CASE pres Flashcards
You have measured the BPE- what is this? Discuss the results and how it influences your treatment of the Patient?
The BPE score indicates the level of examination & provide basic guidance on TX.
My patient has BPE 4 in all sextants- This means pockets >5.5mm present in all sextants. As well as bleeding on probing/calculus and plaque retentive factors.
Because we had BPEs of 4s we complete a 6 point pocket chart pre and post treatment as per the BSP & SDCEP Guidelines .
Discuss your 6 point pocket chart results?
Generalised loss of attachment (consistent with radiographs)
Generalised bleeding (Patient a smoker- reduces gingival bleeding)
No furcation involvement/ mobility of teeth.
Largest loss of attachment- 12mm DL to 44.
Largest pocket- 9mm DB to 46.
Why did you select OPT radiography and why?
The OPT was selected to see the patient’s bone levels.
This was selected over full mouth periapicals as we would need at least 7 more PA (1-8microsv per radiograph) compared to one OPT (4-30Mmicrosv)
These radiation dosages were are according to the international atomic energy agency.
What is your periodontal diagnosis and explain why you have selected it.
Generalised Stage 4 Grade C periodontitis, currently unstable with risk factor of smoking.
Generalised- >30% bone loss
Unstable- pockets > 4mm with BoP
Periodontitis- inflammation of Soft and hard tissues.
Stage IIII- Greatest bone loss apical third of the root (46 distal)
Grade C- 70%/age = 2.4 which is >1 so rapid progression.
Risk factors- patient smoked 10 a day for 13 years so 6.5 pack years.
Why is smoking a risk factor for periodontal disease
Smoking alters the balance present in the biofilm of the mouth triggering an immune system attack.
Increased production of inflammatory mediating cytokines- causing tissue breakdown.
There is reduced gingival blood flow- signs & symptoms of gingivitis are supressed.
Impaired white cell function causing impaired wound healing.
What are the modified plaque and bleeding scores and when do you complete them?
These are scores graded at each appointment using Ramfjord’s 6 teeth (16 21 24 36 41 44)- This pt doesn’t have all of ramfjord’s teeth- we used the 38 instead.
Used to monitor patient engagement.
Plaque score- 2(visible) 1(on probe) 0 (no plaque)- measured buccal/lingual/interproximal. out of 36.
Bleeding score- 1(Bleeding) 0(no bleeding)- measured buccal/ lingual/mesial/ distal out of 24.
For patient enagement- we want a Plaque score <20%. Bleeding score <30% or >50% improvement.
Your treatment plan includes a 3 month evaluation. Why is that?
3 months gives enough time for healing and decreased pocket depths for:
Oedema to reduce (causing gingival recession)
Increased clinical attachment due to the formation of the junctional epithelium. This increases tissue tone & causes resistance to probing.
What are we looking for at the 3 month patient evaluation?
SDCEP- pockets <4mm. Plaque score <15%. Bleeding score <10%
BSP-
Stable if <=4mm pockets (no BoP at any 4mm pockets) and <10% BOP
In remission if <=4mm pockets (no BoP at any 4mm pockets) and >10% BoP
Unstable if >=4mm pockets with BoP
What are the different results we can see at the Re-evaluation of the patient’s periodontal disease?
According to the BSP guidelines:
**Stable periodontitis **
* <=4mm pockets with no BOP at 4mm.
* BoP <10%
Periodontitis in remission
* <=4mm pockets with no BOP at 4mm.
* BoP >10%
**Unstable periodontitis. **
* >4mm pockets with BoP
What is the next part of the treatment plan if the patient returns for the 3 month evaluation and has not achieved the SDCEP or BSP stablility?
Reinforcing OHI/ risk factor control/ behaviour change.
Targeted PMPR of the unresponding pockets and re-evaluate.(4-5mm)
Any deep pockets >6mm refer for pocket management or regenerative therapy.
Hypothetically the patient’s periodontal treatment was successful what does the supportive phase consist of and how do we determine the appointment interval?
Reinforce OH/ risk factor control/ behaviour change
Targeted PMPR if the patient returns with any sites with subgingival pockets/ BoP >=4mm.
Only supragingival on sites <4mm without calculus.
According to the BSP
Patients in remission should be recalled every 3 months
Stable patients should be recalled every 6 months.
Consider- evidence based adjunctive effacious toothpaste/ mouthwash to control the gingival inflammation
Discuss the patient’s risk of Oral cancer?
3/4 of head and neck cancers are due to cigarette use and alcohol .
