- **Option 1 (Selected):** No treatment and monitor. Tooth is currently asymptomatic; investigation could lead to unrestorable status.
- **Option 2:** Restore to prevent progression.
**Tooth 22 (Overhang, poor aesthetics)**
- **Option 1:** No treatment.
- **Option 2:** Recontour restoration.
- **Option 3 (Selected):** Restore to address presenting aesthetic complaint and resolve inflammation.
![]()
A structured clinical decision-making table comparing treatment options for three specific dental cases: Tooth 37 (unsatisfactory restoration), Tooth 27 (cracked tooth), and Tooth 22 (unsatisfactory restoration with poor aesthetics). The table is organized into columns detailing the Option Number, Procedure/Assessment, Commitment Level, Potential Risks, and Notes. It visually contrasts conservative approaches like 'No treatment' or 'Polish restoration' against more invasive ones like 'Endodontic re-treatment', listing associated outcomes such as plaque trapping, caries risk, and tooth preservation status.
<table><tr><td rowspan="3">Tooth 21:<br/>- Unsats. restoration<br/>(M,&amp;D; M&amp;D<br/>secondary caries, M<br/>overhang, poor<br/>aesthetics)</td><td>1</td><td>No treatment</td><td>No commitment<br/>required</td><td>Does not address<br/>presenting complaint</td><td>Option 2:</td></tr><tr><td></td><td></td><td></td><td></td><td>- Eliminate factor in gingival inflammation<br/>- Prevent further breakdown of tooth structure due to caries<br/>- Attempt conservative approach before irreversible invasive approach</td></tr><tr><td>2</td><td>Composite<br/>veneer</td><td>Eliminate plaque trap<br/>for gingival healing<br/>Eliminate caries<br/>More conservative<br/>than option 3<br/>Can be useful as a<br/>mock-up of desired<br/>outcome</td><td>Pulpal irritation, post<br/>-operative sensitivity<br/>May not meet<br/>desired outcome</td><td></td></tr><tr><td></td><td>3</td><td>Full coverage<br/>crown</td><td>Addresses presenting<br/>complaint<br/>Eliminate plaque trap<br/>for gingival healing<br/>Eliminate caries<br/>More predictable<br/>aesthetic outcome</td><td>Pulpal irritation, post<br/>-operative sensitivity<br/>Less conservative<br/>than option 2<br/>Irreversible</td><td></td></tr><tr><td>Tooth 11:<br/>- Unsats. restoration<br/>(crown; chipped<br/>porcelain, poor<br/>aesthetics)<br/>- Unsats. post<br/>(not parallel to root,<br/>inadequate length)<br/>- Questionable RCT</td><td>1</td><td>No treatment</td><td>No commitment<br/>required</td><td>Does not address<br/>presenting complaint</td><td>Option 3:</td></tr><tr><td></td><td>2</td><td>No endodontic<br/>re-treatment<br/>Full coverage<br/>crown</td><td>Addresses presenting<br/>complaint<br/>Less commitment<br/>required than option 3<br/>More predictable<br/>aesthetic outcome</td><td>Less predictable<br/>treatment outcome</td><td>- Addresses presenting<br/>complaint<br/>- Satisfactory support for<br/>coronal restoration<br/>- Quality of RCT controlled resulting in more predictable treatment and aesthetic outcomes</td></tr><tr><td></td><td>3</td><td>Endodontic<br/>re-treatment<br/>Full coverage<br/>crown</td><td>Addresses presenting<br/>complaint<br/>Removal and replacement<br/>of unsatisfactory post<br/>to support coronal<br/>restoration<br/>More predictable<br/>treatment and<br/>aesthetic outcomes</td><td>More commitment<br/>required than option 2<br/>Removal of tooth structure<br/>causes further weakening<br/>of tooth<br/>Inadequate remaining<br/>coronal tooth structure<br/>may involve extensive<br/>restorative work</td><td></td></tr><tr><td>Tooth 12:<br/>- Unsats. restoration<br/>(crown; poor<br/>aesthetics)<br/>- Post wide in relation<br/>to root<br/>- Questionable RCT</td><td>1</td><td>No treatment</td><td>No commitment<br/>required</td><td>Does not address<br/>presenting complaint</td><td>Option 2:</td></tr><tr><td></td><td>2</td><td>No endodontic<br/>re-treatment<br/>Full coverage<br/>crown</td><td>Addresses presenting<br/>complaint<br/>Less commitment<br/>required than option 3<br/>More predictable<br/>aesthetic outcome<br/>Lower risk of<br/>catastrophic root fracture</td><td>Less predictable<br/>treatment outcome</td><td>- Addresses presenting<br/>complaint<br/>- Post appears<br/>biomechanically sound;<br/>removal has potential for<br/>risk catastrophic root fracture<br/>- Although endodontic re-treatment prior to placing new<br/>restoration is ideal risk of catastrophic root fracture outweighs benefits</td></tr><tr><td></td><td>3</td><td>Endodontic<br/>re-treatment<br/>Full coverage<br/>crown</td><td>Addresses presenting<br/>complaint<br/>More predictable<br/>treatment and<br/>aesthetic outcomes</td><td>More commitment<br/>required than option 2<br/>Removal of tooth structure<br/>causes further weakening<br/>of tooth<br/>High risk of<br/>catastrophic root fracture</td><td></td></tr><tr><td>Tooth 13:<br/>- Extrinsic staining</td><td>1</td><td>No treatment</td><td>No commitment<br/>required</td><td>Does not address<br/>presenting complaint</td><td>Option 2:</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td>- Addresses presenting complaint</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr></table>
#### Treatment Options: Anterior Teeth
**Tooth 21 (Secondary caries, poor aesthetics)**
- **Option 2 (Selected):** Composite veneer. Conservative approach to eliminate caries and plaque traps while acting as a mock-up for final outcome.
**Tooth 11 (Unsatisfactory crown/post, questionable RCT)**
- **Option 3 (Selected):** Endodontic re-treatment and full coverage crown. Ensures satisfactory support and controlled RCT quality for predictable aesthetic results.
**Tooth 12 (Unsatisfactory crown, wide post, questionable RCT)**
- **Option 2 (Selected):** Full coverage crown without endodontic re-treatment. Post is biomechanically sound; removal poses a high risk of catastrophic root fracture which outweighs the benefits of re-treatment.
**Tooth 13 (Extrinsic staining)**
- **Option 2 (Selected):** External bleaching to address aesthetic complaint.
![]()
A comprehensive comparison table detailing treatment options for four specific teeth (Tooth 21, Tooth 11, Tooth 12, and Tooth 13). The table is structured with columns defining the tooth case, option number, proposed procedure (e.g., No treatment, Composite veneer, Full coverage crown), benefits/commitment required, risks/outcomes, and alternative considerations. Each row represents a specific clinical scenario and its corresponding treatment pathways.
<table>
<tr>
<td rowspan="2">Tooth 16:<br/>- Unsat. restoration<br/>(M$_{O_3}$/M overhang)</td>
<td><b>2</b><br/>External bleaching</td>
<td>Conservative<br/>Option to choose irreversible option if treatment fails to address presenting complaint</td>
<td>Soft tissue chemical burns<br/>Transient tooth sensitivity<br/>Bleaching addiction</td>
<td>Conservative option that has potential to deliver good outcome<br/>Option to choose irreversible option if treatment fails to address presenting complaint</td>
</tr>
<tr>
<td><b>3</b><br/>Crown</td>
<td>More predictable aesthetic outcome</td>
<td>Pulpal irritation, post-operative sensitivity<br/>Less conservative than option 2<br/>Irreversible</td>
<td></td>
</tr>
<tr>
<td rowspan="2">Tooth 17:<br/>- Unsat. restoration<br/>(crown$_{mn}$/ over-contoured)</td>
<td><b>1</b><br/>No treatment</td>
<td>No commitment required</td>
<td>Plaque trapping, gingival inflammation<br/>Caries<br/>Breakdown of tooth structure</td>
<td>Option 2:<br/>• Eliminate a factor in gingival inflammation<br/>• Prevent caries</td>
</tr>
<tr>
<td><b>2</b><br/>Polish restoration</td>
<td>Eliminate plaque trap for gingival healing<br/>Conservative</td>
<td>Over-polishing could result in open contact</td>
<td></td>
</tr>
<tr>
<td></td>
<td></td>
<td></td>
<td></td>
<td>Option 2:<br/>• Eliminate plaque trap for periodontal health<br/>• Reduce risk caries and potential for breakdown of tooth structure</td>
</tr>
<tr>
<td rowspan="2">Generalised unstable<br/>periodontitis</td>
<td><b>1</b><br/>No treatment</td>
<td>No commitment required</td>
<td>Plaque-induced gingival inflammation<br/>Continue localised bone loss<br/>Poor restorative treatment outcomes</td>
<td>Option 2:<br/>• Intervene to allow periodontal healing and health prior to committing to extensive restorative work</td>
</tr>
<tr>
<td><b>2</b><br/>Scale and clean<br/>Local debridement 17</td>
<td>Remove calculus and plaque for periodontal healing<br/>Conducive to longevity of current and future restorations</td>
<td>Gingival bleeding and sensitivity</td>
<td></td>
</tr>
<tr>
<td rowspan="2">Actinic cheilitis*</td>
<td><b>1</b><br/>Advising patient to consult GP or alternately refer to Oral Medicine<br/>Advising sun protection during recreation<br/>Avoid sun exposure from 10 am – 2 pm<br/>Regular review</td>
<td>Duty of care, otherwise supervised neglect<br/>Increase patient awareness and likelihood of changing lifestyle factors with encouragement</td>
<td>Nil</td>
<td>Option 1:<br/>Clinician’s responsibility to carry out duty of care and inform payment of findings and refer appropriately for specialized care</td>
</tr>
<tr>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</table>
*Potentially premalignant condition of the lower lip. Does not predict malignancy, however all lip carcinomas are associated with pre-existing actinic cheilitis. Expected demographic is usually fair-skinned, middle-aged and with history of accumulated sun exposure to lower lip. Same demographic describes typical patient with general skin changes from sun exposure. Common clinical signs: dryness, atrophy, scaly sites, swelling, erythema, ulceration, vermillion border indistinct. [32]
#### Treatment Options: General and Oral Medicine
**Tooth 16 (Unsatisfactory restoration/overhang)**
- **Option 2 (Selected):** External bleaching (conservative) or Crown (predictable). Selected conservative option first.
**Tooth 17 (Over-contoured crown)**
- **Option 2 (Selected):** Polish restoration to eliminate plaque trap and prevent caries.
**Generalised Unstable Periodontitis**
- **Option 2 (Selected):** Scale and clean, local debridement at 17. Essential for healing prior to restorative work.
**Actinic Cheilitis**
- **Option 1 (Selected):** Consult GP/Oral Medicine, advise sun protection, and regular review. Duty of care for a potentially premalignant condition.
![]()
A structured table outlining dental treatment options for various clinical conditions. The table is organized into rows representing different cases (Tooth 16 with unsatisfactory restoration, Tooth 17 with unsatisfactory restoration, Generalised unstable periodontitis, and Actinic cheilitis) and columns detailing the option number/name, description of the option, potential risks/complications, and alternative options or considerations. It includes specific details like 'External bleaching', 'Crown', 'No treatment', 'Polish restoration', 'Scale and clean', and patient advice for actinic cheilitis.
<table><tbody><tr><td><b>Systemic phase</b></td><td>Not applicable</td></tr><tr><td><b>Emergency phase</b></td><td>Not applicable</td></tr><tr><td><b>Control phase</b><i>Eliminate pain, infection,<br>inflammation</i></td><td>Patient education and consent to treatment</td></tr><tr><td colspan="2"></td></tr><tr><td colspan="2">Hygienic phase of periodontal therapy: scale and clean, local periodontal debridement 17MB, fluoride application, oral hygiene instruction</td></tr><tr><td colspan="2">Recontour existing restorations: 16M, 15M, 37M</td></tr><tr><td colspan="2">Caries control: 21M&amp;D, 36D, 45MO, 46M, 47M</td></tr><tr><td colspan="2">Replace unsatisfactory restorations: 22M, 35O*</td></tr><tr><td colspan="2">Endodontic re-treatment: 11</td></tr><tr><td></td></tr><tr><td><b>Holding phase</b><i>Preserve residual dentition</i></td><td>Assess response to periodontal therapy and oral hygiene compliance</td></tr><tr><td colspan="2">Monitor symptoms: 36, 47</td></tr><tr><td><b>Reconstructive phase</b><i>Replace lost tissue and stabilise occlusion</i></td><td>Indirect restorations: [left box set] [right box set] [middle box set]</td></tr><tr><td colspan="2">Post-core: 11</td></tr><tr><td colspan="2">External bleaching: 13</td></tr><tr><td><b>Maintenance phase</b><i>Prevention of further breakdown</i></td><td>Recall exam</td></tr><tr><td colspan="2">Periodontal maintenance</td></tr><tr><td colspan="2">Reinforce oral hygiene</td></tr><tr><td colspan="2">*Added to treatment plan following changes identified during recall examination 2020.</td></tr></tbody></table>
**2.6.2 Treatment sequence**
* There was uncertainty regarding patient’s potential relocation to Sydney and a reluctance to discuss definitive timeframes.
* Discussed with patient risks of commencing complex treatment plan that requires multiple appointments over an extended period of time:
* Incomplete endodontic treatment and risk of dislodging interim restoration leading to potential for infection of root canal system
* Incomplete restorative treatment and risk of provisional restorations dislodging which is more of a concern in aesthetic areas
* Discussed with patient ideal sequence for treatment plan considering:
* Patient’s presenting complaints i.e. tooth sensitivity and aesthetics
* Patient’s possibility of relocation and lack of definite timeframe given
* Clinician’s opinion on patient’s treatment needs i.e. control active disease and prevent further breakdown
* Clinician’s availability given rotation in final year
* Ideal treatment plan would be sequenced in stages starting in lower arch then upper arch:
1. Quadrant 4 then quadrant 3
2. Upper anterior then upper posterior
* Treatment of aesthetic region delayed until adequate rapport with patient established.
#### Integrated Treatment Plan
**Control Phase**
- Patient education and consent.
- Periodontal therapy: Scale and clean, local debridement (17MB), fluoride, OHI.
- Recontour restorations: 16M, 15M, 37M.
- Caries control: 21, 36, 45, 46, 47.
- Replace unsatisfactory restorations: 22M, 35O.
- Endodontic re-treatment: 11.
**Holding Phase**
- Assess periodontal response and OHI compliance.
- Monitor symptoms: 36, 47.
**Reconstructive Phase**
- Indirect restorations for posterior and anterior teeth.
- Post-core and crown: 11.
- External bleaching: 13.
**Maintenance Phase**
- Recall exams and periodontal maintenance.
#### Treatment Sequencing Strategy
- **Priority:** Address sensitivity and active disease (Control phase) first.
- **Staging:** Lower arch (Q4 then Q3) followed by upper arch (Anterior then Posterior).
- **Aesthetics:** Delayed until rapport is established.
- **Relocation Risk:** Discussed risks of incomplete treatment (e.g., dislodged temporaries) due to potential move to Sydney.
![]()
A detailed dental treatment plan table organized by phases. The 'Control phase' lists procedures such as periodontal therapy and caries control with specific tooth numbers (e.g., 17MB, 21M&D). The 'Reconstructive phase' includes a visual grid of pink-highlighted boxes representing indirect restorations for teeth like 17, 47, 46, 45, 12, 11, 21, and 36. Other phases listed are Holding, Maintenance, and Emergency/Systemic phases marked as not applicable.
```html
<table border="1">
<tr>
<th>Treatment</th>
<th>Rationale for sequence</th>
</tr>
<tr>
<td>Control</td>
<td>• Scale and clean, local debridement 17<br>• Fluoride application<br>• Oral hygiene instruction</td>
<td>• Build rapport, trust, confidence<br>• Improve current periodontal condition<br>• Assess patient's oral hygiene compliance</td>
</tr>
<tr>
<td></td>
<td>• Caries control 47, 46, 45</td>
<td>• Address presenting complaint as soon as possible<br>• Arrest further tissue destruction in same quadrant<br>• Provisionally restore 47, 46, 45</td>
</tr>
<tr>
<td></td>
<td>• Caries control 36<br>• Recontour 37</td>
<td>• Arrest further tissue destruction in contralateral quadrant and provisionally restore 36 while monitoring 47 response to treatment<br>• Removal of 36 restoration facilitates access to 37M</td>
</tr>
<tr>
<td>Holding</td>
<td>• Monitor 47, 36 for symptoms</td>
<td>• Assess pulp and periodontal condition prior to restoration</td>
</tr>
<tr>
<td>Reconstructive</td>
<td>• Indirect restoration 36</td>
<td>• If asymptomatic, definitively restore 36<br>• Assess patient's response to treatment</td>
</tr>
<tr>
<td></td>
<td>• Indirect restorations 47, 46, 45</td>
<td>• If asymptomatic, definitively restore 47, 46, 45 concurrently to obtain better contours and contacts<br>• Assess patient's response to treatment</td>
</tr>
<tr>
<td>Holding</td>
<td>• Review and monitor for changes<br>• Periodontal review and maintenance<br>• Recontour 15, 16</td>
<td>• Monitor restored teeth for symptoms<br>• Maintain periodontal condition<br>• Reassess patient's oral hygiene compliance<br>• Establish lower arch stability prior to commencing treatment in upper arch</td>
</tr>
<tr>
<td>Control</td>
<td>• Caries control 21<br>• Replace unsatisfactory restoration 22</td>
<td>• Arrest further tissue destruction and attempt conservative treatment before extensive treatment</td>
</tr>
<tr>
<td></td>
<td>• Endodontic re-treatment 11</td>
<td>• Commence endodontic re-treatment as soon as possible to gain maximum therapeutic effect of medicament</td>
</tr>
<tr>
<td>Reconstructive</td>
<td>• Preparation indirect restorations 12, 21</td>
<td>• Commence crown preparations while waiting for endodontic re-treatment</td>
</tr>
<tr>
<td></td>
<td>• Post-core 11<br>• Prepare indirect restoration 11</td>
<td>• If asymptomatic, after completion of endodontic re-treatment</td>
</tr>
<tr>
<td></td>
<td>• Indirect restorations 12, 21, 11</td>
<td>• If asymptomatic, definitively restore 12, 11, 21 concurrently to obtain better aesthetics, contours and contacts</td>
</tr>
<tr>
<td>Holding</td>
<td>• Review and monitor for changes<br>• Periodontal review and maintenance<br>• Replace unsatisfactory restoration 35*</td>
<td>• Monitor restored teeth for symptoms<br>• Maintain periodontal condition<br>• Reassess patient's oral hygiene compliance</td>
</tr>
<tr>
<td>Reconstructive</td>
<td>• Indirect restoration 17<br>• Indirect restoration 27*</td>
<td>• Arrest further tissue destruction<br>• If asymptomatic, definitively restore 17</td>
</tr>
<tr>
<td></td>
<td>• External bleaching 13</td>
<td>• Least important in relation to other items on treatment plan<br>• Establish occlusal stability prior to fabricating bleaching tray</td>
</tr>
<tr>
<td>Maintenance</td>
<td>• Review and monitor for changes<br>• Periodontal review and maintenance<br>• Reinforce oral hygiene</td>
<td>• Monitor restored teeth for symptoms and changes<br>• Early intervention to prevent further breakdown<br>• Maintain periodontal condition<br>• Monitor patient's oral hygiene compliance</td>
</tr>
</table>
*Added to treatment plan after changes identified during recall examination 2020.
Note: Continuous reassessment of patient's plans to move to Sydney and discussion of potential implication on dental treatment during each phase of treatment.
```
#### Detailed Treatment Sequence
1. **Initial Control:** Scale/clean and OHI to build trust and assess compliance.
2. **Lower Right (Q4):** Caries control 47, 46, 45 to address sensitivity and arrest destruction.
3. **Lower Left (Q3):** Caries control 36 and recontour 37 while monitoring 47.
4. **Lower Reconstruction:** Definitively restore 36, 47, 46, 45 once asymptomatic.
5. **Upper Control:** Caries control 21, replace 22, and commence endodontic re-treatment 11.
6. **Upper Reconstruction:**
- Prepare 12 and 21 for crowns.
- Post-core and crown preparation for 11 after RCT completion.
- Definitively restore 12, 11, 21 concurrently for optimal aesthetics.
7. **Final Steps:** Indirect restorations for 17 and 27; external bleaching for 13.
8. **Maintenance:** Ongoing periodontal review and OHI reinforcement.
![]()
A detailed treatment plan table for a dental patient, organized into three columns: 'Treatment', 'Rationale for sequence', and an implicit phase column (Control, Holding, Reconstructive, Maintenance). The table lists specific procedures such as 'Scale and clean', 'Caries control', 'Indirect restoration', 'Endodontic re-treatment', and 'External bleaching' with corresponding tooth numbers (e.g., 47, 36, 11, 13). Each procedure is paired with its clinical rationale, such as 'Build rapport', 'Arrest further tissue destruction', or 'Establish occlusal stability'. A footnote indicates that restoration 35 was added after changes identified during a 2020 recall examination. A note at the bottom mentions continuous reassessment of the patient's plans to move to Sydney.
2.7 Treatment delivery
2.7.1 Treatment delivery
Date: May 2019 – July 2020
| Treatment | Date completed | Comments, photographs and radiographs documenting treatment |
| :--- | :--- | :--- |
| Scale and clean<br>Debridement 17<br>Fluoride application<br>Oral hygiene instruction | July 2019 | * Copious gingival bleeding from inflammation.<br> * Demonstrated Modified Bass technique of toothbrushing on model.<br> * Patient advised plans to potentially relocate to Sydney at the end of December 2019. Aim to commence and finish treatment up to reconstructive phase of lower arch by December 2019. |
| Caries control 47 | | **47:** Removed caries and existing restoration. Tooth investigation revealed cracks Li, D. Little coronal tooth structure remaining. Temporised with GIC and monitored. |
| Caries control 36D<br>Recontour 37M<br>Tooth preparation 36, 37 | August 2019 | <br> * 36: Removed caries and existing restoration. Tooth investigation revealed cracks Li, D, MB into MB canal. Endodontist assessed tooth as unrestorable with hopeless prognosis and tooth was indicated for extraction. Patient refused extraction. Prosthodontist assessed tooth as restorable with poor long-term prognosis. As tooth is asymptomatic and remaining tooth structure appears clean and sound, lined pulp chamber with Vitrebond to seal area with plan to restore with Enamic endocrown*. Patient chose to keep tooth with understanding that tooth has poor prognosis and restoration may fail at any time in future.<br> * 37: M re-contoured at same time. However, due to large open contact between 36 and 37 decision made to replace 37MO amalgam with Enamic* overlay for better contact to avoid plaque and food trapping.<br> * 36: Tooth prepared for Enamic endocrown, provisional stainless-steel band with IRM.<br> * 37: Tooth prepared for Enamic MOL overlay, provisional Luxatemp restoration cemented with TempoCem.<br><br> *Enamic is a hybrid polymer-infiltrated ceramic network (PICN) material comprised of 86 wt% sintered ceramic matrix filled with 14 wt% polymer material. (Vita ENAMIC Technical and scientific documentation). Polymer filling imparts a lower modulus of elasticity and stiffness than conventional ceramics which it provides material with degree of elasticity between that of enamel and dentine, allowing higher levels of continuous loading than conventional ceramics before fracturing. (ii) allows milling of thin margin areas without material fracturing (Dental Visionist magazine). A study suggests that the higher polymer content of Enamic may lead to stronger crack growth resistance, with cracks propagating predominantly through the ceramic network and deflected by the polymer-ceramic interface. (33) The same study has shown that Enamic has lower wear resistance than human enamel with wear mechanism similar to human enamel. (33) Current literature on clinical use, longevity and success rate of PICN is limited. With respect to the mentioned properties, it was decided that 36 and 37 would be restored with Enamic, with the idea that cuspal coverage and crack deflection would help to protect the teeth from further damage by cracking.<br><br> *Endocrowns are an adhesive monolithic ceramic restoration anchored in the pulp chamber using micromechanical retention properties of the pulp chamber walls. A systematic review of endocrowns found that endocrowns are a promising treatment alternative for extensively damaged endodontically-treated premolars and molars - good survival rates in the short to long term, fewer catastrophic root fractures (6%) than crowns (29%) with or without posts. Main failure mode was due to loosening (71%). Successful endocrown requires good preparation design to limit displacement and strict adherence to adhesion protocol to prevent marginal leakage and penetration of microorganisms. Nanofill composite resins may be suitable due to their modulus of elasticity similar to that of dentine thus reducing stress in the dentine and limiting irreversible root fracture while retaining high fracture resistance, however this increases stress at the interface predisposing restoration to debonding. Materials with greater adhesion properties such as lithium disilicate may be the best choice. (34) Systematic review and meta-analysis estimates 5-year survival (restoration present in oral cavity but with biological/technical complications) rate 91.4% and 5-year success rate (restorations with no complications) 77.7% for endocrowns. (35) |
66
#### Treatment Delivery: Phase 1
**Periodontal Therapy (July 2019)**
- Scale, clean, and OHI. Copious bleeding noted. Modified Bass technique demonstrated.
**Caries Control 47**
- Removed caries; revealed Li and D cracks. Temporised with GIC.
**Caries Control 36 & 37 (August 2019)**
- **36:** Cracks found in Li, D, and MB canal. Endodontist deemed unrestorable; Prosthodontist suggested poor prognosis but restorable. Patient chose to keep tooth. Prepared for Enamic endocrown.
- **37:** Re-contoured M; decided on Enamic MOL overlay for better contact.
**Material Rationale: Enamic**
- Chosen for its modulus of elasticity (between enamel and dentine) and crack growth resistance. Ideal for protecting cracked teeth under loading.
**Clinical Note: Endocrowns**
- Adhesive monolithic restorations anchored in the pulp chamber. Studies show good survival rates for extensively damaged endodontically-treated molars.
![]()
A clinical treatment log table titled 'Treatment delivery'. The table is divided into three columns: 'Treatment', 'Date completed', and 'Comments, photographs and radiographs documenting treatment'. It documents dental procedures from May 2019 to July 2020. Key rows include 'Scale and clean' (July 2019) noting gingival bleeding and instruction on the Modified Bass technique; 'Caries control 47' detailing removal of caries and cracks in tooth 47; and 'Tooth preparation 36, 37' (August 2019). This row contains embedded clinical photos showing the tooth investigation process for teeth 36 and 37. The text details the decision-making process regarding Enamic endocrowns due to crack propagation and poor prognosis.
![]()
A composite image containing five sequential clinical photographs captioned 'Tooth investigation 36 (12/8/19 & 19/8/19)'. The images document the endodontic assessment of tooth 36. They show the tooth under a surgical light or microscope, revealing cracks extending into the MB canal, as referenced in the OCR context describing the diagnosis of an unrestorable tooth that was ultimately restored with an Enamic endocrown.
| Final impressions and cementation<br>indirect restoration<br>36, 37 | September 2019 | Final impression and 3Shape TRIOS® scan 36-37 (5/9/19)<br>Final impression 36 endocrown and 37 MOL overlay preparations.<br>Cementation procedure was performed under rubber dam to prevent moisture contamination. Restorations were treated with Ivoclean and then Monobond. Variolink dual cure luting cement was used. |
| Monitor 47 symptoms<br>Caries control<br>45, 46<br>Tooth preparation<br>45, 46, 47<br>Final impressions and cementation<br>indirect restoration<br>45, 46, 47 | October – November 2019 | PA 47 to check for periapical pathology after 11 weeks of monitoring (7/10/19)<br>47: Temporary GIC restoration remained intact with slight mesial deficiency and open contact. Patient was advised to keep area clean to prevent gingival inflammation. Pulpal pathology resolved and no symptoms were experienced after 11 weeks of temporisation. Tooth prepared for Enamic* MODBL overlay. Provisional stainless-steel band with IRM placed.<br>45: Removed caries and existing restoration. Tooth prepared for MOD inlay. Buccal and lingual walls were preserved to conserve tooth structure. Provisional stainless-steel band with IRM placed.<br>46: Removed caries and existing restoration. Clinically satisfactory pinned amalgam core underlying metallic crown. Decision made to retain existing core and restore with zirconia** crown. Tooth prepared for zirconia crown. Provisional Luxembtemp restoration cemented with TempoCem placed. Gingival inflammation resolved after removal of restoration and placement of provisional restoration.<br>Cementation procedure was performed under cotton roll isolation and high-volume suction to prevent moisture contamination. Restorations were treated with Ivoclean and then Monobond. Variolink dual cure luting cement was used for 45 and 47. Panavia dual-cure self-adhesive resin cement was used for 46. |
*Enamic was the material chosen for the same reasons as 36 and 37. In this case, 47 tooth structure also exhibited cracks. Cuspal overlay was considered to limit crack progression and Enamic for crack deflection in order to preserve the tooth for as long as possible.
**Zirconia was chosen for the following reasons (i) patient predominantly chews on her back teeth thus strength and durability is required in posterior region (ii) not as important in posterior region to have aesthetic glass-based ceramic (ii) underlying core is dark amalgam which will show through a glass-based ceramic.
#### Treatment Delivery: Phase 2
**Cementation 36, 37 (September 2019)**
- Final impressions via 3Shape TRIOS® scan. Cemented under rubber dam using Variolink dual cure luting cement.
**Quadrant 4 Restorations (October – November 2019)**
- **47:** Asymptomatic after 11 weeks. Prepared for Enamic MODBL overlay.
- **45:** Prepared for MOD inlay, preserving buccal/lingual walls.
- **46:** Retained existing pinned amalgam core. Prepared for Zirconia crown.
- **Cementation:** 45 and 47 cemented with Variolink; 46 cemented with Panavia. Cotton roll isolation used.
**Material Rationale: Zirconia (46)**
- Selected for high strength in the posterior chewing region and ability to mask the dark underlying amalgam core.
![]()
Clinical photo of a green final dental impression in a tray for teeth 36 and 37. Caption: 'Final impression and 3Shape TRIOS® scan 36-37 (5/9/19)'.
![]()
Photo of a grey stone dental cast showing the lower arch with teeth 36 and 37 prepared for restoration. Caption: 'Final impression and 3Shape TRIOS® scan 36-37 (5/9/19)'.
![]()
Periapical radiograph (PA) of tooth 47. Caption: 'PA 47 to check for periapical pathology after 11 weeks of monitoring (7/10/19)'.
![]()
Clinical photo of intraoral view showing preparations on teeth 45, 46, and 47. Caption: 'Tooth preparations and 3Shape TRIOS® scan 45, 46, 47'.
![]()
Photo of a blueish-grey digital dental scan model showing the lower arch with teeth 45, 46, and 47 prepared.
<html><body><table><tr><td><b>Post-treatment review lower arch</b></td><td><b>January 2020</b></td><td></td></tr><tr><td><b>Recall exam</b><br><b>Scale and clean</b></td></tr><tr><td><b>Recontour</b><br>15M, 16M<br><b>Caries control</b><br>21M&amp;D</td></tr><tr><td><b>Replace unsatisfactory restoration</b><br>22</td></tr><tr><td>Recall examination following 10 weeks of absence. Examination revealed all restored teeth were asymptomatic, 27B cracked tooth, 35O GIC restoration crumbling. Treatment plan was amended to incorporate new problems; tooth investigation and restoration 27, replacement of unsatisfactory restoration 35O with composite.</td></tr><tr><td>Patient advised plans to potentially relocate to Sydney at the end of May 2020.<br>Aim to commence and finish treatment up to reconstructive phase of upper anterior teeth by March 2019.</td></tr><tr><td>21: Removed caries and existing restorations. Replaced with composite.<br>Following assessment decision made to definitively restore 21 with zirconia crown to achieve desired aesthetic outcomes.</td></tr><tr><td>22: Removed existing restoration. Subgingival caries detected on mesial, removed. Temporised with GIC to allow gingival healing. Replaced with composite after 6 weeks.</td></tr></table></body></html>
#### Treatment Delivery: Phase 3 (January 2020)
**Recall and Plan Amendment**
- Examination showed all restorations asymptomatic.
- New issues: 27B crack and 35O GIC crumbling. Plan amended to include these restorations.
**Upper Anterior Work**
- **21:** Caries removed and replaced with composite. Decision made to upgrade to a Zirconia crown for final aesthetics.
- **22:** Subgingival mesial caries removed. Temporised with GIC for 6 weeks to allow gingival healing before final composite restoration.
![]()
Clinical photograph set labeled 'Post-treatment lower arch (23/1/20)', showing three views of the patient's lower teeth: left view displays a dental instrument in contact with molar teeth, center view shows an occlusal perspective revealing anterior and posterior teeth, right view highlights a dark restoration on a lateral tooth.
| Endodontic<br>re-treatment 11<br>Cast post-core<br>duralay pattern<br>Tooth preparation<br>12, 21 | February 2020 | <br><br>11: Removed existing restoration. Clinically unsatisfactory stainless-steel pin and composite core underlying ceramic-metal crown removed. Assessment of remaining tooth structure revealed adequate coronal tooth structure for post-core and definitive restoration. Adequate ferrule on D and Pa aspects of remaining coronal tooth structure. GP removed. Canal cleaned. Working length obtained. Minimal preparation of canal and irrigation. No clinical or radiographic signs of infection. Medicated with Ca(OH)₂. Provisional plastic burnout post and Luxatemp crown cemented with IRM. Two weeks later tooth was asymptomatic and was obturated leaving 5 mm apical GP and space for post-core.<br><br>*Generally a minimum ferrule width of 2 mm is required to provide fracture resistance. (36) If an endodontically treated anterior tooth is to receive a crown, a post is often indicated as in most cases the remaining coronal tooth structure is thin after root canal treatment and crown preparations. In addition, pulp chambers are too small to provide adequate retention and resistance without a post. (37) Post length should be at least the length of the crown, about 2/3 the root length and no more than 1/3 the root width as non-ideal posts increase the chances of root fracture. At least 5 mm root filling should be maintained for apical seal. The main mode of failure for metal posts is root fracture, due to greater stiffness of metal in comparison to dentine. (38)<br><br><br><br>12: Removed existing restoration. Tooth prepared for zirconia crown. Labial margin reduced to equigingival for aesthetics. Height of cast post-core reduced. Provisional Luxatemp restoration cemented with TempoCem placed. Warned patient of risk of provisional restoration dislodging and that colour may not accurately reflect shade of other teeth in mouth.<br><br>21: Removed existing restorations. Tooth prepared for zirconia crown. Undercuts on mesial and distal built up with composite. Provisional Luxatemp restoration cemented with TempoCem placed. Same warnings for 12 given for 21.<br><br><br><br>11: Duralay pattern for cast post-core 11 fabricated. | 69 |
#### Treatment Delivery: Phase 4 (February 2020)
**Endodontic Re-treatment 11**
- Removed old crown and core. Adequate ferrule (2mm) present on D and Pa aspects. Canal cleaned, medicated with Ca(OH)₂, and later obturated leaving space for a post.
**Anterior Preparations**
- **12:** Prepared for Zirconia crown. Labial margin reduced equigingivally for aesthetics. Height of existing cast post-core reduced.
- **21:** Prepared for Zirconia crown. Undercuts built up with composite.
- **11:** Duralay pattern fabricated for a new cast post-core.
**Clinical Note: Posts and Ferrules**
- A 2mm ferrule is required for fracture resistance. Posts are indicated when remaining structure is thin, but must be carefully sized (2/3 root length, <1/3 root width) to avoid root fracture.
![]()
Composite radiograph panel showing four sequential endodontic stages for tooth 11: Working length (7/2/20), master GP placement (21/2/20), apical third preparation (21/2/20), and post-obturation (21/2/20). Radiographs illustrate the procedural progression of root canal treatment and obturation.
![]()
Clinical intraoral photograph labeled 'Tooth preparation 12'. Shows a dental mirror reflecting the prepared tooth with visible cavity and margin reduction, demonstrating the equigingival labial margin mentioned in text.
![]()
Schematic diagram labeled 'Duralay pattern post-core 11'. Illustrates a red-colored cast post-core shape used to fabricate the final restoration, corresponding to the fabricated Duralay pattern mentioned in the text.
| Procedure | Date | Description |
| :--- | :--- | :--- |
| Cementation cast post-core 11 | March 2020 | **Tooth preparations 12, 11, 21** (3/3/20)<br><br>Try-in of the cast-post cure revealed a labial gap < 1 mm on the labial aspect. This is not ideal, however was clinically acceptable. Panavia dual-cure self-adhesive resin cement was used to cement cast post-core 11. Tooth was prepared for zirconia crown. |
| Tooth preparation 11 | | |
| Final impressions and cementation indirect restoration 12, 11, 21 | | **Final impression and die stone models 12, 11, 21**<br><br>**3Shape TRIOS® scan 12, 11, 21**<br><br>**Zirconia crowns 12, 11, 21**<br><br>*Generally, glass-based ceramics such as lithium disilicate is chosen for anterior crowns. With new materials on the market, for a single anterior tooth, all ceramics have sufficient longevity based on clinical trial data, so the choice can be made on aesthetic capability alone. (18) In this case, however, 12 and 11 both had cast post-cores to support the coronal restoration. The colour of the metal would show through a glass-based ceramic; hence zirconia was chosen as a safer option. Zirconia was used for 12, 11 and 21 for consistency and more control over the final outcome. Zirconia aesthetics have improved over the years and is available in different translucencies. Use of an opaque cement may also be beneficial to mask the metallic shade under the crowns. Metal-ceramic crowns are another viable option with proven clinical outcomes and aesthetic outcomes. However, due availability and ease of fabrication zirconia was chosen.*<br><br>• Cementation procedure was performed under cotton roll isolation and high-volume suction to prevent moisture contamination. Restorations were treated with Ivoclean and then Monobond. Panavia dual-cure self-adhesive resin cement was used for 12, 11, 21. |
70
#### Treatment Delivery: Phase 5 (March 2020)
**Cementation and Final Prep**
- **11:** Cast post-core cemented with Panavia. Final crown preparation completed.
- **12, 11, 21:** Final impressions taken via 3Shape TRIOS® scan.
**Material Rationale: Zirconia (Anterior)**
- Zirconia was chosen for 12, 11, and 21 to ensure consistency and to mask the underlying metallic cast post-cores on 12 and 11. Zirconia offers improved translucency and high durability.
**Cementation**
- Performed under cotton roll isolation. Restorations treated with Ivoclean/Monobond and cemented with Panavia dual-cure self-adhesive resin cement.
![]()
Clinical photo showing tooth preparations 12, 11, and 21. The image displays three adjacent teeth with the coronal portions removed to expose the root structure, revealing the prepared dentin surfaces and gingival margins.
![]()
Photo of final impression and die stone models for teeth 12, 11, and 21. The left panel shows a tray with green impression material containing impressions of the prepared teeth. The right panels show the poured die stone replicas of the prepared teeth arranged in a row.
![]()
Photo of a 3Shape TRIOS® digital intraoral scan of teeth 12, 11, and 21. The image displays a white 3D printed or rendered model of the dental arch showing the prepared teeth.
![]()
Clinical photos of Zirconia crowns on teeth 12, 11, and 21. Two side-by-side images show the restored teeth from different angles (occlusal and lateral views), displaying the completed ceramic restorations.