Normal risk 2.5 per 100,000
Pt 5x more at risk (as they smoke and drink)
How does smoking affect a patient’s oral health
Smoker’s keratosis
Leukoplakia
Chronic hyperplastic candidasis (promotes candida adhesion)
Lumps (that could be cancerous)
It alters the components in saliva (leading to a drier mouth)
Oral cancer- Cigarette smoke contains carcinogenic chemicals
Increased risk of periodontal disease
Failed dental treatments
Staining of teeth/dental restorations/ dentures
Halitosis
Black hairy tongue (due to the nictoine staining the papillae of the tongue)
What is smoker’s keratosis
Trauma found where the tobacco is held from thermal gases which causes a white and brown staining on the patient’s palate.
This is due to a thicker keratin layer (white colour) & melanin overproduction.
Malignancy is not common but can be seen.
What is leukoplakia and how is it related to smoking?
Leukoplakia is an undiagnosed white patch that cannot be scraped off.
It is a potentially malignant lesion that smokers are x6 more likely to have.
Your patient attends with a leukoplakia, what do you do?
A Leukoplakia is a pottentially malignant lesion- so we biopsy this to exclude carcinoma and assess for candida.
How does chronic hyperplastic candidosis cause damage?
- Adherence to host cells
- Hydrolytic enzymes
- Candida hyphae invade deeper causing tissue damage & so we can observe epithelial dysplasia (increased malignancy risk)
Why are smokers at increased risk of chronic hyperplastic candiosis?
Smoking promotes increased keratinisation in the oral epithelium & smoke constituents increase fungal virulence (ability to cause harm )
What is chronic hyperplastic candiosis?
A candidal infection associated with smoking.
This cannot be scraped off.
We biopsy leukoplakia to test for this.
It is pre-malignant.
What are some clinical predictors of oral cancer malignancy?
Age (older >younger)
Gender (female > male)
Site (buccal mucosa low risk. Floor of mouth & tongue- high risk)
Clinical- if it is non homogeneous- verrucous/ ulcerated/leukoerythroplakia.
You have requested histopathology of your biopsied site. What are we looking for?
Changes in the tissue architecture/ cytology.
Can be:
Basal hyperplasia/ Mild/ Moderate/ Severe/ Carcinoma in situ.
What is the most common type of oral cancer ?
Squamous cell carcinoma
-Verrucous (outward growing)
-Basaloid (associated with HPV)
-Spindle cell (aggressive)
Tell us about the patient’s smoking habits
He used to smoke 10 cigarettes a day for the past 13 years.
Started when he was 16.
He is currently using a vape to help him quit. Positive- not smoking tobacco. Negative- we don’t know the long term implications.
List the 7 red flags for oral cancer.
- Ulcer persisting >2 weeks
- Rolled borders with necrotic centre
- Speckled- red and white appearance.
- Cervical lymphadenopathy (enlarged >1cm/ firm/ fixed tethered/ cannot move/ not tender)
- Worsening pain (neuropathic/ paraesthesia/ dysaestheisa)
- Weight loss (i.e. local or systemic effects)
The imediate treatment included extraction of the 37. Discuss the special tests used to diagnose this tooth.
What was the diagnosis
The patient was complaining of pain on the LHS
Radiograph- 37distal cavity with radiolucency on the 37 mesial root.
Sensibility testing-
TTP (Inflamation & swelling of the PDL within the bone)
Endo Frost- pain on cold (A delta fibres triggered telling us of pulpal involvement)
Symptomatic Irreversible pulpitis with symptomatic apical periodontitis.
Symptomatic irreversible pulpitis- Pain keeps patient up at night Sharp pain on thermal stimuli.
Symptomatic apical periodontitis- Radiograph shows an apical radiolcuent area. There is a painful response to percussion.
Define symptomatic irreversible pulpitis.
Findings indicate the vital inflamed pulp is incapable of healing.
Sharp Pain on thermal stimuli
Pain lasts 30s after stimuli is removed
Patient is kept up at night by pain (increased pressure in the pulp chamber if the patient lies down)
Typically over the counter analgesics are ineffective.
Define symptomatic apical periodontitis?
Inflammation- usually of the apical periodontium.
Painful response to biting/percussion/palpitation.
This can be associated with an apical radiolucent area.
Discuss all the treatment options considered for the 37?
Accept (but pt in pain )
Pulp extirpate- 38 was mesioangular impacted. Difficulty clamping for dental dam & achieval of moisture control needed to pulp extirpate. It would also be difficult to keep the distal restoration clean due to the impacted 8.
Extract.
The immediate treatment included extraction of the 36. Discuss the special tests used to diagnose this tooth.
What was the diagnosis
Clinically- Grossly broken down and carious.
Radiographically- caries MOD and radiolucency around the distal root.
Sensibility testing-
TTP NIL
Endo Frost - NIL.
Diagnosis- Previously treated with asymptomatic apical periodontitis.
Previous RCT.
Asymptomatic apical periodontitis- no clinical symptoms (TTP) but there is an apical radiolucency present on the distal root.
What does previously treated mean?
Tooth has been endodontically treated and the canals are obturated. The tooth does not respond to thermal or the EPT.
What does asymptomatic apical periodontitis mean?
Inflammation and destruction of the apical periodontium that is of pulpal origin
There are no clinical symptoms but there is an apical radiolucent area.
What were the treatment options considered for the 36?
Accept- Not currently causing patient pain. But tooth needs extracted due to gross caries
Extract- Doing this at the same time gives us more space mesially for the 37 extraction.
Discuss the extraction technique for extraction of the 36 and 37?
LA
Luxator to cut the PDL
Couplands elevator
Cowhorns for 36. Molar forceps for 37.
Idea- to extract the 36 first to provide space for the 37 extraction.
Why is the 48 not restorable.
Radiographically- 48mo gross caries.
Will not be enough tooth tissue left once caries is removed.
48- has moisture control difficulties.
Discuss the treatment options for 48
Accept- as not currently causing the patient pain.
Coronectomy- ruled out as likely caries has spread & infected the root.
Extraction- gross caries is at risk of causing the patient pain down the line. Roots are not close to the IADC. Royal college guidelines indicate Asymptomatic but diseased teeth should be extracted. (Not Near the IADN)
Discuss the extraction technique for the 48?
LA
Luxator to cut the PDL
Couplands elevator
Cowhorns (as very broken down)
Discuss the treatment options for the retained 36 root.
About 8mm in size.
Accept & monitor- with risk of extraction at future date. No current periapical lucency and the patient is not currently in pain.
Extract-
This is a decision the patient made:
He decided at present to retain the root & monitor as symptom & caries free with no PA radiolucency)
But patient was informed of the risks- of infection/ caries and extraction at a later date.
What do we inform the patient of to consent to an extraction?
*** Reason for extraction;
**Risks of extraction:
Pain/ Swelling/ Infection/ Bleeding/ Bruising/Dry socket/ Damage to adjacent teeth/ sensitivity/ retained roots/May need further treatment
Upper teeth- maxillary sinus involvement (OAC/OAF/
Lower teeth- IADN. Risk of mandibular fracture lone standing tooth. Risk of extraction becoming surgical.
Benefits of extraction
Other treatment options. Risks of not having treatment.
What do we do for after extraction?
Check socket for:
leftover roots
Socket filling up with blood.
Get the patient to bite down on gauze for 10/15 minutes
Provide aftercare instructions.
How does the patient smoking affect the extraction
Smokers are at increased risk of dry socket. Smokers who smoke >5 cigarettes within the 1st 24 hours are 3x as likely to have dry socket.
Smoking is causing a reduced blood supply (affecting clotting factors getting to the area)
What Diet advice would you give the patient?
Swap out the cans of mango water consumed at breakfast (contain 15 cans of sugar)
Swap the 2 teaspoons of sugar for sweetener.
Avoid drinking sugary drinks such as the can of mango water/ irn bru between meals.
If he is drinking fizzy drinks to try and drink the sugar free alternatives.
Patient also said he comonly drinks Dragon soops- over 50g of sugar per glass.
The patient has filled out a diet diary for his caries.
Discuss your findings.
Can of mango water at breakfast- The rubicon can 15g grams of sugar.
Irn Bru- Full fat irn bru 7.5g per glass and 15g per can.
Patient also asked about his alcoholic drinks- commonly drinks Dragon Soops (similar alcoholic drinks have over 50g of sugar per can)
Food- he is not a snacker.
Has 2 sugars with his coffee
Compare the endo frost test to the ethyl chloride test?
Ethyl chloride is sprayed on a cotton wool pledget and touched against the tooth.
Chloroethane’s low boiling point creates a localised chilling effect.
Endo frost is a propane/ butane/ isobutane gas mixture that produces a colder temperature than ethyl chloride.
What is the Endo frost test?
This is a thermal sensibility test .
Endo frost is sprayed on a cotton wool pledget and touched against the tooth.
Endo frost is a propane/ butane/ isobutane gas mixture. This produces a cold temperature -50 degrees
This is testing the A-delta nerve fibes.
If the tooth is still alive, the patient should feel the cold & if the pt has pulpitis. It will be a painful sensation.
What is the purpose of the TTP test?
Any inflammation of the PDL and swelling around the root would cause the patient to feel pain and react when you tap the tooth.
It important to tap multiple teeth in a random order.
Discuss the treatment options for the 46d?
Radiograph showed secondary caries underneath the amalgam restoration.
Options:
Accept- with risk of caries progression.
Replacement of filling
Amalgam- Less likely to fail/ doens’t need moisture control
Composite- aesthetic.