<table>
<tr>
<td>Post-treatment review upper anterior teeth</td>
<td>March 2020</td>
<td>Post-insert review 12, 11, 21 (20/3/20)</td>
</tr>
<tr>
<td></td>
<td></td>
<td>Review photographs (17/3/20)</td>
</tr>
<tr>
<td></td>
<td></td>
<td> Patient was very satisfied with outcome to date.<br/>• Patient advised plans to potentially relocate to Sydney are uncertain due to COVID-19. Plan to contact patient in July 2020 to reassess patient's situation and adjust treatment plan accordingly.</td>
</tr>
<tr>
<td>Post-treatment review upper anterior teeth<br/>Recall exam<br/>Scale and clean</td>
<td>July 2020</td>
<td>• Examination revealed all restored teeth were asymptomatic.<br/>• Patient advised plans to potentially relocate to Sydney have been cancelled due to COVID-19.</td>
</tr>
<tr>
<td>Tooth preparation 27</td>
<td>July 2020</td>
<td>• 27: Tooth prepared for Emax onlay, provisional stainless steel band with IRM.</td>
</tr>
<tr>
<td>Tooth preparation 17</td>
<td>August 2020</td>
<td>• 17: Tooth prepared for Emax crown. Composite core build-up required as inadequate coronal tooth structure to support a crown remained. Preparation had deep subgingival mesial margin. Provisional Luxatemp restoration cemented with TempoCem.</td>
</tr>
<tr>
<td></td>
<td></td>
<td> 17 remaining tooth structure after metallic crown removal and before core build-up</td>
</tr>
<tr>
<td>Final impressions 17, 27<br/>Cementation 27</td>
<td>August 2020</td>
<td> Final PVS impressions of 17 and 27 taken. As 17 preparation had deep subgingival mesial margin and there was chronic gingival inflammation and bleeding in the area, it was difficult to take final PVS impression even with use of retraction cord and Expasyl. 3Shape TRIOS® scan was taken, digital impression adequate.</td>
</tr>
<tr>
<td></td>
<td></td>
<td>27 onlay preparation PVS impression and 3D CADCAM model printed from 3Shape TRIOS® scan.<br/>• 27: cemented with Variolink.</td>
</tr>
</table>
#### Treatment Delivery: Phase 6 (March – August 2020)
**Review and COVID-19 Impact**
- March 2020: Patient very satisfied. Relocation plans uncertain due to COVID-19.
- July 2020: Relocation cancelled. All restorations asymptomatic.
**Upper Posterior Work**
- **27:** Prepared for Emax onlay.
- **17:** Metallic crown removed; composite core build-up required due to inadequate structure. Deep subgingival mesial margin noted.
**Final Impressions 17, 27**
- Difficult PVS impression at 17 due to subgingival margin and inflammation. Digital scan (TRIOS®) provided an adequate impression. 27 onlay cemented with Variolink.
![]()
Clinical radiograph showing the upper anterior teeth (teeth 12, 11, 21). The image displays dental implants with posts and crowns. Caption reads: 'Post-insert review 12, 11, 21 (20/3/20)'.
![]()
Intraoral clinical photograph of the maxillary arch from a superior view. It shows restored anterior teeth and posterior metallic restorations (crowns or bridges) on molars. Caption reads: 'Review photographs (17/3/20)'.
![]()
Intraoral clinical photograph of the maxillary anterior teeth from a frontal view, showing the alignment and appearance of the restored teeth. Caption reads: 'Review photographs (17/3/20)'.
![]()
Close-up intraoral clinical photograph of tooth 17. It shows the remaining tooth structure after the removal of a metallic crown, prior to a composite core build-up procedure. Caption reads: '17 remaining tooth structure after metallic crown removal and before core build-up'.
![]()
Clinical photograph of a PVS impression tray containing an impression of the prepared tooth 27. Caption reads: '27 onlay preparation PVS impression...'.
![]()
Photograph of a 3D CADCAM model printed from a digital scan of the tooth preparation. Caption reads: '...and 3D CADCAM model printed from 3Shape TRIOS® scan.'.
<table>
<tr>
<td>Cementation 17</td>
<td>September 2020</td>
<td>
<ul>
<li>17: cemented with Variolink.</li>
</ul>
<p align="center">Post-insert 17 Emax crown and 27 Emax onlay</p>
</td>
</tr>
<tr>
<td>External bleaching 13</td>
<td>Ongoing</td>
<td>
<ul>
<li>Incomplete due to lack of appointments for remainder of year.</li>
</ul>
</td>
</tr>
<tr>
<td>Post-treatment review<br><br>Recall exam<br><br>Scale and clean<br><br>Reinforce oral hygiene</td>
<td>Ongoing</td>
<td>
<ul>
<li>Patient transferred to another student for continuation of care.</li>
</ul>
</td>
</tr>
</table>
Note: Maintained conformative occlusal scheme throughout treatment plan.
#### Final Treatment Steps
**Cementation 17 (September 2020)**
- 17 Emax crown cemented with Variolink.
**Incomplete/Ongoing Items**
- **External Bleaching 13:** Incomplete due to lack of remaining appointments.
- **Maintenance:** Patient transferred to another student for continuation of care, including recall exams and periodontal maintenance.
**Occlusal Note**
- A conformative occlusal scheme was maintained throughout the entire treatment plan.
![]()
Clinical intraoral photograph showing the maxillary arch with multiple dental restorations. Visible are metal crowns on teeth 16 and 26, and a crown on tooth 17. The caption below reads: 'Post-insert 17 Emax crown and 27 Emax onlay', correlating with the text in the adjacent table cell.
2.7.2 Before and after photographs
Date: May 2019 – September 2020
73
#### Before and After Photographs
Date: May 2019 – September 2020
![]()
Before and after clinical photographs of a patient's smile and dentition from May 2019 to September 2020. The images show the transition from a discolored, worn denture with visible metal clasps (left column) to a restored set of teeth with improved aesthetics and alignment (right column). The top row displays frontal facial views, while subsequent rows provide close-ups of the upper and lower arches.
**2.7.3 Patient response to treatment**
- Patient was very satisfied with overall outcome of treatment provided to date.
- “I can smile again – I can’t stop smiling!”
- Resolution of presenting complaints:
i. “I don’t smile anymore because my front teeth are so bad. The front tooth (21) is brown, they’re all mismatched. I want the teeth (13-21) to look the same colour because when I smile, I’m self-conscious.”
✓ 12-21 indirect restorations placed.
(Treatment for 13 incomplete)
ii. “My crown (11) has fallen off and been stuck on again – I’m afraid it will fall off again.”
✓ 11 endodontically re-treated, crown preparation refined and indirect restoration placed.
iii. “I had some sensitivity last week when eating sweet foods (47).”
✓ 47 investigated, cause of sensitivity resolved and indirect restoration placed.
- Patient was compliant with dental advice and instructions as the months passed despite initial apprehension.
- Patient has never missed an appointment without notice and will continue to attend OHCWA for maintenance.
#### Patient Response to Treatment
**Satisfaction**
- Patient was very satisfied: "I can smile again – I can’t stop smiling!"
**Resolution of Complaints**
1. **Aesthetics:** 12-21 indirect restorations placed (13 incomplete).
2. **Crown Stability (11):** Endodontically re-treated and new crown placed.
3. **Sensitivity (47):** Cause investigated and resolved with an indirect restoration.
**Compliance**
- Patient was highly compliant with instructions and reliable with appointments. She will continue maintenance at OHCWA.
2.7.4 Reflection
| | Challenges | Management |
| :--- | :--- | :--- |
| **Patient-related** | **Strong gag reflex** | • **For impressions:** <br> └ Salt on tongue <br> └ Xylocaine spray <br> └ Distraction techniques <br> └ Breathing techniques <br> └ Encouragement and guidance <br><br>• **For radiographs:** <br> └ Alternative radiographic techniques e.g. occlusal PA <br> └ Encouragement and guidance <br><br>• **Rubber dam clamps** <br> └ Local anaesthetic <br> └ Wingless or tucked wing clamps |
| | Lack of trust in student clinician | • Build rapport, trust, confidence <br>• Factual and transparent communication <br>• Proceed through treatment plan slowly and involve patient in all aspects to provide patient with a sense of control |
| | Apprehension towards radiation | • Patient education to put radiation exposure into context <br>• Explain risk of substandard care if radiographs not available for diagnosis and certain procedures |
| | Possible relocation | • Regular open communication regarding likely date for relocation and potential impacts on treatment plan <br>• Appropriate revision and sequencing of treatment plan in line with patient's situation <br>• Avoiding over-promising treatment that can be delivered and providing patient with what can be achieved realistically to an acceptable standard <br>*Due to COVID-19 patient was able to attend appointments through 2020* |
| **Clinical** | **45 preparation** | • Initially aimed to be conservative of tooth structure, however the preparation shape and outline was not ideal for CAD-CAM fabrication of restoration <br>• Preparation shape also left remaining tooth structure susceptible to cuspal flexure and cracking. <br>*Preparation was refined by further occlusal reduction to overlay remaining tooth structure to prevent cuspal flexure and to produce preparation shape and contours favourable to CAD-CAM processes* |
| | **11 cast post-core cement gap** | • At try-in of 11 cast post-core there was a cement gap left after insert which although not ideal, was accepted clinically <br>• Reasons for poor fit include error in post-space impression, casting error |
| | **Changes to treatment plan** | • **Additions to treatment plan included:** <br> └ Restoration for 22 due to mesial subgingival caries <br> └ Restoration for 35 due to crumbling GIC <br> └ Restoration for 27 due to cracked tooth |
75
#### Reflection on Challenges
**Patient-Related Challenges**
- **Strong Gag Reflex:** Managed with salt on tongue, Xylocaine spray, distraction, and breathing techniques. Used wingless clamps for rubber dam.
- **Lack of Trust:** Managed by building rapport slowly and involving the patient in all decisions.
- **Radiation Apprehension:** Managed through education on risk vs. benefit.
- **Relocation Uncertainty:** Managed through regular communication and flexible sequencing. COVID-19 ultimately allowed for treatment completion.
**Clinical Challenges**
- **45 Preparation:** Initial conservative prep was not ideal for CAD-CAM; refined with further occlusal reduction to prevent cuspal flexure.
- **11 Cast Post-Core:** A small cement gap was noted at try-in; accepted clinically but noted as a minor fit error.
- **Plan Changes:** Additions included 22 (subgingival caries), 35 (crumbling GIC), and 27 (cracked tooth).
![]()
A structured table titled '2.7.4 Reflection' summarizing clinical challenges and their management strategies. The table is divided into two main categories: 'Patient-related' (including strong gag reflex, lack of trust, apprehension towards radiation, possible relocation) and 'Clinical' (including 45 preparation, 11 cast post-core cement gap, changes to treatment plan). Each row details specific challenges in the second column and corresponding management actions in the third column, including bullet points for techniques like using salt on tongue or xylocaine spray for gag reflex, building rapport for trust issues, and refining tooth preparations for CAD-CAM processes.
CASE 3
Removable Aesthetic
76
CASE 3
Removable Aesthetic
CASE 3
Removable Aesthetic
**3.1.1 Details**
* 82 year-old male
**3.1.2 Presenting complaint/s**
* Presented in July 2020 for initial examination with the following complaints:
i. “My fillings (21, 22) have broken off.”
ii. “I have a missing tooth (11) that bothers me.”
**3.1.3 History of presenting complaint/s**
* 22 restored with pinned composite July 2020.
* 21 restored with pinned composite twice, in July then August 2020.
* 11 missing for some time.
77
#### Patient Details
- 82-year-old male
#### Presenting Complaints
Presented in July 2020 for initial examination with the following complaints:
1. "My fillings (21, 22) have broken off."
2. "I have a missing tooth (11) that bothers me."
#### History of Presenting Complaints
- 22 restored with pinned composite July 2020.
- 21 restored with pinned composite twice, in July then August 2020.
- 11 missing for some time.
![]()
Clinical photograph of an 82-year-old male patient's face. The eyes are obscured by a black bar for privacy. The image serves as the visual identification for Case 3 regarding a removable aesthetic treatment.
### HTML Table 1: Medical Condition
| Medical condition | Description | Dental implications (1) |
|---|---|---|
| History of myocardial infarction (MI) Bypass surgery 2005 Stent procedure 2017 | Blockage of coronary artery. Most common sign is chest discomfort or pain which can spread to arms, neck, jaw, back and can often last longer than 10 minutes. Requires emergency treatment. | Heart attack in dental chair. Basic life support. Call 000. |
| History of stroke Carotid surgery 2019 | Haemorrhagic stroke; bleeding into the brain, or ischaemic stroke; blockage of carotid arteries. Both cause brain damage. FAST check for stroke: Face – smile (is one side droopy?) Arms – raise both arms (is one side weak?) Speech – speak a simple sentence (slurred?) Time – get to hospital fast (emergency) | Stroke in dental chair. Basic life support. Call 000. |
| Arrhythmia Subdermal loop recorder 2020 | Fault in the heart’s electrical signalling system which affects heartbeat. | Patient discomfort in dental chair. Offer to reschedule appointment and send patient home. |
| Hard of hearing | Age-related hearing loss. Wears hearing aids. | Hearing impairment. Requires high volume speech. |
| Peripheral vision loss (tunnel vision) | Unknown cause of vision loss. | Peripheral vision impairment. Requires clinician to present directly in front of the patient. |
### Notes:
(1) Therapeutic guidelines: oral and dental (2019).
### HTML Table 2: Medication
| Medication | Dosage | Use & Mechanism of action (2, 3) | Dental implications (2, 3) |
|---|---|---|---|
| Lorstat (Atorvastatin) | 20 mg tab q.d. | HMG-CoA reductase (involved in cholesterol synthesis) inhibitor. Increases hepatic cholesterol uptake from blood, reduce concentrations of total cholesterol, LDL and triglycerides. For hypercholesterolaemia and hypertensive patients with additional risk factors for coronary heart disease. | Nil. |
| Cardiprin (Aspirin) | 100 mg tab q.d. | Anti-platelet to reduce risk of MI/stroke. Inhibits platelet aggregation by binding to P2Y<sub>12</sub> platelet receptor and inhibiting cyclo-oxygenase (COX), reducing synthesis of thromboxane (induces platelet aggregation). | Prolongs bleeding time. NSAIDs may be contraindicated due to drug interaction with aspirin. |
| Bispro (Bisoprolol fumarate) | 2.5 mg tab q.d. | β-blocker for hypertension, MI, chronic heart failure. Reduces heart rate, blood pressure and cardiac contractility via unknown mechanism. | Potential for drug interactions used in General Aesthesia resulting in severe bradyarrhythmia, attenuation of reflex tachycardia and hypotension, decreased reflex to compensate for blood loss and hypovolaemia, regional sympathetic blockade, increased propensity for vagal induced bradycardia. May increase sensitivity to allergens and severity of anaphylaxis, adrenaline treatment may not always give expected therapeutic effect. |
#### Medical History
| Medical condition | Description | Dental implications |
|---|---|---|
| History of myocardial infarction (MI) Bypass surgery 2005 Stent procedure 2017 | Blockage of coronary artery. Chest discomfort or pain spreading to arms, neck, jaw, back. | Heart attack in dental chair. Basic life support. Call 000. |
| History of stroke Carotid surgery 2019 | Haemorrhagic or ischaemic stroke causing brain damage. FAST check: Face, Arms, Speech, Time. | Stroke in dental chair. Basic life support. Call 000. |
| Arrhythmia Subdermal loop recorder 2020 | Fault in heart’s electrical signalling affecting heartbeat. | Patient discomfort. Offer to reschedule. |
| Hard of hearing | Age-related hearing loss. Wears hearing aids. | Requires high volume speech. |
| Peripheral vision loss | Unknown cause (tunnel vision). | Requires clinician to present directly in front of patient. |
#### Medications
| Medication | Dosage | Use & Mechanism of action | Dental implications |
|---|---|---|---|
| Lorstat (Atorvastatin) | 20 mg tab q.d. | HMG-CoA reductase inhibitor for hypercholesterolaemia. | Nil. |
| Cardiprin (Aspirin) | 100 mg tab q.d. | Anti-platelet; inhibits platelet aggregation via COX inhibition. | Prolongs bleeding time. NSAIDs may be contraindicated. |
| Bispro (Bisoprolol fumarate) | 2.5 mg tab q.d. | β-blocker for hypertension/MI. Reduces heart rate and blood pressure. | Potential GA interactions (bradyarrhythmia, hypotension). May increase allergen sensitivity; adrenaline may have reduced effect. |
![]()
Table titled 'Medical Condition' with columns for Medical condition, Description, and Dental implications. Rows include entries for History of myocardial infarction (MI), History of stroke, Arrhythmia, Hard of hearing, and Peripheral vision loss, each with corresponding descriptions and dental implications.
![]()
Table titled 'Medication' with columns for Medication, Dosage, Use & Mechanism of action, and Dental implications. Rows include entries for Lorstat (Atorvastatin), Cardiprin (Aspirin), and Bispro (Bisoprolol fumarate), each with corresponding dosages, mechanisms of action, and dental implications.
<table border="1" cellspacing="0" cellpadding="4">
<tr>
<th>Uremide</th>
<th>40 mg q.d.</th>
<th>Loop diuretic, inhibits reabsorption of sodium and chloride in kidney. For oedema associated with heart failure and hypertension.</th>
<th>May increase ototoxic and nephrotoxic potential of aminoglycoside and cephalosporin antibiotics.<br/>NSAIDs may reduce natriuretic and antihypertensive effect.</th>
</tr>
<tr>
<th>Multivitamin</th>
<th></th>
<th>Dietary supplement.</th>
<th>Nil.</th>
</tr>
<tr>
<th>Garlic</th>
<th></th>
<th>Dietary supplement.</th>
<th>May inhibit platelet aggregation and increase bleeding risk.</th>
</tr>
<tr>
<th>Horseradish</th>
<th></th>
<th>Dietary supplement.</th>
<th>Nil.</th>
</tr>
<tr>
<th>Vitamin C complex</th>
<th></th>
<th>Dietary supplement.</th>
<th>Nil.</th>
</tr>
</table>
<br/>
(2) Monthly Index of Medical Specialities Australia. (3) Australian Medicines Handbook.
<br/>
<table border="1" cellspacing="0" cellpadding="4">
<tr>
<th>Allergy</th>
<th>Description</th>
<th>Dental implications</th>
</tr>
<tr>
<td colspan="2">No known allergies.</td>
<td></td>
</tr>
</table>
<br/>
<table border="1" cellspacing="0" cellpadding="4">
<tr>
<th>Alcohol &amp; Tobacco Use</th>
<th>Amount, Frequency &amp; Duration</th>
<th>Dental implications</th>
</tr>
<tr>
<td>Current drinker</td>
<td>1 standard drink per week.</td>
<td>Alcohol consumption raises risk of cancer including on lip and in oral cavity. (5)</td>
</tr>
<tr>
<td>Non-smoker</td>
<td>N/A.</td>
<td>Nil.</td>
</tr>
</table>
<br/>
### 3.1.5 Dental history and dental attitude
- Dental history
- History of regular attendance at OHCWA.
- Co-Cr partial upper dentures made in the past – not worn due to poor fit.
- Presented to student clinic for initial examination in July 2020 following transfer from another DMD student.
- Dental attitude
- Aesthetic motivation.
- Concerned about broken front teeth.
- Experiences no issues with function – chews food slowly on back teeth.
- Motivated; attends all appointments using public transport.
### 3.1.6 Oral hygiene
- Poor oral hygiene:
- Uses manual toothbrush and fluoride toothpaste twice daily.
- Does not use interproximal cleaning aids.
- Does not use any other cleaning adjuncts.
### 3.1.7 Social history
- Retired.
- Wife also attends OHCWA.
- Spends time reading poetry, tending to farm, maintaining light aircraft.
#### Additional Medications and Supplements
| Medication/Supplement | Dosage | Use & Mechanism | Dental implications |
|---|---|---|---|
| Uremide | 40 mg q.d. | Loop diuretic for oedema/hypertension. | May increase ototoxic/nephrotoxic potential of certain antibiotics. NSAIDs may reduce effect. |
| Multivitamin | - | Dietary supplement. | Nil. |
| Garlic | - | Dietary supplement. | May inhibit platelet aggregation and increase bleeding risk. |
| Horseradish | - | Dietary supplement. | Nil. |
| Vitamin C complex | - | Dietary supplement. | Nil. |
#### Allergies and Social Habits
- **Allergies:** No known allergies.
- **Alcohol:** Current drinker (1 standard drink per week). Raises risk of oral cavity cancer.
- **Tobacco:** Non-smoker.
#### Dental History and Attitude
- **History:**
- Regular attendance at OHCWA.
- Previous Co-Cr partial upper dentures not worn due to poor fit.
- Transferred to current student clinic in July 2020.
- **Attitude:**
- Aesthetic motivation; concerned about front teeth.
- No functional issues reported; chews slowly on posterior teeth.
- Highly motivated; uses public transport for all appointments.
#### Oral Hygiene and Social History
- **Oral Hygiene:** Poor. Uses manual toothbrush and fluoride toothpaste twice daily. No interproximal cleaning aids.
- **Social History:** Retired. Enjoys reading poetry, farming, and maintaining light aircraft. Wife also attends OHCWA.
![]()
Table listing medications and dietary supplements. Rows include Uremide (Furosemide), Multivitamin, Garlic, Horseradish, and Vitamin C complex. Columns describe dosage, function/description, and dental implications.
![]()
Table titled 'Allergy' with columns for 'Description' and 'Dental implications'. Content states 'No known allergies'.
![]()
Table titled 'Alcohol & Tobacco Use' with columns for 'Amount, Frequency & Duration' and 'Dental implications'. Rows list patient status as 'Current drinker' (1 standard drink per week) and 'Non-smoker', with associated risk notes.
3.2 Examination and diagnostics
Date: July 2020
3.2.1 Extra-oral examination
| Findings |
| --- |
| Facial symmetry | Absence of facial swelling |
| Facial skin | Hyperpigmentation |
| Lips | Hydrated, smooth lips and distinct vermilion border |
| Temporomandibular joint | Clicking on opening and closing bilaterally |
| | Absence of clicking and in excursion bilaterally |
| | Absence of pain and tenderness on palpation |
| Lymph nodes | No sign of lymphadenopathy |
| | Absence of pain and tenderness on palpation |
| Muscles of mastication | Absence of pain and tenderness on palpation |
| Thyroid gland | No obvious abnormal enlargement |
3.2.2 Extra-oral photographs
*Patient refused to show teeth when smiling.
3.2.3 Intraoral examination
| Findings |
| --- |
| Labial mucosa | Nil abnormalities detected |
| Buccal mucosa | Nil abnormalities detected |
| Hard palate | Nil abnormalities detected |
| Soft palate | Nil abnormalities detected |
| Gingivae | Nil abnormalities detected |
| Tongue | White coat on dorsum |
| Floor of mouth | Nil abnormalities detected |
80
#### Extra-oral Examination (July 2020)
| Findings | Observations |
| --- | --- |
| Facial symmetry | Absence of facial swelling |
| Facial skin | Hyperpigmentation |
| Lips | Hydrated, smooth; distinct vermilion border |
| TMJ | Bilateral clicking on opening/closing; no pain or tenderness |
| Lymph nodes | No lymphadenopathy; no pain or tenderness |
| Muscles of mastication | Absence of pain and tenderness on palpation |
| Thyroid gland | No obvious abnormal enlargement |
*Note: Patient refused to show teeth when smiling for extra-oral photographs.*
#### Intraoral Examination
| Findings | Observations |
| --- | --- |
| Labial/Buccal mucosa | Nil abnormalities detected |
| Hard/Soft palate | Nil abnormalities detected |
| Gingivae | Nil abnormalities detected |
| Tongue | White coat on dorsum |
| Floor of mouth | Nil abnormalities detected |
![]()
Table titled '3.2.1 Extra-oral examination' listing findings for facial symmetry, skin, lips, temporomandibular joint, lymph nodes, muscles of mastication, and thyroid gland with corresponding clinical observations.
![]()
Three extra-oral photographs showing a patient's face from different angles (left profile, frontal view, right profile). Eyes are blacked out for privacy. Caption below notes: '*Patient refused to show teeth when smiling.'
![]()
Table titled '3.2.3 Intraoral examination' listing findings for labial mucosa, buccal mucosa, hard palate, soft palate, gingivae, tongue, and floor of mouth with corresponding clinical observations.
![]()
A structured table titled '3.2.4 Intraoral photographs and findings' presenting detailed clinical data for a dental patient. The table is organized into columns labeled 'View', 'Teeth', 'Restorations', and 'Soft tissues'. It categorizes findings by anatomical views: Maxillary occlusal, Mandibular occlusal, Right buccal, Left buccal, and Anterior. Key details include partial denture classifications (Kennedy-Applegate Class II Mod 2 and III Mod 1), tooth conditions such as fractures, discoloration, and enamel infractions, restoration types like amalgam and composite, and soft tissue issues including gingival inflammation and recession.
3.2.5 Occlusion
3.2.5 Occlusion
| Findings | |
| --- | --- |
| Overjet | Edge to edge |
| Overbite | Edge to edge |
| Canine class | LHS: Class III, RHS: Class III |
| Molar class | LHS: -, RHS: Class III |
| Crossbite | Bilateral posterior crossbite |
| Crowding / Spacing | Absent |
| Rotation | 24, 26 |
| Supraeruption | 26 |
| Occlusal scheme | Group function |
82
#### Occlusal Analysis
| Findings | Description |
| --- | --- |
| Overjet | Edge to edge |
| Overbite | Edge to edge |
| Canine class | Class III (Bilateral) |
| Molar class | RHS: Class III; LHS: Not recorded |
| Crossbite | Bilateral posterior crossbite |
| Crowding / Spacing | Absent |
| Rotation | 24, 26 |
| Supraeruption | 26 |
| Occlusal scheme | Group function |
![]()
Clinical intraoral photographs showing occlusion from multiple views: maxillary arch (top), frontal view of teeth with edge-to-edge overjet and overbite, right lateral view, left lateral view, and mandibular arch. Images show multiple dental restorations including amalgam fillings and crowns, discoloration, and malocclusion features consistent with Class III canine and molar relationships.
![]()
Table titled '3.2.5 Occlusion' listing findings such as Overjet (Edge to edge), Overbite (Edge to edge), Canine class (LHS: Class III, RHS: Class III), Molar class (LHS: -, RHS: Class III), Crossbite (Bilateral posterior crossbite), Crowding/Spacing (Absent), Rotation (24, 26), Supraeruption (26), and Occlusal scheme (Group function).
### 3.2.6 Odontogram
<div>
</div>
---
### 3.2.7 Periodontal assessment
### 3.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)
```
| CPITN | Findings |
|-------|---------------------------|
| | Sextant 1 |
| 3 1 1 | 15MP 4 mm |
| 1 1 1 | Sextant 2 |
| | Generalised staining |
| | Sextant 3 |
| | Generalised staining and gingival recession especially around 26 |
| | Sextant 4 |
| | Generalised staining and gingival recession |
| | Sextant 5 |
| | Generalised staining |
| | Sextant 6 |
| | Generalised staining and gingival recession |
```
---
### 3.2.7.2 Periodontal examination
```
| Clinical | Gingival tissues |
|-----------------|----------------------------|
| | Bleeding on probing interproximally |
| | Oedematous texture |
| | Pink with red marginal inflammation |
| | Blunted papillae around lower anterior teeth |
| | Thick biotype |
| | |
| | Plaque distribution |
| | Interproximal areas |
| | Plaque score |
| | - |
| | Calculus distribution |
| | Posterior teeth |
| | Plaque-retentive factors |
| | Open contacts between 21-24, 31-43 |
| | Buccal groove 46 |
| | Furcation involvement |
| | 46, 47 |
| | Halitosis |
| | No |
| Radiographic | Bone levels |
| | Generalised mild horizontal bone loss in maxilla and mandible |
```
#### Periodontal Assessment
**Community Index of Periodontal Treatment Needs (CPITN)**
- Sextant 1: Score 3 (15MP 4 mm)
- Sextant 2: Score 1 (Generalised staining)
- Sextant 3: Score 1 (Generalised staining and recession around 26)
- Sextant 4: Score 1 (Generalised staining and recession)
- Sextant 5: Score 1 (Generalised staining)
- Sextant 6: Score 1 (Generalised staining and recession)
**Clinical Findings**
- **Gingival Tissues:** Bleeding on probing interproximally; oedematous texture; pink with red marginal inflammation; blunted papillae around lower anterior teeth; thick biotype.
- **Plaque/Calculus:** Distributed in interproximal areas and posterior teeth.
- **Plaque-retentive factors:** Open contacts (21-24, 31-43); buccal groove 46.
- **Furcation involvement:** 46, 47.
- **Halitosis:** Absent.
**Radiographic Findings**
- Bone levels: Generalised mild horizontal bone loss in maxilla and mandible.
![]()
Odontogram diagram showing tooth numbering and surface codes. The top row displays numbered squares (1-8) representing teeth in quadrants, with color-coded symbols for restorations: grey for amalgam restoration, yellow for metallic crown, orange for composite restoration, red 'x' for unsatisfactory restoration, green outline for non-carious tooth surface loss, hatched pattern for enamel infraction, dot for cracked tooth, 'I' for impacted, and RCT box for root-canal treated.
![]()
Table titled 'Community Index of Periodontal Treatment Needs (CPITN)' with two columns: CPITN and Findings. The CPITN column shows values 3, 1, 1 in the first row and 1, 1, 1 in the second row. The Findings column lists findings for each sextant: Sextant 1 has '15MP 4 mm'; Sextant 2 has 'Generalised staining'; Sextant 3 has 'Generalised staining and gingival recession especially around 26'; Sextant 4 has 'Generalised staining and gingival recession'; Sextant 5 has 'Generalised staining'; Sextant 6 has 'Generalised staining and gingival recession'.
![]()
Table titled 'Periodontal examination' with three columns: Clinical, Gingival tissues, and Findings. Under Clinical, it includes Gingival tissues with findings such as bleeding on probing interproximally, oedematous texture, pink with red marginal inflammation, blunted papillae around lower anterior teeth, thick biotype; Plaque distribution in interproximal areas; Plaque score '-'; Calculus distribution in posterior teeth; Plaque-retentive factors include open contacts between 21-24, 31-43 and buccal groove 46; Furcation involvement at 46, 47; Halitosis 'No'. Radiographic section notes generalised mild horizontal bone loss in maxilla and mandible.
3.2.7.3 Periodontal tests
| Mobility | 0 | 0 | 0 | 0 | I | 0 | 0 | 0 | 0 | 0 |
|---|---|---|---|---|---|---|---|---|---|---|
| TTPalp | - | - | - | - | - | - | - | - | - | - |
| TTP | - | - | - | - | - | - | - | - | - | - |
| 48 | 47 | 46 | 15 | 14 | 13 | 12 | 21 | 22 | 23 |
| | | | 44 | 43 | 42 | 41 | 31 | 32 | 33 |
| | | | | | | | 34 | | |
| TTP | - | - | - | - | - | - | - | - | - | - |
| TTPalp | - | - | - | - | - | - | - | - | - | - |
| Mobility | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| | | | | | | | 36 | 37 | 26 | 27 |
3.2.7.4 Periodontal chart
- Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
3.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)
Age: 82
Number of teeth and implants: 22 (1 - 32)
Number of sites per tooth / implant: 6
Number of BOP-pos. sites: 22 of 132
Number of sites with PPDesem: 0
Number of missing teeth: 7
% alveolar bone loss (estimated in % or 10% per 1mm): 20 %
Syst./Gen.: No
Env.: Non-smoker (NS)
Polygon surface: 11.25833
Periodontal Risk: medium
Suggested Recall Interval: 6 Months
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool, (8)
#### Periodontal Tests and Risk Assessment
**Mobility and Tenderness**
- Mobility: Grade I noted for tooth 13; all other teeth Grade 0.
- TTP/TTPalp: Negative for all tested teeth (48-46, 15-12, 21-23, 44-41, 31-34, 36-37, 26-27).
**Periodontal Charting**
- Full periodontal chart not warranted due to lack of pocketing >3 mm.
**Periodontal Risk Assessment (PRA)**
- **Age:** 82
- **Teeth present:** 22
- **BOP-positive sites:** 22 of 132 (16.7%)
- **Alveolar bone loss:** Estimated 20%
- **Systemic factors:** None
- **Environmental factors:** Non-smoker
- **Periodontal Risk:** Medium
- **Suggested Recall:** 6 Months
![]()
Table titled '3.2.7.3 Periodontal tests'. Displays data for Mobility (values 0 and I), TTPalp (-), and TTP (-) across a series of tooth positions numbered 48 through 37.
![]()
Periodontal Risk Assessment (PRA) visualization. Features a radar chart with axes labeled BOP%, PD≥5mm, Tooth loss, BL/Age, Syst./Gen., and Envir. The chart displays calculated metrics: BOP% = 17, BL/Age = 0.24, Polygon surface = 11.25833, and Periodontal Risk = medium. Adjacent input fields show patient demographics (Age 82, Non-smoker) and clinical data (Number of teeth/implants 22, sites per tooth 6).
3.2.8 Pulp sensibility tests
• Not applicable.
3.2.9 Radiographs
Rationale: each radiograph taken has rationale where stated – ALARA
Note: Subscript a = amalgam, c = composite, m = metallic, p = metal-ceramic
3.2.9.1 Orthopantogram
Date: 24/1/2018
Findings (9)
| Category | Observations |
| :--- | :--- |
| **Periphery and corners** | Radiopacities anterior to spine bilaterally* |
| **Cortices of mandible** | Radiopacities superimposed over body of mandible** |
| **Cortices of maxilla** | Nil abnormalities detected |
| **Zygomatic bones** | Nil abnormalities detected |
| **Maxillary sinuses** | Internal density of sinuses: Radiopaque shadow within sinuses – superimposition of inferior nasal conchae and zygomatic buttresses |
| **Nasal cavity and palate** | Nil abnormalities detected |
| **Bone pattern of maxilla** | Normal density and trabeculation |
| **Bone pattern of mandible** | Normal density and trabeculation<br>One radiopaque spot on left angle of mandible inferior to mandibular canal<br>One radiolucent spot on apex of distal root of 38 |
| **Alveolar processes** | Generalised mild horizontal bone loss in maxilla and mandible<br>Radiopacity at apices 16<br>Possible furcation involvement 46, 47 |
| **Teeth** | Heavily restored dentition<br>Endodontically treated 41<br>Metallic crown 46<br>Amalgam restorations 16, 15, 14, 24, 26, 27, 37, 34, 33, 44, 47, 48<br>Composite restorations 12, 21, 22, 41<br>Long, thin roots 46<br>Missing 17, 25, 36, 35, 38, 45<br>Impacted 18, 28 |
Interpretation of panoramic radiographs, Perschbacher (2012). (9)
*\*Consultation with Radiology – Ddx tonsilloliths, sialoliths, lymph node calcification. Confirmed tonsilloliths as superimposed over body of mandible, the latter are superimposed in submandibular region.*
**\*\*Consultation with Radiology – Ddx atherosclerosis of carotid arteries, cricoid cartilage calcification. Confirmed atherosclerosis of carotid arteries.**
85
#### Radiographic Findings
**Orthopantogram (24/1/2018)**
| Category | Observations |
| :--- | :--- |
| **Periphery** | Radiopacities anterior to spine (Tonsilloliths) |
| **Mandible** | Atherosclerosis of carotid arteries; radiopaque spot on left angle; radiolucent spot at apex of 38 distal root |
| **Maxillary sinuses** | Radiopaque shadow (superimposition of nasal conchae/zygomatic buttresses) |
| **Bone pattern** | Normal density; generalised mild horizontal bone loss; radiopacity at apices 16; possible furcation 46, 47 |
| **Teeth** | Heavily restored; RCT 41; Metallic crown 46; Amalgam (16, 15, 14, 24, 26, 27, 37, 34, 33, 44, 47, 48); Composite (12, 21, 22, 41); Missing (17, 25, 36, 35, 38, 45); Impacted (18, 28) |
![]()
Orthopantogram radiograph dated 24/1/2018 showing the full dentition and maxillofacial skeleton. The image displays heavily restored teeth with metallic crowns (e.g., tooth 46), amalgam restorations, and endodontically treated teeth. There is evidence of generalized mild horizontal bone loss in both maxilla and mandible. Radiopaque shadows are visible anterior to the spine bilaterally, confirmed as tonsilloliths superimposed over the mandibular body. A radiolucent spot is noted at the apex of distal root 38.
![]()
Structured findings table summarizing observations from the orthopantogram under categories including Periphery and corners, Cortices of mandible/maxilla, Zygomatic bones, Maxillary sinuses, Nasal cavity/palate, Bone patterns, Alveolar processes, and Teeth. Key entries include: 'Radiopacities anterior to spine bilaterally' (tonsilloliths), 'Normal density and trabeculation' for bone patterns, 'Generalised mild horizontal bone loss' in alveolar processes, and a detailed list of dental restorations (metallic crown on 46, amalgams on multiple teeth) and missing/impacted teeth (17, 25, 36, 35, 38, 45; impacted 18, 28).
![]()
A structured table under the heading 'Bitewings' with a subheading 'Bitewing – Left'. It includes an X-ray image labeled 'a' showing teeth with date '26/3/2018' and rationale 'interproximal caries detection'. The table lists findings for categories: Caries (24D (?)*), Restorations (24DOs, 26MO & OPs, etc.), Pulp (Nil abnormalities detected), Periodontium (23D, 34D PDL space widening, Generalised crestal bone loss, Alveolar ridge resorption 36 region), and Other (26 supraeruption, 37 mesial tilt). A footnote states '*Clinically non-carious and asymptomatic.'.
![]()
A structured table under the heading 'Bitewings' with a subheading 'Bitewing – Right'. It includes an X-ray image labeled 'b' showing teeth with date '26/3/2018' and rationale 'interproximal caries detection'. The table lists findings for categories: Caries (15M (?)*), Restorations (16MODBPs, 15MODBPs, etc.), Pulp (Nil abnormalities detected), Periodontium (44D, 43D PDL space widening, Generalised crestal bone loss, Alveolar ridge resorption 45 region, Furcation involvement 46), and Other (13, 12 incisal wear, Tight contact 46D & 47M). A footnote states '*Clinically non-carious and asymptomatic.'.
![]()
A structured table under the heading 'Periapicals' with a subheading 'Periapical – 21 & 22'. It includes an X-ray image labeled 'c' showing roots of teeth with date '2/9/20' and rationale 'Check for pathology'. The table lists findings for categories: Caries (Nil detected), Restorations (21 pinned composite (failed), 22 pinned composite (failed)), Pulp (Nil abnormalities detected), Periodontium (Intact PDL space & lamina dura 21, 22; Nil PA radiolucency 21, 22), and Other (Missing 11).
![]()
A structured table under the heading 'Periapicals' with a subheading 'Periapical – 26'. It includes an X-ray image labeled 'd' showing tooth roots with date '2/9/2020' and rationale 'Check for pathology'. The table lists findings for categories: Caries (24D (?)*), Restorations (24DOs, 26MO & OPs, 27MOs, 37Os), Pulp (Nil abnormalities detected), Periodontium (Intact PDL space & lamina dura 24, 26, 27; Nil PA radiolucency 24, 26, 27), and Other (Missing 25, Impacted 28). A footnote states '*Clinically non-carious and asymptomatic.'.
3.2.10 Caries risk assessment
3.2.10.1 Dietary assessment
- Generally, diet is:
- High fermentable carbohydrates
- Low sugar
- Low acid
- Limited snacking frequency
3.2.10.2 Saliva test
| | | Unstimulated saliva | | Stimulated saliva | |
| :--- | :--- | :--- | :--- | :--- | :--- |
| | Flow rate | Consistency | pH | Quantity at 5 mins | Buffering capacity |
| >60 s – low | Sticky/frothy | 5.0–5.8 | <3.5 mL – very low | 0–5 – very low |
| 30–60 s – normal | Frothy/bubbly | 6.0–6.6 | 3.5–5.0 mL – low | 6–9 – low |
| <30 s – high | Watery/clear | 6.8–7.8 | >5.0 mL – normal | 10–12 – normal |
3.2.10.3 Caries Management By Risk Assessment (CAMBRA) (10)
| | |
| :--- | :--- |
| Disease indicators | Radiographic approximal enamel lesions |
| Risk factors | Visible heavy plaque on teeth |
| | Exposed roots |
| Protective factors | Lives/works/school in fluoridated community |
| | Fluoride toothpaste (1000 ppm+) at least twice daily |
| | Fluoride varnish in last 6 months |
| | Adequate saliva flow (>1.0 mL/min stimulated) |
- Caries risk:
- Low
- Suggested management:
- OTC toothpaste with 1000 ppm fluoride, twice daily
- 12-month recall
(10) Caries Management by Risk Assessment, Featherstone & Chaffee (2018).
#### Caries Risk Assessment
**Dietary Assessment**
- High fermentable carbohydrates.
- Low sugar and low acid.
- Limited snacking frequency.
**Saliva Test Results**
- **Unstimulated:** Normal flow rate (30–60 s), watery/clear consistency, pH 6.8–7.8.
- **Stimulated:** Normal quantity (>5.0 mL at 5 mins), normal buffering capacity (10–12).
**CAMBRA Assessment**
- **Disease indicators:** Radiographic approximal enamel lesions.
- **Risk factors:** Visible heavy plaque; exposed roots.
- **Protective factors:** Fluoridated community; fluoride toothpaste twice daily; fluoride varnish (last 6 months); adequate saliva flow.
- **Caries Risk:** Low.
- **Management:** OTC 1000 ppm fluoride toothpaste; 12-month recall.
![]()
Table titled 'Saliva test' comparing Unstimulated saliva (Flow rate, Consistency, pH) with Stimulated saliva (Quantity at 5 mins, Buffering capacity). It categorizes results into Low (<60s flow), Normal (30-60s flow), and High (>60s flow) based on specific values for consistency, pH, quantity, and buffering capacity.
![]()
Table titled 'Caries Management By Risk Assessment (CAMBRA)' listing Disease indicators (Radiographic approximal enamel lesions), Risk factors (Visible heavy plaque, Exposed roots), and Protective factors (Fluoridated community residence, Fluoride toothpaste usage, Fluoride varnish application, Adequate saliva flow).
# 3.3 Diagnoses and problem list
## 3.3.1 Diagnoses
| Pathological | Focusing | Diagnosis |
| :--- | :--- | :--- |
| Restorations | | Heavily restored dentition – large posterior amalgam restorations, large anterior composite restorations with history of multiple failures, crown |
| Endodontic disease (11, 12) | | 41 clinically and radiographically satisfactory root canal treatment with no clinical signs of infection |
| Periodontal disease (13) | | Generalised Stage II Grade A stable periodontitis* |
| Non-carious tooth surface loss | | Attrition 13-12, 21-23, 34-43 |
| Cracked teeth | | 13, 23, 26, 34, 33, 43, 47 |
| Traumatic occlusion | | 21 |
| Medical | | Atherosclerotic carotid arteries bilaterally<br>Tonsiloliths |
| Morphological | Focusing | Diagnosis |
| :--- | :--- | :--- |
| Malocclusion | | Class III malocclusion – habitual forward posture of mandible<br>Bilateral posterior crossbite<br>Rotated 24, 26 |
| Overbite/Overjet | | Edge to edge |
| Impacted teeth | | 18, 28 |
| Missing teeth | | 17, 16, 11, 25, 36, 35, 45 |
| Anterior impairment | | Loss of vertical dimension / prosthetic space |
| Posterior impairment | | Supraerupted 26<br>Mesially tilted 37 |
| Aesthetic harmony | | Missing 11<br>Fractured 21, 22<br>Discolouration 41 |
| Occlusal plane | | Uneven |
| Occlusal stability | | Stable occlusion |
| Guidance system | | Group function |
| Host-related factors | Focusing | Diagnosis |
| :--- | :--- | :--- |
| Psychosocial | | Excellent personal presentation<br>Aesthetic concern<br>Good dental attitude and motivated to attend appointments |
| Habits | | Fair oral hygiene<br>High fermentable carbohydrate diet |
| Socioeconomic | | Financial resources available for dental care |
| Medical | | Medically compromised<br>Limited manual dexterity |
| Functional | | Possible parafunction |
**(11)** Classification, diagnosis and clinical manifestations of apical periodontitis, Abbott (2004). **(12)** A clinical classification of the status of the pulp and the root canal system, Abbott & Yu (2007). **(13)** Periodontitis: Consensus report if workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions, Papapanou et. al. (2018).
---
***Stage II** – RBL 15%-33%, no tooth loss due to periodontitis, max probing depth $\leq$ 5 mm, mostly horizontal bone loss. Generalised – bone loss affects all teeth. Grade B – %RL/age 0.25-1.0, however heavy biofilm deposits with low levels of destruction, non-smoker, normoglycaemic. Unstable - probing depth $\geq$ 5 mm, however limited to one site. (13)*
88
#### Diagnoses
**Pathological and Morphological**
- **Restorations:** Heavily restored dentition; history of multiple anterior composite failures.
- **Endodontic:** Satisfactory RCT 41.
- **Periodontal:** Generalised Stage II Grade A stable periodontitis (Stage II: 15-33% RBL, no tooth loss, PD ≤5mm).
- **Tooth Surface Loss:** Attrition 13-12, 21-23, 34-43.
- **Cracked Teeth:** 13, 23, 26, 34, 33, 43, 47.
- **Malocclusion:** Class III (habitual forward posture); bilateral posterior crossbite; edge-to-edge overbite/overjet.
- **Missing/Impacted:** Missing 17, 16, 11, 25, 36, 35, 45; Impacted 18, 28.
- **Aesthetics:** Missing 11; fractured 21, 22; discoloured 41.
**Medical and Host Factors**
- **Medical:** Atherosclerotic carotid arteries; tonsilloliths; medically compromised.
- **Psychosocial:** Aesthetic concern; motivated; excellent presentation.
- **Functional:** Possible parafunction; limited manual dexterity.
![]()
A structured table titled 'Diagnoses' (section 3.3.1) presenting a patient's dental and medical problem list. The table is organized into three main categories in the first column: Pathological, Morphological, and Host-related factors. Each category contains specific sub-diagnoses such as 'Restorations', 'Endodontic disease', 'Malocclusion', 'Missing teeth', 'Psychosocial', and 'Habits'. The corresponding descriptions for each diagnosis are listed in the rightmost column. For example, under 'Pathological', it lists 'Heavily restored dentition' and 'Generalised Stage II Grade A stable periodontitis*'. Under 'Morphological', it details issues like 'Class III malocclusion' and 'Supraerupted 26'. Footnotes referencing Abbott (2004), Abbott & Yu (2007), and Papapanou et al. (2018) appear below the table, along with detailed definitions for Periodontitis stages and grades.
**3.3.2 Problem list**
* **Carotid artery disease**
* **Poor aesthetics:**
* Missing 11
* Failed composite restorations 21, 22
* Discolouration 41
* **Tight contact:** 46D & 47M
* **Generalised Stage II Grade A stable periodontitis with furcation involvement** 46, 47
* **Generalised anterior tooth wear:**
* Loss of vertical dimension / prosthetic space
* Uneven occlusal plane
* Group function
* Missing posterior teeth: 17, 16, 25, 36, 35, 45
* Impacted 18, 28
* Tonsilloiths
**3.4 Prognosis (14)**
**3.4.1 Individual teeth**
| Liatrogenic compromising factors | | | | | | | | | | | | | | | | | | | |
| :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- |
| Anatomic irregularities | | | | | | | | | | | | | | | | | | | |
| Occlusal plane & tooth position | | | | | | | | | | | | | | | | | | | |
| Endodontic condition | | | | | | | | | | | | | | | | | | | |
| Restorability | | | | | | | | | | | | | | | | | | | |
| Periodontal condition | | | | | | | | | | | | | | | | | | | |
| **48** | **47** | **46** | **15** | **14** | **13** | **12** | **21** | **22** | **23** | **24** | **26** | **27** | **37** | | | | | | |
| **48** | **47** | **46** | **44** | **43** | **42** | **41** | **31** | **32** | **33** | **34** | **37** | | | | | | | | |
| Periodontal condition | | | | | | | | | | | | | | | | | | | |
| Restorability | | | | | | | | | | | | | | | | | | | |
| Endodontic condition | | | | | | | | | | | | | | | | | | | |
| Occlusal plane & tooth position | | | | | | | | | | | | | | | | | | | |
| Anatomic irregularities | | | | | | | | | | | | | | | | | | | |
| Liatrogenic factors | | | | | | | | | | | | | | | | | | | |
**Key:**
* **Good**
* **Fair**
* **Questionable**
* **Poor**
* **Hopeless**
#### Problem List
- Carotid artery disease.
- Poor aesthetics (Missing 11, failed 21/22, discoloured 41).
- Tight contact 46D & 47M.
- Periodontitis with furcation involvement 46, 47.
- Generalised anterior wear (loss of vertical dimension/prosthetic space).
- Missing posterior teeth; impacted 18, 28.
- Tonsilloliths.
#### Prognosis Summary
- **Good:** Most posterior teeth (15, 14, 24, 27, 44, 43, 42, 31-34).
- **Fair:** 48, 46, 47, 26, 37 (due to furcation or restorations).
- **Questionable:** 13, 23, 41.
- **Poor:** 12, 22.
- **Hopeless:** 21.
![]()
Clinical prognosis table titled '3.4.1 Individual teeth' evaluating dental health factors (Liatrogenic compromising factors, Anatomic irregularities, Occlusal plane & tooth position, Endodontic condition, Restorability, Periodontal condition) for multiple teeth numbered 12-48. The table uses a color-coded key (Green=Good, Yellow=Questionable, Orange=Poor, Red=Hopeless, Grey=Fair) to indicate the status of each factor per tooth.
![]()
Table titled 'Evaluation of pathology and scale of severity'. It categorizes dental prognosis into four classes (A-Good, B-Fair, C-Questionable, D-Poor) based on Periodontal condition, Restorability, Endodontic condition, and Occlusal plane & tooth position. Each cell contains specific criteria regarding bone support percentages, remaining sound tooth structure, treatment predictability, and occlusal alignment.
![]()
Small table titled 'Factors that result in drop of determined class'. It lists 'iatrogenic compromising factors' such as perforations, extensive post preparations, minimal tooth structure thickness left after preparation, and cracked teeth from large amalgam restorations.
![]()
Large table under section '3.4.2 Patient-level risk factors'. It is divided into three sections: 'Biologic risk factors', 'Behavioural risk factors', and 'Financial and personal risk factors'. The right column indicates the status using colored dots (green, yellow). Specific items include medical conditions, oral hygiene, diet, smoking habits, motivation for treatment, and aesthetic expectations.
![]()
Color-coded key/legend for the patient-level risk factors table. It displays three colored rectangles corresponding to ratings: Green for 'Favourable', Yellow for 'Questionable', and Red for 'Unfavourable'.
3.4.3 Overall dentition
* All teeth have sound periodontal health with exception of 46, 47 which have furcation involvement.
* All teeth have sound pulpal health with exception of 41 which has questionable root canal treatment.
* History of extensive restoration of posterior teeth has detrimental effect on restorability and prognosis.
* Anterior teeth 12, 21, 22 have poor to hopeless prognosis given little remaining tooth structure.
* Patient’s medical history reveals high risk factors for stroke, therefore dental issues are of low priority.
* Despite this, low cariogenic, low acid diet and ability to maintain fair oral hygiene is favourable to prognosis of dentition.
* Patient has aesthetic motivation and is willing to commit finances, effort and time to treatment.
* If patient receives no attention for current condition:
* High risk of stroke (carotid artery disease)
* Detrimental effect on psychosocial wellbeing (poor aesthetics)
* Loss of teeth (wear)
* Discussion of diagnoses and prognoses of dentition with patient led patient to decide on and commit to treatment.
91
#### Overall Dentition Prognosis
- **Periodontal:** Sound health except 46, 47 (furcation).
- **Pulpal:** Sound except 41 (questionable RCT).
- **Restorability:** Detrimental effect from extensive posterior restorations; anterior teeth 12, 21, 22 have poor/hopeless prognosis due to minimal tooth structure.
- **Medical Priority:** High risk for stroke makes dental issues lower priority, though diet and hygiene are favourable.
- **Patient Factors:** Motivated for aesthetics and willing to commit resources.
- **Risk of No Treatment:** Stroke risk, psychosocial impact from poor aesthetics, and further tooth loss from wear.
### 3.5 Treatment options
<table>
<thead>
<tr>
<th>Problem</th>
<th></th>
<th>Treatment Option</th>
<th>Benefits</th>
<th>Risks</th>
<th>Decision &amp; Rationale</th>
</tr>
</thead>
<tbody>
<tr>
<td>Carotid artery disease</td>
<td>1</td>
<td><ul><li>Immediate referral to General Practitioner</li></ul></td>
<td><ul><li>Immediate management of atherosclerotic calcification</li><li>Reduce risk of stroke</li></ul></td>
<td><ul><li>Patient refusal to listen to advice</li></ul></td>
<td>Option 1:<ul><li>Clinician's responsibility to diagnose disease from available information and refer patient to appropriate health care practitioner for management</li></ul></td>
</tr>
<tr>
<td rowspan="3">Poor aesthetics: Missing 11</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="3">Option 2:<ul><li>Patient does not want commitment to extensive treatment plan involved with full mouth rehabilitation</li><li>Option addresses problem adequately with known risks</li></ul></td>
</tr>
<tr>
<td>2</td>
<td><ul><li>Partial denture</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Moderate time and financial commitment</li></ul></td>
<td><ul><li>Patient may feel uncomfortable and be unable to adapt to denture</li><li>History of unsatisfactory dentures, likelihood of similar outcome</li><li>Minimal prosthetic / material space, risking failure to provide aesthetics and durability</li></ul></td>
</tr>
<tr>
<td>3</td>
<td><ul><li>Referral to Prosthodontist for full mouth rehabilitation</li><li>Implant?</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Predictable outcome</li></ul></td>
<td><ul><li>Substantial time and financial commitment</li><li>Surgical and post-surgical risks</li></ul></td>
</tr>
<tr>
<td rowspan="3">Poor aesthetics: Failed composite 21</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="3">Option 3:<ul><li>Patient wants to keep tooth as long as possible; tooth has hopeless prognosis</li><li>Immediate acrylic partial denture can function as transitional denture before committing to Co-Cr partial denture</li></ul></td>
</tr>
<tr>
<td>2</td>
<td><ul><li>Remove remaining restoration</li><li>Restore tooth</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Minimal commitment required</li></ul></td>
<td><ul><li>Tooth has hopeless prognosis</li><li>Little remaining tooth structure</li><li>History of failed restorations, likelihood of similar outcome</li></ul></td>
</tr>
<tr>
<td>3</td>
<td><ul><li>Extraction</li><li>Immediate partial denture</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Moderate time and financial commitment</li></ul></td>
<td><ul><li>Extraction complications</li><li>Post-extraction complications</li><li>Patient may feel uncomfortable and be unable to adapt to denture</li><li>History of unsatisfactory dentures, likelihood of similar outcome</li><li>Minimal prosthetic / material space, risking failure to provide aesthetics and durability</li></ul></td>
</tr>
</tbody>
</table>
92
#### Treatment Options: Medical and Anterior Aesthetics
| Problem | Option | Benefits | Risks | Decision |
|---|---|---|---|---|
| Carotid artery disease | Immediate GP referral | Manage calcification; reduce stroke risk. | Patient refusal. | **Selected:** Clinician responsibility to refer. |
| Missing 11 | Partial denture | Addresses complaint; moderate commitment. | Adaptation issues; minimal prosthetic space. | **Selected:** Addresses problem without full mouth rehab. |
| Failed composite 21 | Extraction & immediate partial denture | Addresses complaint; moderate commitment. | Extraction risks; adaptation issues. | **Selected:** Transitional step before Co-Cr denture. |
![]()
A structured clinical decision table titled '3.5 Treatment options' (page 92). The table compares three distinct dental problems: 'Carotid artery disease', 'Poor aesthetics: Missing 11', and 'Poor aesthetics: Failed composite 21'. For each problem, it lists specific treatment options (numbered 1, 2, or 3), their benefits, associated risks, and the clinician's decision rationale.
<table>
<tr>
<td>Poor aesthetics: Failed composite 22</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="2">Option 3:<ul><li>Patient wants to keep tooth as long as possible; tooth has poor prognosis</li><li>Tooth is restorable but longevity likely short-lived</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Remove remaining restoration</li><li>Restore tooth</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Minimal commitment required</li></ul></td>
<td><ul><li>Tooth has poor prognosis</li><li>Little remaining tooth structure</li><li>History of failed restorations, likelihood of similar outcome</li><li>Minimal prosthetic / material space, risking failure to provide aesthetics and durability</li></ul></td>
</tr>
<tr>
<td></td>
<td>3</td>
<td><ul><li>Extraction</li><li>Immediate partial denture</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Moderate time and financial commitment</li></ul></td>
<td><ul><li>Extraction complications</li><li>Post-extraction complications</li><li>Patient may feel uncomfortable and be unable to adapt to denture</li><li>History of unsatisfactory dentures, likelihood of similar outcome</li><li>Minimal prosthetic / material space, risking failure to provide aesthetics and durability</li></ul></td>
<td></td>
</tr>
<tr>
<td rowspan="2">Poor aesthetics: Discolouration 41</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Poor aesthetics</li></ul></td>
<td rowspan="2">Option 1:<ul><li>Patient does not want treatment; discolouration does not bother patient</li></ul></td>
</tr>
<tr>
<td>2</td>
<td><ul><li>Remove restoration</li><li>Restore tooth</li></ul></td>
<td><ul><li>Minimal commitment required</li></ul></td>
<td><ul><li>Little remaining tooth structure, likelihood of restoration failure</li></ul></td>
</tr>
<tr>
<td rowspan="2">Tight contact 46D &amp; 47M</td>
<td>1</td>
<td><ul><li>No treatment</li><li>Monitor</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Plaque and food trapping, gingival inflammation</li><li>Caries, pulpal involvement, infection</li><li>Breakdown of tooth structure</li><li>Tooth loss</li></ul></td>
<td rowspan="2">Option 1:<ul><li>Patient does not want treatment</li></ul></td>
</tr>
<tr>
<td>2</td>
<td><ul><li>Remove restoration</li><li>Assess restorability</li><li>Restore tooth</li></ul></td>
<td><ul><li>Eliminate plaque and food trap</li><li>Reduce risk of caries and periodontal problems</li><li>Restore with contours favourable for oral hygiene</li></ul></td>
<td><ul><li>Inadequate remaining coronal tooth structure may involve extensive restorative work</li><li>Margins likely to be subgingival, difficult to restore</li></ul></td>
</tr>
</table>
#### Treatment Options: Aesthetics and Posterior Issues
| Problem | Option | Benefits | Risks | Decision |
|---|---|---|---|---|
| Failed composite 22 | Restore tooth | Minimal commitment. | Poor prognosis; minimal space. | **Selected:** Patient wants to keep tooth as long as possible. |
| Discolouration 41 | No treatment | No commitment. | Poor aesthetics. | **Selected:** Patient not bothered by discolouration. |
| Tight contact 46D/47M | No treatment / Monitor | No commitment. | Plaque trap; caries; infection. | **Selected:** Patient does not want treatment. |
![]()
A comprehensive clinical decision-making table detailing treatment options for various dental issues. The table is structured with columns for the condition (e.g., 'Poor aesthetics: Failed composite 22', 'Tight contact 46D & 47M'), Treatment Option Number, Procedure Steps, Pros/Cons, and Patient Considerations. It compares different strategies such as 'No treatment', 'Restore tooth', and 'Extraction' against specific criteria like commitment required, prognosis, and complications.
<PdfPage>
<table style="width:100%">
<tr>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Generalised Stage II<br>
Grade A stable periodontitis
</td>
<td>
1
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>No treatment</li>
<li>No commitment required</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Plaque and calculus accumulation</li>
<li>Deterioration of periodontal condition</li>
<li>Caries</li>
<li>Tooth loss</li>
<li>Systemic health effects</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Option 2:<br>
&nbsp;&nbsp;&bull; Favour periodontal and systemic health<br>
&nbsp;&nbsp;&bull; Reduce risk of caries, potential for breakdown of tooth structure<br>
&nbsp;&nbsp;&bull; Reduce risk of tooth loss<br>
&nbsp;&nbsp;&bull; Create favourable environment for indirect and direct restoration procedures
</td>
</tr>
<tr>
<td>
2
</td>
</tr>
<tr>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Generalised tooth wear:<br>
Attrition
</td>
<td>
1
</td>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Non-surgical periodontal therapy</li>
<li>Oral hygiene instruction</li>
</ul>
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Remove plaque and calculus to promote periodontal and systemic health</li>
<li>Reduce risk of caries</li>
<li>Reduce risk of tooth loss</li>
</ul>
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Post-operative pain, bleeding, swelling, bruising, infection</li>
<li>Increased tooth sensitivity</li>
<li>Gingival recession</li>
<li>Root surface exposure</li>
</ul>
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Option 1:</li>
<li>&nbsp;&nbsp;&bull; Patient does not want to wear occlusal splint</li>
<li>&nbsp;&nbsp;&bull; Patient does not want commitment to extensive treatment plan involved with full mouth rehabilitation</li>
</ul>
</td>
</tr>
<tr>
<td>
2
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>No commitment required</li>
</ul>
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Tooth wear</li>
<li>Tooth sensitivity</li>
<li>Cracked tooth syndrome</li>
<li>Pulpal involvement</li>
<li>Possibility of extensive treatment to save teeth</li>
<li>Loss of vertical dimension and prosthetic space</li>
<li>Aesthetic changes</li>
<li>Occlusal changes</li>
<li>Functional changes</li>
<li>Tooth loss</li>
</ul>
</td>
</tr>
<tr>
<td>
3
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Simple to use</li>
<li>Quick to fabricate</li>
<li>Reduce tooth wear and sequelae of tooth wear</li>
</ul>
</td>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Patient may not use appliance</li>
</ul>
</td>
</tr>
<tr>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Referral to Prosthodontist<br>
Full mouth rehabilitation
</td>
<td>
1
</td>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>No commitment required</li>
</ul>
</td>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Potential to address presenting complaints with predictable outcome</li>
</ul>
</td>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Substantial time and financial commitment</li>
</ul>
</td>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Option 1:<br>
&nbsp;&nbsp;&bull; Patient does not want treatment; missing upper posterior teeth does not bother patient
</td>
</tr>
<tr>
<td>
2
</td>
</tr>
<tr>
<td>
No treatment
</td>
</tr>
<tr>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Missing upper teeth:<br>
17, 16, 25
</td>
<td>
1
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Moderate time and financial commitment</li>
<li>May improve function</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Partial denture</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Option 1:</li>
<li>&nbsp;&nbsp;&bull; Patient does not want treatment; missing upper posterior teeth does not bother patient</li>
</ul>
</td>
</tr>
<tr>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px; text-align:center;">
No treatment
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px; text-align:center;">
<ul style="margin:0; padding-left:20px;">
<li>Does not address presenting complaint</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px; text-align:center;">
<ul style="margin:0; padding-left:20px;">
<li>Does not address presenting complaint</li>
</ul>
</td>
</tr>
<tr>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Missing lower teeth:<br>
36, 35, 45
</td>
<td>
1
</td>
<td rowspan="3" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Moderate time and financial commitment</li>
<li>May improve function</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>No treatment</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
<ul style="margin:0; padding-left:20px;">
<li>Does not address presenting complaint</li>
</ul>
</td>
<td rowspan="2" style="background-color:#e8f4f8; border:1px solid #000; padding:5px;">
Option 1:<br>
&nbsp;&nbsp;&bull; Patient does not want treatment; missing lower teeth does not bother patient
</td>
</tr>
<tr>
<td style="background-color:#e8f4f8; border:1px solid #000; padding:5px; text-align:center;">
No treatment
</td>
</tr>
<tr>
<td colspan="6" style="background-color:#e8f4f8; border:1px solid #000; padding:5px; text-align:center;">
<ul style="margin:0; padding-left:20px;">
<li>Predictable outcome</li>
<li>May improve function</li>
<li>Substantial time and financial commitment</li>
</ul>
</td>
</tr>
<tr>
<td>
2
</td>
<td>
<ul style="margin:0; padding-left:20px;">
<li>Patient may feel uncomfortable and be unable to adapt to denture</li>
<li>History of unsatisfactory dentures, likelihood of similar outcome</li>
</ul>
</td>
</tr>
<tr>
<td>
3
</td>
<td>
<ul style="margin:0; padding-left:20px;">
<li>Implants</li>
</ul>
</td>
<td>
<ul style="margin:0; padding-left:20px;">
<li>Surgical and post-surgical risks</li>
</ul>
</td>
</tr>
</table>
</PdfPage>
94
#### Treatment Options: Periodontal and Wear
| Problem | Option | Benefits | Risks | Decision |
|---|---|---|---|---|
| Periodontitis | Non-surgical therapy & OHI | Favour systemic health; reduce caries/loss risk. | Sensitivity; recession. | **Selected:** Essential for health and restorative environment. |
| Attrition | No treatment | No commitment. | Sensitivity; loss of vertical dimension. | **Selected:** Patient refused splint or full rehab. |
| Missing 17, 16, 25 | No treatment | No commitment. | Reduced function. | **Selected:** Missing posterior teeth do not bother patient. |
| Missing 36, 35, 45 | No treatment | No commitment. | Reduced function. | **Selected:** Missing posterior teeth do not bother patient. |
![]()
A comprehensive clinical decision table comparing treatment options for various dental conditions. The table is structured into four main sections based on the condition: 'Generalised Stage II Grade A stable periodontitis', 'Generalised tooth wear: Attrition', 'Missing upper teeth: 17, 16, 25', and 'Missing lower teeth: 36, 35, 45'. For each condition, it lists numbered options (ranging from 1 to 3), detailing the specific procedure (e.g., No treatment, Non-surgical periodontal therapy, Occlusal splint, Partial denture, Implants). Columns provide information on commitment required, benefits/risks associated with the option, and specific patient scenarios or contraindications (labeled as 'Option 1' or 'Option 2'). The page number '94' is centered at the bottom.
| Impacted:
18, 28 | 1 | • No treatment | • No commitment required | • Root resorption adjacent tooth • Pericoronitis | Option 1: • Asymptomatic • Present for long time, unlikely to cause issues |
|---|---|---|---|---|---|
| | 2 | • Surgical extraction | • Complete removal of non-functional teeth | • Surgical extraction complications • Post-extraction complications | • Patient’s concurrent medical issues higher priority • Risks outweigh benefits of extraction |
| Tonsilloliths | 1 | • Self-management (asymptomatic) • Oral hygiene • Warm salt water rinses | • Easy to manage • Potential for deposits to dislodge | • Patient refusal to listen to advice • Patient not able to maintain oral hygiene and consequent development of problems | Option 1: • Asymptomatic • Referral to General Practitioner if symptoms develop |
| | 2 | • Referral to General Practitioner (symptomatic) | • Complete removal of large/symptomatic deposits | • Surgical risks | |
### 3.6 Management plan
| Systemic phase | Referral to General Practitioner for management of carotid artery disease |
|---|---|
| Emergency phase | Not applicable |
| Control phase<br><i>Eliminate pain, infection, inflammation</i> | Patient education and consent to treatment |
| | Hygienic phase of periodontal therapy: scale and clean, local periodontal debridement 46 & 47, fluoride application, oral hygiene instruction |
| | Replace unsatisfactory restorations: 22MDL a |
| | Extraction: 21 |
| Holding phase<br><i>Preserve residual dentition</i> | Assess response to periodontal therapy and oral hygiene compliance |
| | Monitor cracked teeth: 26, 47 |
| Reconstructive phase<br><i>Replace lost tissue and stabilise occlusion</i> | Indirect prosthesis: Immediate acrylic upper partial denture replacing 16, 11, 21 |
| Maintenance phase<br><i>Prevention of further breakdown</i> | 1-week post-insert review |
| | Recall exam: 6 monthly periodontal maintenance Reinforce oral hygiene Monitor cracked teeth 26, 47 |
| | Review immediate acrylic upper partial denture and replace with Co-Cr upper partial denture if appropriate |
*Conformative approach taken.
95
#### Treatment Options: Impacted Teeth and Tonsilloliths
- **Impacted 18, 28:** No treatment. Asymptomatic and unlikely to cause issues; medical issues are higher priority.
- **Tonsilloliths:** Self-management (OH, salt water rinses). GP referral only if symptomatic.
#### Management Plan
- **Systemic:** Referral to GP for carotid artery disease.
- **Control Phase:**
- Periodontal therapy (Scale/clean, debridement 46/47, fluoride, OHI).
- Replace 22MDL composite.
- Extraction of 21.
- **Holding Phase:** Assess periodontal response and monitor cracked teeth (26, 47).
- **Reconstructive Phase:** Immediate acrylic upper partial denture (replacing 16, 11, 21).
- **Maintenance Phase:**
- 1-week post-insert review.
- 6-monthly recall for periodontal maintenance and monitoring.
- Future review for Co-Cr partial denture.
![]()
Table comparing management options for Impacted teeth (18, 28) and Tonsilloliths. Columns include treatment approaches (e.g., No treatment, Surgical extraction), benefits/risks, and referral criteria.
![]()
Table outlining the Management plan across different phases: Systemic, Emergency, Control, Holding, Reconstructive, and Maintenance. Details specific actions like periodontal therapy, extractions, prosthesis replacement, and maintenance schedules.
3.7 Treatment delivery
## 3.7.1 Treatment delivery
**Date:** July 2020 – September 2020
<table border="1" class="data-table">
<tr>
<th rowspan="8"></th>
<th>Date</th>
<th>Treatment</th>
</tr>
<tr>
<td rowspan="6">2020</td>
<td>July</td>
<td>Comprehensive exam</td>
</tr>
<tr>
<td></td>
<td>Patient education and consent to treatment</td>
</tr>
<tr>
<td></td>
<td>Supragingival scale and clean</td>
</tr>
<tr>
<td></td>
<td>Fluoride application</td>
</tr>
<tr>
<td></td>
<td>Oral hygiene instruction</td>
</tr>
<tr>
<td></td>
<td>Referral to General Practitioner for management of carotid artery disease</td>
</tr>
<tr>
<td>August</td>
<td>22 MIDLa composite replaced</td>
</tr>
<tr>
<td></td>
<td>Immediate maxillary partial acrylic final impressions</td>
</tr>
<tr>
<td>September</td>
<td>Immediate maxillary partial acrylic try-in</td>
</tr>
<tr>
<td></td>
<td>21 extraction and immediate maxillary partial acrylic insert</td>
</tr>
<tr>
<td></td>
<td>1 week post-operative review</td>
</tr>
</table>
*Note: Maintained conformative occlusal scheme throughout treatment plan.*
- Patient education and consent to treatment:
- Informed patient that due to lack of prosthetic space and current occlusal scheme, acrylic in anterior region will be thin and highly likely to fracture
- Metal reinforcement will be requested to increase strength in anterior region
- Immediate maxillary partial acrylic denture to be used as a transitional denture for partial Co-Cr denture
- Patient understood issues, chose to follow through with treatment plan and consented to treatment
- Referral to General Practitioner management of carotid artery disease:
- Patient underwent carotid surgery in 2019
- Immediate maxillary partial acrylic final impressions:
- Maxillary PVS impression
- Sent to lab for pour-up and fabrication of base and rim with teeth 16 and 11
- Discussion of edge to edge placement: **Unaesthetic** due to short incisal length, decision to create increased overjet and minimal overbite.
#### Treatment Delivery (July – September 2020)
- **July:** Comprehensive exam, patient education, scale/clean, fluoride, OHI, GP referral.
- **August:** Replaced 22 MIDLa composite; final PVS impressions for immediate maxillary partial denture.
- **September:** Try-in; extraction of 21 and insert of immediate partial denture; 1-week review.
#### Clinical Notes
- **Prosthetic Space:** Patient informed that thin acrylic in the anterior region is likely to fracture; metal reinforcement requested.
- **Occlusion:** Decision made to create increased overjet and minimal overbite rather than edge-to-edge for better aesthetics.
![]()
A treatment delivery schedule table for July to September 2020. Columns include 'Date' (grouped by month) and 'Treatment'. Rows list specific clinical interventions: Comprehensive exam, Patient education/consent, Supragingival scale/clean, Fluoride application, Oral hygiene instruction, Referral to GP for carotid artery disease, Composite replacement, Immediate maxillary partial acrylic final impressions, Try-in, Extraction with insert, and post-op review.
![]()
Clinical photograph of a blue Maxillary PVS impression material in the dental arch. The image demonstrates the negative mold taken during the immediate maxillary partial acrylic final impressions step mentioned in the text.
![]()
Three-panel figure illustrating the decision-making process regarding denture aesthetics. It shows a comparison between an edge-to-edge placement (labeled as unaesthetic due to short incisal length) and a modified design with increased overjet and minimal overbite to improve aesthetics.
- Immediate base and rim try-in:
- Confirmed shade selection Dentsply Portrait IPN A4
- Midline satisfactory
- Incisal width satisfactory, length could be shortened
- Bilateral even contacts in occlusion and no interference in excursive movements in current overbite and overjet
- Circumferential periodontal probing depth < 2 mm around 21 noted for decoronation and tooth addition
- Enameloplasty 32DI to create prosthetic space for 21 tooth addition
- Note 22MIDL composite was built up on the labial surface only
- Sent to lab for immediate denture fabrication
- 21 extraction and immediate maxillary partial acrylic insert:
- Extraction uneventful
- Immediate denture acrylic and clasps adjusted to fit, patient satisfied
- Post-operative instructions for immediate denture given: leave in for 24 hours and remove if painful, warm salt water rinses
- Oral and denture hygiene instruction
- 1-week post-operative review:
- 21 extraction site has been sore and patient is not chewing on front
- 21 extraction site healing normally with minimal bleeding and inflammation, granulation tissue present
- Advised to continue warm salt-water rinses and to leave denture out until extraction site has healed and denture is tolerable
- Immediate denture acrylic relieved and clasps tightened, assessed fit, stability and retention satisfactory
- Prophylaxis and reinforced oral and dental hygiene
#### Clinical Procedures Continued
- **Denture Try-in:** Confirmed shade A4; midline and width satisfactory. Enameloplasty performed on 32DI to create space for 21 tooth addition.
- **Extraction and Insertion:** 21 extraction uneventful. Immediate denture adjusted for fit. Post-operative instructions provided (24-hour wear, salt water rinses).
- **1-Week Review:** Extraction site healing normally. Denture acrylic relieved and clasps tightened. Patient advised to leave denture out until site is less tender.
![]()
Clinical intraoral photograph showing the immediate base and rim try-in of a maxillary denture. The image displays the upper teeth in place against the patient's gums. Notable features include the midline alignment, incisal width, and occlusal contacts. The text notes that the shade selection was Dentsply Portrait IPN A4, and there is mention of enameloplasty to create space for tooth addition.
![]()
Laboratory photograph of the maxillary denture base prior to insertion into the mouth. It shows the pink acrylic base with the anterior teeth attached, demonstrating the shape and fit before being sent to the lab for fabrication as per the OCR context.
![]()
Laboratory photograph of the maxillary denture mounted on an articulator or dental cast. This view provides a clear perspective of the tooth arrangement, occlusion, and the overall structure of the prosthetic device after it has been fabricated.
3.7.2 Before and after photographs
*Note: After immediate denture insertion, open bite present due to thick acrylic on palatal which was relieved to close bite.
3.7.3 Patient response to treatment
- Patient was satisfied with overall outcome of treatment.
- “It looks good.”
- Resolution of presenting complaints:
i. “My fillings (21, 22) have broken off.”
- 21 extracted and replaced with immediate denture.
- 22 restored with composite.
ii. “I have a missing tooth (11) that bothers me.”
- 11 replaced with immediate denture.
- Patient was compliant with dental advice and instructions and attended all dental appointments as scheduled despite serious ongoing medical issues.
98
#### Patient Response to Treatment
- **Satisfaction:** Patient satisfied with outcome; stated "It looks good."
- **Resolution:**
- Broken fillings addressed (21 extracted/replaced, 22 restored).
- Missing 11 replaced via denture.
- **Compliance:** Patient attended all appointments despite serious medical issues.
![]()
Clinical before and after photographs of a patient's dentition. Top-left panel shows the pre-treatment state with missing teeth and broken fillings on the lower arch. Top-right panel shows the post-treatment state with immediate dentures in place. The images are grouped under section header '3.7.2 Before and after photographs' and include a note about an open bite present after insertion.
![]()
Pre-treatment facial photograph of an elderly male patient showing his face without smiling. This is part of the 'Before and after photographs' comparison set (Section 3.7.2).
![]()
Post-treatment facial photograph of the same elderly male patient smiling, demonstrating the improved appearance following dental treatment. This is the right-hand image in the 'Before and after photographs' comparison set (Section 3.7.2).
3.7.4 Reflection
| | Challenges | Management |
|---|---|---|
| Patient | Unwillingness to communicate | • Built rapport, trust, confidence over multiple appointments |
| Clinical | Edge to edge occlusion and Lack of prosthetic space | • Pathological and physiological tooth wear has resulted in loss of vertical dimension, tooth structure and occlusion<br>• Due to patient age, medical issues and general unwillingness to undertake extensive treatment, decision made to undertake rehabilitation with conformance with the knowledge that treatment would not be ideal but a compromise<br>• Denture teeth could be set with edge to edge occlusion, however tooth length would be excessively short resulting in poor aesthetic outcome<br>• Therefore denture teeth set with increased overjet<br>• In addition, palatal acrylic would be very thin due to lack of space<br>• Patient was warned that acrylic is highly likely to fracture, but immediate denture with metal mesh reinforcement could function as transitional denture for future Co-Cr denture |
99
#### Reflection
| Category | Challenges | Management |
|---|---|---|
| Patient | Unwillingness to communicate | Built rapport and trust over multiple appointments. |
| Clinical | Edge-to-edge occlusion and lack of space | Conformative approach taken due to age and medical status. Increased overjet used for aesthetics. Metal mesh reinforcement used to mitigate fracture risk of thin palatal acrylic. |
![]()
A structured table titled '3.7.4 Reflection' containing two main columns: 'Challenges' and 'Management'. The table is divided into two rows based on the category column on the far left ('Patient' and 'Clinical'). The first row addresses patient challenges regarding unwillingness to communicate and lists management strategies like building rapport. The second row details clinical challenges including edge-to-edge occlusion and lack of prosthetic space, outlining a management plan involving conformance, increased overjet, and metal mesh reinforcement for an immediate denture.
# CASE 4
## Fixed Occlusal Rehabilitation
100
CASE 4
Fixed Occlusal Rehabilitation
CASE 4
Fixed Occlusal Rehabilitation
4.1.1 Details
• 70 year-old male
4.1.2 Presenting complaint/s
• Presented in January 2019 for initial examination with the following complaints:
i. "My teeth are stained."
ii. "My back tooth on the left feels sensitive when I bite and it’s wobbly."
iii. "I feel like I’m chewing on my gums on the left side (27, 36) and have been avoiding chewing on that side for a long time."
4.1.3 History of presenting complaint/s
• 27 surgically extracted in February 2018 due to deep buccal caries.
• 28 gradually became mobile and sensitive on biting after extraction of 27.
• Predominantly been chewing on right side for about a decade due to soreness when chewing on edentulous spaces (27, 36).
101
#### 4.1.1 Details
- 70 year-old male
#### 4.1.2 Presenting complaint/s
- Presented in January 2019 for initial examination with the following complaints:
1. "My teeth are stained."
2. "My back tooth on the left feels sensitive when I bite and it’s wobbly."
3. "I feel like I’m chewing on my gums on the left side (27, 36) and have been avoiding chewing on that side for a long time."
#### 4.1.3 History of presenting complaint/s
- 27 surgically extracted in February 2018 due to deep buccal caries.
- 28 gradually became mobile and sensitive on biting after extraction of 27.
- Predominantly been chewing on right side for about a decade due to soreness when chewing on edentulous spaces (27, 36).
![]()
Clinical photo of a 70-year-old male patient's face. The image is cropped into a circular format and shows the subject from the nose up. A black bar obscures the eyes for privacy.