Decision-
Amalgam of 46d due to moisture control difficulties (not enough tooth tissue on the 48 to clamp for dental dam)
Patient wasn’t bothered about the aesthetic.
You have selected to replace the 46d amalgam restoration with another amalgam restoration. What lining material should be used and why?
Vitrebond which is a RMGIC.
This protects the tooth from the thermal stimuli due to heat being conducted through the metal fillings.
It prevents microleakage.
It also releases fluoride.
Why did you not line the 46d amalgam with Dycal?
Dycal is CaOH and this wasn’t used due to the difficulties with moisture control.
Discuss the treatment options for the 14 23 24?
These buccal abrasion cavities are to be filled.
The gold standard is RMGI due to asthetics and moisture control.
This problem is likely to be due to his toothbrushing habits (no other abrasive habits) and so we would also highlight this when providing him with OHI.
Discuss the treatment options for 16md?
Radiographically-
There is secondary caries of the distal amalgam restoration.
There is primary caries of the meisal.
The caries is deep- so there is a risk of pulpal exposure- We discuss this risk of that the decay could be bigger than the radiograph shows which could result in further treatment.
Could be restoration, could require indirect restoration dependent on extent of the carious lesion. (i.e. if cusps are undermined)
The patient is experiencing pain in his tooth. What do we expect would make the pain worse?
Cold water- causing a pain that lingers for more than 30s
How is the patient trying to quit smoking
The patient is using a vape (an e-cigarette)
You have said that the patient drinks 12 units of alcohol a week. How did you find this out?
On further discussion with the patient he informed me he drinks 3 dragon soops on a saturday night.
Dragon soops contain 3.75 units a can so
3.75x3 = 11.25.
Describe the sebaceous cyst present on the paient’s face .
2cm in diameter
Located on the Left infraorbital medial part of the cheek.
Lump
homogeneous colour
Not tender to palpate.
Pt was complaining that it had grown in size.
According to the notes in 2020 it was only detectable by palpatation. However when he presented in 2023 it was detectable visually
The 38 is impacted- describe the impaction of the 38
The 38 is
mesioangularly impacted with a moderate depth.
This means that the 8 is at a mesial angle to the 7.
The moderate depth refers to the corwn of the 8 being related to the crown AND the root of the 7.
In future, if the 38 became carious- what other radiographs would we want prior to extraction?
The royal College of surgeons guidance recomends a panoramic radiograph to see the relationship.
If the relationship with the IADC is influencing treatment e.g. tx coronectomy- we can use a CBCT. This could alter treatment if the IADC & the tooth aren’t closely related- allowing extraction.
What do we look for on a radiograph that indicate there may be a risk of damage to the inferior alveolar nerve.
What is the study that discusses them.
4 root indicators:
Darkened roots
Deflected roots
Narrowed roots
Dark & bifid roots
3 nerve indicators:
Interuption of the lamina dura
Narrowing of the IADC
Diversion & deflection of the IADC
Rood and Shehab 1990.
How many roots does the 38 have?
2 roots.
How many roots does the 48 have?
2 roots.
Is there caries present in the 38?
We did not note anything clinically, then the periapical looks like it could be, however after another check of the occlusal surface- the tooth is clinically sound.
The patient has stage IIII grade C periodontal disease. Do you think the patient is motivated enough for the treatment to be successful and why?
Yes- he is attending all of the appointments and is receptive to the advice that has been given to him.
He is also a motivated person shown through his challenge to quit smoking. He was already quitting when I first saw the patient and had decided that vapes would be his preferred choice for quitting.
Patients who are motivated in one part of treatment are more likely to be motivated in another.
You have said that at present there is no reconstruction until the periodontal disease is stable.
What if the periodontal disease never becomes stable- Would you consider reconstructing with a denture to replace the missing teeth?
No,
At present the patient is not concerned about the gaps between his teeth aesthetically as they are back teeth.
Functionally there is no need for a denture as on the left side of the patient there is a gap on the upper and the lower. There is only 1 tooth that is out of occlusion which is the 18.
What is amalgam?
Give the setting reaction.
A metal alloy filling material containing:
Mercury
Silver
Tin
Copper
Silver and Tin form an intermetallic compound (Ag3Sn) which reacts with Hg to form amalgam.
What material did you choose for the buccal abrasion cavities and why?
I used Self Cure Glass ionomer cement.
It has a similar thermal expansion to dentine
Low microleakage
Stable chemical bond.
Does not contract on setting (good for buccal abrasion cavities as we don’t want material shrinking in the cavity)
Can you talk me through how a patient with asthma is treated?
Patients taking a long acting beta 2 agonist also need to take an inhaled corticosteroid (due to the risk of heart disease)