### 4.1.4 Medical history
| Medical condition | Description | Dental implications (1) |
|---|---|---|
| History of myocardial infarction (heart attack) <br> Stent procedure 2001 | Blockage of coronary artery. Most common sign is chest discomfort or pain which can spread to arms, neck, jaw, back and can often last longer than 10 minutes. Requires emergency treatment. | Heart attack in dental chair. Call 000. |
| Hypertension (controlled) | Blood pressure reading >140/90 mmHg. Medical emergency when >180/110 mmHg. Can lead to serious problems including heart attack, stroke, heart failure, kidney failure. | Hypertensive emergency in dental chair. Call 000. |
| Asthma (controlled) | Triggered by exposure to airborne irritants. Wheezing, coughing, chest tightness or shortness of breath. Medical emergency when symptoms worsen rapidly, speaking becomes difficult, lips look blue or little relief from reliever inhaler. | Asthma attack in dental chair. Sit person upright, reassure. Give water. Give 4 puffs blue/grey reliever every 4 minutes. If symptoms do not improve call 000. |
(1) Therapeutic guidelines: oral and dental (2019).
| Medication | Dosage | Use & Mechanism of action (2, 3) | Dental implications (2, 3) |
|---|---|---|---|
| CoPlavix <br> (Clopidogrel/Aspirin) | 75/100mg <br> tab q.d. | Anti-platelet to reduce risk of stent clotting and post-MI. Inhibits platelet aggregation by binding to P2Y12 platelet receptor and inhibiting cyclo-oxygenase (COX), reducing synthesis of thromboxane (induces platelet aggregation) | Prolongs bleeding time.<br>NSAIDs may be contraindicated due to drug interaction. |
| Tryzan <br> (Ramipril) | 10mg tab <br> q.d. | ACE inhibitor to reduce blood pressure and post-MI. Blocks conversion of Angiotensin I to Angiotensin II (induces vasoconstriction, sodium retention, and aldosterone release which mediates sodium retention). Inhibits breakdown of bradykinin (vasodilator and diuretic) | NSAIDs may be contraindicated due to drug interaction. |
| Dilatrend <br> (Carvedilol) | 25mg tab <br> q.d. | Non-selective vasodilating β-blocker to reduce blood pressure. Reduces heart rate, blood pressure and cardiac contractility. | May increase sensitivity to allergens and severity of anaphylaxis, adrenaline treatment may not always give expected therapeutic effect. |
| Azotet <br> (Ezetimibe/Atorvastatin) | 10/80mg <br> tab q.d. | Cholesterol intestinal absorption inhibitor and HMG-CoA reductase (involved in cholesterol synthesis) inhibitor for hypercholesterolaemia. | Nil. |
| Temazepam <br> (Benzodiazepine) | 10mg tab <br> p.r.n. | Sedative/hypnotic used as adjunct in short term management of insomnia. Depresses central nervous system. | Nil.<br>Note: drug of dependence |
| Symbicort <br> (Budesonide/Formoterol) | p.r.n. | Inhaled corticosteroid and long-acting β2-adrenergic agonist for maintenance and symptom relief of asthma. Anti-inflammatory action and bronchodilation. | Increases susceptibility to dental caries, dental erosion, periodontal disease, oral candidiasis. (4) |
| Zyrtec <br> (Cetirizine hydrochloride) | p.r.n. | Antihistamine for symptom relief of allergic rhinitis. Anti-inflammatory action. | Nil. |
102
#### 4.1.4 Medical history
| Medical condition | Description | Dental implications |
| :--- | :--- | :--- |
| History of myocardial infarction (heart attack); Stent procedure 2001 | Blockage of coronary artery. Most common sign is chest discomfort or pain which can spread to arms, neck, jaw, back and can often last longer than 10 minutes. | Heart attack in dental chair. Call 000. |
| Hypertension (controlled) | Blood pressure reading >140/90 mmHg. Medical emergency when >180/110 mmHg. | Hypertensive emergency in dental chair. Call 000. |
| Asthma (controlled) | Triggered by exposure to airborne irritants. Wheezing, coughing, chest tightness or shortness of breath. | Asthma attack in dental chair. Sit person upright, reassure. Give 4 puffs blue/grey reliever every 4 minutes. If symptoms do not improve call 000. |
#### Medications
| Medication | Dosage | Use & Mechanism of action | Dental implications |
| :--- | :--- | :--- | :--- |
| CoPlavix (Clopidogrel/Aspirin) | 75/100mg tab q.d. | Anti-platelet to reduce risk of stent clotting and post-MI. Inhibits platelet aggregation. | Prolongs bleeding time. NSAIDs may be contraindicated. |
| Tryzan (Ramipril) | 10mg tab q.d. | ACE inhibitor to reduce blood pressure and post-MI. Blocks conversion of Angiotensin I to Angiotensin II. | NSAIDs may be contraindicated. |
| Dilatrend (Carvedilol) | 25mg tab q.d. | Non-selective vasodilating β-blocker to reduce blood pressure. | May increase sensitivity to allergens; adrenaline treatment may not give expected effect. |
| Azotet (Ezetimibe/Atorvastatin) | 10/80mg tab q.d. | Cholesterol intestinal absorption inhibitor and HMG-CoA reductase inhibitor. | Nil. |
| Temazepam (Benzodiazepine) | 10mg tab p.r.n. | Sedative/hypnotic used as adjunct in short term management of insomnia. | Nil. Note: drug of dependence. |
| Symbicort (Budesonide/Formoterol) | p.r.n. | Inhaled corticosteroid and long-acting β2-adrenergic agonist for asthma. | Increases susceptibility to dental caries, erosion, periodontal disease, oral candidiasis. |
| Zyrtec (Cetirizine hydrochloride) | p.r.n. | Antihistamine for symptom relief of allergic rhinitis. | Nil. |
![]()
Table titled '4.1.4 Medical history' with columns: Medical condition, Description, Dental implications (1). Lists conditions including myocardial infarction, hypertension, and asthma, detailing their descriptions and dental emergency protocols such as calling 000 or administering relievers.
![]()
Table listing medications with columns: Medication, Dosage, Use & Mechanism of action (2, 3), Dental implications (2, 3). Includes drugs like CoPlavix, Tryzan, Dilatrend, Azotet, Temazepam, Symbicort, and Zyrtec, describing their mechanisms and dental contraindications or notes.
<table>
<tbody>
<tr>
<td>Nasonex (Mometasone furoate)</td>
<td>p.r.n.</td>
<td>Topical corticosteroid for symptom relief of allergic rhinitis. Anti-inflammatory action. </td>
<td>Nil.</td>
</tr>
<tr>
<td>Nurofen (Ibuprofen)</td>
<td>p.r.n.</td>
<td>Analgesic, antipyretic and anti-inflammatory action for temporary relief of back pain. Inhibits synthesis of COX-1 and COX-2 which mediate synthesis of prostaglandins (involved in inflammatory process). </td>
<td>Nil.</td>
</tr>
<tr>
<td>Panadol (Paracetamol)</td>
<td>p.r.n.</td>
<td>Analgesic and antipyretic action for temporary relief of back pain. Unknown mechanism of action.</td>
<td>Nil.</td>
</tr>
<tr>
<td>Turmeric</td>
<td>b.d.</td>
<td>Naturopathic medicine to delay dementia.</td>
<td>Nil.</td>
</tr>
<tr>
<td>Magnesium</td>
<td>b.d.</td>
<td>Muscle relaxant for muscular twitches.</td>
<td>Nil.</td>
</tr>
<tr>
<td>Coenzyme Q10</td>
<td>q.d.</td>
<td>Antioxidant for general wellbeing skin health.</td>
<td>Nil.</td>
</tr>
</tbody>
</table>
<table>
<tbody>
<tr>
<td>
(2) Monthly Index of Medical Specialities Australia. (3) Australian Medicines Handbook.</td>
<td>
</td>
</tr>
<tr>
<td>Allergy</td>
<td>Description</td>
<td>Dental implications</td>
</tr>
<tr>
<td>Hay fever (allergic rhinitis)</td>
<td>Allergic response to indoor and outdoor allergens. Immune response releases histamine triggering inflammation causing runny and itchy nose, sneezing, itchy and watery eyes.</td>
<td>Nil.</td>
</tr>
<tr>
<td>Alcohol &amp; Tobacco Use</td>
<td>Amount, Frequency &amp; Duration</td>
<td>Dental implications</td>
</tr>
<tr>
<td>Current smoker</td>
<td>35 cigarettes per week for &gt; 50 years.</td>
<td>Staining of teeth and restorations. Reduced ability to taste, smell Impaired wound healing. Susceptibility to oral candidosis, caries, periodontal disease, implant failure. Development of oral mucosal diseases and oral cancer. (39)</td>
</tr>
<tr>
<td>Current drinker</td>
<td>1 – 2 standard drinks per year.</td>
<td>Alcohol consumption raises risk of cancer including on lip and in oral cavity. (5)</td>
</tr>
</tbody>
</table>
## 4.1.5 Dental history and dental attitude
### Dental history
- History of irregular attendance to dentist.
- Presented for extraction of infected 27 due to buccal caries in February 2018.
- Presented to student clinic for initial examination in February 2019.
### Dental attitude
- Functional and aesthetic motivation.
- Concerned about bad breath and stained teeth.
- Concerned about damage to teeth from dental procedures.
- Never missed an appointment.
| Medication | Dosage | Use & Mechanism of action | Dental implications |
| :--- | :--- | :--- | :--- |
| Nasonex (Mometasone furoate) | p.r.n. | Topical corticosteroid for allergic rhinitis. | Nil. |
| Nurofen (Ibuprofen) | p.r.n. | Analgesic, antipyretic and anti-inflammatory for back pain. | Nil. |
| Panadol (Paracetamol) | p.r.n. | Analgesic and antipyretic for back pain. | Nil. |
| Turmeric | b.d. | Naturopathic medicine to delay dementia. | Nil. |
| Magnesium | b.d. | Muscle relaxant for muscular twitches. | Nil. |
| Coenzyme Q10 | q.d. | Antioxidant for general wellbeing skin health. | Nil. |
#### Allergies
| Allergy | Description | Dental implications |
| :--- | :--- | :--- |
| Hay fever (allergic rhinitis) | Allergic response to indoor and outdoor allergens. | Nil. |
#### Social Habits
| Habit | Amount, Frequency & Duration | Dental implications |
| :--- | :--- | :--- |
| Current smoker | 35 cigarettes per week for > 50 years. | Staining, reduced taste/smell, impaired healing, susceptibility to candidosis, caries, periodontal disease, oral cancer. |
| Current drinker | 1 – 2 standard drinks per year. | Alcohol consumption raises risk of cancer including on lip and in oral cavity. |
#### 4.1.5 Dental history and dental attitude
**Dental history**
- History of irregular attendance to dentist.
- Presented for extraction of infected 27 due to buccal caries in February 2018.
- Presented to student clinic for initial examination in February 2019.
**Dental attitude**
- Functional and aesthetic motivation.
- Concerned about bad breath and stained teeth.
- Concerned about damage to teeth from dental procedures.
- Never missed an appointment.
![]()
Table listing medications (Nasonex, Nurofen, Panadol, Turmeric, Magnesium, Coenzyme Q10), their administration frequency (p.r.n., b.d., q.d.), descriptions of their medical action, and dental implications (all Nil). Includes a footnote citing sources.
![]()
Table detailing Allergy (Hay fever/allergic rhinitis) with its description of immune response to allergens and resulting symptoms, and stating 'Nil' for dental implications.
![]()
Table covering Alcohol & Tobacco Use, specifying the patient is a current smoker (>50 years) and current drinker. Details include specific health impacts like staining, impaired wound healing, susceptibility to oral diseases/cancer, and cancer risks associated with alcohol consumption.
4.1.6 Oral hygiene
• Good oral hygiene
- Uses electric toothbrush and fluoride toothpaste twice daily.
- Uses oral irrigator daily, struggles to use floss.
- Does not use any other cleaning adjuncts.
4.1.7 Social history
• Works as a casual removalist.
• Separated with adult children.
• Enjoys socialising with friends.
104
#### 4.1.6 Oral hygiene
- Good oral hygiene
- Uses electric toothbrush and fluoride toothpaste twice daily.
- Uses oral irrigator daily, struggles to use floss.
- Does not use any other cleaning adjuncts.
#### 4.1.7 Social history
- Works as a casual removalist.
- Separated with adult children.
- Enjoys socialising with friends.
4.2 Examination and diagnostics
Date: February 2019
4.2.1 Extra-oral examination
<table>
<thead>
<tr>
<th style="text-align: center;">Findings</th>
</tr>
</thead>
<tbody>
<tr>
<td style="text-align: center;">Facial symmetry</td>
<td>Absence of facial swelling</td>
</tr>
<tr>
<td style="text-align: center;">Facial skin</td>
<td>Hyperpigmentation</td>
</tr>
<tr>
<td style="text-align: center;">Lips</td>
<td>Hydrated, smooth lips and distinct vermillion border</td>
</tr>
<tr>
<td style="text-align: center;">Temporomandibular joint</td>
<td>Clicking and crepitus on opening left hand side<br>
Absence of clicking and crepitus on closing and in excursion bilaterally<br>
Absence of pain and tenderness on palpation</td>
</tr>
<tr>
<td style="text-align: center;">Lymph nodes</td>
<td>No sign of lymphadenopathy<br>
Absence of pain and tenderness on palpation</td>
</tr>
<tr>
<td style="text-align: center;">Muscles of mastication</td>
<td>Absence of pain and tenderness on palpation</td>
</tr>
<tr>
<td style="text-align: center;">Thyroid gland</td>
<td>No obvious abnormal enlargement</td>
</tr>
</tbody>
</table>
4.2.2 Extra-oral photographs
<img>Extra-oral photographs of patient: frontal, left lateral, right lateral, and smile
### 4.2 Examination and diagnostics
Date: February 2019
#### 4.2.1 Extra-oral examination
| Feature | Findings |
| :--- | :--- |
| Facial symmetry | Absence of facial swelling |
| Facial skin | Hyperpigmentation |
| Lips | Hydrated, smooth lips and distinct vermillion border |
| Temporomandibular joint | Clicking and crepitus on opening left hand side; Absence of clicking/crepitus on closing and in excursion bilaterally; Absence of pain/tenderness |
| Lymph nodes | No sign of lymphadenopathy; Absence of pain and tenderness on palpation |
| Muscles of mastication | Absence of pain and tenderness on palpation |
| Thyroid gland | No obvious abnormal enlargement |
#### 4.2.2 Extra-oral photographs
Extra-oral photographs of patient: frontal, left lateral, right lateral, and smile
![]()
Clinical findings table from 'Extra-oral examination' dated February 2019. Rows include: Facial symmetry (Absence of facial swelling), Facial skin (Hyperpigmentation), Lips (Hydrated, smooth lips and distinct vermillion border), Temporomandibular joint (Clicking and crepitus on opening left hand side; Absence of clicking and crepitus on closing and in excursion bilaterally; Absence of pain and tenderness on palpation), Lymph nodes (No sign of lymphadenopathy; Absence of pain and tenderness on palpation), Muscles of mastication (Absence of pain and tenderness on palpation), Thyroid gland (No obvious abnormal enlargement).
![]()
Frontal clinical photograph of a male patient with eyes redacted. The image shows the patient's face at rest, demonstrating facial features noted in the text as having hyperpigmentation.
![]()
Left lateral clinical photograph of the same patient. This view is part of the extra-oral documentation to assess facial symmetry and temporomandibular joint function.
![]()
Right lateral clinical photograph of the same patient. This view complements the left lateral photo for assessing facial asymmetry.
![]()
Frontal clinical photograph of the same patient smiling. This view demonstrates the smile line and lip dynamics, corresponding to the finding of 'distinct vermillion border'.
4.2.3 Intraoral examination
| | Findings |
|---|---|
| Labial mucosa | No abnormalities detected |
| Buccal mucosa | Bilateral horizontal white lines level with occlusal plane*<br>8mm x 8mm white patch left buccal mucosa**|
| Hard palate | No abnormalities detected |
| Soft palate | No abnormalities detected |
| Gingivae | Generalised brown spots on gingiva*** |
| Tongue | White coat on dorsum<br>Scalloping on lateral borders |
| Floor of mouth | No abnormalities detected |
*Frictional hyperkeratosis.
**Oral medicine referral confirmed frictional hyperkeratosis
***Racial pigmentation.
4.2.4 Intraoral photographs and findings
| View | Teeth | Findings |
|---|---|---|
| Maxillary occlusal | | Stained dentition<br>Spacing between 14 and 13, 23 and 24<br>Non-carious tooth surface loss 13, 21, 23 |
| | Restorations | Amalgam restorations 17, 16, 26 |
| | Soft tissues | Generalised racial pigmentation |
| | | |
| Mandibular occlusal | | Stained dentition<br>Missing 36<br>Non-carious tooth surface loss incisal 33-43 |
| | Restorations | Amalgam restorations 37, 45, 47<br>Metal-ceramic crown 46 |
| | Soft tissues | - |
| Right buccal | | Stained dentition<br>Spacing between 14 and 13 |
| | Restorations | Amalgam restoration 16<br>Metal-ceramic crown 46 (stained margin) |
| | Soft tissues | Gingival recession at 16, 44, 45, 47<br>Generalised racial pigmentation |
| Left buccal | | Stained dentition<br>Non-carious tooth surface loss 24B, 26B, 37B<br>Missing 27, 36<br>Present 28, 38 |
| | Restorations | Amalgam restoration 37<br>Composite restoration 35, 34 |
| | Soft tissues | Gingival recession at 24, 26, 35, 34<br>Generalised racial pigmentation |
| | | |
| Anterior | | Stained dentition<br>White opacities labial 12-22<br>Non-carious tooth surface loss 16, 13, 21, 23, 33-43<br>Spacing between 31 and 41<br>Supraeruption of anterior teeth<br>Uneven occlusal plane |
| | Restorations | Metal-ceramic restoration 46<br>Composite restoration 35, 34 |
| | Soft tissues | Gingival recession at 16, 13, 23, 35, 34, 33, 43, 44, 45<br>Loss of interdental papilla 33-43<br>Generalised racial pigmentation |
106
#### 4.2.3 Intraoral examination
| Site | Findings |
| :--- | :--- |
| Labial mucosa | No abnormalities detected |
| Buccal mucosa | Bilateral horizontal white lines level with occlusal plane (frictional hyperkeratosis); 8mm x 8mm white patch left buccal mucosa (confirmed frictional hyperkeratosis) |
| Hard palate | No abnormalities detected |
| Soft palate | No abnormalities detected |
| Gingivae | Generalised brown spots on gingiva (racial pigmentation) |
| Tongue | White coat on dorsum; Scalloping on lateral borders |
| Floor of mouth | No abnormalities detected |
#### 4.2.4 Intraoral photographs and findings
| View | Findings |
| :--- | :--- |
| Maxillary occlusal | Stained dentition; Spacing 14-13, 23-24; Non-carious tooth surface loss 13, 21, 23; Amalgam restorations 17, 16, 26 |
| Mandibular occlusal | Stained dentition; Missing 36; Non-carious tooth surface loss incisal 33-43; Amalgam 37, 45, 47; Metal-ceramic crown 46 |
| Right buccal | Stained dentition; Spacing 14-13; Amalgam 16; Metal-ceramic crown 46 (stained margin); Gingival recession 16, 44, 45, 47 |
| Left buccal | Stained dentition; Non-carious tooth surface loss 24B, 26B, 37B; Missing 27, 36; Present 28, 38; Amalgam 37; Composite 35, 34; Gingival recession 24, 26, 35, 34 |
| Anterior | Stained dentition; White opacities labial 12-22; Non-carious tooth surface loss 16, 13, 21, 23, 33-43; Spacing 31-41; Supraeruption of anterior teeth; Uneven occlusal plane; Gingival recession 16, 13, 23, 35, 34, 33, 43, 44, 45; Loss of interdental papilla 33-43 |
![]()
Table titled '4.2.3 Intraoral examination'. Columns: Findings. Rows list oral structures (Labial mucosa, Buccal mucosa, Hard palate, Soft palate, Gingivae, Tongue, Floor of mouth) with corresponding clinical findings such as 'No abnormalities detected' or 'Generalised brown spots on gingiva'. Includes footnotes defining hyperkeratosis and pigmentation.
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Table titled '4.2.4 Intraoral photographs and findings'. Columns: View, Teeth, Restorations, Soft tissues. Rows detail findings for specific views (Maxillary occlusal, Mandibular occlusal, Right buccal, Left buccal, Anterior), listing dental conditions like spacing, restorations, and soft tissue issues including racial pigmentation and recession.
**107**
[Page contains only the number 107]
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Clinical photo showing a multi-panel view of dental anatomy. The central image is a frontal intraoral view of the upper and lower teeth in occlusion, displaying alignment, tooth morphology, and gingival health. Flanking this are two lateral views: the left shows the right side of the dentition with visible restorations or discoloration on posterior teeth; the right shows the left side with similar features. Above and below these are occlusal views (bitewing-style) of the maxillary and mandibular arches respectively, revealing molar crowns, fillings, and overall arch form.
4.2.5 Occlusion
| | |
|---|---|
| Findings | |
| Overjet | 1.5 mm |
| Overbite | 1 mm |
| Canine class | LHS: Class III, RHS: Class III |
| Molar class | LHS: -, RHS: Class III |
| Crossbite | Absent |
| Crowding / Spacing | Between 14 and 13, 23 and 24, 31 and 41 |
| Rotation | Absent |
| Supraeruption | 26 |
| Occlusal scheme | Group function |
4.2.6 Odontogram
Amalgam restoration
Metal-ceramic crown
Composite restoration
Non-carious tooth surface loss
Enamel infraction
Cracked tooth
Unsatisfactory restoration
4.2.7 Periodontal assessment
4.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)
| CPITN | Findings |
|---|---|
| 0 | |
| 1 | 1 |
| 2 | 1 |
| | 0 |
| | 2 |
| | 2 |
| | 1 |
| Sextant 1 | Generalised staining and gingival recession 16B, 17B |
| Sextant 2 | Generalised staining |
| Sextant 3 | Generalised staining and gingival recession 26BPD |
| Sextant 4 | Generalised staining and gingival recession 34B, 37B, 38B |
| Sextant 5 | Generalised staining |
| Sextant 6 | Generalised staining and gingival recession 46B, 47B |
4.2.7.2 Periodontal examination
| | |
|---|---|
| | Findings |
| Clinical | Gingival tissues | Firm stippled texture |
| | Pink with racial pigmentation |
| | Blunted papillae around lower anterior teeth |
| | No bleeding on probing |
| | Plaque distribution | Interproximal areas around molars |
| | Plaque score | 13% |
| | Calculus distribution | Lingual lower anterior teeth |
| | Plaque-retentive factors | Tight contact 46D |
| | Furcation involvement | No |
| | Halitosis | Yes |
| Radiographic | Bone levels | Generalised mild horizontal bone loss in maxilla and mandible |
108
#### 4.2.5 Occlusion
| Feature | Findings |
| :--- | :--- |
| Overjet | 1.5 mm |
| Overbite | 1 mm |
| Canine class | LHS: Class III, RHS: Class III |
| Molar class | LHS: -, RHS: Class III |
| Crossbite | Absent |
| Crowding / Spacing | Between 14 and 13, 23 and 24, 31 and 41 |
| Rotation | Absent |
| Supraeruption | 26 |
| Occlusal scheme | Group function |
#### 4.2.6 Odontogram
- Amalgam restoration
- Metal-ceramic crown
- Composite restoration
- Non-carious tooth surface loss
- Enamel infraction
- Cracked tooth
- Unsatisfactory restoration
#### 4.2.7 Periodontal assessment
**4.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)**
- Sextant 1: 1 (Generalised staining and gingival recession 16B, 17B)
- Sextant 2: 1 (Generalised staining)
- Sextant 3: 0 (Generalised staining and gingival recession 26BPD)
- Sextant 4: 2 (Generalised staining and gingival recession 34B, 37B, 38B)
- Sextant 5: 2 (Generalised staining)
- Sextant 6: 1 (Generalised staining and gingival recession 46B, 47B)
**4.2.7.2 Periodontal examination**
- Gingival tissues: Firm stippled texture, pink with racial pigmentation, blunted papillae around lower anterior teeth.
- Bleeding on probing: No.
- Plaque score: 13% (distribution in interproximal areas around molars).
- Calculus: Lingual lower anterior teeth.
- Plaque-retentive factors: Tight contact 46D.
- Furcation involvement: No.
- Halitosis: Yes.
- Bone levels: Generalised mild horizontal bone loss.
![]()
Table titled 'Occlusion' listing dental findings including Overjet (1.5 mm), Overbite (1 mm), Canine class (LHS: Class III, RHS: Class III), Molar class (LHS: -, RHS: Class III), Crossbite (Absent), Crowding/Spacing locations, Rotation (Absent), Supraeruption (26), and Occlusal scheme (Group function).
![]()
Odontogram visualizing dental restorations and conditions for the maxillary (top) and mandibular (bottom) arches. Legend indicates Amalgam restoration (grey), Metal-ceramic crown (blue), Composite restoration (orange), Non-carious tooth surface loss (green outline), Enamel infraction (hatching), Cracked tooth (asterisk), and Unsatisfactory restoration (red cross). Maxilla shows amalgam on teeth 7, 6; metal-ceramic crown on 6; enamel infraction on 5, 4; cracked tooth on 3. Mandible shows amalgam on 7, 6; composite restoration on 2; non-carious surface loss on 3; enamel infraction on 4.
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Table titled 'Community Index of Periodontal Treatment Needs (CPITN)' showing CPITN scores and sextant-specific findings. A small inset grid displays numerical values (1, 1, 0 / 2, 2, 1). Findings include generalised staining and gingival recession in sextants 1, 3, 4, 6; generalised staining in sextants 2, 5; specific affected teeth noted for each sextant.
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Table titled 'Periodontal examination' with two main sections: Clinical and Radiographic. Clinical findings include firm stippled gingival tissues, pink with racial pigmentation, blunted papillae around lower anterior teeth, no bleeding on probing, interproximal plaque distribution around molars, 13% plaque score, lingual calculus on lower anterior teeth, tight contact at 46D, no furcation involvement, and halitosis present. Radiographic finding is generalised mild horizontal bone loss in maxilla and mandible.
4.2.7.3 Periodontal tests
4.2.7.4 Periodontal chart
• Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
4.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)
BOP%$_0 = $0
Age
70
Number of teeth and implants
29 (1 - 32)
Number of sites per tooth / implant
|17| 2| 4| 6|
Number of BOP-pos. sites
0 of **174**
Number of sites with PPD≥5mm
Number of missing teeth
2
% alveolar bone loss (estimated in % or 10% per 1mm)
<font style="color:blue">20</font> %
**BL/Age = 0.29**
Syst./Gen. |Yes| No|
Envir.
|Non-smoker (NS)| | |
|Former smoker (FS)| |
|**Occasional smoker (OS)**| |
|Smoker (S)| |
|Heavy smoker (HS)| |
- Pre-Selection
<br>
- Mobility
GI
-
-
-
-
-
-
-
-
-
-
-
-
-
-
GI
-
TTPalp
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
+
PD≥5mm
48 47 46 45 44 43 42 41
26
37 38
TTP
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
TTPalp
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Mobility
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
17 16
15
14
13
12
11
21
22
23
24
25
22
Sys./Gen.
Polygon surface: **6.928203**
Periodontal Risk: <font style="color:blue; text-decoration:underline;">low</font>
*Suggested Recall Interval:* **12** Months
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool. (8)
**4.2.7.3 Periodontal tests**
| **Mobility** | | | | | | | | | | | | | | | **GI** |
| :--- | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: |
| | | | | | | | | | | | | | | | 1 |
| **TTPalp** | | | | | | | | | | | | | | | - |
| | | | | | | | | | | | | | | | **TTP** |
| | | | | | | | | | | | | | | | *+* |
| | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 28 |
| 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | - | 37 | 38 |
| **TTP** | | | | | | | | | | | | | | | - | - |
| **TTPalp** | | | | | | | | | | | | | | | - | - |
| **Mobility** | | | | | | | | | | | | | | | - | - |
**4.2.7.4 Periodontal chart**
* Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
**4.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)**
| |
| :---: |
| Age | <u>**70**</u> |
| :--- | :--- |
| **Syst./Gen.** | <font color ="blue">BL/Age = 0.29</font> |
| | **Number of teeth and implants** | **Number of teeth and implants** | **29** <u style="color:blue">(1 - 32)</u> |
| | | **Number of sites per tooth / implant** | | **6** |
| | **Number of BOP-pos. sites** | **0** <font color ="blue">of</font> <font color ="blue">174</font> |
| | **Number of sites with PPD>=5mm** | **0** |
| | **Number of missing teeth** | **2** |
| | % alveolar bone loss<br>(estimated in % or 10% per 1mm) | <u>**20**</font> % |
**Envir.** [|Non-smoker (NS)| | |
| :--- | :---: | :---: | :---: | :---: |
| | **Occasional smoker (OS)**| | |
| | | | |
| | | | |
**Polygon surface: 6.928203**
**Periodontal Risk:** <font color ="blue">low</font>
**Suggested Recall Interval:** **12** Months
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool. (8)
**4.2.7.3 Periodontal tests**
| | | | | | | | | | | | | | | | | |
| :--- | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: |
| **Mobility** | | | | | | | | | | | | | | **GI** | - | - | - | - | - | - | - | - | - | - | - |
| | | | | | | | | | | | | | | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 28 |
| | | | | | | | | | | | | | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | - | 37 | 38 |
| **TTPalp** | | | | | | | | | | | | | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTP** | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | |
| **TTP** | | | | | | | | | | | | | | | | | | | | | | | | |
| **TTPalp** | | | | | | | | | | | | | | | | | | - | - | - | - | - | - | - | - | - | - | - | - |
| **Mobility** | | | | | | | | | | | | | | | - | - | - | - |
**4.2.7.4 Periodontal chart**
* Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
**4.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)**
| TTP | | | | | | | | | | | | | | | | |
| :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: |
| TTP | Alveolar Bone Loss Factor <br>(BL) | | | | | | | | | | | | | | | | |
| Syst./Gen. | | | | | | | | | | | | | | | | | |
| Envir | | | | | | | | | | | | | | | | | |
| Number of teeth and implants | **29** <u style="color:blue">(1 - 32)</u> | | | | | | | | | | | | | | |
| Number of sites per tooth / implant | <u style="color:blue" align="right">6</u> | | | | | | | | | | | | | | |
| Number of BOP-pos. sites | **0** <font color ="blue">of</font> <font color ="blue">174</font> | | | | | | | | | | | | | | |
| Number of sites with PPD>=5mm | **0** | | | | | | | | | | | | | | |
| Number of missing teeth | **2** | | | | | | | | | | | | | | |
| % alveolar bone loss <br>(estimated in % or 10% per 1mm) | **20** % | | | | | | | | | | | | | | |
| Syst./Gen. | <u style="color:blue" align="right">No</u> | | | | | | | | | | | | | | |
| Envir. | <u style="color:blue" align="right">Occasional smoker (OS)</u> | | | | | | | | | | | | | | |
* **Polygon surface: 6.928203**
* **Periodontal Risk:** <font color ="blue">low</font>
* **Suggested Recall Interval:** **12** Months
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool. (8)
---
**4.2.7.3 Periodontal tests**
| **Mobility** | | | | | | | | | | | | | | | - |
| :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: |
| | | | | | | | | | | | | | | | | 1 |
| **TTPalp** | | | | | | | | | | | | | | | - |
| | | | | | | | | | | | | | | | **TTP** |
| | | | | | | | | | | | | | | | *+* |
| | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 28 |
| 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | - | 37 | 38 |
| **TTP** | | | | | | | | | | | | | | | - | - |
| **TTPalp** | | | | | | | | | | | | | | | - | - |
| **Mobility** | | | | | | | | | | | | | | | - | - |
**4.2.7.4 Periodontal chart**
* Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
**4.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)**
BOP%$_0 =$0
Age
70
Number of teeth and implants
29 (1 - 32)
Number of sites per tooth / implant
|17| 2| 4| 6|
Number of BOP-pos. sites
0 of **174**
Number of sites with PPD≥5mm
Number of missing teeth
2
% alveolar bone loss (estimated in % or 10% per 1mm)
<font style="color:blue">20</font> %
**BL/Age = 0.29**
Syst./Gen. |Yes| No|
Envir.
|Non-smoker (NS)| | |
|Former smoker (FS)| |
|**Occasional smoker (OS)**| |
|Smoker (S)| |
|Heavy smoker (HS)| |
Polygon surface: **6.928203**
Periodontal Risk: <font style="color:blue; text-decoration:underline;">low</font>
**Suggested Recall Interval:** **12** Months
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool. (8)
---
**4.2.7.3 Periodontal tests**
*Predictor of Periodontal Disease*
| |
| :---: |
| |
| **Mobility** | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| **GI** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| **TTPalp** | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
**4.2.7.4 Periodontal chart**
* Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
**4.2.7.5 Periodontal Risk Assessment (PRA) (7, 8)**
* **BOP%$_0 =$0**
* **PD>=5mm**
* **Envir.**
* **Tooth loss**
* **Syst./Gen.**
* **BL/Age = 0.29**
| | |
| :--- | :--- |
| Age | <u>**70**</u> |
| Number of teeth and implants | **29** <u style="color:blue">(1 - 32)</u> |
| Number of sites per tooth / implant | <u style="color:blue" align="right">6</u> |
| Number of BOP-pos. sites | **0** <font color ="blue">of</font> <font color ="blue">174</font> |
| Number of sites with PPD>=5mm | **0** |
| Number of missing teeth | **2** |
| % alveolar bone loss <br>(estimated in % or 10% per 1mm) | **20** % |
| Syst./Gen. | <u style="color:blue" align="right">No</u> |
| Envir. | <u style="color:blue" align="right">Occasional smoker (OS)</u> |
* **Polygon surface: 6.928203**
* **Periodontal Risk:** <font color ="blue">low</font>
* **Suggested Recall Interval:** **12** Months
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool. (8)
#### 4.2.7.3 Periodontal tests
- Mobility: Nil detected.
- TTP/TTPalp: Negative for all teeth except 28 (TTP+).
- GI: 1.
#### 4.2.7.4 Periodontal chart
- Lack of periodontal pocketing >3 mm and general risk assessment did not warrant full periodontal chart.
#### 4.2.7.5 Periodontal Risk Assessment (PRA)
- Age: 70
- Number of teeth: 29
- BOP-positive sites: 0 of 174 (0%)
- Sites with PPD ≥ 5mm: 0
- Missing teeth: 2
- Alveolar bone loss: 20% (BL/Age = 0.29)
- Environmental factor: Occasional smoker
- Systemic/Genetic: No
- **Periodontal Risk: Low**
- **Suggested Recall Interval: 12 Months**
![]()
Table titled '4.2.7.3 Periodontal tests' displaying mobility and TTP (Tenderness to Palpation) data for teeth numbered 17 through 38.
![]()
Periodontal Risk Assessment (PRA) radar chart with axes labeled BOP%, PD≥5mm, Tooth loss, BL/Age, Syst./Gen., and Envir. The chart includes input fields for age (70), number of sites (6 selected), BOP-pos. sites (0), missing teeth (2), bone loss (20%), and smoking status (Occasional smoker OS). Key metrics shown: Polygon surface 6.928203, Periodontal Risk: low, Suggested Recall Interval: 12 Months.
4.2.8 Pulp sensibility tests
| EPT | 27 | 24 | 19 | 19 |
|----|----|----|----|----|
| CO₂ | - | - | + | + |
| 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 28 |
| 48 47 46 45 44 43 42 41 31 32 33 34 35 37 38 |
| CO₂ | - | - | + | + |
| EPT | 27 | 25 | 9 | 15 |
*26, 35, 37 tested prior to fixed prosthodontics. 28 tested as symptomatic.
4.2.9 Radiographs
Rationale: each radiograph taken has rationale where stated – ALARA
Note: Subscript a = amalgam, c = composite, m = metallic, p = metal-ceramic
4.2.9.1 Orthopantogram
Date: 24/1/2018
Findings (9)
| Periphery and corners | Nil abnormalities detected |
| Cortices of mandible | Continuous and even |
| Cortices of maxilla | Nil abnormalities detected |
| Zygomatic bones | Nil abnormalities detected |
| Maxillary sinuses | Internal density of sinuses: radiopaque shadow within sinuses |
| Nasal cavity and palate | Nil abnormalities detected |
| Bone pattern of maxilla | Normal density and trabeculation |
| Bone pattern of mandible | Normal density and trabeculation<br>One radiopaque spot on left angle of mandible inferior to mandibular canal<br>One radiolucent spot on apex of distal root of 38 |
| Alveolar processes | Generalised mild horizontal bone loss in maxilla and mandible<br>Possible furcation involvement 46 |
| Teeth | Endodontically treated 27<br>Caries 35M?<br>Large restorations 27, 46<br>Amalgam restorations 16, 26, 37, 45, 47<br>Composite restorations 22, 43<br>Missing 36, present 28, 38 |
Interpretation of panoramic radiographs, Perschbacher (2012). (9)
110
#### 4.2.8 Pulp sensibility tests
| Test | Findings |
| :--- | :--- |
| CO₂ | Positive (+) for 15, 14; Negative (-) for 27, 24 |
| EPT | 27: -, 25: -, 9: +, 15: + |
*Note: 26, 35, 37 tested prior to fixed prosthodontics. 28 tested as symptomatic.
#### 4.2.9 Radiographs
**4.2.9.1 Orthopantogram (24/1/2018)**
- Periphery/Corners: Nil abnormalities.
- Cortices: Continuous and even.
- Maxillary sinuses: Radiopaque shadow within sinuses.
- Bone pattern: Normal density; radiopaque spot on left angle of mandible; radiolucent spot on apex of 38 distal root.
- Alveolar processes: Generalised mild horizontal bone loss; possible furcation involvement 46.
- Teeth: Endodontically treated 27; Caries 35M?; Large restorations 27, 46; Amalgams 16, 26, 37, 45, 47; Composites 22, 43; Missing 36.
![]()
Table titled '4.2.8 Pulp sensibility tests'. It contains columns for EPT (Electric Pulp Test) results and rows for CO₂ (Carbon Dioxide) tests. The table lists specific tooth numbers (e.g., 27, 24, 19) with corresponding test results marked as positive (+), negative (-), or blank.
![]()
Orthopantogram radiograph dated 24/1/2018. The image displays a panoramic view of the maxilla and mandible showing teeth, bone structure, and various dental restorations. A letter 'L' is visible in the bottom right corner indicating the left side.
![]()
Detailed findings table associated with the Orthopantogram. The table categorizes observations into sections including Periphery and corners, Cortices of mandible/maxilla, Maxillary sinuses, Bone pattern, Alveolar processes, and Teeth. Specific findings are listed such as 'Internal density of sinuses: radiopaque shadow', 'Possible furcation involvement 46', and details on amalgam/composite restorations.
# 4.2.9.2 Bitewings
## Bitewing – Left
| Category | Findings |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | 26DO<sub>a</sub> (deep radiopaque lining), 37O<sub>a</sub>, 35B<sub>c</sub>, 34B<sub>c</sub> |
| **Pulp** | Receded pulp horns all teeth |
| **Periodontium** | 26M, 37M slight PDL space widening<br>Generalised crestal bone loss<br>Lower bone height 27 extraction site |
| **Other** | 26 supraeruption<br>37 & 38 mesial tilt<br>Overlapping contact points |
Date: 11/2/2019
Rationale: interproximal caries detection
*Clinically confirmed non-carious.
## Bitewing – Right
| Category | Findings |
| :--- | :--- |
| **Caries** | 15MO (?)\*, 46D (?)\*\* |
| **Restorations** | 17O<sub>a</sub>, 16MO<sub>a</sub>, 45MO<sub>a</sub>, 46 pinned core & crown<sub>p</sub>, 47O<sub>a</sub> |
| **Pulp** | Receded pulp horns all teeth |
| **Periodontium** | Generalised crestal bone loss |
| **Other** | Calculus 16D<br>Overlapping contact points |
Date: 11/2/2019
Rationale: interproximal caries detection
\*Clinically non-carious and asymptomatic.
\*\*Clinically satisfactory.
# 4.2.9.3 Periapicals
## Periapical – 26
| Category | Findings |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | 26MO<sub>a</sub> (deep radiopaque lining) |
| **Pulp** | Receded pulp horns all teeth |
| **Periodontium** | Intact PDL space & lamina dura 24, 25<br>Slightly widened PDL space 26M, 28M<br>Generalised crestal bone loss<br>Lower bone height 27 extraction site<br>Nil PA radiolucency 24, 25, 26 |
| **Other** | - |
Date: 28/3/2019
Rationale: Check for pathology before fixed prosthodontics
*Clinically non-carious and asymptomatic.
## Periapical – 28
| Category | Findings |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | Nil |
| **Pulp** | Receded pulp horn |
| **Periodontium** | Widened PDL space 28M<br>Nil PA radiolucency |
| **Other** | Calculus 28D |
Date: 28/3/2019
Rationale: Check for pathology as tooth symptomatic
111
#### 4.2.9.2 Bitewings (11/2/2019)
**Bitewing – Left**
- Caries: Nil detected.
- Restorations: 26DO (amalgam), 37O (amalgam), 35B (composite), 34B (composite).
- Periodontium: 26M, 37M slight PDL space widening; generalised crestal bone loss.
- Other: 26 supraeruption; 37 & 38 mesial tilt.
**Bitewing – Right**
- Caries: 15MO (?), 46D (?).
- Restorations: 17O, 16MO, 45MO, 46 pinned core & crown, 47O.
- Periodontium: Generalised crestal bone loss.
- Other: Calculus 16D.
#### 4.2.9.3 Periapicals (28/3/2019)
**Periapical – 26**
- Restorations: 26MO (amalgam with deep radiopaque lining).
- Periodontium: Slightly widened PDL space 26M, 28M; generalised crestal bone loss.
**Periapical – 28**
- Periodontium: Widened PDL space 28M; nil PA radiolucency.
- Other: Calculus 28D.
![]()
Table titled 'Bitewing – Left' containing findings for dental categories: Caries (Nil detected), Restorations (26DOₐ deep radiopaque lining, 37Oₐ, 35Bc, 34Bc), Pulp (Receded pulp horns all teeth), Periodontium (26M, 37M slight PDL space widening, Generalised crestal bone loss, Lower bone height 27 extraction site), and Other (26 supraeruption, 37 & 38 mesial tilt, Overlapping contact points). Includes date 11/2/2019 and rationale interproximal caries detection.
![]()
Table titled 'Bitewing – Right' containing findings for dental categories: Caries (15MO (?)*, 46D (?)**), Restorations (17Oₐ, 16MOₐ, 45MOₐ, 46 pinned core & crownp, 47Oₐ), Pulp (Receded pulp horns all teeth), Periodontium (Generalised crestal bone loss), and Other (Calculus 16D, Overlapping contact points). Includes date 11/2/2019 and rationale interproximal caries detection. Footnotes indicate clinical status of specific teeth.
![]()
Table titled 'Periapical – 26' containing findings for dental categories: Caries (Nil detected), Restorations (26MOₐ deep radiopaque lining), Pulp (Receded pulp horns all teeth), Periodontium (Intact PDL space & lamina dura 24, 25; Slightly widened PDL space 26M, 28M; Generalised crestal bone loss; Lower bone height 27 extraction site; Nil PA radiolucency 24, 25, 26), and Other (-). Includes date 28/3/2019 and rationale check for pathology before fixed prosthodontics.
![]()
Table titled 'Periapical – 28' containing findings for dental categories: Caries (Nil detected), Restorations (Nil), Pulp (Receded pulp horn), Periodontium (Widened PDL space 28M; Nil PA radiolucency), and Other (Calculus 28D). Includes date 28/3/2019 and rationale check for pathology as tooth symptomatic.
<table>
<tr>
<th colspan="2">Periapical – 35</th>
<th colspan="2">Findings</th>
</tr>
<tr>
<td rowspan="6" style="text-align: center;"><br><br></td>
<td style="text-align:center;"><p>Caries</p></td>
<td colspan="2">Nil detected</td>
</tr>
<tr>
<td style="text-align:center;"><p>Restorations</p></td>
<td colspan="2">35B<sub>c</sub></td>
</tr>
<tr>
<td style="text-align:center;"><p>Pulp</p></td>
<td colspan="2">Receded pulp horn</td>
</tr>
<tr>
<td style="text-align:center;"><p>Periodontium</p></td>
<td colspan="2">Intact PDL &amp; lamina dura<br/>Generalised crestal bone loss<br/>Nil PA radiolucency</td>
</tr>
<tr>
<td style="text-align:center;"><p>Other</p></td>
<td colspan="2">-</td>
</tr>
<tr>
<td style="text-align: left;">Date: 28/3/2019<br/>Rationale: Check for pathology before fixed prosthodontics</td>
</tr>
<tr>
<th colspan="2">Periapical – 37, 38</th>
<th colspan="2">Findings</th>
</tr>
<tr>
<td rowspan="6" style="text-align: center;"><br><br></td>
<td style="text-align:center;"><p>Caries</p></td>
<td colspan="2">Nil detected</td>
</tr>
<tr>
<td style="text-align:center;"><p>Restorations</p></td>
<td colspan="2">47O<sub>a</sub></td>
</tr>
<tr>
<td style="text-align:center;"><p>Pulp</p></td>
<td colspan="2">Receded pulp horns</td>
</tr>
<tr>
<td style="text-align:center;"><p>Periodontium</p></td>
<td colspan="2">Intact PDL space &amp; lamina dura 24, 25<br/>Widened PDL space 37M<br/>Generalised crestal bone loss<br/>Nil PA radiolucency 37, 38</td>
</tr>
<tr>
<td style="text-align:center;"><p>Other</p></td>
<td colspan="2">37 &amp; 38 mesial tilt<br/>37 blurring of distal root*<br/>Overlapping contact points</td>
</tr>
<tr>
<td style="text-align: left;">Date: 28/3/2019<br/>Rationale: Check for pathology before fixed prosthodontics</td>
</tr>
<tr>
<td colspan="4"><i>*Mental foramen</i></td>
</tr>
<tr>
<th colspan="2">Periapical – 46</th>
<th colspan="2">Findings</th>
</tr>
<tr>
<td rowspan="6" style="text-align: center;"><br><br></td>
<td style="text-align:center;"><p>Caries</p></td>
<td colspan="2">45M (secondary caries)</td>
</tr>
<tr>
<td style="text-align:center;"><p>Restorations</p></td>
<td colspan="2">45MO<sub>a</sub>, 46 pinned core &amp; crown<sub>p</sub>, 47O<sub>a</sub></td>
</tr>
<tr>
<td style="text-align:center;"><p>Pulp</p></td>
<td colspan="2">Receded pulp horns all teeth</td>
</tr>
<tr>
<td style="text-align:center;"><p>Periodontium</p></td>
<td colspan="2">Widened PDL space 44D, 45M&amp;D, 46M&amp;D<br/>Generalised crestal bone loss<br/>PA radiolucency 45?*</td>
</tr>
<tr>
<td style="text-align:center;"><p>Other</p></td>
<td colspan="2">44 bulbosity lower third root<br/>45 bulbosity middle third root<br/>46 blurring of distal root?**</td>
</tr>
<tr>
<td style="text-align: left;">Date: 11/2/2019<br/>Rationale: Check for pathology due to large restoration</td>
</tr>
<tr>
<td colspan="4"><i>*Mental foramen</i><br/><i>**Possibly ankylosed</i></td>
</tr>
</table>
<p style="text-align:center;">112</p>
#### Periapical Findings (Continued)
**Periapical – 35**
- Restorations: 35B (composite).
- Periodontium: Intact PDL & lamina dura; generalised crestal bone loss.
**Periapical – 37, 38**
- Restorations: 47O (amalgam).
- Periodontium: Widened PDL space 37M; generalised crestal bone loss.
- Other: 37 & 38 mesial tilt; 37 blurring of distal root (mental foramen).
**Periapical – 46**
- Caries: 45M (secondary caries).
- Restorations: 45MO, 46 pinned core & crown, 47O.
- Periodontium: Widened PDL space 44D, 45M&D, 46M&D; PA radiolucency 45? (mental foramen).
- Other: 44/45 root bulbosity; 46 blurring of distal root (possibly ankylosed).
![]()
A clinical findings table for the Periapical radiograph of tooth 35. The table lists categories: Caries (Nil detected), Restorations (35Bc), Pulp (Receded pulp horn), Periodontium (Intact PDL & lamina dura, Generalised crestal bone loss, Nil PA radiolucency), and Other (-). Below the table is a small radiographic image labeled 'e' with date 28/3/2019 and rationale 'Check for pathology before fixed prosthodontics'.
![]()
A clinical findings table for the Periapical radiographs of teeth 37 and 38. The table lists categories: Caries (Nil detected), Restorations (47Oa), Pulp (Receded pulp horns), Periodontium (Intact PDL space & lamina dura 24, 25; Widened PDL space 37M; Generalised crestal bone loss; Nil PA radiolucency 37, 38), and Other (37 & 38 mesial tilt; 37 blurring of distal root*; Overlapping contact points). A footnote explains *Mental foramen. Below the table is a small radiographic image labeled 'e' with date 28/3/2019 and rationale 'Check for pathology before fixed prosthodontics'.
![]()
A clinical findings table for the Periapical radiograph of tooth 46. The table lists categories: Caries (45M secondary caries), Restorations (45MOa, 46 pinned core & crownp, 47Oa), Pulp (Receded pulp horns all teeth), Periodontium (Widened PDL space 44D, 45M&D, 46M&D; Generalised crestal bone loss; PA radiolucency 45?*), and Other (44 bulbosity lower third root; 45 bulbosity middle third root; 46 blurring of distal root?**). Footnotes explain *Mental foramen and **Possibly ankylosed. Below the table is a small radiographic image labeled 'e' with date 11/2/2019 and rationale 'Check for pathology due to large restoration'.
# 4.2.10 Caries risk assessment
## 4.2.10.1 Dietary assessment
- Generally, diet is:
- High in fatty foods
- Moderate fermentable carbohydrates
- Low sugar
- Low acid
- Limited snacking frequency
## 4.2.10.2 Saliva test
| | Unstimulated saliva | Stilmulated saliva |
|:--------------------|:-----------------------|:-------------------------|
| **Flow rate** | Consistency | pH | Quantity at 5 mins | Buffering capacity |
| &gt;60 s – low | Sticky/frothy | 5.0-5.8 | &lt;3.5 mL – very low | 0-5 – very low |
| 30-60 s – normal | Frothy/bubbly | 6.0-6.6 | 3.5-5.0 mL – low | 6-9 – low |
| &lt;30 s – high | Watery/clear | 6.8-7.8 | &gt;5.0 mL – normal | 10-12 – normal |
## 4.2.10.3 Cames Management By Risk Assessment (CAMBRA) (10)
| Disease indicators | Visible cavities or radiographic penetration of dentine |
|:------------------------------------------------------------|:---------------------------------------------------------|
| Risk factors | Exposed roots |
| Protective factors | Lives/work/school in fluoridated community |
| | Fluoride toothpaste (1000 ppm+) at least twice daily |
| | Adequate saliva flow (&gt;1.0 mL/min stimulated) |
| Caries risk: |
|:----------------------------------------------------------------------------|
| Low |
| Suggested management: |
|:----------------------------------------------------------------------|
| OTC toothpaste with 1000 ppm fluoride, twice daily |
| 12-month recall |
(10) Caries Management by Risk Assessment, Featherstone & Chaffee (2018).
#### 4.2.10 Caries risk assessment
**4.2.10.1 Dietary assessment**
- High in fatty foods.
- Moderate fermentable carbohydrates.
- Low sugar and low acid.
- Limited snacking frequency.
**4.2.10.2 Saliva test**
- Unstimulated flow: Normal (>30 s).
- Consistency: Frothy/bubbly.
- Stimulated pH: 6.8-7.8 (Normal).
- Stimulated quantity: >5.0 mL (Normal).
- Buffering capacity: 10-12 (Normal).
**4.2.10.3 Caries Management By Risk Assessment (CAMBRA)**
- Disease indicators: None.
- Risk factors: Exposed roots.
- Protective factors: Fluoridated community, fluoride toothpaste twice daily, adequate saliva flow.
- **Caries Risk: Low**
- **Suggested Management:** OTC 1000 ppm fluoride toothpaste, 12-month recall.
![]()
Table titled 'Saliva test' comparing unstimulated and stimulated saliva parameters. Columns include Flow rate, Consistency, pH for unstimulated saliva; Quantity at 5 mins, Buffering capacity for stimulated saliva. Rows show values categorized as low, normal, or high with corresponding ranges (e.g., >60 s – low flow rate, sticky/frothy consistency, pH 5.0-5.8).
![]()
Table titled 'Caries Management By Risk Assessment (CAMBRA)' listing disease indicators (visible cavities or radiographic penetration of dentine), risk factors (exposed roots), and protective factors (fluoridated community residence, fluoride toothpaste use, adequate saliva flow). Below the table are bullet points summarizing caries risk level ('Low') and suggested management (OTC toothpaste with 1000 ppm fluoride twice daily, 12-month recall).
## 4.3 Diagnoses and problem list
### 4.3.1 Diagnoses
| Diagnosis Category | Diagnosis |
| :--- | :--- |
| **Caries** | 45M (secondary) |
| **Restorations** | Posterior amalgams and composite restorations, 16, 26, 43, unsatisfactory
Metal-ceramic crown 46, unsatisfactory |
| **Periodontal disease (13)** | Generalised Stage II Grade B stable periodontitis modified by smoking\* |
| **Oral medicine** | Bilateral frictional keratosis of buccal mucosa |
| **Non-carious tooth surface loss** | 16-15, 13-23, 35-45 |
| **Cracked teeth** | 16, 21-22, 37, 31, 43, 45, 47 |
| **Trauma** | 28 traumatic occlusion |
| **Angle class** | Indications Angle skeletal class III |
| **Malocclusion** | Class III malocclusion
Supraerupted 26 and lower anterior teeth
Mesially tilted 37, 38 |
| **Overbite/Overjet** | 1 mm / 1.5 mm |
| **Missing teeth** | 18, 27, 36 |
| **Occlusal stability** | Stable occlusion |
| **Guidance system** | Group function |
| **Habits** | Good oral hygiene
Low sugar, acid and fermentable carbohydrate diet
Current smoking habit with no intention to quit
- Tar and nicotine staining of teeth
- Halitosis |
| **Socioeconomic** | Unlikely to use financial resources for dental care |
| **Medical** | Compromised cardiovascular and respiratory health |
| **Functional** | Parafuncional habits |
### Psychosocial
Excellent personal presentation
High aesthetic and functional concern
Good oral hygiene compliance
Good dental attitude and motivated to attend appointments
\*(11) Classification, diagnosis and clinical manifestations of apical periodontitis, Abbott (2004). (12) A clinical classification of the status of the pulp and the root canal system, Abbott & Yu (2007). (13) Periodontitis: Consensus report if workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions, Papapanou et al. (2018).
\*Stage II – RBL 15-33%, no tooth loss due to periodontitis, max probing depth ≤ 5 mm, mostly horizontal bone loss. Generalised – bone loss affects all teeth. Grade B – %BL/age 0.25-1.0, smoker, normoglycaemic. Stable – probing depth ≤ 5 mm (13)
## 4.3.2 Problem list
- Secondary caries: 45M
- Unsatisfactory restorations: 16MB fractured, 26DO cracked, 43D debonded, 46D tight contact and catch at buccal furcation
- Traumatic occlusion: 28
- Missing 27 and 36 causing discomfort during function
- Generalised Stage II Grade B stable periodontitis modified by smoking
- Generalised staining and halitosis related to smoking
- Non-carious tooth surface loss 16-15, 13-23, 35-45 and cracked teeth 16, 21-22, 37, 31, 43, 45, 47 likely related to parafunction
- Current smoking habit with no intention to quit
114
#### 4.3.1 Diagnoses
- **Caries:** 45M (secondary).
- **Restorations:** Unsatisfactory posterior amalgams/composites (16, 26, 43); unsatisfactory metal-ceramic crown 46.
- **Periodontal:** Generalised Stage II Grade B stable periodontitis modified by smoking.
- **Oral Medicine:** Bilateral frictional keratosis of buccal mucosa.
- **Tooth Surface Loss:** Non-carious loss 16-15, 13-23, 35-45.
- **Cracked Teeth:** 16, 21-22, 37, 31, 43, 45, 47.
- **Trauma:** 28 traumatic occlusion.
- **Malocclusion:** Class III; supraerupted 26 and lower anterior teeth; mesially tilted 37, 38.
- **Missing Teeth:** 18, 27, 36.
- **Habits:** Parafunction; current smoker (staining, halitosis).
#### 4.3.2 Problem list
- Secondary caries: 45M.
- Unsatisfactory restorations: 16MB fractured, 26DO cracked, 43D debonded, 46D tight contact.
- Traumatic occlusion: 28.
- Missing 27 and 36 causing functional discomfort.
- Generalised Stage II Grade B stable periodontitis.
- Generalised staining and halitosis (smoking).
- Tooth wear and cracked teeth related to parafunction.
![]()
A structured diagnostic table titled 'Diagnoses' with three main column categories: Pathological, Morphological, and Host-related factors. It lists specific dental diagnoses including Caries (45M), Restorations (Posterior amalgams/composite on teeth 16, 26, 43; metal-ceramic crown 46 unsatisfactory), Periodontal disease (Generalised Stage II Grade B stable periodontitis modified by smoking*), Oral medicine (Bilateral frictional keratosis of buccal mucosa), Non-carious tooth surface loss (teeth 16-15, 13-23, 35-45), Cracked teeth (teeth 16, 21-22, 37, 31, 43, 45, 47), Trauma (28 traumatic occlusion), Angle class (Indications Angle skeletal class III), Malocclusion (Class III malocclusion, supraerupted 26, lower anterior teeth, mesially tilted 37, 38), Overbite/Overjet (1 mm / 1.5 mm), Missing teeth (18, 27, 36), Occlusal stability (Stable occlusion), Guidance system (Group function), Psychosocial (Excellent personal presentation, high aesthetic concern, good oral hygiene compliance, motivated patient), Habits (Good oral hygiene, low sugar diet, current smoking habit with no intention to quit, tar/nicotine staining, halitosis), Socioeconomic (Unlikely to use financial resources), Medical (Compromised cardiovascular/respiratory health), and Functional (Parafuncional habits). Includes footnote definitions for Stage II, Grade B, and Stable periodontitis parameters.
# 4.4 Prognosis (14)
## 4.4.1 Individual teeth
**Key:** **Good**, **Questionable**, **Fair**, **Poor**, **Hopeless**
### Evaluation of pathology and scale of severity
| | **Class A – Good** | **Class B – Fair** | **Class C – Questionable** |
| :--- | :--- | :--- | :--- |
| **Periodontal condition** | 80%-100% bone support. Easily maintained. | 50%-80% bone support. Can be well maintained. | 30%-50% remaining bone support. Difficult to be well maintained. |
| **Restorability** | 80%-100% remaining sound coronal tooth structure. Easily restored. | 50%-80% remaining sound coronal tooth structure. Restoration results in no infringement of biologic width, has adequate ferrule, good crown-root ratio. | 30%-50% remaining sound coronal tooth structure. Achieving adequate ferrule would compromise crown-root ratio to some extent or affect adjacent structures. |
| **Endodontic condition** | Can receive straightforward primary endodontic treatment, or already has good endodontic therapy. | Failing endodontic treatment can receive predictable re-treatment, or requires a difficult primary endodontic treatment. | Failing endodontic treatment that is difficult to predictably re-treat. |
| **Occlusal plain & tooth position** | Tooth in correct occlusal plane, position, slightly deviated from ideal. | Tooth out of correct occlusal plane, can be adjusted to function within correct occlusal plane. | Tooth out of occlusal plane and requires multiple procedures to function within occlusal plane. |
### Factors that result in drop of determined class
| | |
| :--- | :--- |
| **Anatomic irregularities** | Irregularly shaped roots, multiple canals and/or roots, thin and/or short roots, and excessively conical roots, etc. |
| **Iatrogenic compromising factors** | Perforations, extensive post preparations, minimal tooth structure thickness left after preparation, dental materials that cannot be removed, etc. 16, 26, 37, 45, 47 – cracked teeth from amalgam restorations, parafunction |
#### 4.4 Prognosis
**Individual Tooth Evaluation Criteria**
- **Class A (Good):** 80-100% bone support; 80-100% sound structure; straightforward endodontics; correct occlusal plane.
- **Class B (Fair):** 50-80% bone support; 50-80% sound structure; predictable endodontic re-treatment; adjustable occlusal plane.
- **Class C (Questionable):** 30-50% bone support; 30-50% sound structure; difficult endodontic re-treatment; multiple procedures needed for occlusal plane.
**Compromising Factors**
- Anatomic irregularities (thin/short roots).
- Iatrogenic factors (perforations, extensive preparations).
- Cracked teeth from amalgam restorations/parafunction (16, 26, 37, 45, 47).
![]()
Table titled '4.4 Prognosis (14) - 4.4.1 Individual teeth'. It presents a matrix evaluating prognosis for individual teeth based on factors including 'iatrogenic compromising factors', 'Anatomic irregularities', 'Occlusal plane & tooth position', 'Endodontic condition', 'Restorability', and 'Periodontal condition'. Rows represent specific prognostic classes (numbered 17-38). Columns correspond to different scenarios or cases. Visual indicators include green dots (Good), yellow dots (Fair/Questionable), and black/red squares (Hopeless/Poor).
![]()
A continuation of the prognostic evaluation table from the previous visual region. It lists the same prognostic factors in rows: 'Periodontal condition', 'Restorability', 'Endodontic condition', 'Occlusal plane & tooth position', 'Anatomic irregularities', and 'Iatrogenic factors'. The columns align with the previous table's prognostic classes.
![]()
A legend table defining the color coding used in the preceding prognostic tables. It maps colors to outcomes: Green square = 'Good', Yellow square = 'Questionable', Red square = 'Hopeless', Light Green square = 'Fair', Orange square = 'Poor'.
![]()
Table titled 'Evaluation of pathology and scale of severity'. It categorizes clinical conditions into three classes: Class A – Good, Class B – Fair, and Class C – Questionable. Rows detail criteria for 'Periodontal condition', 'Restorability', 'Endodontic condition', and 'Occlusal plane & tooth position', providing specific descriptions for each class level.
![]()
Table titled 'Factors that result in drop of determined class'. It lists two categories of factors: 'Anatomic irregularities' (e.g., irregularly shaped roots, multiple canals) and 'Iatrogenic compromising factors' (e.g., perforations, extensive post preparations, cracked teeth from amalgam restorations).
```html
<html><body>
<h3>4.4.2 Patient-level risk factors</h3>
<table border="1">
<tr><td>Biologic risk factors</td><td>• Nil</td></tr>
<tr><td>Medical conditions that impair immune function and healing</td><td>• Nil</td></tr>
<tr><td>Impaired salivary flow/function</td><td>• Adequate salivary flow</td></tr>
<tr><td>Medical condition or disability limiting oral hygiene</td><td>• Nil</td></tr>
<tr><td>Other missing teeth</td><td>• History of missing teeth due to periodontal disease or caries</td></tr>
<tr><td>Behavioural risk factors</td><td></td></tr>
<tr><td>Compromised or poor oral hygiene</td><td>• Good oral hygiene</td></tr>
<tr><td>Cariogenic diet</td><td>• Low cariogenic diet</td></tr>
<tr><td>Low exposure to fluoride</td><td>• Adequate exposure to fluoride</td></tr>
<tr><td>Parafunctional habits</td><td>• Yes</td></tr>
<tr><td>Ability and willingness to adhere to long-term maintenance protocol</td><td>• Yes</td></tr>
<tr><td>Smoking</td><td>• Current smoker</td></tr>
<tr><td>Financial and personal risk factors</td><td></td></tr>
<tr><td>Motivation for treatment</td><td>• Highly motivated</td></tr>
<tr><td>Available resources for dental care</td><td>• Maybe</td></tr>
<tr><td>Willingness to commit finances, time, and effort</td><td>• Yes</td></tr>
<tr><td>Attitude toward losing teeth</td><td>• Strong willingness to preserve existing teeth</td></tr>
<tr><td>Understanding of one’s condition and needed treatment</td><td>• Yes</td></tr>
<tr><td>Aesthetic expectations</td><td>• Reasonable</td></tr>
<tr><td>Low dental IQ</td><td>• Adequate dental IQ with education</td></tr>
</table>
<Key: Favourable</h3>
<h3>Questionable</h3>
<p>Unfavourable</p>
<p>(14) Evaluation of prognosis of individual teeth and patient-level risk factors adapted from Samet and Jotkowitz (2009).</p>
<h3>4.4.3 Overall dentition</h3>
<ul><li>All teeth have sound periodontal and pulp health, and are in the correct occlusal plane or require little occlusal adjustment</li><li>History of amalgam restorations in posterior teeth and parafunction has detrimental effect on restorability and prognosis of 16, 26, 37, 45, 46, 47.</li><li>High occlusal loading and conical root pattern of 28 gives tooth questionable prognosis</li><li>Patient’s unremarkable medical history, low cariogenic diet, overall dental attitude and motivation, and ability to maintain good oral hygiene is favourable to prognosis of dentition however smoking habit has detrimental effect on periodontal condition</li><li>If patient receives no treatment for current condition:</li><li>Aesthetic and social issues associated with stained teeth and halitosis</li><li>Functional issues due to inability to comfortably function using left side</li><li>Progression of periodontal disease and worsening of periodontal condition</li><li>Progression of carious disease process, potential to cause pulpal involvement and consequently infection, pain and tooth loss with no intervention</li><li>Potential for pulpal involvement of cracked teeth</li><li>Discussion of diagnoses and prognoses of dentition with patient led patient to decide on and commit to treatment.</li></ul>
<p>116</p>
</body></html>
```
#### 4.4.2 Patient-level risk factors
- **Biologic:** Adequate salivary flow; no medical conditions impairing healing.
- **Behavioural:** Good oral hygiene; low cariogenic diet; parafunctional habits present; current smoker.
- **Psychosocial:** Highly motivated; strong willingness to preserve teeth; reasonable aesthetic expectations.
#### 4.4.3 Overall dentition prognosis
- **Favourable:** Sound periodontal/pulp health; good oral hygiene; high motivation.
- **Questionable/Unfavourable Factors:** History of amalgam restorations and parafunction (16, 26, 37, 45, 46, 47); conical root pattern of 28; smoking habit.
- **Risks of No Treatment:** Aesthetic/social issues (staining, halitosis); functional discomfort; progression of periodontal and carious disease; potential pulpal involvement of cracked teeth.
![]()
Table titled '4.4.2 Patient-level risk factors' with three sections: Biologic risk factors, Behavioural risk factors, and Financial and personal risk factors. Each row lists a factor (e.g., Medical conditions that impair immune function and healing) and its status (e.g., Nil). A key at the bottom indicates color-coded statuses: green for Favourable, yellow for Questionable, red for Unfavourable.
4.5 Treatment options
<table border="1" data-bbox="125 76 913 945">
<tr>
<th>Problem</th>
<th>Treatment Option</th>
<th>Benefits</th>
<th>Risks</th>
<th>Decision &amp; Rationale</th>
</tr>
<tr>
<td rowspan="2">45: secondary caries under MO amalgam</td>
<td>1</td>
<td>• No treatment</td>
<td>• No commitment required</td>
<td>• Pulpal involvement, infection<br/>• Breakdown of tooth structure<br/>• Tooth loss</td>
<td>Option 2:<br/>• Prevent further breakdown of tooth structure due to caries</td>
</tr>
<tr>
<td>2</td>
<td>• Remove caries and restoration<br/>• Restore tooth</td>
<td>• Tooth preservation</td>
<td>• Pulpal irritation, post-operative sensitivity</td>
<td>• Further deterioration of tooth may involve extensive/invasive treatment in future to save tooth or render tooth unrestorable</td>
</tr>
<tr>
<td rowspan="2">16: unsatisfactory MO amalgam; MB fracture</td>
<td>1</td>
<td>• No treatment</td>
<td>• No commitment required</td>
<td>• Plaque trapping<br/>• Caries, pulpal involvement, infection<br/>• Breakdown of tooth structure</td>
<td>Option 2:<br/>• Eliminate plaque trap<br/>• Prevent breakdown of tooth structure due to caries</td>
</tr>
<tr>
<td>2</td>
<td>• Remove restoration<br/>• Restore tooth</td>
<td>• Eliminate plaque trap<br/>• Tooth preservation</td>
<td>• Pulpal irritation, post-operative sensitivity</td>
<td></td>
</tr>
<tr>
<td rowspan="2">26: unsatisfactory DO amalgam; cracked tooth (asymptomatic)</td>
<td>1</td>
<td>• No treatment<br/>• Monitor</td>
<td>• No commitment required<br/>• Conservative</td>
<td>• Crack progression<br/>• Caries, pulpal involvement, infection<br/>• Breakdown of tooth structure<br/>• Tooth loss</td>
<td>Option 1:<br/>• Asymptomatic<br/>• Crack investigation could lead to inability to restore tooth<br/><br/>Option 2:<br/>• After tooth became symptomatic (cold sensitivity, TTP)</td>
</tr>
<tr>
<td>2</td>
<td>• Remove restoration<br/>• Assess restorability<br/>• Restore tooth with direct/indirect restoration</td>
<td>Early intervention may prevent crack progression, caries, pulpal involvement, infection, catastrophic tooth fracture</td>
<td>• Pulpal irritation, post-operative sensitivity<br/>• Inadequate remaining coronal tooth structure may involve extensive restorative work<br/>• Following crack extensions could render tooth unrestorable and indicate tooth for extraction</td>
<td></td>
</tr>
<tr>
<td rowspan="2">43: unsatisfactory D composite; open margins</td>
<td>1</td>
<td>• No treatment</td>
<td>• No commitment required</td>
<td>• Plaque trapping<br/>• Caries, pulpal involvement, infection<br/>• Breakdown of tooth structure<br/>• Tooth loss</td>
<td>Option 2:<br/>• Eliminate plaque trap<br/>• Prevent breakdown of tooth structure due to caries</td>
</tr>
<tr>
<td>2</td>
<td>• Remove restoration<br/>• Restore tooth</td>
<td>• Eliminate plaque trap<br/>• Eliminate caries<br/>• Tooth preservation</td>
<td>• Pulpal irritation, post-operative sensitivity</td>
<td></td>
</tr>
<tr>
<td>46: unsatisfactory metal-ceramic crown; D tight contact, catch at buccal furcation</td>
<td>1</td>
<td>• No treatment<br/>• Monitor<br/>• Oral hygiene instruction</td>
<td>• No commitment required</td>
<td>• Plaque and food trapping, gingival inflammation<br/>• Caries, pulpal involvement, infection<br/>• Breakdown of tooth structure</td>
<td>Option 1:<br/>• Patient did not want treatment<br/>• No gingival inflammation, bleeding or pocketing in area</td>
</tr>
</table>
117
#### 4.5 Treatment options
| Problem | Option | Benefits | Risks | Decision & Rationale |
| :--- | :--- | :--- | :--- | :--- |
| 45: secondary caries | Restore tooth | Tooth preservation | Pulpal irritation | Option 2: Prevent further breakdown. |
| 16: unsatisfactory amalgam | Restore tooth | Eliminate plaque trap | Pulpal irritation | Option 2: Prevent caries/breakdown. |
| 26: unsatisfactory amalgam; cracked | Monitor (Opt 1) / Restore (Opt 2) | Conservative (Opt 1); Prevent fracture (Opt 2) | Crack progression (Opt 1); Unrestorable (Opt 2) | Option 1 initially (asymptomatic); Option 2 later when symptomatic. |
| 43: unsatisfactory composite | Restore tooth | Eliminate plaque trap | Pulpal irritation | Option 2: Prevent caries. |
| 46: unsatisfactory crown | Monitor | No commitment | Plaque/food trap | Option 1: Patient declined treatment; no active inflammation. |
![]()
A structured table titled '4.5 Treatment options' listing dental problems (e.g., secondary caries, unsatisfactory amalgam), treatment options, benefits, risks, and decision rationales.
<table>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Remove restoration</li><li>Assess restorability</li><li>Restore tooth</li></ul></td>
<td><ul><li>Eliminate plaque and food trap</li><li>Restore with contours favourable for oral hygiene</li></ul></td>
<td><ul><li>Inadequate remaining coronal tooth structure may involve extensive restorative work</li></ul></td>
<td><ul><li>Provide oral hygiene instruction, monitor, reassess</li></ul></td>
</tr>
<tr>
<td>28: traumatic occlusion</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li><li>Conservative</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="3">Option 2:<ul><li>Tooth is in function</li><li>Extraction still an option if occlusal adjustment does not alleviate symptoms</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Occlusal adjustment</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Conservative</li></ul></td>
<td><ul><li>May be ineffective</li></ul></td>
</tr>
<tr>
<td></td>
<td>3</td>
<td><ul><li>Extraction</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Irreversible</li></ul></td>
<td><ul><li>Extraction complications</li><li>Post-extraction complications</li></ul></td>
</tr>
<tr>
<td>27: missing tooth; discomfort during function</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="4">Option 1:<ul><li>Patient does not want removable prosthesis</li><li>28 is not a sound abutment due to poor periodontal support and size of tooth</li><li>Patient cannot afford implant, OHCWA waitlist is long with strict requirements, high risk of implant failure</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Partial denture</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Low cost</li><li>Easy to remove and maintain</li><li>Relatively quick to fabricate</li></ul></td>
<td><ul><li>Patient may feel uncomfortable and be unable to adapt to denture</li><li>Preparation of sound teeth to replace one tooth</li></ul></td>
</tr>
<tr>
<td></td>
<td>3</td>
<td><ul><li>Conventional bridge</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Moderate cost</li><li>Comfortable and easier for patient to adapt to denture</li><li>Preparation of one previously restored tooth and one sound tooth</li><li>Relatively quick to fabricate</li></ul></td>
<td><ul><li>More difficult to maintain</li><li>28 is not a sound abutment due to poor periodontal support and size of tooth</li><li>Loss of abutment tooth</li></ul></td>
</tr>
<tr>
<td></td>
<td>4</td>
<td><ul><li>Implant</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Comfortable and easy for patient to adapt to denture</li><li>No preparation of sound teeth</li></ul></td>
<td><ul><li>Expensive</li><li>Surgical and post-surgical risks</li><li>High risk of peri-implantitis and implant failure</li></ul></td>
</tr>
<tr>
<td>36: missing tooth; discomfort during function</td>
<td>1</td>
<td><ul><li>No treatment</li></ul></td>
<td><ul><li>No commitment required</li></ul></td>
<td><ul><li>Does not address presenting complaint</li></ul></td>
<td rowspan="3">Option 3:<ul><li>Patient does not want removable prosthesis</li><li>Patient cannot afford implant, OHCWA waitlist is long with strict requirements, high risk of implant failure</li><li>Only option that addresses presenting complaint with low risk</li></ul></td>
</tr>
<tr>
<td></td>
<td>2</td>
<td><ul><li>Partial denture</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Low cost</li><li>Easy to remove and maintain</li><li>Relatively quick to fabricate</li></ul></td>
<td><ul><li>Patient may feel uncomfortable and be unable to adapt to denture</li><li>Preparation of sound teeth to replace one tooth</li></ul></td>
</tr>
<tr>
<td></td>
<td>3</td>
<td><ul><li>Conventional bridge</li></ul></td>
<td><ul><li>Addresses presenting complaint</li><li>Moderate cost</li><li>Comfortable and easier for patient to adapt to denture</li><li>Abutment teeth are previously restored and have good periodontal support</li><li>Relatively quick to fabricate</li></ul></td>
<td><ul><li>More difficult to maintain</li></ul></td>
</tr>
</table>
#### Treatment Options (Continued)
| Problem | Option | Benefits | Risks | Decision & Rationale |
| :--- | :--- | :--- | :--- | :--- |
| 28: traumatic occlusion | Occlusal adjustment | Addresses complaint; conservative | May be ineffective | Option 2: Tooth is in function; extraction remains a backup. |
| 27: missing tooth | No treatment | No commitment | Functional discomfort | Option 1: Patient declined denture; 28 not a sound abutment; implant too expensive. |
| 36: missing tooth | Conventional bridge | Addresses complaint; comfortable | Difficult to maintain | Option 3: Abutments are previously restored with good support; addresses complaint with low risk. |
![]()
A detailed decision matrix table for dental treatment options organized by clinical scenarios: '28: traumatic occlusion', '27: missing tooth; discomfort during function', and '36: missing tooth; discomfort during function'. The table includes columns for Treatment Number, Procedure Name (e.g., No treatment, Occlusal adjustment, Extraction, Partial denture, Conventional bridge, Implant), Advantages/Cons of the procedure, Potential Complications/Risks, and specific Options based on patient constraints or anatomical limitations.
<table><tbody><tr><td style="text-align: left;" rowspan="2">Generalised Stage II<br>Grade B periodontitis</td><td style="text-align: center;">4</td><td style="text-align: center;">Implant</td><td style="text-align: left;">Addresses presenting complaint<br>Comfortable and easy for patient to adapt to denture<br>Minimal preparation of sound teeth</td><td style="text-align: left;">High cost<br>Surgical and post-surgical risks<br>High risk of peri-implantitis and implant failure</td><td style="text-align: center;"></td></tr><tr><td style="text-align: center;"></td><td style="text-align: center;"></td><td style="text-align: left;"></td><td style="text-align: left;"></td><td style="text-align: center;"></td></tr><tr><td style="text-align: left;">Halitosis</td><td style="text-align: center;">1</td><td style="text-align: center;">No treatment</td><td style="text-align: left;">No commitment required</td><td style="text-align: left;">Plaque and calculus accumulation<br>Deterioration of periodontal condition<br>Caries<br>Tooth loss<br>Systemic health effects<br>Poor aesthetic appearance and effect on self-esteem<br>Halitosis and effect on self-esteem</td><td style="text-align: center;">Option 2:<br>Favour periodontal and systemic health<br>Reduce risk of caries, potential for breakdown of tooth structure<br>Reduce risk of tooth loss<br>Create favourable environment for indirect and direct restoration procedures<br>Removal of stains to create aesthetic appearance<br>Reduce halitosis for self confidence</td></tr><tr><td style="text-align: left;"></td><td style="text-align: center;"></td><td style="text-align: center;"></td><td style="text-align: left;"></td><td style="text-align: left;"></td><td style="text-align: center;"></td></tr><tr><td style="text-align: left;"></td><td style="text-align: center;">2</td><td style="text-align: left;">Non-surgical periodontal therapy<br>Oral hygiene instruction<br>Counsel cessation of smoking habit</td><td style="text-align: left;">Remove plaque and calculus to promote periodontal and systemic health<br>Reduce risk of caries<br>Reduce risk of tooth loss<br>Remove tar and nicotine staining<br>Reduce halitosis</td><td style="text-align: left;">Post-operative pain, bleeding, swelling, bruising, infection<br>Increased tooth sensitivity<br>Gingival recession<br>Root surface exposure</td><td style="text-align: center;"></td></tr><tr><td style="text-align: left;">Parafunction</td><td style="text-align: center;">1</td><td style="text-align: center;">No treatment</td><td style="text-align: left;">No commitment required</td><td style="text-align: left;">Tooth wear<br>Tooth sensitivity<br>Cracked tooth syndrome<br>Pulpal involvement<br>Possibility of extensive treatment to save teeth<br>Loss of vertical dimension<br>Aesthetic changes<br>Occlusal changes<br>Functional changes<br>Tooth loss</td><td style="text-align: center;">Option 2:<br>Reduce potential for further breakdown of tooth structure</td></tr><tr><td style="text-align: left;"></td><td style="text-align: center;"></td><td style="text-align: center;"></td><td style="text-align: left;"></td><td style="text-align: left;"></td><td style="text-align: center;"></td></tr><tr><td style="text-align: left;"></td><td style="text-align: center;">2</td><td style="text-align: left;">Occlusal splint<br>Counsel awareness of parafunctional habit</td><td style="text-align: left;">Simple to use<br>Quick to fabricate<br>Reduce tooth wear and sequelae of tooth wear</td><td style="text-align: left;">Patient may not use appliance</td><td style="text-align: center;"></td></tr><tr><td style="text-align: left;">Smoking habit</td><td style="text-align: center;">1</td><td style="text-align: left;">Counsel cessation of smoking habit</td><td style="text-align: left;">Eliminate source of tar and nicotine staining on teeth<br>Eliminate major cause of halitosis<br>Reduce risk of unstable periodontitis<br>Reduce risk of oral (and other) cancers<br>Reduce risk of post-operative infections and poor healing<br>Reduce adverse effects on systemic health</td><td style="text-align: left;">Patient refusal to listen to advice</td><td style="text-align: center;">Option 1:<br>Failure to counsel cessation of habit and discuss oral health implications constitutes supervised neglect</td></tr><tr><td style="text-align: left;"></td><td style="text-align: center;"></td><td style="text-align: left;"></td><td style="text-align: left;"></td><td style="text-align: left;"></td><td style="text-align: center;"></td></tr></tbody></table>
#### Treatment Options (Continued)
| Problem | Option | Benefits | Risks | Decision & Rationale |
| :--- | :--- | :--- | :--- | :--- |
| Periodontitis / Halitosis | Non-surgical therapy; OHI; Smoking cessation | Promote health; remove stains; reduce halitosis | Sensitivity; recession | Option 2: Favour systemic health and aesthetic appearance. |
| Parafunction | Occlusal splint; awareness | Reduce wear and sequelae | Non-compliance | Option 2: Reduce potential for further breakdown. |
| Smoking habit | Cessation counseling | Reduce cancer risk; improve healing/staining | Patient refusal | Option 1: Essential to avoid supervised neglect. |
![]()
A comprehensive clinical comparison table detailing treatment options for various oral health conditions. The table includes columns for the condition (e.g., 'Generalised Stage II Grade B periodontitis', 'Halitosis', 'Parafunction', 'Smoking habit'), treatment option number and name (e.g., 'No treatment', 'Implant', 'Occlusal splint'), benefits, risks/side effects, and additional notes or options. Specific entries include detailed bullet points on procedures like 'Non-surgical periodontal therapy' and their associated outcomes such as plaque removal, tooth sensitivity, and systemic health effects.
**4.6 Management plan**
| | |
| :--- | :--- |
| **Systemic phase** | Counsel cessation of smoking and discuss oral health implications<br>Counsel development of awareness of parafunctional habit |
| **Emergency phase** | Not applicable |
| **Control phase**<br><i>Eliminate pain, infection, inflammation</i> | Patient education and consent to treatment |
| | Hygienic phase of periodontal therapy: |
| | Supragingival scaling, fluoride application, oral hygiene instruction |
| | Occlusal adjustment: 28 |
| | Caries control: 45MO |
| | Replace unsatisfactory restorations: |
| | 16MO, 43D |
| | 26DOP*, 16B & 17B**, 21MI & 31DIL***, 32D**** |
| | Referral to Oral Medicine: |
| | Investigation of white patch left buccal mucosa |
| **Holding phase**<br><i>Preserve residual dentition</i> | Assess response to periodontal therapy and oral hygiene compliance |
| | Monitor for symptoms: 28, 26 |
| **Reconstructive phase**<br><i>Replace lost tissue and stabilise occlusion</i> | Indirect restorations: |
| | 35-37 conventional bridge |
| | 26 onlay |
| **Maintenance phase**<br><i>Prevention of further breakdown</i> | 1 week post-insert review |
| | Occlusal splint |
| | 12-monthly recall examination and clean |
*Added to treatment plan following development of symptoms (thermal sensitivity, tenderness to percussion, crack progression) in 2020
**Added to treatment plan following development of dentine hypersensitivity in 2020
***Added to treatment plan following patient complaint of poor aesthetics in 2020
****Added to treatment plan following cavitation in 2020
120
#### 4.6 Management plan
- **Systemic phase:** Smoking cessation counseling; parafunction awareness.
- **Control phase:**
- Patient education/consent.
- Periodontal therapy (scaling, fluoride, OHI).
- Occlusal adjustment: 28.
- Caries control: 45MO.
- Replace restorations: 16MO, 43D, 26DOP, 16B, 17B, 21MI, 31DIL, 32D.
- Oral Medicine referral: White patch investigation.
- **Holding phase:** Assess periodontal response and OHI compliance; monitor 28 and 26.
- **Reconstructive phase:**
- 35-37 conventional bridge.
- 26 onlay.
- **Maintenance phase:**
- Post-insert reviews.
- Occlusal splint.
- 12-monthly recall.
![]()
Table titled '4.6 Management plan' with columns for 'Systemic phase', 'Emergency phase', 'Control phase', 'Holding phase', 'Reconstructive phase', and 'Maintenance phase'. Each row contains specific actions or instructions relevant to oral health management. For example, under 'Control phase', it lists activities like 'Patient education and consent to treatment', 'Hygienic phase of periodontal therapy: Supragingival scaling, fluoride application, oral hygiene instruction', 'Occlusal adjustment: 28', 'Caries control: 45MO', 'Replace unsatisfactory restorations: 16MO, 43D', etc. The table also includes footnotes marked with asterisks (*) explaining when certain treatments were added to the plan.
4.7 Treatment delivery
4.7.1 Treatment delivery
Date: February 2019 – September 2020
<table>
<tr>
<th></th>
<th>Date</th>
<th>Treatment</th>
</tr>
<tr>
<td rowspan="20">2019</td>
<td rowspan="9">January</td>
<td>Comprehensive exam</td>
</tr>
<tr>
<td>Counsel cessation of smoking</td>
</tr>
<tr>
<td>Counsel development of awareness of parafunctional habits</td>
</tr>
<tr>
<td>Patient education and consent to treatment</td>
</tr>
<tr>
<td>28 occlusal adjustment</td>
</tr>
<tr>
<td>Supragingival scale and clean</td>
</tr>
<tr>
<td>Fluoride application</td>
</tr>
<tr>
<td>Oral hygiene instruction</td>
</tr>
<tr>
<td>Referral to Oral Medicine for white lesion left buccal mucosa</td>
</tr>
<tr>
<td rowspan="2">February</td>
<td>45 MO amalgam replaced</td>
</tr>
<tr>
<td>16 MO amalgam replaced</td>
</tr>
<tr>
<td>March</td>
<td>43DB composite placed</td>
</tr>
<tr>
<td rowspan="2">April</td>
<td>28 review following occlusal adjustment</td>
</tr>
<tr>
<td>35-37 bridge preparation commenced</td>
</tr>
<tr>
<td>May</td>
<td>35-37 bridge preparation continuation</td>
</tr>
<tr>
<td>June</td>
<td>-</td>
</tr>
<tr>
<td rowspan="4">July</td>
<td>35-37 bridge preparation completed</td>
</tr>
<tr>
<td>35-37 bridge shade selection and final impressions</td>
</tr>
<tr>
<td>35-37 bridge bisque try-in</td>
</tr>
<tr>
<td>35-37 bridge insert</td>
</tr>
<tr>
<td></td>
<td rowspan="2">August</td>
<td>35-37 bridge post-insert review</td>
</tr>
<tr>
<td></td>
<td>28 review</td>
</tr>
<tr>
<td></td>
<td>September</td>
<td>-</td>
</tr>
<tr>
<td></td>
<td>October</td>
<td>-</td>
</tr>
<tr>
<td></td>
<td>November</td>
<td>-</td>
</tr>
<tr>
<td></td>
<td>December</td>
<td>-</td>
</tr>
</table>
<table>
<tr>
<th></th>
<th>Date</th>
<th>Treatment</th>
</tr>
<tr>
<td rowspan="17">2020</td>
<td>January</td>
<td>Recall exam</td>
</tr>
<tr>
<td rowspan="6">February</td>
<td>Supragingival scale and clean</td>
</tr>
<tr>
<td>Fluoride application</td>
</tr>
<tr>
<td>Reinforce oral hygiene instruction</td>
</tr>
<tr>
<td>16B composite</td>
</tr>
<tr>
<td>22MI composite</td>
</tr>
<tr>
<td>26 investigation</td>
</tr>
<tr>
<td>March</td>
<td>-</td>
</tr>
<tr>
<td>April</td>
<td>-</td>
</tr>
<tr>
<td>May</td>
<td>-</td>
</tr>
<tr>
<td>June</td>
<td>-</td>
</tr>
<tr>
<td>July</td>
<td>-</td>
</tr>
<tr>
<td rowspan="2">August</td>
<td>26 onlay preparation</td>
</tr>
<tr>
<td>26 shade selection and final impressions</td>
</tr>
<tr>
<td rowspan="5">September</td>
<td>17B composite</td>
</tr>
<tr>
<td>31DIL composite</td>
</tr>
<tr>
<td>32D composite</td>
</tr>
<tr>
<td></td>
<td>26 onlay insert</td>
</tr>
<tr>
<td></td>
<td>26 onlay post-insert review</td>
</tr>
</table>
121
#### 4.7.1 Treatment delivery timeline
**2019**
- **January:** Exam, counseling, 28 adjustment, scale/clean, OHI, Oral Medicine referral.
- **February:** 45MO and 16MO amalgams replaced.
- **March:** 43DB composite.
- **April - July:** 35-37 bridge preparation, shade selection, impressions, bisque try-in, and insert.
- **August:** Bridge review; 28 review.
**2020**
- **January:** Recall exam.
- **February:** Scale/clean, OHI, 16B and 22MI composites, 26 investigation.
- **August:** 26 onlay preparation, shade selection, impressions.
- **September:** 17B, 31DIL, 32D composites; 26 onlay insert and review.
![]()
Treatment delivery table for the period February 2019 – September 2020. Columns: Date (with year labels '2019' and '2020'), Treatment. Rows list monthly treatments including exams, counseling, scaling, fluoride application, amalgam replacement, composite placement, bridge preparation and insertion, reviews, and referrals.
![]()
Continuation of treatment delivery table for 2020 (January–September). Columns: Date, Treatment. Rows include recall exam, hygiene instructions, composite placements, onlay preparation and insertion, shade selection, investigations, and post-insert reviews.
- Counsel cessation of smoking:
- Educated patient on health risks, staining of teeth and halitosis due to cigarette smoking and advised cessation.
- Patient had no intention to quit, however had reduced amount of cigarettes smoked for financial reasons.
- 28 occlusal adjustment:
- Tooth adjusted out of occlusion to reduce loading and monitored.
- Referral to Oral Medicine for white lesion on left buccal mucosa:
- Confirmed diagnosis of frictional hyperkeratosis.
- Scale and clean:
- Minimal calculus, excessive tar and nicotine staining removed, difference shown to patient in mirror.
- 28 review following occlusal adjustment:
- Patient reported reduction of symptoms and mobility and chose to leave tooth.
- 35-37 bridge preparation:
- Pulp and periodontal status of teeth checked prior to commencement of tooth preparations.
- 35 gross preparation and temporised with provisional Luxatemp crown.
- 37 composite core build-up to increase preparation height and retention, then gross preparation and temporised with provisional Luxatemp crown.
- 35-37 bridge preparation refined and temporised with provisional Luxatemp bridge fabricated from wax-up.
- Multiple appointments required for preparation and refinement due to issues with path of insertion, inadequate reductions and uneven margins.
#### Clinical Notes on Delivery
- **Smoking Cessation:** Patient educated on risks; no intention to quit but reduced frequency for financial reasons.
- **28 Adjustment:** Adjusted out of occlusion; patient reported reduction in symptoms and mobility.
- **Oral Medicine:** Confirmed diagnosis of frictional hyperkeratosis.
- **Scale and Clean:** Removed excessive tar and nicotine staining.
- **35-37 Bridge Preparation:**
- 37 required composite core build-up for retention.
- Multiple appointments needed for path of insertion and margin refinement.
![]()
Clinical photo showing a white lesion on the left buccal mucosa. The image displays an irregular, whitish patch on the pink oral tissue. Context indicates this was diagnosed as frictional hyperkeratosis.
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Intraoral procedure photograph of a dental bridge preparation (teeth 35-37) temporised with a provisional Luxatemp crown/bridge. The image shows the prepared teeth with the temporary restoration in place, illustrating the result after refinement from wax-up.
• 35-37 shade selection and final impressions
- Shade Vitapan C4 selected with lab assistance and patient input.
- Assessed gingiva underlying future pontic, firm and incompressible.
- Final PVS impression and Trios digital scan taken and sent to lab.
- Trios scan used to mill 3D model.
- 35-37 zirconia bridge milled from CAD-CAM machine.
• 35-37 bridge bisque try-in:
- Bisque try-in to confirm shade of bridge and check path of insertion.
#### Bridge Fabrication
- **Shade Selection:** Vitapan C4 selected with lab assistance.
- **Impressions:** Final PVS impression and Trios digital scan taken.
- **Laboratory:** Trios scan used for 3D model; 35-37 zirconia bridge milled via CAD-CAM.
- **Bisque Try-in:** Confirmed shade and path of insertion.
- 35-37 bridge insert:
- Satisfactory fit, stability, retention, contacts, margins, contours
- Occlusion high, adjusted.
- 35-37 bridge post-insert review:
- Patient reported nil symptoms.
- Intraoral exam found nil abnormalities.
- Patient has maintained good oral hygiene and routinely uses oral irrigator to clean teeth and around bridge.
- Final periapical radiograph taken – good marginal adaptation 35 & 37, PDL widening 37M, possible excess cement on 37M cleaned off, nil pathology.
- Recall exam:
- Intraoral exam revealed 26 fractured amalgam and cracked tooth structure.
- Maintained good oral hygiene.
- 26 investigation:
- Radiograph taken to check for pathology, nil detected.
- Removed fractured amalgam and cracks in tooth.
- Assessed restorability, tooth requires full cuspal coverage for protection from cuspal flexure.
- Temporised with GIC and monitored.
#### Bridge and Onlay Progress
- **35-37 Bridge Insert:** Satisfactory fit; occlusion adjusted. Post-insert review showed good adaptation and OHI compliance.
- **Recall Exam (2020):** 26 found with fractured amalgam and cracked structure.
- **26 Investigation:** Radiograph showed no pathology. Fractured amalgam and cracks removed. Determined tooth required full cuspal coverage. Temporised with GIC.
![]()
Clinical intraoral photographs showing the insertion of a dental bridge on teeth 35-37. The left image displays an occlusal view with the bridge in place, while the right image shows a lateral view. Context indicates these images demonstrate satisfactory fit, stability, retention, contacts, margins, and contours, with occlusion noted as high and adjusted.
![]()
Periapical radiograph of teeth 35 and 37 post-insertion review. The image visualizes the root structures and the crown length of the bridge abutments. According to the OCR context, this radiograph demonstrates good marginal adaptation for teeth 35 & 37, PDL widening at tooth 37M (mesial), possible excess cement cleaned off, and no pathology detected.
![]()
Periapical radiograph of tooth 26 taken during investigation following recall exam. The text notes that the intraoral exam revealed a fractured amalgam and cracked tooth structure. This radiograph was used to check for pathology, which was not detected.
- 26 onlay preparation:
- Deep preparation on supraerupted tooth with sound enamel margins.
- Flowable composite liner placed at base of preparation.
- Temporised with spot-etch and Luxatemp onlay.
- 26 shade selection and final impressions:
- Shade Vitapan C4 selected.
- Final PVS impression and Trios digital scan taken and sent to lab.
- PVS impression poured up and used to fabricate 26 emax onlay.
- 26 onlay insert
- Satisfactory fit, stability, retention, contours.
- Distal vertical discrepancy <1.0 mm, clinically accepted.
- Mesial horizontal discrepancy, adjustable, clinically accepted.
- Light contact with 25, clinically accepted.
- Even occlusion.
125
#### 26 Onlay Delivery
- **Preparation:** Deep preparation on supraerupted tooth; flowable composite liner placed; temporised with Luxatemp.
- **Shade/Impressions:** Vitapan C4; PVS and Trios scan taken.
- **Fabrication:** PVS impression used for Emax onlay.
- **Insert:** Satisfactory fit and stability; distal vertical discrepancy <1.0 mm and mesial horizontal discrepancy accepted; even occlusion.
![]()
Clinical photo of tooth 26 onlay preparation showing deep preparation on supraerupted tooth with sound enamel margins.
![]()
Clinical photo demonstrating shade selection for tooth 26 using Vitapan C4 shade guide.
![]()
Clinical photo showing final PVS impression and Trios digital scan taken for lab fabrication.
![]()
Two clinical photos showing PVS impression poured up used to fabricate the 26 emax onlay.
![]()
Clinical photo of the inserted 26 onlay showing satisfactory fit, stability, retention, contours, and even occlusion.
- 26 onlay post-insert review
- Patient reported nil symptoms; 28 remained asymptomatic.
- Intraoral exam found nil abnormalities.
- Patient has maintained good oral hygiene and routinely uses oral irrigator to clean teeth and around all indirect restorations (26 onlay, 35-37 bridge, 46 crown).
Zirconia was material of choice for 3-unit bridge. Systematic review of published studies on zirconia-based fixed dental prostheses concluded that these perform reasonably well and may be considered a viable alternative to metal-ceramic fixed dental prostheses. (40) Common complications include abutment teeth needing endodontic therapy, re-cementation, repair of carious lesions. (41) The percentage of complete failures resulting from framework fracture (insufficient connector size) or loss of retention (under-reduction of tooth structure) was less than 10%. (41) Marginal discrepancy resulting in secondary caries was another issue. (41) As mechanical properties of zirconia, except modulus of elasticity, is superior to other tooth-coloured restorations, and rate of fracture of zirconia was low or non-existent. (41) Prospective clinical study confirmed effectiveness of zirconia as clinical option to fabricate short-span posterior fixed dental prostheses with the material performing satisfactorily long-term, functionally and aesthetically, in posterior areas and in patients with standard biomechanical conditions (>90% cumulative survival rate). As the patient exhibits parafunction, metal-ceramic is another viable option for restoration of posterior area. (42)
Emax was material of choice for onlay due to evidence around survival of emax partial coverage restorations. (21) Tooth had good amount of enamel around margins after preparation available for bonding.
126
#### Clinical Rationale
- **Zirconia (3-unit bridge):** Material of choice for posterior FDPs due to high survival rates (>90%) and superior mechanical properties. Viable alternative to metal-ceramic, especially for short-span posterior bridges.
- **Emax (26 onlay):** Selected due to high survival rates for partial coverage restorations and availability of enamel margins for bonding.
- **Maintenance:** Patient uses oral irrigator for cleaning around 26 onlay, 35-37 bridge, and 46 crown.
![]()
Clinical intraoral photograph showing the maxillary arch with a fixed dental prosthesis (bridge) on teeth 35-37. The restoration appears to be zirconia-based as indicated by text context. The image demonstrates good oral hygiene and proper fit around the indirect restorations.
![]()
Clinical intraoral photograph showing the mandibular arch with an onlay restoration on tooth 26. The image shows the prepared tooth margin and bonding area for Emax material as referenced in the text. Good enamel margins are visible suitable for bonding.
4.7.2 Before and after photographs
Date: February 2019 – September 2020
127
#### 4.7.2 Before and after photographs
Date: February 2019 – September 2020
![]()
Heading text '4.7.2 Before and after photographs' indicating the context of the visual content.
![]()
Date range 'February 2019 – September 2020' specifying the timeline for the before and after comparison.
![]()
Before and after facial photos showing a man's smile, with eyes redacted for privacy.
![]()
Close-up dental photos comparing the patient's teeth alignment before treatment (left) and after treatment (right).
![]()
Intraoral photos showing the condition of the patient's teeth before (left) and after (right) dental intervention.
![]()
Occlusal view intraoral photos showing the arrangement of teeth in the upper jaw before (left) and after (right) treatment.
**4.7.3 Patient response to treatment**
- Patient was satisfied with overall outcome of treatment.
- “I can chew on my left side now.”
- Resolution of presenting complaints:
i. “My teeth are stained.”
- Tar and nicotine stains cleaned and advice given regarding cessation of smoking habit.
ii. “My back tooth on the left feels sensitive when I bite and it’s wobbly.”
- Occlusal adjustment and placement of indirect restorations to 28 resulted in resolution symptoms.
iii. “I feel like I’m chewing on my gums on the left side (27, 36) and have been avoiding chewing on that side for a long time.”
- 35-37 bridge placement resolved issue however 27 edentulous site remained unchanged due to limited treatment options available.
- Patient was compliant with dental advice and instructions, but continues smoking habit.
- Patient has attended all appointments to date and will continue to attend OHCWA for maintenance.
**4.7.4 Reflection**
<table>
<thead>
<tr>
<th>Challenges</th>
<th>Management</th>
</tr>
</thead>
<tbody>
<tr>
<td>
Smoker’s cough
</td>
<td>
<ul>
<li>Patient has chronic cough associated with cigarette irritants, causing difficulty with certain procedures. For example, during 35-37 bridge preparation laceration to floor of mouth occurred.</li>
<li>Sit patient up for water breaks</li>
<li>Use tongue guard</li>
<li>Use assistance</li>
<li>Offer to reschedule appointments</li>
</ul>
</td>
</tr>
<tr>
<td>
<p>35-37 bridge preparation</p>
</td>
<td>
<ul>
<li>Issues with path of insertion, reductions, margins</li>
<li>Practice</li>
<li>Principle of conservation of tooth structure is important, however in some circumstances it is not a priority for success of restoration</li>
<li>More aggressive preparation of margins sometimes necessary to increase axial wall height for increased retention</li>
</ul>
</td>
</tr>
<tr>
<td>
35-37 bridge provisional restoration
</td>
<td>
<ul>
<li>Provisional Luxatemp crown dislodged and bridge fractured</li>
<li>Call patient in for re-make to protect exposed tooth structure</li>
<li>Adjust putty index to increase width of connector for increased strength</li>
<li>Fill in provisional deficiencies with flowable composite</li>
<li>Use provisional restorations as a guide to check adequacy of reductions</li>
</ul>
</td>
</tr>
<tr>
<td>
35-37 bridge final impressions
</td>
<td>
<ul>
<li>Bubble on external margin 37</li>
<li>Practice impression technique</li>
</ul>
</td>
</tr>
<tr>
<td>
<p>35-37 try-in</p>
</td>
<td>
<ul>
<li>Loose point contact with 34 due to distal tilt of 34</li>
<li>Enameloplasty of 34D would have broadened contact area and reduced potential for plaque and food trapping</li>
</ul>
</td>
</tr>
<tr>
<td>
26 cementation
</td>
<td>
<ul>
<li>Difficulty locking in restoration onto tooth</li>
<li>Preparation of positive groove to lock in restoration</li>
</ul>
</td>
</tr>
</tbody>
</table>
#### 4.7.3 Patient response to treatment
- Patient satisfied: "I can chew on my left side now."
- Stains cleaned; smoking cessation advice given.
- 28 symptoms resolved via occlusal adjustment.
- 35-37 bridge resolved functional issues on the left; 27 site remains unchanged.
- Patient compliant with advice but continues smoking.
#### 4.7.4 Reflection
| Challenge | Management |
| :--- | :--- |
| Smoker’s cough | Sit patient up; use tongue guard/assistance; reschedule if needed. |
| Bridge preparation | Practice; aggressive margin prep sometimes needed for retention. |
| Provisional failure | Re-make to protect tooth; widen connectors; use as reduction guide. |
| Final impressions | Practice technique to avoid bubbles. |
| Try-in contact | Enameloplasty of adjacent tooth (34D) to broaden contact area. |
| 26 cementation | Use positive groove to assist in locking restoration. |
![]()
A table titled '4.7.4 Reflection' summarizing clinical challenges and management strategies for a dental case involving bridge preparation on teeth 35-37. The table has three columns: 'Challenges', 'Management', and an implicit category column (Patient-related/Clinical). Key rows include: Smoker's cough (management includes sitting patient up, using tongue guard); 35-37 bridge preparation (issues with path of insertion, conservative vs aggressive margin prep); provisional restoration (crown dislodged, fractured bridge, adjusted putty index); final impressions (bubble on margin 37); try-in (loose contact with tooth 34); and cementation (difficulty locking in restoration).
# CASE 5
Removable Occlusal Rehabilitation
129
#### Case Overview
Removable Occlusal Rehabilitation
CASE 5
Removable Occlusal Rehabilitation
**5.1.1** Details
* 62 year-old female.
**5.1.2** Presenting complaint/s
* Presented in July 2019 for initial examination with the following complaints:
i. “My denture (F/-) is hurting me, I think it’s too high (labial flange).”
ii. “I don’t have any teeth left.”
**5.1.3** History of presenting complaint/s
* Maxillary clearance due to severe periodontal disease and immediate maxillary full denture insert August 2018.
* Experienced no issues with soft tissue and bone healing following maxillary clearance.
* Teeth extracted over the years predominantly due to periodontal disease.
130
#### 5.1.1 Details
- 62 year-old female.
#### 5.1.2 Presenting complaint/s
- Presented in July 2019 for initial examination with the following complaints:
1. “My denture (F/-) is hurting me, I think it’s too high (labial flange).”
2. “I don’t have any teeth left.”
#### 5.1.3 History of presenting complaint/s
- Maxillary clearance due to severe periodontal disease and immediate maxillary full denture insert August 2018.
- Experienced no issues with soft tissue and bone healing following maxillary clearance.
- Teeth extracted over the years predominantly due to periodontal disease.
![]()
Clinical facial photograph of a 62-year-old female patient (Case 5). The image is cropped to the head and neck region. The eyes are obscured by a black bar for privacy. The text below identifies this as 'CASE 5 Removable Occlusal Rehabilitation', relating to a patient presenting with denture discomfort.
5.1.4 Medical history
| Medical condition | Description | Dental implications (1) |
| :--- | :--- | :--- |
| **Hypertension** | Blood pressure reading >140/90 mmHg. Medical emergency when >180/110 mmHg. Can lead to serious problems including heart attack, stroke, heart failure, kidney failure. | Hypertensive emergency in dental chair. Call 000. |
| Hypercholesterolaemia | Increased triglycerides and LDL cholesterol and decreased HDL cholesterol. Increases chance of atherosclerosis and cardiovascular disease. | Nil. |
| Iron deficiency anaemia | Low (quality or quantity) red blood cell count or low haemoglobin level. Caused by blood loss or problems with red blood cells (diet, illness, medication side effects). | Anaesthetic risk – anoxia and increased risk of myocardial/cerebral ischaemia resulting in cardiac arrest. <br> Delayed wound healing. <br> Post-operative haemorrhage, aggravation of anaemia, interference with haemostasis. <br> Susceptibility to glossitis and angular cheilitis. <br> Susceptibility to oral ulceration. <br> Susceptibility to *Candida albicans* infection. <br> (43, 44) |
| Reflux oesophagitis | Reflux of stomach contents into oesophagus resulting in chemical insult to oesophagus from gastric acid, enzymes, bile. | Difficulty tolerating horizontal position. <br> Acid erosion and accelerated tooth wear. |
| Osteoarthritis | Inflammation and/or damage of joints affecting bone, cartilage, ligaments, muscles and causing pain, swelling, difficulty moving. | Physical difficulty maintaining oral hygiene. <br> Unmanaged chronic pain may affect psychological wellbeing and capacity to maintain self-care, including oral hygiene. |
| History of Bells Palsy 2018 Managed by ENT specialist | Sudden weakness or paralysis on one side of the face. Thought to be caused by viral infection causing inflammation or damage to facial nerve. Symptoms include unilateral drooping of face to affected side, difficulty eating/drinking, drooling, pain/sensitivity around affected area, headache, taste impairment, changes in amount of tears/saliva. Usually temporary with full recovery in 3-6 months. | Drooling and susceptibility to angular cheilitis. <br> Xerostomia and higher caries risk <br> Inability to function normally (eating, speaking). <br> Food trapping and plaque accumulation. <br> (45) |
(1) Theraeuteic guidelines: oral and dental (2019).
131
#### 5.1.4 Medical History
| Medical condition | Description | Dental implications |
| :--- | :--- | :--- |
| **Hypertension** | Blood pressure reading >140/90 mmHg. Medical emergency when >180/110 mmHg. Can lead to serious problems including heart attack, stroke, heart failure, kidney failure. | Hypertensive emergency in dental chair. Call 000. |
| **Hypercholesterolaemia** | Increased triglycerides and LDL cholesterol and decreased HDL cholesterol. Increases chance of atherosclerosis and cardiovascular disease. | Nil. |
| **Iron deficiency anaemia** | Low (quality or quantity) red blood cell count or low haemoglobin level. Caused by blood loss or problems with red blood cells (diet, illness, medication side effects). | Anaesthetic risk – anoxia and increased risk of myocardial/cerebral ischaemia resulting in cardiac arrest. <br> Delayed wound healing. <br> Post-operative haemorrhage, aggravation of anaemia, interference with haemostasis. <br> Susceptibility to glossitis, angular cheilitis, oral ulceration, and *Candida albicans* infection. |
| **Reflux oesophagitis** | Reflux of stomach contents into oesophagus resulting in chemical insult to oesophagus from gastric acid, enzymes, bile. | Difficulty tolerating horizontal position. <br> Acid erosion and accelerated tooth wear. |
| **Osteoarthritis** | Inflammation and/or damage of joints affecting bone, cartilage, ligaments, muscles and causing pain, swelling, difficulty moving. | Physical difficulty maintaining oral hygiene. <br> Unmanaged chronic pain may affect psychological wellbeing and capacity to maintain self-care. |
| **History of Bells Palsy 2018** | Sudden weakness or paralysis on one side of the face. Thought to be caused by viral infection causing inflammation or damage to facial nerve. | Drooling and susceptibility to angular cheilitis. <br> Xerostomia and higher caries risk. <br> Inability to function normally (eating, speaking). <br> Food trapping and plaque accumulation. |
![]()
A structured table titled '5.1.4 Medical history' containing three columns: 'Medical condition', 'Description', and 'Dental implications (1)'. The table lists six specific medical conditions including Hypertension, Hypercholesterolaemia, Iron deficiency anaemia, Reflux oesophagitis, Osteoarthritis, and History of Bells Palsy. Each row provides detailed clinical descriptions and corresponding dental risks or guidelines relevant to the condition.
| Medication | Dosage | Use & Mechanism of action (2, 3) | Dental implications (2, 3) |
|---|---|---|---|
| Atenolol | 50 mg tab q.d. | β-blocker for hypertension. Reduces heart rate, blood pressure and cardiac contractility via unknown mechanism. | Potential for drug interactions used in General Aesthesia resulting in severe bradyarrhythmia, attenuation of reflex tachycardia and hypotension, decreased reflex to compensate for blood loss and hypovolaemia, regional sympathetic blockade, increased propensity for vagal induced bradycardia. May increase sensitivity to allergens and severity of anaphylaxis, adrenaline treatment may not always give expected therapeutic effect. |
| Ranitidine | 150 mg tab b.d. | Selective parietal cell H2-receptor antagonist reducing gastric acid secretion. For short term symptomatic treatment of reflux oesophagitis unresponsive to conservative anti-reflux treatment e.g. antacids. | Nil. |
| Rabeprazole | 20 mg tab t.d. | Proton pump inhibitor that binds to hydrogen-potassium ATPase enzyme system inhibiting stimulated and basal gastric acid production and secretion. For reflux oesophagitis. | Nil. |
| Ezetrol (Ezetimibe) | 10 mg tab q.d. | Reduces absorption of dietary and biliary cholesterol by inhibiting transport across intestinal wall leading to increased LDL uptake and reduced plasma cholesterol. | Nil. |
| Panadol (Paracetamol) | p.r.n. | Analgesic and antipyretic action for temporary relief of back pain. Unknown mechanism of action. | Nil. |
| Echinacea | q.d. | Dietary supplement. | Long term use may have potential for immunosuppression and increased risk of poor wound healing and opportunistic infections. (46) |
| Omega-3 | q.d. | Dietary supplement. | May inhibit platelet aggregation and increase bleeding risk. (46) |
| Magnesium | q.d. | Dietary supplement. | Nil. |
(2) Monthly Index of Medical Specialities Australia. (3) Australian Medicines Handbook.
| Allergy | Description | Dental implications |
|---|---|---|
| Bees | Anaphylactic reaction to bee venom. | Nil. |
| Alcohol & Tobacco Use | Amount, Frequency & Duration | Dental implications |
|---|---|---|
| Current drinker | 1 – 2 standard drinks per year. | Alcohol consumption raises risk of cancer including on lip and in oral cavity. (5) |
132
#### Medication and Allergy History
| Medication | Dosage | Use & Mechanism of action | Dental implications |
|---|---|---|---|
| **Atenolol** | 50 mg tab q.d. | β-blocker for hypertension. Reduces heart rate and blood pressure. | Potential for drug interactions in General Anaesthesia; severe bradyarrhythmia; decreased reflex to compensate for blood loss. Adrenaline treatment may not always give expected therapeutic effect. |
| **Ranitidine** | 150 mg tab b.d. | Selective parietal cell H2-receptor antagonist reducing gastric acid secretion. | Nil. |
| **Rabeprazole** | 20 mg tab t.d. | Proton pump inhibitor inhibiting gastric acid production. | Nil. |
| **Ezetrol (Ezetimibe)** | 10 mg tab q.d. | Reduces absorption of dietary and biliary cholesterol. | Nil. |
| **Panadol (Paracetamol)** | p.r.n. | Analgesic and antipyretic for back pain. | Nil. |
| **Echinacea** | q.d. | Dietary supplement. | Long term use may have potential for immunosuppression and increased risk of poor wound healing. |
| **Omega-3** | q.d. | Dietary supplement. | May inhibit platelet aggregation and increase bleeding risk. |
| **Magnesium** | q.d. | Dietary supplement. | Nil. |
**Allergies**
- **Bees:** Anaphylactic reaction to bee venom. No dental implications.
**Alcohol & Tobacco Use**
- **Current drinker:** 1 – 2 standard drinks per year. Raises risk of cancer including on lip and in oral cavity.
![]()
A large reference table listing medications (Atenolol, Ranitidine, Rabeprazole, Ezetrol, Panadol, Echinacea, Omega-3, Magnesium) with columns for Dosage, Use & Mechanism of action, and Dental implications. It details specific dental risks such as drug interactions during General Aesthesia for Atenolol and bleeding risks for Omega-3.
![]()
A small table summarizing Allergy information. It lists 'Bees' and describes the associated anaphylactic reaction to bee venom, noting 'Nil' for dental implications.
![]()
A summary table regarding Alcohol & Tobacco Use. It categorizes a patient as a 'Current drinker' (1–2 standard drinks per year) and notes the increased risk of oral cancer.
5.15 Dental history and dental attitude
- Dental history
- History of irregular attendance at OHCWA.
- Maxillary clearance due to severe periodontal disease and immediate maxillary full denture insert August 2018.
- Nil issues with soft and hard tissue healing following extractions.
- Maxillary immediate denture soft relined twice.
- Unhappy with maxillary denture stability, retention and comfort.
- Dental attitude
- Aesthetic and social motivation.
- General negative attitude and apathy.
- Poor adaptive capacity.
- Tendency to attend dental appointments in unwell state.
5.16 Oral hygiene
- Poor oral hygiene
- Uses manual toothbrush and sensitivity toothpaste twice daily.
- Does not use interproximal cleaning aids.
- Uses non-alcohol mouthwash.
5.17 Social history
- Part-time Red Cross volunteer.
- Unstable family relationships; main support sister and friends.
- Significant psychosocial issues caused by marriage breakdown and imprisonment of son in Laos.
133
#### 5.1.5 Dental History and Attitude
- **Dental History**
- History of irregular attendance at OHCWA.
- Maxillary clearance due to severe periodontal disease and immediate maxillary full denture insert August 2018.
- Nil issues with soft and hard tissue healing following extractions.
- Maxillary immediate denture soft relined twice.
- Unhappy with maxillary denture stability, retention and comfort.
- **Dental Attitude**
- Aesthetic and social motivation.
- General negative attitude and apathy.
- Poor adaptive capacity.
- Tendency to attend dental appointments in unwell state.
#### 5.1.6 Oral Hygiene
- **Poor oral hygiene**
- Uses manual toothbrush and sensitivity toothpaste twice daily.
- Does not use interproximal cleaning aids.
- Uses non-alcohol mouthwash.
#### 5.1.7 Social History
- Part-time Red Cross volunteer.
- Unstable family relationships; main support sister and friends.
- Significant psychosocial issues caused by marriage breakdown and imprisonment of son in Laos.
5.2 Examination and diagnostics
Date: July 2019
5.2.1 Extra-oral examination
| | Findings |
| :--- | :--- |
| Facial symmetry | Absence of facial swelling |
| Facial skin | Nil abnormalities detected |
| Lips | Hydrated, smooth lips and distinct vermilion border |
| Temporomandibular joint | Clicking on opening bilaterally<br>Pain on palpation and opening right hand side<br>Deviation to right hand side |
| Lymph nodes | No sign of lymphadenopathy<br>Absence of pain and tenderness on palpation |
| Muscles of mastication | Pain on palpation |
| Thyroid gland | No obvious abnormal enlargement |
5.2.2 Extra-oral photographs
<div>
<img>
</div>
134
#### 5.2 Examination and Diagnostics (July 2019)
#### 5.2.1 Extra-oral Examination
| Feature | Findings |
| :--- | :--- |
| Facial symmetry | Absence of facial swelling |
| Facial skin | Nil abnormalities detected |
| Lips | Hydrated, smooth lips and distinct vermilion border |
| Temporomandibular joint | Clicking on opening bilaterally; Pain on palpation and opening right hand side; Deviation to right hand side |
| Lymph nodes | No sign of lymphadenopathy; Absence of pain and tenderness on palpation |
| Muscles of mastication | Pain on palpation |
| Thyroid gland | No obvious abnormal enlargement |
#### 5.2.2 Extra-oral Photographs
(Photographs omitted)
![]()
Clinical examination table under section '5.2.1 Extra-oral examination' listing findings for facial symmetry, skin, lips, temporomandibular joint (noting clicking and pain on right side), lymph nodes, mastication muscles, and thyroid gland.
![]()
Extra-oral photograph of a patient's face showing facial features with eyes redacted; part of the visual documentation under section '5.2.2 Extra-oral photographs'.
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Left lateral profile view of the patient’s head and neck as part of extra-oral photographic documentation.
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Right lateral profile view of the patient’s head and neck as part of extra-oral photographic documentation.
# 5.2.3 Intraoral examination
| Findings |
| :--- |
| Labial mucosa | Nil abnormalities detected |
| Buccal mucosa | Nil abnormalities detected |
| Hard palate | Nil abnormalities detected |
| Soft palate | Nil abnormalities detected |
| Gingivae | Nil abnormalities detected |
| Tongue | Plaque on dorsum |
| Floor of mouth | Shallow |
# 5.2.4 Intraoral photographs and findings
| View | Findings |
| :--- | :--- |
| **Maxillary occlusal** | |
| &nbsp;&nbsp;&nbsp;&nbsp;Teeth | Edentulous |
| &nbsp;&nbsp;&nbsp;&nbsp;Restorations | Nil |
| &nbsp;&nbsp;&nbsp;&nbsp;Soft tissues | Flat U-shaped palate |
| **Mandibular occlusal** | |
| &nbsp;&nbsp;&nbsp;&nbsp;Teeth | Heavily restored dentition<br>Missing 34-42, 46-47<br>Non-carious tooth surface loss incisal/occlusal 43-44 |
| &nbsp;&nbsp;&nbsp;&nbsp;Restorations | Amalgam restorations 37, 36, 45 |
| &nbsp;&nbsp;&nbsp;&nbsp;Soft tissues | Marginal gingival inflammation<br>Severe generalised gingival recession<br>Thin, flat alveolar ridge<br>Plaque on tongue dorsum |
| **Anterior** | |
| &nbsp;&nbsp;&nbsp;&nbsp;Teeth | Partially dentate: Kennedy Applegate Class I (6)<br>Missing 34-42, 46-47<br>Supraeruption of anterior teeth<br>Root exposure all teeth<br>Uneven occlusal plane |
| &nbsp;&nbsp;&nbsp;&nbsp;Restorations | Amalgam restorations 36, 45 |
| &nbsp;&nbsp;&nbsp;&nbsp;Soft tissues | Marginal gingival inflammation<br>Severe generalised gingival recession, loss of interdental papilla<br>Thin, flat alveolar ridge |
<img>maxillary occlusal view: flat u-shaped palate and edentulous maxilla
<img>mandibular occlusal: missing teeth, restorations of 37, 36, 45
<img>mandibular anterior view: supraeruption, root exposure
<img>mandibular anterior occlusal view: missing teeth, restorations of 36, 45
135
#### 5.2.3 Intraoral Examination
- **Labial mucosa:** Nil abnormalities detected
- **Buccal mucosa:** Nil abnormalities detected
- **Hard palate:** Nil abnormalities detected
- **Soft palate:** Nil abnormalities detected
- **Gingivae:** Nil abnormalities detected
- **Tongue:** Plaque on dorsum
- **Floor of mouth:** Shallow
#### 5.2.4 Intraoral Findings
| View | Findings |
| :--- | :--- |
| **Maxillary occlusal** | Edentulous; Flat U-shaped palate |
| **Mandibular occlusal** | Heavily restored dentition; Missing 34-42, 46-47; Non-carious tooth surface loss incisal/occlusal 43-44; Amalgam restorations 37, 36, 45; Marginal gingival inflammation; Severe generalised gingival recession; Thin, flat alveolar ridge |
| **Anterior** | Partially dentate: Kennedy Applegate Class I; Missing 34-42, 46-47; Supraeruption of anterior teeth; Root exposure all teeth; Uneven occlusal plane; Loss of interdental papilla |
![]()
Table titled '5.2.3 Intraoral examination' listing findings for labial mucosa, buccal mucosa, hard palate, soft palate, gingivae, tongue, and floor of mouth.
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Table titled '5.2.4 Intraoral photographs and findings' with columns for View (Maxillary occlusal, Mandibular occlusal, Anterior) and Findings subdivided into Teeth, Restorations, and Soft tissues.
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Set of four intraoral clinical photographs: top-left shows a flat U-shaped palate; top-right shows mandibular occlusal view with missing teeth and amalgam restorations; bottom-left shows mandibular anterior view with supraeruption and root exposure; bottom-right shows another mandibular anterior occlusal view with restorations.
> ignore this image and do not process it
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Table titled 'Findings' under section '5.2.5 Occlusion'. Rows include: Overjet (-), Overbite (-), Canine class (LHS: -, RHS: -), Molar class (LHS: -, RHS: -), Crossbite (-), Crowding / Spacing (-), Rotation (Absent), Supraeruption (37-35, 43-45), Occlusal scheme (Group function).
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Odontogram diagram showing teeth numbered 1–8 on both sides of the mouth. Symbols indicate: Amalgam restoration (gray square) at tooth 5 and 6; Unsatisfactory restoration (red cross) at tooth 5; Cracked tooth (black dot) at tooth 5; Non-carious tooth surface loss (green outline) at teeth 4, 6, and 7.
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Table under section '5.2.7 Periodontal assessment — 5.2.7.1 Community Index of Periodontal Treatment Needs (CPITN)'. Left column shows CPITN scores: three '-' values and three '2*' values. Right column lists findings by sextant: Sextants 1–3 show no findings ('-'); Sextants 4–6 show generalized gingival recession >5 mm, furcation involvement (37-36 in sextant 4), abundant plaque/calculus, and bleeding on probing.
**5.2.7.2 Periodontal examination**
**Findings**
| Clinical | Gingival tissues | Copious bleeding on probing<br>Marginal red, inflamed gingiva<br>Soft, smooth, oedematous<br>Blunted papillae |
| :--- | :--- | :--- |
| | Plaque distribution | Heavy around interproximal areas<br>Heavy on mesial 35, 43 |
| | Plaque score | 100% |
| | Calculus distribution | Interproximal areas<br>Mesial 35, 43<br>Furcation areas |
| | Plaque-retentive factors | Large interproximal areas<br>Furcation areas<br>Tooth anatomy – rounded crown contours |
| | Furcation involvement | Yes 37-36 |
| | Halitosis | No |
| **Radiographic** | **Bone levels** | Generalised severe horizontal bone loss in maxilla and mandible |
**5.2.7.3 Periodontal tests**
| | | 45 | 44 | 43 | | | | | | | 35 | 36 | 37 |
| :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- |
| **Mobility** | | | | | | | | | | | | | |
| **TTPalp** | | | | | | | | | | | | | |
| **TTP** | | I | I | | | | | | | | I | I | I |
| | | - - - | | | | | | | | | - - - | | |
| | | - - - | | | | | | | | | - - - | | |
| | | | | | | | | | | | | | |
**5.2.7.4 Periodontal chart**
#### 5.2.7.2 Periodontal Examination
**Clinical Findings**
- **Gingival tissues:** Copious bleeding on probing; Marginal red, inflamed gingiva; Soft, smooth, oedematous; Blunted papillae.
- **Plaque distribution:** Heavy around interproximal areas; Heavy on mesial 35, 43. Score: 100%.
- **Calculus distribution:** Interproximal areas; Mesial 35, 43; Furcation areas.
- **Plaque-retentive factors:** Large interproximal areas; Furcation areas; Rounded crown contours.
- **Furcation involvement:** Yes (37-36).
- **Halitosis:** No.
**Radiographic Findings**
- **Bone levels:** Generalised severe horizontal bone loss in maxilla and mandible.
#### 5.2.7.3 Periodontal Tests
- **TTP (Tender to Percussion):** Positive (I) for 45, 44, 35, 36, 37.
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A table titled '5.2.7.2 Periodontal examination' presenting clinical and radiographic findings in a grid format. The Clinical section details Gingival tissues (bleeding on probing, inflamed gingiva), Plaque distribution (heavy interproximal areas), Plaque score (100%), Calculus distribution, Plaque-retentive factors, Furcation involvement (Yes 37-36), and Halitosis (No). The Radiographic section notes generalised severe horizontal bone loss.
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A chart titled '5.2.7.3 Periodontal tests' displaying mobility data for teeth 45, 44, 43, 35, 36, and 37. It includes rows for Mobility classification (I, II) and TTP/TTPalp measurements, with specific values indicated by Roman numerals (e.g., I, II) or dashes (-).
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Two periodontal charts titled '5.2.7.4 Periodontal chart'. These diagrams show tooth arches with numbered teeth, colored bars indicating pocket depth (PD), and numerical data tables below for Rec (recession), AL (attachment level), Mob (mobility), and Buccal/Lingual classifications.
Periodontal Risk Assessment (PRA) (7, 8)
BOP% = 78
Age: **62**
Number of teeth and implants: **6** (1 - 32)
Number of sites per tooth / implant: **6** (selected)
Number of BOP-pos. sites: **28** of **36**
Number of sites with PPD>5mm: **3**
Number of missing teeth: **22**
% alveolar bone loss (estimated in % or 10% per 1mm): **50** %
Syst./Gen.: **No**
Envir.: **Non-smoker (NS)**
Polygon surface: 45.88934
Periodontal Risk: **high**
Suggested Recall Interval: **3 Months**
Periodontal Risk Assessment (PRA) for patients in Supportive Periodontal Therapy (SPT). (7) PRA tool. (8)
5.2.8 Pulp sensibility tests
| | EPT | CO2 | | | | | | | | | | | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| | | | | | | | | | | | | | | |
| | CO2 | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ | ↔ |
| | | | 45 | 44 | 43 | | | | | | | | 35 | 36 | 37 |
| CO2 | ++ | ++ | ++ | | | | | | | | | | + | ++ | ++ |
| EPT | 32 | 30 | 33 | | | | | | | | | | 21 | 40 | 28 |
*26, 35, 37 tested prior to fixed prosthodontics. 28 tested as symptomatic.
138
#### Periodontal Risk Assessment (PRA)
- **BOP%:** 78%
- **Number of teeth:** 6
- **Sites with PPD > 5mm:** 3
- **Missing teeth:** 22
- **Alveolar bone loss:** 50%
- **Periodontal Risk:** High
- **Suggested Recall Interval:** 3 Months
#### 5.2.8 Pulp Sensibility Tests
| Tooth | CO2 | EPT |
| :--- | :--- | :--- |
| 45 | ++ | 32 |
| 44 | ++ | 30 |
| 43 | ++ | 33 |
| 35 | + | 21 |
| 36 | ++ | 40 |
| 37 | ++ | 28 |
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Periodontal Risk Assessment (PRA) radar chart. The diagram features a hexagonal grid with axes labeled 'Envir.', 'PD≥5mm', 'Tooth loss', 'BL/Age = 0.81', 'Syst./Gen.', and an unlabeled axis corresponding to BOP%. A shaded polygon represents the patient's risk profile across these categories. Key values are annotated: BOP% = 78, BL/Age = 0.81.
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Table for Pulp sensibility tests (Section 5.2.8). Columns represent tooth numbers (45, 44, 43, 35, 36, 37). Rows record results for CO2 test (indicated by symbols like ++ or +) and EPT (Electric Pulp Test) scores (numerical values like 32, 30, 33, etc.).
**5.2.9 Radiographs**
Rationale: each radiograph taken has rationale where stated – ALARA
Note: Subscript a = amalgam, c = composite, m = metallic, p = metal-ceramic
**5.2.9.1 Orthopantogram**
Date: 23/8/2019
**Findings (9)**
| Category | Findings |
| :--- | :--- |
| **Periphery and corners** | Nil abnormalities detected |
| **Cortices of mandible** | Continuous and even |
| **Cortices of maxilla** | Nil abnormalities detected |
| **Zygomatic bones** | Nil abnormalities detected |
| **Maxillary sinuses** | Nil abnormalities detected |
| **Nasal cavity and palate** | Nil abnormalities detected |
| **Bone pattern of maxilla** | Normal density and trabeculation |
| **Bone pattern of mandible** | Normal density and trabeculation |
| **Alveolar processes** | Generalised severe horizontal bone loss in maxilla and mandible<br>Furcation involvement 37-36 |
| **Teeth** | Edentulous maxilla<br>Missing 34-42, 46-47<br>38, 48 retained roots<br>Unusual bend 43<br>Amalgam restorations 37, 36, 45 |
Interpretation of panoramic radiographs, Perschbacher (2012). (9)
**5.2.9.2 Bitewings**
• Nil taken.
139
#### 5.2.9 Radiographs
#### 5.2.9.1 Orthopantogram (23/8/2019)
| Category | Findings |
| :--- | :--- |
| **Cortices** | Continuous and even (mandible); Nil abnormalities (maxilla) |
| **Bone pattern** | Normal density and trabeculation |
| **Alveolar processes** | Generalised severe horizontal bone loss; Furcation involvement 37-36 |
| **Teeth** | Edentulous maxilla; Missing 34-42, 46-47; 38, 48 retained roots; Unusual bend 43; Amalgam restorations 37, 36, 45 |
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Orthopantogram radiograph dated 23/8/2019. The image displays the maxilla and mandible, revealing a fully edentulous maxilla and multiple dental implants in the mandible. A 'L' marker indicates the left side.
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Table titled 'Findings (9)' summarizing the radiographic interpretation. It lists categories such as Periphery and corners, Cortices of mandible/maxilla, Zygomatic bones, Maxillary sinuses, Nasal cavity and palate, Bone pattern of maxilla/mandible, Alveolar processes, and Teeth. Key findings include: Nil abnormalities detected for most bony structures; Generalised severe horizontal bone loss in maxilla and mandible with furcation involvement 37-36; Edentulous maxilla; Missing teeth 34-42, 46-47; Retained roots 38, 48; Unusual bend 43; Amalgam restorations 37, 36, 45.
**5.2.9.3 Periapicals**
**Periapical – 37-36**
| Finding | Details |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | 37Oₐ, 36Oₐ |
| **Pulp** | Nil abnormalities detected |
| **Periodontium** | * Intact PDL space & lamina dura 37-36<br>* Widened PDL space 36M<br>* Generalised crestal bone loss<br>* Furcation involvement 37-36<br>* Bulbous roots 37-36<br>* Nil PA radiolucency 37-36 |
| **Other** | - |
| **Date:** | 29/10/19 |
| **Rationale:** | Check for pathology |
**Periapical – 35**
| Finding | Details |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | 36Oₐ |
| **Pulp** | Nil abnormalities detected |
| **Periodontium** | * Intact PDL space & lamina dura 36-35<br>* Widened PDL space 35M&D<br>* Generalised crestal bone loss<br>* Furcation involvement 36<br>* Bulbous roots 36-35<br>* Nil PA radiolucency 36-35 |
| **Other** | Cone cut |
| **Date:** | 28/3/2019 |
| **Rationale:** | Check for pathology |
**Periapical – 43-44**
| Finding | Details |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | 45Oₐ |
| **Pulp** | Nil abnormalities detected |
| **Periodontium** | * Intact PDL space & lamina dura 43-35<br>* Widened PDL space 43M&D, 44M<br>* Generalised crestal bone loss<br>* Nil PA radiolucency 43-44 |
| **Other** | Unusual bend 43<br>Cone cut |
| **Date:** | 28/3/2019 |
| **Rationale:** | Check for pathology |
**Periapical – 44-45**
| Finding | Details |
| :--- | :--- |
| **Caries** | Nil detected |
| **Restorations** | 45Oₐ |
| **Pulp** | Nil abnormalities detected |
| **Periodontium** | * Intact PDL space & lamina dura 45<br>* Widened PDL space 44M<br>* Generalised crestal bone loss<br>* Nil PA radiolucency 44-45 |
| **Other** | Occlusal PA |
| **Date:** | 28/3/2019 |
| **Rationale:** | Check for pathology |
#### 5.2.9.3 Periapicals
- **37-36:** 37O, 36O amalgams. Intact PDL space; widened PDL 36M. Generalised crestal bone loss and furcation involvement. Bulbous roots.
- **35:** 36O amalgam. Widened PDL 35M&D. Generalised crestal bone loss. Bulbous roots.
- **43-44:** 45O amalgam. Widened PDL 43M&D, 44M. Generalised crestal bone loss. Unusual bend 43.
- **44-45:** 45O amalgam. Widened PDL 44M. Generalised crestal bone loss.
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Radiograph (Periapical X-ray) labeled 'Periapical - 37-36'. Shows teeth #37 and #36 with restorations. Date: 29/10/19.
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Radiograph (Periapical X-ray) labeled 'Periapical - 35'. Shows tooth #35 with a restoration. Date: 28/3/2019.
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Radiograph (Periapical X-ray) labeled 'Periapical - 43-44'. Shows teeth #43 and #44. Date: 28/3/2019.
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Radiograph (Periapical X-ray) labeled 'Periapical - 44-45'. Shows teeth #44 and #45. Date: 28/3/2019.
5.2.10 Caries risk assessment
5.2.10.1 Dietary assessment
• Generally, diet is:
- High in fermentable carbohydrates
- Low sugar
- Low acid
- Limited snacking frequency
5.2.10.2 Saliva test
| Unstimulated saliva | | Stimulated saliva | |
|----------------------------|-------------------|-------------------------------|----------------------|
| **Flow rate**, **Consistency**, **pH** | **Quantity at 5 mins**, **Buffering capacity** |
| >60 s – low, Sticky/frothy, 5.0-5.8 | <3.5 mL – very low, 0-5 – very low |
| 30-60 s – normal, Frothy/bubbly, 6.0-6.6 | 3.5-5.0 mL – low, 6-9 – low |
| <30 s – high, Watery/clear, 6.8-7.8 | >5.0 mL – normal, 10-12 – normal |
5.2.10.3 Caries Management By Risk Assessment (CAMBRA) (10)
| Disease indicators | Nil |
|--------------------|-----|
| Risk factors | Visible heavy plaque on teeth<br>Exposed roots |
| Protective factors | Lives/works/school in fluoridated community<br>Fluoride toothpaste (1000 ppm+) at least twice daily<br>Adequate saliva flow (>1.0 mL/min stimulated) |
• Caries risk:
- Moderate
• Suggested management:
- OTC toothpaste with 1000 ppm fluoride, 2x daily
- OTC mouthrinse with 500 ppm fluoride, daily
- Xylitol candies or gum, 4x daily
- 6-month recall
(10) Caries Management by Risk Assessment, Featherstone & Chaffee (2018).
#### 5.2.10 Caries Risk Assessment
- **Dietary Assessment:** High in fermentable carbohydrates; low sugar; low acid; limited snacking frequency.
- **Saliva Test:**
- Unstimulated: >60s (low flow), sticky/frothy, pH 5.0-5.8.
- Stimulated: <3.5 mL (very low quantity), buffering capacity 0-5 (very low).
- **CAMBRA Risk Factors:** Visible heavy plaque; exposed roots.
- **Caries Risk:** Moderate.
- **Management:** 1000 ppm fluoride toothpaste (2x daily); 500 ppm fluoride mouthrinse (daily); Xylitol gum (4x daily); 6-month recall.
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Table titled 'Saliva test' comparing unstimulated and stimulated saliva parameters. Columns include Flow rate, Consistency, pH for unstimulated saliva, and Quantity at 5 mins, Buffering capacity for stimulated saliva. Rows categorize values as low (>60s flow, sticky/frothy consistency, pH 5.0-5.8), normal (30-60s flow, frothy/bubbly consistency, pH 6.0-6.6), or high (<30s flow, watery/clear consistency, pH 6.8-7.8).
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Table titled 'Caries Management By Risk Assessment (CAMBRA)'. Columns include Disease indicators, Risk factors, and Protective factors. Content lists specific clinical indicators such as visible heavy plaque, exposed roots, living in a fluoridated community, fluoride toothpaste usage, and adequate saliva flow.
5.2.11 Prosthetic assessment
- Immediate maxillary full denture assessment:
- Poor fit: patient finds denture uncomfortable in anterior flange area. Anterior flange overextended and interferes with labial frenum.
- Poor retention: Patient uses large amount of denture adhesive to maintain retention during function. Large gap in post dam area allowing food trapping and breakage of posterior seal. Buccal flange right side heavily relined.
- Reasonable stability: denture has some movement while seated intraorally
- Good aesthetics: Patient satisfied with appearance of denture, including tooth shape, size, colour, midline and contours.
- Adequate saliva quantity for denture retention.
- Denture hygiene assessment:
- Denture removed at night and soaked in sterilising solution.
- Denture cleaned in morning using soft toothbrush.
- Mouth cleaned using soft toothbrush.
- Denture replaced with denture adhesive.
- Consultation with Prosthodontist:
- First line of management for immediate denture is to check extensions – as soft tissue heals and bone resorbs the sulcus depth will be shorter and there will be over-extension. When soft tissue heals after 6-8 weeks, check extensions and soft reline. Over time, check extensions again and soft reline again.
- Hard reline to improve fit, retention and stability is possible, however there will be minimal improvement and a remake is preferable.
- Costs involved for either option.
#### 5.2.11 Prosthetic Assessment
- **Immediate Maxillary Full Denture:**
- **Fit:** Poor; uncomfortable in anterior flange area (overextended).
- **Retention:** Poor; requires large amount of adhesive; posterior seal broken.
- **Stability:** Reasonable; some movement intraorally.
- **Aesthetics:** Good; patient satisfied with tooth shape, size, and colour.
- **Denture Hygiene:**
- Removed at night and soaked in sterilising solution.
- Cleaned with soft toothbrush in the morning.
- **Prosthodontist Consultation:**
- First line: check extensions and soft reline as tissues heal.
- Hard reline possible but minimal improvement expected; remake is preferable.
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Clinical photo of a patient's mouth showing an immediate maxillary full denture in place. The image illustrates the aesthetic result and fit of the prosthesis, including tooth shape, size, colour, midline, and contours as mentioned in the text under 'Good aesthetics'. It also demonstrates how the anterior flange area interfaces with the labial frenum.
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Clinical photo of an immediate maxillary full denture placed on a textured surface. This image shows the upper view of the denture, highlighting its pink acrylic base and teeth arrangement, which relates to the assessment of poor fit due to overextended anterior flange interfering with labial frenum.
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Clinical photo of an immediate maxillary full denture from a side angle, showing the buccal flange area. This image corresponds to the description of 'Poor retention' where the buccal flange right side is heavily relined, demonstrating the gap in post dam area allowing food trapping and breakage of posterior seal.
**5.3 Diagnoses and problem list**
**5.3.1 Diagnoses**
| Pathological | Diagnosis |
| :--- | :--- |
| Periodontal disease (13) | Generalised Stage IV Grade B unstable periodontitis* |
| Temporomandibular joint disorder | Right temporomandibular joint: anterior disk displacement without reduction with significant synovitis in inferior compartment and along under surface of bilaminal zone<br>Left temporomandibular joint: anterior disk displacement with medial reduction without arthritis or condylar remodelling<br>Secondary masticatory myalgia and stress perpetuating chronic pain** |
| Non-carious tooth surface loss | 43, 44 |
| Cracked teeth | 37, 36, 43 |
| Prosthesis | III-fitting immediate maxillary full denture |
| Angle class | Indications Angle skeletal class I |
| Malocclusion | Class III malocclusion – habitual slide into forward posture<br>Posterior crossbite left side |
| Retained roots | 38, 48 |
| Missing teeth | 34-42, 46-47 |
| Aesthetic harmony | Unaesthetic smile:<br>Missing lower anterior teeth<br>Different shades between upper and lower arches<br>Maxillary facial and dental midlines coincide<br>Low smile line, normal width smile, flat incisal curve |
| Morphological | Anterior impairment |
| | Posterior impairment |
| | Occlusal plane |
| | Occlusal stability |
| | Guidance system |
| | Unstable occlusion |
| | Imbalance between left and right sides<br>Non-reproducible centric relation due to habitual slide |
| | Habitual psychosocial attitude and apathy<br>General negative attitude and apathy<br>Possibly poor adaptive capacity<br>Lacking oral hygiene compliance<br>Motivated to attend appointments for companionship |
| | Habits |
| | Socioeconomic |
| | Medical |
| | Functioning |
| | Temporomandibular joint disorder |
(11) Classification, diagnosis and clinical manifestations of apical periodontitis, Abbott (2004). (12) A clinical classification of the status of the pulp and the root canal system, Abbott & Yu (2007). (13) Periodontitis: Consensus report if workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions, Papapanou et al. (2018).
**Stage IV – RBL 50%, >5 teeth lost due to periodontitis, max probing depth ≥5 mm, mostly horizontal bone loss, masticatory dysfunction, bite collapse, drifting of teeth, <20 teeth remaining. Generalised – bone loss affects all teeth. Grade B – %BL/age 0.25-1.0, heavy biofilm deposits with commensurate levels of destruction, non-smoker, normoglycaemic. Unstable - probing depths ≥5 mm. (13)**
**Consultation and management by Oral Medicine.**
#### 5.3 Diagnoses and Problem List
#### 5.3.1 Diagnoses
- **Periodontal:** Generalised Stage IV Grade B unstable periodontitis (RBL 50%, >5 teeth lost, probing depths ≥5 mm).
- **TMJ:** Right side: anterior disk displacement without reduction with synovitis. Left side: anterior disk displacement with medial reduction. Secondary masticatory myalgia.
- **Dental:** Non-carious tooth surface loss (43, 44); Cracked teeth (37, 36, 43); Retained roots (38, 48); Missing teeth (34-42, 46-47).
- **Prosthetic:** Ill-fitting immediate maxillary full denture.
- **Occlusal:** Class III malocclusion (habitual slide); Posterior crossbite (left); Unstable occlusion and uneven occlusal plane.
- **Psychosocial:** Habitual apathy and poor adaptive capacity; lacking oral hygiene compliance.
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A structured table titled '5.3 Diagnoses and problem list' under section '5.3.1 Diagnoses'. The table is organized into three main categories: Pathological, Morphological, and Host-related factors. It lists specific diagnoses such as 'Periodontal disease (13)', 'Temporomandibular joint disorder', 'Non-carious tooth surface loss', and others with detailed descriptions or references to teeth numbers. Additional footnotes provide clinical definitions for terms like Stage IV periodontitis, Grade B bone loss, and unstable occlusion.
5.3.2 Problem list
* Ill-fitting immediate maxillary full denture
* Generalised Stage IV Grade B unstable periodontitis
* Temporomandibular joint disorder
* Unaesthetic smile mainly due to missing lower anterior teeth
* Retained roots 38, 48
* Class III malocclusion with habitual slide into forward posture
* Unstable occlusion and uneven occlusal plane
* Combination of medical and psychosocial issues affecting health and wellbeing
* Poor oral hygiene
5.4 Prognosis (14)
5.4.1 Individual teeth
**Key:**
* **Good**
* **Fair**
* **Questionable**
* **Poor**
* **Hopeless**
Evaluation of pathology and scale of severity
| | Class A – Good | Class B – Fair | Class C – Questionable |
| :--- | :--- | :--- | :--- |
| **Periodontal condition** | 80%-100% bone support. Easily maintained. | 50%-80% bone support. Can be well maintained. | 30%-50% remaining bone support. Difficult to be well maintained. |
| **Restorability** | 80%-100% remaining sound coronal tooth structure. Easily restored. | 50%-80% remaining sound coronal tooth structure. Restoration results in no infringement of biologic width, has adequate ferrule, good crown-root ratio. | 30%-50% remaining sound coronal tooth structure. Achieving adequate ferrule would compromise crown-root ratio to some extent or affect adjacent structures. |
| **Endodontic condition** | Can receive straightforward primary endodontic treatment, or already has good endodontic therapy. | Failing endodontic treatment can receive predictable re-treatment, or requires a difficult primary endodontic treatment. | Failing endodontic treatment that is difficult to predictably re-treat. |
| **Occlusal plane & tooth position** | Tooth in correct occlusal plane, position, slightly deviated from ideal. | Tooth out of correct occlusal plane, can be adjusted to function within correct occlusal plane. | Tooth out of occlusal plane and requires multiple procedures to function within occlusal plane. |
Factors that result in drop of determined class
| | |
| :--- | :--- |
| **Anatomic irregularities** | Irregularly shaped roots, multiple canals and/or roots, thin and/or short roots, and excessively conical roots, etc. |
| **Iatrogenic compromising factors** | Perforations, extensive post preparations, minimal tooth structure thickness left after preparation, dental materials that cannot be removed, etc. |
| | 37, 36, 43 – cracked teeth |
144
#### 5.3.2 Problem List
- Ill-fitting immediate maxillary full denture.
- Generalised Stage IV Grade B unstable periodontitis.
- Temporomandibular joint disorder.
- Unaesthetic smile (missing lower anterior teeth).
- Retained roots 38, 48.
- Class III malocclusion with habitual slide.
- Unstable occlusion and uneven occlusal plane.
- Medical and psychosocial issues affecting wellbeing.
- Poor oral hygiene.
#### 5.4 Prognosis
| Tooth | Periodontal | Restorability | Endodontic | Occlusal Plane |
| :--- | :--- | :--- | :--- | :--- |
| **37, 36, 43** | Questionable | Questionable (Cracked) | Good | Fair |
| **35, 44, 45** | Questionable | Good | Good | Fair |
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A clinical assessment table titled '5.4.1 Individual teeth' evaluating prognosis for specific teeth (45, 44, 43, 35, 36, 37). The table uses colored dots to indicate status: Green for Good, Yellow for Questionable/Fair, and Red/Orange for Hopeless/Poor. Rows assess Periodontal condition, Restorability, Endodontic condition, Occlusal plane & tooth position, Anatomic irregularities, and Iatrogenic factors.
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A classification legend table titled 'Evaluation of pathology and scale of severity'. It defines Class A – Good, Class B – Fair, and Class C – Questionable based on criteria including Periodontal condition (bone support percentage), Restorability (sound coronal tooth structure), Endodontic condition, and Occlusal plane & tooth position.
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A summary table titled 'Factors that result in drop of determined class'. It lists 'Anatomic irregularities' (e.g., irregularly shaped roots) and 'Iatrogenic compromising factors' (e.g., perforations, cracked teeth in specific numbers like 37, 36, 43).
### 5.4.2 Patient-level risk factors
**Biologic risk factors**
| Medical conditions that impair immune function and healing | Impaired salivary flow/function | Medical condition or disability limiting oral hygiene | Other missing teeth | Iron deficiency anaemia | Adequate salivary flow | Bell's Palsy | History of missing teeth due to periodontitis |
|---|---|---|---|---|---|---|---|
| **Behavioural risk factors** | Compromised or poor oral hygiene | Cariogenic diet | Low exposure to fluoride | Parafunctional habits | Ability and willingness to adhere to long-term maintenance protocol | Smoking | Poor oral hygiene | Low cariogenic diet | Adequate exposure to fluoride | No | Depends on personal circumstances and mood | Non-smoker |
| **Financial and personal risk factors** | Motivation for treatment | Available resources for dental care | Willingness to commit finances, time, and effort | Attitude toward losing teeth | Understanding of one’s condition and needed treatment | Aesthetic expectations | Low dental IQ | Depends on personal circumstances and mood | Yes | Yes | Wishes to keep remaining teeth | Surface understanding of problems | Reasonable | Adequate dental IQ with education |
**Key:**
- Green: Favourable
- Yellow: Questionable
- Red: Unfavourable
[14] Evaluation of prognosis of individual teeth and patient-level risk factors adapted from Samet and Jotkowitz (2009).
### 5.4.3 Overall dentition
- Fair-poor periodontal support due to untreated chronic periodontal disease.
- All teeth have adequate remaining tooth structure.
- All teeth have sound pulpal health.
- Teeth in quadrant 4 are not in the correct occlusal plane, adjustments possible.
- Several teeth have cracks, lowering overall prognosis.
- Patient’s medical and psychosocial history impacts on motivation and ability for self-care, affecting overall health and wellbeing.
- Patient’s diet appears to have low contribution to caries risk, may have contribution to plaque accumulation and heightened periodontal risk.
- Patient has some motivation to keep remaining teeth and appears willing to commit finances, effort, and time to treatment.
- Overall prognosis of dentition is not favourable.
- If patient receives no treatment for current condition:
- Progression of periodontal disease and tooth loss.
- Decrease in confidence, self-esteem, and quality of life.
- Added burden to current psychosocial issues and potential for further deterioration of overall health and wellbeing.
- Discussion of diagnoses and prognoses of dentition with patient led patient to decide on and commit to treatment.
**145**
#### 5.4.2 Patient-level Risk Factors
- **Biologic:** Iron deficiency anaemia; Bell's Palsy; History of tooth loss due to periodontitis.
- **Behavioural:** Poor oral hygiene; Low cariogenic diet; Adequate fluoride exposure; Non-smoker.
- **Financial/Personal:** Low dental IQ; Motivation depends on mood; Wishes to keep remaining teeth; Reasonable aesthetic expectations.
#### 5.4.3 Overall Dentition Prognosis
- **Status:** Not favourable.
- **Factors:** Untreated chronic periodontal disease; cracked teeth; quadrant 4 occlusal plane discrepancies; psychosocial impacts on self-care.
- **Risk of No Treatment:** Progression of periodontal disease, further tooth loss, and deterioration of quality of life.
![]()
Table titled '5.4.2 Patient-level risk factors' listing biologic, behavioural, and financial/personal risk factors with associated conditions (e.g., Iron deficiency anaemia, Poor oral hygiene) marked by colored dots indicating prognostic status.
![]()
Key chart showing color-coded legend: Green = Favourable, Yellow = Questionable, Red = Unfavourable.
5.5 Treatment options
| Problem | Treatment Option | Benefits | Risks | Decision & Rationale |
|---|---|---|---|---|
| Ill-fitting immediate maxillary full denture | 1 • No treatment | No commitment required | Does not address presenting complaint<br>Ongoing pain and discomfort<br>Ongoing inability to function<br>Poorer quality of life | Option 3:<br>Addresses presenting complaint<br>Better fit of new denture possible as soft tissues and bone levels stabilised |
| | 2 • Immediate maxillary full denture hard reline | Low cost<br>Low time commitment required<br>Marginal improvement of current denture | Reline here will not fit as well as new denture<br>Patient likely to need new denture in future | • Patient proven adaptation to maxillary full denture and can adapt new denture easily<br>Better to concurrently fabricate mandibular partial denture |
| | • Maxillary full denture remake | 18 months since maxillary clearance elapsed allowing soft tissues and bone levels to stabilise<br>Patient proven adaptation to maxillary full denture<br>Patient proven adequate denture care regime<br>Better fitting denture<br>Can concurrently fabricate mandibular partial denture for better outcome | More cost involved than option 2<br>More time involved than option 2 | |
| Generalised Stage IV Grade B periodontitis | 1 • No treatment | No commitment required | Plaque and calculus accumulation<br>Deterioration of periodontal condition<br>Caries<br>Tooth loss<br>Systemic health effects<br>Poor aesthetic appearance and effect on self-esteem | Option 2:<br>Favour periodontal and systemic health<br>Reduce periodontal disease progression<br>Reduce risk of caries, potential for breakdown of tooth structure<br>Reduce risk of tooth loss |
| | 2 • Non-surgical periodontal therapy<br>• Oral hygiene instruction | Remove plaque and calculus to promote periodontal and systemic health<br>Reduce progression of periodontal disease<br>Reduce risk of caries<br>Reduce risk of further tooth loss | Post-operative pain, bleeding, swelling, bruising, infection<br>Increased tooth sensitivity<br>Gingival recession<br>Root surface exposure | Create favourable environment for commencement and maintenance of indirect prostheses |
| Temporomandibular joint disorder | 1 • No treatment | No commitment required | Ongoing pain<br>Ongoing dysfunction<br>Poorer quality of life | Option 2:<br>Alleviation of pain<br>Rehabilitation to return to normal function<br>Patient learns management techniques for self-care |
| | 2 • Referral to Oral Medicine – soft diet, anti-inflammatory, education, reassurance, MRI. | Accurate diagnosis<br>Appropriate management advice<br>Adequate follow-up care | Patient refusal to listen to advice | |
146
#### 5.5 Treatment Options
- **Maxillary Denture:** Remake (Option 3). Rationale: Tissues stabilised after 18 months; better fit and concurrent fabrication with mandibular denture.
- **Periodontitis:** Non-surgical periodontal therapy and OHI (Option 2). Rationale: Reduce disease progression and create a favourable environment for prostheses.
- **TMJ Disorder:** Referral to Oral Medicine (Option 2). Rationale: Accurate diagnosis and management (soft diet, anti-inflammatories, MRI).
![]()
A structured table titled '5.5 Treatment options' containing a comparison of dental treatment choices for three specific clinical problems: 'Ill-fitting immediate maxillary full denture', 'Generalised Stage IV Grade B periodontitis', and 'Temporomandibular joint disorder'. The table columns are labeled Problem, Treatment Option, Benefits, Risks, and Decision & Rationale. It details specific interventions (e.g., No treatment, Immediate maxillary full denture hard reline, Non-surgical periodontal therapy) alongside their associated benefits, risks, and rationales.
```html
<table border='1'>
<tr>
<td rowspan="7">Unaesthetic smile:<br/>Missing lower anterior<br/>teeth</td>
<td rowspan="3">1</td>
<td>No treatment</td>
<td>No commitment required</td>
<td>Does not address presenting complaint</td>
<td rowspan="4">Option 2:<br/>Addresses presenting complaint<br/>Cost and time<br/>commitment acceptable to patient<br/>Ability to add teeth<br/>onto denture in event<br/>of loss of mandibular<br/>teeth<br/>Can function as<br/>transitional denture to<br/>mandibular full<br/>denture given fair-<br/>poor prognosis of<br/>remaining teeth</td>
</tr>
<tr>
<td>2</td>
<td>Mandibular partial denture</td>
<td>Addresses presenting complaint<br/>Low cost<br/>Low time commitment<br/>Easy to fabricate<br/>Simple to repair fractures and add teeth onto denture<br/>Possibility to function as transitional denture to mandibular full denture<br/>Consideration of fair-poor prognoses of remaining teeth<br/>Patient proven adequate denture care regime</td>
<td>Teeth missing for<br/>long time, never<br/>worn mandibular<br/>denture; habitual<br/>slide into new<br/>forward posture possible difficulties in<br/>work-flow and<br/>patient ability to adapt<br/>Possible low adaptive capacity<br/>Patient discomfort<br/>Patient unwillingness or<br/>inability to adapt to<br/>new denture<br/>Requires meticulous oral hygiene to retain<br/>remaining teeth and maintain oral health</td>
</tr>
<tr>
<td rowspan="4">3</td>
<td rowspan="4">Full clearance<br/>Immediate<br/>mandibular full denture</td>
<td rowspan="4">Addresses presenting complaint<br/>No teeth to maintain at home and at<br/>dentist<br/>Patient proven adequate denture care regime</td>
</tr>
<tr>
<td>Extraction complications<br/>Post-extraction complications<br/>Teeth missing for<br/>long time, never<br/>worn mandibular<br/>denture; habitual<br/>slide into new<br/>forward posture –<br/>possible difficulties in<br/>work-flow and<br/>patient ability to adapt<br/>Possible low adaptive capacity<br/>Patient discomfort<br/>Patient unwillingness or<br/>inability to adapt to<br/>new denture<br/>Mandibular full<br/>dentures difficult to<br/>adapt to due to<br/>poor retention, stability</td>
</tr>
<tr>
<td>Extraction complications<br/>Post-extraction complications<br/>Teeth missing for<br/>long time, never<br/>worn mandibular<br/>denture; habitual<br/>slide into new<br/>forward posture -<br/>possible difficulties in<br/>work-flow and<br/>patient ability to adapt<br/>Possible low adaptive capacity<br/>Patient discomfort<br/>Patient unwillingness or<br/>inability to adapt to<br/>new denture<br/>Mandibular full<br/>dentures difficult to<br/>adapt to due to<br/>poor retention, stability</td>
</tr>
<tr>
<td>Extraction complications<br/>Post-extraction complications<br/>Teeth missing for<br/>long time, never<br/>worn mandibular<br/>denture; habitual<br/>slide into new<br/>forward posture -<br/>possible difficulties in<br/>work-flow and<br/>patient ability to adapt<br/>Possible low adaptive capacity<br/>Patient discomfort<br/>Patient unwillingness or<br/>inability to adapt to<br/>new denture<br/>Mandibular full<br/>dentures difficult to<br/>adapt to due to<br/>poor retention, stability</td>
</tr>
<tr>
<td rowspan="2">Retained roots:<br/>38, 48</td>
<td>1</td>
<td>No treatment</td>
<td>No commitment required</td>
<td>Risk of denture-<br/>induced spontaneous<br/>tooth eruption<br/>Oral infection<br/>Pain</td>
<td rowspan="2">Option 1:<br/>Asymptomatic<br/>Mandibular partial denture<br/>base design not to<br/>extend over area of<br/>third molars</td>
</tr>
<tr>
<td>2</td>
<td>Extraction</td>
<td>Reduce risk of<br/>denture-induced<br/>spontaneous tooth<br/>eruption</td>
<td>Surgical extraction complications<br/>Post-extraction complications</td>
</tr>
<tr>
<td>Medical and psychosocial issues:<br/>Iron deficiency anaemia<br/>Bell’s Palsy</td>
<td>1</td>
<td>Oral health counselling<br/>Oral hygiene instruction</td>
<td>Decrease susceptibility to opportunist infections<br/>Decreases caries risk<br/>Decrease periodontal disease risk</td>
<td>Patient refusal to listen to advice</td>
<td>Option 1:<br/>Clinician responsibility to inform patient of risk factors for<br/>disease or deterioration of oral health and advise on<br/>management to maintain and preserve oral health</td>
</tr>
</table>
```
#### Additional Treatment Options
- **Lower Anterior Edentulism:** Mandibular partial denture (Option 2). Rationale: Addresses aesthetics; low cost; functions as a transitional denture given fair-poor prognosis of remaining teeth.
- **Retained Roots (38, 48):** No treatment (Option 1). Rationale: Asymptomatic; denture base will not extend over these areas.
- **Medical/Psychosocial:** Oral health counselling and OHI (Option 1). Rationale: Clinician responsibility to advise on risk factors for disease.
![]()
A structured comparison table evaluating treatment options for three clinical scenarios: 'Unaesthetic smile: Missing lower anterior teeth', 'Retained roots: 38, 48', and 'Medical and psychosocial issues: Iron deficiency anaemia Bell's Palsy'. The table is organized into columns representing treatment options (e.g., 'No treatment', 'Mandibular partial denture', 'Extraction') and rows detailing associated pros/cons such as cost, time commitment, patient comfort, complications, and specific considerations like 'habitual slide into new forward posture' or 'risk of denture-induced spontaneous tooth eruption'. It includes alternative options labeled 'Option 1' and 'Option 2' with detailed bullet points.
5.6 Management plan
<table>
<tr>
<td>Systemic phase</td>
<td>Not applicable</td>
</tr>
<tr>
<td>Emergency phase</td>
<td>Immediate maxillary full denture adjustment</td>
</tr>
<tr>
<td>Control phase<br><em>Eliminate pain, infection, inflammation</em></td>
<td>Patient education and consent to treatment<br>Advise continuation of medical and psychological management with GP and mental health professional<br>Hygienic phase of periodontal therapy:<br>Scale and clean<br>Periodontal debridement: 37, 36, 43, 44, 45<br>Fluoride application to interproximal areas, exposed roots, furcations<br>Oral hygiene instruction<br>Restorations: 37B restoration*<br>Level occlusal plane: 45O restoration, 44 & 43 enameloplasty<br>Referral: Oral Medicine for TMJ disorder management</td>
</tr>
<tr>
<td>Holding phase<br><em>Preserve residual dentition</em></td>
<td>Assess response to periodontal therapy and oral hygiene compliance<br>Follow-up progress on medical and psychological management</td>
</tr>
<tr>
<td>Reconstructive phase**<br><em>Replace lost tissue and stabilise occlusion</em></td>
<td>Removable prostheses:<br>Immediate maxillary full denture<br>Acrylic mandibular partial denture</td>
</tr>
<tr>
<td>Maintenance phase<br><em>Prevention of further breakdown</em></td>
<td>Recall exam<br>3-monthly periodontal maintenance<br>Reinforce oral hygiene and denture hygiene</td>
</tr>
</table>
\*Added to treatment plan following exposure of furcation following periodontal therapy and patient complaint of extreme sensitivity.
\**Reorganised approach to occlusal rehabilitation.
148
#### 5.6 Management Plan
- **Emergency Phase:** Immediate maxillary full denture adjustment.
- **Control Phase:**
- Periodontal debridement (37, 36, 43, 44, 45).
- Oral hygiene instruction and fluoride application.
- Restorations: 37B (sensitivity management).
- Level occlusal plane: 45O restoration, 44 & 43 enameloplasty.
- Referral: Oral Medicine for TMJ.
- **Holding Phase:** Assess periodontal response and OH compliance.
- **Reconstructive Phase:** New maxillary full denture and acrylic mandibular partial denture.
- **Maintenance Phase:** 3-monthly periodontal maintenance; reinforce hygiene.
![]()
A structured management plan table titled '5.6 Management plan'. The table is organized into two columns: the left column lists phases of treatment (Systemic phase, Emergency phase, Control phase, Holding phase, Reconstructive phase, Maintenance phase) with italicized sub-objectives for most phases. The right column details specific actions and procedures for each phase, such as 'Immediate maxillary full denture adjustment', 'Periodontal debridement: 37, 36, 43, 44, 45', and 'Removable prostheses: Immediate maxillary full denture, Acrylic mandibular partial denture'. Footnotes are present at the bottom referencing modifications to the treatment plan.
5.7 Treatment delivery
**5.7.1 Treatment delivery**
Date: July 2019 – October 2020
<table>
<tr>
<td><b>Date</b></td>
<td><b>Treatment</b></td>
</tr>
<tr>
<td rowspan="5" style="text-align:center; vertical-align:middle;" >2019</td>
<td>Emergency denture adjustment</td>
</tr>
<tr>
<td>Comprehensive exam</td>
</tr>
<tr>
<td>Patient education, treatment plan discussion, consent to treatment</td>
</tr>
<tr>
<td>Initial periodontal charting</td>
</tr>
<tr>
<td>Referral to Oral Medicine for TMJ disorder</td>
</tr>
<tr>
<td rowspan="4">August</td>
<td>First round periodontal debridement</td>
</tr>
<tr>
<td>Fluoride application</td>
</tr>
<tr>
<td>Oral hygiene instruction</td>
</tr>
<tr>
<td>Special tray fabrication and survey models</td>
</tr>
<tr>
<td>September</td>
<td>-</td>
</tr>
<tr>
<td>October</td>
<td>Review periodontal charting #1</td>
</tr>
<tr>
<td></td>
<td>Second round periodontal debridement</td>
</tr>
<tr>
<td></td>
<td>Fluoride application</td>
</tr>
<tr>
<td></td>
<td>Reinforce oral hygiene</td>
</tr>
<tr>
<td><b>Date</b></td>
<td><b>Treatment</b></td>
</tr>
<tr>
<td rowspan="20" style="text-align:center; vertical-align:middle;" >2020</td>
<td>February</td>
<td>Recall exam</td>
</tr>
<tr>
<td>Review periodontal charting #2</td>
</tr>
<tr>
<td>Third round periodontal debridement</td>
</tr>
<tr>
<td>Fluoride application</td>
</tr>
<tr>
<td>Reinforce oral hygiene</td>
</tr>
<tr>
<td>Levelling of occlusal plane:<br>45MODBL composite<br>44, 43 enameloplasty</td>
</tr>
<tr>
<td>March</td>
<td>Review periodontal charting #3</td>
</tr>
<tr>
<td>April</td>
<td>-</td>
</tr>
<tr>
<td>May</td>
<td>Scale and clean</td>
</tr>
<tr>
<td>Fluoride application</td>
</tr>
<tr>
<td>Reinforce oral hygiene</td>
</tr>
<tr>
<td>Denture adjustment</td>
</tr>
<tr>
<td>Try-in special trays</td>
</tr>
<tr>
<td>June</td>
<td>-</td>
</tr>
<tr>
<td>July</td>
<td>Recall exam</td>
</tr>
<tr>
<td>Fourth round periodontal debridement</td>
</tr>
<tr>
<td>Denture adjustment</td>
</tr>
<tr>
<td>August</td>
<td>TMJ inflammatory fluid drainage and cortisone injection by specialist<br>37B GIC</td>
</tr>
<tr>
<td rowspan="2">September</td>
<td>Maxillary and mandibular final impressions #1</td>
</tr>
<tr>
<td><b>Maxillary and mandibular final impressions #2</b></td>
</tr>
<tr>
<td>Relations</td>
</tr>
<tr>
<td>Anterior-Posterior try-in</td>
</tr>
<tr>
<td>Maxillo-mandibular relations & try-in</td>
</tr>
<tr>
<td>October</td>
<td>Maxillary full denture and mandibular partial denture insert</td>
</tr>
<tr>
<td></td>
<td>Post-operative review</td>
</tr>
</table>
#### 5.7 Treatment Delivery Timeline
- **2019 (July - Oct):** Emergency adjustments, comprehensive exam, initial periodontal charting, referral to Oral Medicine, first and second rounds of periodontal debridement.
- **2020 (Feb - May):** Recall exams, third round debridement, levelling of occlusal plane (45MODBL composite, 44/43 enameloplasty), scale and clean, special tray fabrication.
- **2020 (July - Oct):** Fourth round debridement, TMJ fluid drainage/cortisone injection, 37B GIC restoration, final impressions, jaw relations, try-ins, and final denture insert.
![]()
A detailed treatment delivery schedule table spanning from July 2019 to October 2020. The table is structured with two main column headers: 'Date' and 'Treatment'. It chronologically lists specific dental procedures, exams, and interventions for a patient. Key entries include periodontal debridement rounds, fluoride applications, denture adjustments, TMJ disorder referrals, occlusal plane leveling (45MODBL composite), specialist injections, and final denture insertions.
- Emergency denture adjustment:
- Immediate maxillary full denture fit and extensions checked
- Reduced acrylic at labial frenum and buccal extensions
- Patient education and consent to treatment:
- Major problem is periodontal disease caused by plaque accumulation and poor oral hygiene
- Loss of teeth brought about changes in oral cavity that make rehabilitation challenging (uneven occlusal plane, bone resorption and loss of alveolar ridge height)
- In addition, oral morphology (shallow palate, shallow sulci, high frenal attachments) unfavourable for retention and stability of dentures
- For best rehabilitation treatment outcomes, periodontal disease needs to be treated and condition stabilised, and occlusal plane levelled for denture retention and stability
- Patient has not had teeth for a long time and never worn lower denture making adaptation to mandibular dentures difficult
- Remaining teeth have fair to poor prognoses due to poor periodontal support, eventual tooth loss is inevitable
- As such, mandibular denture will function as transitional denture as remaining mandibular teeth are lost
- Managed expectations by warning patient that new maxillary denture will not be perfect but will be an improvement on immediate denture, and new mandibular denture
- **Initial periodontal chart (July 2019):**
- Plaque score 100%
- Bleeding on probing 23/36 sites (64%)
- Periodontal probing depth ≥4 mm 11/36 sites (31%)
- Attachment loss ≥6 mm on at least one site on all teeth, maximum 9 mm 36, 37
- Grade II furcation involvement 36, 37
- Grade I mobility 37, 36, 35, 43, 45 and Grade II mobility 44
- Extreme gingival pain
- Oral hygiene extremely poor, instruction to use electric toothbrush, Sensodyne
- First round periodontal debridement completed; local anaesthetic given however patient is difficult to anaesthetise
#### Clinical Notes: Initial Phases
- **Patient Education:** Emphasised that periodontal disease is the primary issue. Managed expectations regarding denture retention due to unfavourable oral morphology (shallow palate/sulci).
- **Initial Periodontal Status (July 2019):**
- Plaque score: 100%.
- BOP: 64%.
- PPD ≥4 mm: 31%.
- Attachment loss: Up to 9 mm (36, 37).
- Mobility: Grade I-II on all teeth.
- Extreme gingival pain noted.
![]()
Periodontal chart for the upper arch (teeth 45 to 48 visible). Shows a plaque score of 100% and bleeding on probing at 23/36 sites. Probing depths are recorded with values such as 214, 314, 413, 313, 524, 623. Attachment loss is noted with values like 436, 567, 646, 344, 433, 333, 657, 957, 956. Mobility grades are indicated with symbols.
![]()
Periodontal chart for the lower arch (teeth 36 to 38 visible). Shows a plaque score of 100% and bleeding on probing at 23/36 sites. Probing depths include values such as 234, 424, 323, 223, 244, 333, 343, 444, 343, 566, 668, 876, 668. Attachment loss includes values like 456, 668, 656, 000, 000, 566, 668, 876, 668. Mobility grades are indicated with symbols.
- Review periodontal chart #1 (October 2019):
- Plaque score 71%↓
- Bleeding on probing 14/36 sites (39%)↓
- Periodontal probing depth ≥4 mm 6/36 sites (17%)↓
- Attachment loss ≥6 mm all teeth, maximum 9 mm 36, 44
- Grade II furcation involvement 37 only↓
- Grade I mobility on all teeth↓
- Reduced gingival pain↓
- Oral hygiene still poor but improved
- Second round periodontal debridement completed
- Review periodontal chart #2 (February 2020):
- Bleeding on probing 21/36 sites (58%)↑
- Periodontal probing depth ≥4 mm 7/36 sites (19%)↑
- Attachment loss ≥6 mm all teeth, maximum 8 mm 36, 44↓
- Grade I furcation involvement 36, 37↓
- Grade I mobility 37, 36, 35, 43, 44 and Grade 0 mobility 45↓
- Reduced gingival pain
- Oral hygiene still poor but improved
- Third round periodontal debridement completed
- Patient appears to be in better head space, overall appearance and oral hygiene improvement noticeable
151
#### Periodontal Progress Reviews
- **Review #1 (Oct 2019):** Plaque score 71%; BOP 39%; PPD ≥4 mm 17%. Reduced gingival pain and improved mobility.
- **Review #2 (Feb 2020):** BOP 58%; PPD ≥4 mm 19%. Grade I mobility maintained. Oral hygiene improved.
- **Observation:** Patient appeared in a better psychological state; improvement in overall appearance and hygiene noticeable.
![]()
Periodontal chart #1 (October 2019) showing two panels labeled 'Buccal' and 'Lingual'. Each panel includes a diagram of teeth with colored markings indicating probing depths, recession, attachment loss, and mobility. Below each diagram is a data table with columns for PD (probing depth), Rec (recession), AL (attachment loss), and Mob (mobility). The chart correlates with text noting plaque score 71%, bleeding on probing 39%, periodontal probing depth ≥4 mm at 17% of sites, maximum attachment loss 9 mm in teeth 36 and 44, Grade II furcation involvement in tooth 37 only, and Grade I mobility on all teeth.
![]()
Periodontal chart #2 (February 2020) with identical structure to Chart #1: two panels ('Buccal' and 'Lingual') each containing a tooth diagram with color-coded clinical indicators and an accompanying data table for PD, Rec, AL, and Mob. Associated text reports increased bleeding on probing (58%), increased probing depth ≥4 mm (19%), reduced maximum attachment loss (8 mm in teeth 36, 44), Grade I furcation involvement in teeth 36 and 37, and Grade I mobility in multiple teeth including 37, 36, 35, 43, 44; Grade 0 mobility in tooth 45.
![]()
Clinical photograph of a female patient's face, captioned as showing improved head space, overall appearance, and noticeable oral hygiene improvement after third round of periodontal debridement. Image serves as visual documentation of patient response to treatment.
- Labelling of occlusal plane: - Wax-up to occlusal level on study model - Build-up 45MODBL composite and enameloplasty 44, 43 using guide
- Review periodontal chart #3 (March 2020):
- Plaque score 50%↓
- Bleeding on probing 18/36 sites (50%)↓
- Periodontal probing depth ≥4mm 5/36 sites (14%)↓
- Attachment loss =6mm all teeth, maximum 9mm 37↑
- Grade I furcation involvement 36, 37
- Grade I mobility 37, 36, 35, 44 and Grade 0 mobility 45
- Reduced gingival pain
- Oral hygiene still poor but improved
### Patient History:
- Fourth round periodontal debridement completed
- Final impressions maxillary and mandibular #2:
- Border moulding of maxillary custom tray
- First attempt at final impressions unsatisfactory, second attempt satisfactory
- Shade selected Dentsply Portrait IPN A3.5
#### Occlusal and Impression Phase
- **Occlusal Levelling:** Wax-up used as a guide for 45MODBL composite and enameloplasty of 44, 43.
- **Review #3 (March 2020):** Plaque score 50%; BOP 50%; PPD ≥4 mm 14%.
- **Final Impressions:** Border moulding of maxillary custom tray. Second attempt successful. Shade selected: Dentsply Portrait IPN A3.5.
![]()
Clinical photo showing a dental study model with blue wax-ups on the lower arch (mandible), demonstrating the 'Wax-up to required level' and 'Build-up' procedure for teeth 43, 44, and 45.
![]()
Periodontal chart #3 (March 2020) - Buccal view. Shows periodontal probing depths (PD), recession (Rec), attachment loss (AL), and mobility (Mob). Data indicates high values for specific sites (e.g., PD 4mm at site 43, AL 7mm at site 43).
![]()
Periodontal chart #3 (March 2020) - Lingual view. Shows detailed periodontal measurements including bleeding on probing indicators (red dots) and depth values. Notable findings include Grade I furcation involvement at sites 36, 37.
![]()
Photo of a maxillary custom impression tray undergoing border moulding. The image corresponds to the text describing the preparation of the tray before final impressions.
![]()
Photo of a purple silicone impression material, representing the 'Shade selected Dentsply Portrait IPN A3.5' used for the second satisfactory attempt at final impressions.
- Relations:
- Maxillary and mandibular base and rims fabricated
- Attempted to record relations in centric, however found it difficult to get patient into reproducible position
- Attributed to loss of teeth for long duration, loss of guidance, development of habitual forward posture of mandible and muscle memory
- Maxillary and mandibular base and rims tried in and evaluated for fit, retention and stability
- Approximate centric record taken and models mounted
- Anterior and posterior teeth set on maxillary and mandibular base and rims, note unilateral posterior crossbite
- Try-in appointment #1:
- Try-in unsuccessful as centric record was inaccurate, all teeth were set rather than anterior teeth only, and in centric occlusion rather than centric relation due to miscommunication with lab
- With assistance from Prosthodontist, posterior teeth removed, centric record re-taken and mandibular model re-mounted
153
#### Prosthetic Fabrication: Relations and Try-in #1
- **Jaw Relations:** Difficulty recording reproducible centric due to long-term tooth loss and habitual forward posture. Approximate centric record taken.
- **Try-in #1:** Unsuccessful. Centric record was inaccurate; miscommunication with lab resulted in all teeth being set in centric occlusion rather than centric relation. Posterior teeth removed for re-mounting.
![]()
Clinical photograph of dental study models showing maxillary and mandibular bases with teeth set. Three views are presented: left view shows anterior crossbite; center view shows occlusion from front; right view shows unilateral posterior crossbite. The image corresponds to the OCR note about 'unilateral posterior crossbite' observed after setting anterior and posterior teeth on the base and rims.
- Try-in appointment #2:
- Anterior try-in successful; aesthetics, midline, overbite and overjet satisfactory
- With assistance from Prosthodontist, centric record re-tested and found incorrect
- Lucia jig fabricated in chair to de-program jaw; patient asked to hold centric for a few minutes, bite in de-programmed position, centric record re-taken
- Mandibular model re-mounted and posterior teeth set while patient in the chair
- Posterior try-in successful; aesthetics, midline, occlusion re-checked and found satisfactory, phonetics checked and found to be difficult with 's' sound, OVD kept at 58 mm, noted slight slide from centric
- Accepted work and dentures processed
154
#### Try-in Appointment #2
- **Anterior Try-in:** Successful aesthetics, midline, and overjet.
- **Centric Verification:** Lucia jig used to de-program the jaw. New centric record taken in de-programmed position.
- **Posterior Try-in:** Successful occlusion and midline. OVD set at 58 mm. Phonetics ('s' sound) noted as difficult but acceptable. Dentures sent for processing.
![]()
Clinical photo of an upper denture try-in on a maxillary cast. The image shows the anterior teeth set in position with the pink acrylic base covering the palate and gingival areas.
![]()
Clinical photo showing a side view of the dental arches during a posterior try-in. Visible are the upper and lower dentures mounted on casts, with metal clasps or attachments present on the lower denture.
![]()
Clinical photo of a frontal view of both upper and lower dentures mounted on stone models. This view demonstrates the occlusion relationship between the upper and lower teeth.
![]()
Clinical photo showing a lateral view of the dental arches from the right side. It highlights the alignment of the teeth and the fit of the denture flange against the model.
![]()
Clinical photo of a lower denture try-in on a mandibular cast. The image displays the arrangement of posterior and anterior teeth within the pink acrylic base.
- Maxillary full denture and mandibular partial denture insert:
- Maxillary full denture fit, retention and stability satisfactory
- Mandibular partial denture fit unsatisfactory, required adjustment to over-extended distal extension and anterior flange to fit comfortably
- Phonetics and function felt “different” but not uncomfortable or painful
- Aesthetics excellent, patient satisfied
- Static occlusion checked, posterior crossbite left hand side, bilateral even posterior contacts and anterior open bite
- Dynamic occlusion checked, practiced biting in centric position, however patient tended to regress to habitual bite.
- Oral hygiene and denture care instructions given, emphasised importance to success and longevity of treatment considering periodontal condition.
- Advised patient time and persistence required to adapt to wearing and functioning with new dentures and encouraged patient to do so, otherwise will not be able to adapt.
- Encouragement based on excellent aesthetics and improvement in patient’s appearance.
- Review
- Maxillary full denture stable, retentive, comfortable, worn consistently.
- Mandibular partial denture not worn consistently due to pain; denture extensions checked, adjusted and replaced.
- Encouraged patient to give it time and persistence to allow adaptation.
155
#### Insertion and Follow-up
- **Insert:** Maxillary denture fit satisfactory. Mandibular denture required adjustments to distal extension and anterior flange. Aesthetics excellent.
- **Occlusion:** Posterior crossbite on left; bilateral even contacts; anterior open bite. Patient tended to regress to habitual bite.
- **Post-operative Review:** Maxillary denture worn consistently. Mandibular denture not worn consistently due to pain; extensions adjusted. Encouraged continued adaptation.
5.7.2 Before and after photographs
Date: July 2019 – October 2020
5.7.3 Patient response to treatment
* Patient was satisfied with overall outcome of treatment.
* - 'I look 10 years younger!'
* Resolution of presenting complaints:
i. "My denture (F/-) is hurting me, I think it’s too high (labial flange)"
* - [check] New maxillary full denture fabricated
ii. "I don’t have any teeth left"
* - [check] New mandibular partial denture fabricated
* Significant improvement in aesthetics.
* Psychosocial component to overall health and wellbeing noticeably improved over course of 16 months, and this was reflected in general demeanour and physical appearance at dental visits.
* Continues to be compliant with dental advice and instructions and will return for periodontal maintenance and denture adjustments as required.
#### 5.7.3 Patient Response to Treatment
- **Satisfaction:** Patient very satisfied; stated, "I look 10 years younger!"
- **Resolution of Complaints:**
- New maxillary denture resolved pain from high flange.
- New mandibular partial denture addressed the lack of teeth.
- **Outcome:** Significant aesthetic improvement. Psychosocial wellbeing and general demeanour noticeably improved over 16 months. Patient remains compliant with maintenance.
![]()
Clinical photograph of a female patient's face prior to treatment. The subject has brown hair and is wearing pink earrings. Her expression is neutral with no smile, demonstrating the 'before' state referenced in section 5.7.2.
![]()
Clinical photograph of the same female patient after treatment. She has blonde hair, is smiling broadly showing her teeth, and is wearing colorful earrings. This image demonstrates the 'after' state, correlating with the text note 'I look 10 years younger!' and significant aesthetic improvement mentioned in section 5.7.3.
5.7.4 Reflection
| Challenges | Management |
| :--- | :--- |
| **Patient-related** | **Reflux oesophagitis** |
| | • Reflux in the chair |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Patient reclined to semi-supine position to avoid triggering reflux |
| | |
| | **Medical issues** |
| | • Generally felt unwell and spent most of the time at medical appointments |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Dental treatment was not a priority |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Constantly checked in with patient before, during and after visits and rescheduled appointments as required |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Encouraged to seek medical attention as required and dental visits would be arranged around medical appointments |
| | |
| | Shallow palate Shallow sulci High frenal attachments |
| | • Manage patient expectations |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Under-promise and over-deliver treatment outcomes (if possible) |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Ample warnings of likely difficulties in denture fabrication, adaptation and use |
| | • Constant encouragement |
| | |
| | Loss of teeth over years |
| | • Patient education |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Discuss cause of and processes to rectify current oral issues |
| | • Manage patient expectations |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Under-promise and over-deliver treatment outcomes (if possible) |
| | &nbsp;&nbsp;&nbsp;&nbsp;- Ample warnings of likely difficulties in denture fabrication, adaptation and use |
| | • Constant encouragement |
| | |
| | Negative attitude and apathy |
| | • Patient management |
| | |
| **Clinical** | |
| | Difficulty taking periapical radiographs |
| | • Shallow floor of mouth and long roots |
| | • Used occlusal PA or OPG |
| | |
| | Difficulty achieving anaesthesia for periodontal debridement |
| | • Practice locating anatomical landmarks |
| | • Used greater volume of local anaesthetic with adrenaline |
| | |
| | Difficulty taking centric record |
| | • Practice manipulation of mandible for reproducible centric |
| | • Engaged help of Prosthodontist |
| | • Consider de-programming exercises |
157
#### 5.7.4 Reflection
#### Patient-Related Challenges
- **Reflux Oesophagitis:** Managed by reclining patient to semi-supine position.
- **Medical Issues:** Dental treatment was secondary to medical appointments; required constant check-ins and flexible scheduling.
- **Anatomy:** Shallow palate/sulci and high frenal attachments required careful management of expectations and constant encouragement.
- **Attitude:** Addressed through patient management and education regarding the causes of oral issues.
#### Clinical Challenges
- **Radiographs:** Difficulty with PAs due to shallow floor of mouth; used occlusal PAs or OPG.
- **Anaesthesia:** Difficulty achieving anaesthesia for debridement; used higher volumes of local anaesthetic with adrenaline.
- **Centric Record:** Difficulty achieving reproducibility; managed with Prosthodontist assistance and de-programming exercises.
![]()
A structured table titled '5.7.4 Reflection' with columns for 'Challenges' and 'Management'. The table is categorized into 'Patient-related' (covering reflux oesophagitis, medical issues, anatomical challenges like shallow palate/sulci/frenal attachments, tooth loss, negative attitude) and 'Clinical' (covering radiograph difficulties, anaesthesia challenges, centric record issues). Each row details specific clinical challenges and corresponding management strategies.
**1. Oral and Dental Expert Group. Therapeutic guidelines: oral and dental Melbourne: Therapeutic Guidelines Limited; 2019.**
2. Monthly Index of Medical Specialties Australia.: MIMS Australia; 2020 [Available from: https://www.mimsonline-com-au.
3. Australian Medicines Handbook: Australian Medicines Handbook Pty Ltd; 2020 [Available from: **https://amhonline-amh-net-au**.
4. Thomas MS, Parolia A, Kundabala M, Vikram M. Asthma and oral health: a review. Aust Dent J. 2010;55(2):128-33.
5. Collaborators GBDA. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 2018;392(10152):1015-35.
6. Carr A, Brown D. McCracken's Removable Partial Prosthodontics 13th ed. Maryland Heights: Mosby; 2015. 392 p.
7. Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent. 2003;1(1):7-16.
8. Periodontal Risk Assessment (PRA): Ramseier, C. A.; 2020 [Available from: https://www.perio-tools.com/pra/fr.
9. Persbach S. Interpretation of panoramic radiographs. Aust Dent J. 2012;57 Suppl 1:40-5.
10. Featherstone JDB, Chaffee BW. The Evidence for Caries Management by Risk Assessment (CAMBRA(R)). Adv Dent Res. 2018;29(1):9-14.
11. Abbott PV. Classification, diagnosis and clinical manifestations of apical periodontitis. Endodontic Topics 2004. 2004;8:36-54.
12. Abbott PV, Yu C. A clinical classification of the status of the pulp and the root canal system. Aust Dent J. 2007;52(1 Suppl):S17–31.
13. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018;45 Suppl 20:S162-S70.
14. Samet N, Jotkowitz A. Classification and prognosis evaluation of individual teeth—a comprehensive approach. Quintessence Int. 2009;40(5):377-87.
15. Cheung W. A review of the management of endodontically treated teeth. Post. core and the final restoration. J Am Dent Assoc. 2005;136(5):611-9.
16. Nayyar A, Walton RE, Leonard LA. An amalgam coronal-radicular dowel and core technique for endodontically treated posterior teeth. J Prosthet Dent. 1980;43(5):511-5.
17. Della Bona A, Kelly JR. The clinical success of all-ceramic restorations. J Am Dent Assoc. 2008;139 Suppl:85–135.
18. Kelly JR, Benetti P. Ceramic materials in dentistry: historical evolution and current practice. Aust Dent J. 2011;56 Suppl 1:84–96.
19. Brandt S, Winter A, Lauer HC, Kollmar F, Portschner-Kim SJ, Romanos GE. IPS e.max for All-Ceramic Restorations: Clinical Survival and Success Rates of Full-Coverage Crowns and Fixed Partial Dentures. Materials (Basel). 2019;12(3).
20. Malament KA, Natto ZS, Thompson V, Rekow D, Eckert S, Weber HP. Ten-year survival of pressed, acid-etched e.max lithium disilicate monolithic and bilayered complete-coverage restorations: Performance and outcomes as a function of tooth position and age. J Prosthet Dent. 2019;121(5):782–90.
21. Malament KA, Margvelashvili-Malame M, Natto ZS, Thompson V, Rekow D, Att W. 10.9-year survival of pressed acid etched monolithic e.max lithium disilicate glass-ceramic partial
1. Oral and Dental Expert Group. Therapeutic guidelines: oral and dental Melbourne: Therapeutic Guidelines Limited; 2019.
2. Monthly Index of Medical Specialties Australia.: MIMS Australia; 2020 [Available from: https://www.mimsonline-com-au].
3. Australian Medicines Handbook: Australian Medicines Handbook Pty Ltd; 2020 [Available from: https://amhonline-amh-net-au].
4. Thomas MS, Parolia A, Kundabala M, Vikram M. Asthma and oral health: a review. Aust Dent J. 2010;55(2):128-33.
5. Collaborators GBDA. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 2018;392(10152):1015-35.
6. Carr A, Brown D. McCracken's Removable Partial Prosthodontics 13th ed. Maryland Heights: Mosby; 2015. 392 p.
7. Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent. 2003;1(1):7-16.
8. Periodontal Risk Assessment (PRA): Ramseier, C. A.; 2020 [Available from: https://www.perio-tools.com/pra/fr].
9. Persbach S. Interpretation of panoramic radiographs. Aust Dent J. 2012;57 Suppl 1:40-5.
10. Featherstone JDB, Chaffee BW. The Evidence for Caries Management by Risk Assessment (CAMBRA(R)). Adv Dent Res. 2018;29(1):9-14.
11. Abbott PV. Classification, diagnosis and clinical manifestations of apical periodontitis. Endodontic Topics 2004. 2004;8:36-54.
12. Abbott PV, Yu C. A clinical classification of the status of the pulp and the root canal system. Aust Dent J. 2007;52(1 Suppl):S17–31.
13. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018;45 Suppl 20:S162-S70.
14. Samet N, Jotkowitz A. Classification and prognosis evaluation of individual teeth—a comprehensive approach. Quintessence Int. 2009;40(5):377-87.
15. Cheung W. A review of the management of endodontically treated teeth. Post. core and the final restoration. J Am Dent Assoc. 2005;136(5):611-9.
16. Nayyar A, Walton RE, Leonard LA. An amalgam coronal-radicular dowel and core technique for endodontically treated posterior teeth. J Prosthet Dent. 1980;43(5):511-5.
17. Della Bona A, Kelly JR. The clinical success of all-ceramic restorations. J Am Dent Assoc. 2008;139 Suppl:85–135.
18. Kelly JR, Benetti P. Ceramic materials in dentistry: historical evolution and current practice. Aust Dent J. 2011;56 Suppl 1:84–96.
19. Brandt S, Winter A, Lauer HC, Kollmar F, Portschner-Kim SJ, Romanos GE. IPS e.max for All-Ceramic Restorations: Clinical Survival and Success Rates of Full-Coverage Crowns and Fixed Partial Dentures. Materials (Basel). 2019;12(3).
20. Malament KA, Natto ZS, Thompson V, Rekow D, Eckert S, Weber HP. Ten-year survival of pressed, acid-etched e.max lithium disilicate monolithic and bilayered complete-coverage restorations: Performance and outcomes as a function of tooth position and age. J Prosthet Dent. 2019;121(5):782–90.
21. Malament KA, Margvelashvili-Malame M, Natto ZS, Thompson V, Rekow D, Att W. 10.9-year survival of pressed acid etched monolithic e.max lithium disilicate glass-ceramic partial
**text in different colour format as bold:**
coverge restorations: Performance and outcomes as a function of tooth position, age, sex, and the type of partial coverage restoration (inlay or onlay). J Prosthet Dent. 2020.
Kayser AF. [The shortened dental arch - philosophy, examination and clinical application]. Rev Belge Med Dent. 1982;37(3):96-101.
Gottfredsen K, Walls AW. What dentition assures oral function? Clin Oral Implants Res. 2007;18 Suppl 3:34-45.
Yeung AL, Lo EC, Chow TW, Clark RK. Oral health status of patients 5-6 years after placement of cobalt-chromium removable partial dentures. J Oral Rehabil. 2002;27(3):183-9.
Yeung AL, Lo EC, Clark RK, Chow TW. Usage and status of cobalt-chromium removable partial dentures 5-6 years after placement. J Oral Rehabil. 2002;29(2):127-32.
AlHarthi SSY, Natto ZS, Middle JB, Gyrko R, O'Neill R, Steffensen B. Association between time since quitting smoking and periodontitis in former smokers in the National Health and Nutrition Examination Surveys (NHANES) 2009 to 2012. J Periodontol. 2019;90(1):16-25.
Williams RP, Rinchuse DJ, Zullo TG. Perceptions of midline deviations among different facial types. Am J Orthod Dentofacial Orthop. 2014;145(2):249-55.
Nelson SJ, Ash MM. Wheeler’s Dental Anatomy, Physiology and Occlusion 9th ed. St. Louis: Saunders-Elsevier; 2010. 401 p.
Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics 5th ed. St. Louis: Mosby 2012. 768 p.
Al ahmari A, Bamusa B, Bakhadher W, shafshak S, Ayed M. Gingival esthetic of upper maxillary anterior teeth - A review of literature. Dental, Oral and Craniofacial Research. 2019;5(2).
Topkara A. External apical root resorption caused by orthodontic treatment: a review of the literature. Eur J Paediatr Dent. 2011;12(3):163-6.
Savage NW, McKay C, Faulkner C. Actinic cheilitis in dental practice. Aust Dent J. 2010;55 Suppl 1:78-84.
Xu Z, Yu P, Arola DD, Min J, Gao S. A comparative study on the wear behavior of a polymer infiltrated ceramic network (PICN) material and tooth enamel. Dent Mater. 2017;33(12):1351-61.
Govare N, Contrepois M. Endocrowns: A systematic review. J Prosthet Dent. 2020;123(3):411-8 e9.
Al-Dabbagh RA. Survival and success of endocrowns: A systematic review and meta-analysis. J Prosthet Dent. 2020.
Joseph J, Ramachandran G. Fracture resistance of dowel channel preparations with various dentin thickness. Fed Oper Dent. 1990;1(1):32-5.
Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: a literature review. J Endod. 2004;30(5):289-301.
Heydecke G, Peters MC. The restoration of endodontically treated, single-rooted teeth with cast or direct posts and cores: a systematic review. J Prosthet Dent. 2002;87(4):380-6.
Johnson NW, Bain CA. Tobacco and oral disease. EU-Working Group on Tobacco and Oral Health. Br Dent J. 2000;189(4):200-6.
Stefanescu C, Ionita C, Nechita V, Drafta S, Oancea L, Petre A. Survival Rates and Complications for Zirconia-Based Fixed Dental Prostheses in a Period up to 10 Years: A Systematic Review. Eur J Prosthodont Restor Dent. 2018;26(2):54-61.
Raigrodski AJ, Hillstead MB, Meng GK, Chung KH. Survival and complications of zirconia-based fixed dental prostheses: a systematic review. J Prosthet Dent. 2012;107(3):170-7.
Zarone F, Di Mauro MI, Spagnuolo G, Gherlone E, Sorrentino R. Fourteen-year evaluation of posterior zirconia-based three-unit fixed dental prostheses: A Prospective clinical study of all ceramic prosthesis. J Dent. 2020;101:103419.
21. (Continued) coverage restorations: Performance and outcomes as a function of tooth position, age, sex, and the type of partial coverage restoration (inlay or onlay). J Prosthet Dent. 2020.
22. Kayser AF. [The shortened dental arch - philosophy, examination and clinical application]. Rev Belge Med Dent. 1982;37(3):96-101.
23. Gottfredsen K, Walls AW. What dentition assures oral function? Clin Oral Implants Res. 2007;18 Suppl 3:34-45.
24. Yeung AL, Lo EC, Chow TW, Clark RK. Oral health status of patients 5-6 years after placement of cobalt-chromium removable partial dentures. J Oral Rehabil. 2002;27(3):183-9.
25. Yeung AL, Lo EC, Clark RK, Chow TW. Usage and status of cobalt-chromium removable partial dentures 5-6 years after placement. J Oral Rehabil. 2002;29(2):127-32.
26. AlHarthi SSY, Natto ZS, Middle JB, Gyrko R, O'Neill R, Steffensen B. Association between time since quitting smoking and periodontitis in former smokers in the National Health and Nutrition Examination Surveys (NHANES) 2009 to 2012. J Periodontol. 2019;90(1):16-25.
27. Williams RP, Rinchuse DJ, Zullo TG. Perceptions of midline deviations among different facial types. Am J Orthod Dentofacial Orthop. 2014;145(2):249-55.
28. Nelson SJ, Ash MM. Wheeler’s Dental Anatomy, Physiology and Occlusion 9th ed. St. Louis: Saunders-Elsevier; 2010. 401 p.
29. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics 5th ed. St. Louis: Mosby 2012. 768 p.
30. Al ahmari A, Bamusa B, Bakhadher W, shafshak S, Ayed M. Gingival esthetic of upper maxillary anterior teeth - A review of literature. Dental, Oral and Craniofacial Research. 2019;5(2).
31. Topkara A. External apical root resorption caused by orthodontic treatment: a review of the literature. Eur J Paediatr Dent. 2011;12(3):163-6.
32. Savage NW, McKay C, Faulkner C. Actinic cheilitis in dental practice. Aust Dent J. 2010;55 Suppl 1:78-84.
33. Xu Z, Yu P, Arola DD, Min J, Gao S. A comparative study on the wear behavior of a polymer infiltrated ceramic network (PICN) material and tooth enamel. Dent Mater. 2017;33(12):1351-61.
34. Govare N, Contrepois M. Endocrowns: A systematic review. J Prosthet Dent. 2020;123(3):411-8 e9.
35. Al-Dabbagh RA. Survival and success of endocrowns: A systematic review and meta-analysis. J Prosthet Dent. 2020.
36. Joseph J, Ramachandran G. Fracture resistance of dowel channel preparations with various dentin thickness. Fed Oper Dent. 1990;1(1):32-5.
37. Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: a literature review. J Endod. 2004;30(5):289-301.
38. Heydecke G, Peters MC. The restoration of endodontically treated, single-rooted teeth with cast or direct posts and cores: a systematic review. J Prosthet Dent. 2002;87(4):380-6.
39. Johnson NW, Bain CA. Tobacco and oral disease. EU-Working Group on Tobacco and Oral Health. Br Dent J. 2000;189(4):200-6.
40. Stefanescu C, Ionita C, Nechita V, Drafta S, Oancea L, Petre A. Survival Rates and Complications for Zirconia-Based Fixed Dental Prostheses in a Period up to 10 Years: A Systematic Review. Eur J Prosthodont Restor Dent. 2018;26(2):54-61.
41. Raigrodski AJ, Hillstead MB, Meng GK, Chung KH. Survival and complications of zirconia-based fixed dental prostheses: a systematic review. J Prosthet Dent. 2012;107(3):170-7.
42. Zarone F, Di Mauro MI, Spagnuolo G, Gherlone E, Sorrentino R. Fourteen-year evaluation of posterior zirconia-based three-unit fixed dental prostheses: A Prospective clinical study of all ceramic prosthesis. J Dent. 2020;101:103419.
The provided image $100$ is a segment of a reference list from an academic document. The text is clear and legible, so I will transcribe it exactly as it appears. There are no figures, images, or tables to extract.
**Transcribed Text:**
43. Kennett S. Anaemia in dental patients. Br J Oral Maxillofac Surg. 1968;6(1):1-6.
44. Jenkins A. Nutritional deficiency in oral candidiasis. Int J Oral Maxillofac Surg. 1977;6(4):204-10.
45. Dental and oral hygiene for facial paralysis & Bell's Palsy patients: The Facial Paralysis Institute; 2020 [Available from: https://www.facialparalysisinstitute.com/treatments/dental-and-oral-hygiene-for-facial-paralysis-and-bells-palsy-patients/].
46. Wang C. Commonly used dietary supplements on coagulation function during surgery. Med. 2015;2:157-85.
---
</img>
43. Kennett S. Anaemia in dental patients. Br J Oral Maxillofac Surg. 1968;6(1):1-6.
44. Jenkins A. Nutritional deficiency in oral candidiasis. Int J Oral Maxillofac Surg. 1977;6(4):204-10.
45. Dental and oral hygiene for facial paralysis & Bell's Palsy patients: The Facial Paralysis Institute; 2020 [Available from: https://www.facialparalysisinstitute.com/treatments/dental-and-oral-hygiene-for-facial-paralysis-and-bells-palsy-patients/].
46. Wang C. Commonly used dietary supplements on coagulation function during surgery. Med. 2015;2:157-85.
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