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Module 8 > CASE PRES > Flashcards

CASE PRES Flashcards

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1
Q

what is your pts presenting complaints?

A

“S” 42 year old male, presented at the start of module 7 for an assessment on cons.
Pt had no complaints but queried the ‘gap’ in between teeth where a tooth was extracted.
HPC: LR6 extracted 09/23. “S” keen to restore the gap at some point.

no complaints about any other teeth

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2
Q

what is your pts MH?

A

Nil, fit and healthy.
6ft2 19.5 stone
BMI = 35.1 (obese category)

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3
Q

what is your pts SH?

A

Full time electrician however looking for work at the moment.
Smoking: socially on occasions
Alcohol: 5 units a week
HX of throwing up after alcohol

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4
Q

what is your pts DH?

A

Brushes 2xday with non-fluoride containing toothpaste
No interdental cleaning unless food gets stuck, then a floss harp used
Uses mouthwash occasionally after brushing

Multiple A+E appointments.
- RCT and then XLA LR6
Multiple FTAs for cons appointments.
RCT LR5 done in Tunisia.

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5
Q

on initial assessment, were there any intraoral findings?

A

Benign alveolar ridge keratosis (ARK) LR6 area.
- Caused by chronic irritation from food packing during mastication
- Appears as a white patch/ plaque on the keratinized mucosa of the alveolar ridge

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6
Q

what is your treatment for the ARK in the LR6 area?

A

monitor at every appointment

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7
Q

what did you find in your dental chart on initial assessment?

A

UR3-UL3 palatal erosion
UR5 d caries
UL5d caries

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8
Q

what BPE scores did you get?

A

3 2 4
2 2 3

however, when assessed in perio the 4 changed to a 3

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9
Q

why do you think your BPE score changed from initial assessment?

A

probing force too high?? it should be 20-25g
or has there been some healing after initial OHI

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10
Q

what probe did you use for the BPE and describe it?

A

WHO probe
0.5mm diameter ball end and black banding between 3.5 and 5.5mm

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11
Q

why did you complete a BPE?

A

SDCEP guidelines: carry out a BPE for all new adult patients, and all adult patients without a periodontitis diagnosis at each recall appt

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12
Q

what is a BPE code 2?

A

no probing depths >3.5mm, calculus present

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13
Q

what is a BPE code 3?

A

probing depths of at least 4mm present

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14
Q

what is a BPE code 4?

A

probing depths of at least 6mm present

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15
Q

what special investigations were used at the initial appt?

A

right and left bitewings

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16
Q

why did you take bitewings?

A

pt has never had dental xrays before
guidelines:
take BWs every 2 years low caries risk
take BWs every 1 year high caries risk

to assess for caries, bone levels, overhangs, and pathology

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17
Q

how did you take the bitewings?

A

with the red holder and size 2 film
notch sitting distal of the 6

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18
Q

what did the BWs show?

A

caries: UR5m UL5m
calculus: gross
bone levels: <15% bone loss
restorations: UL7mo amalgam overhang

general: several sites of interproximal carious lesions, not seen clinically

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19
Q

what are your diagnoses?

A

NCTSL
palatal erosion
caries
secondary caries
generalised periodontitis stage I grade A currently unstable - risk factor plaque control and smoking

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20
Q

what do you think is the cause of the palatal erosion?

A

frequent alcohol consumption and HX of throwing up - stomach acid and acid from fizzy drinks used as mixers

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21
Q

what do you think is the cause of the caries?

A

interproximal lesions - no ID cleaning
occlusal lesions - non fluoride containing toothpaste

occasional mouthwash after brushing

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22
Q

how is a periodontitis stage assessed? and what is your patients?

A

the worst site of bone loss due to periodontitis
stage 1 = <15% bone loss

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23
Q

how is periodontitis grade assessed? and what is your patients?

A

% bone loss (worst site) / pt age
grade A: <0.5
(slow rate of progression)

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24
Q

what was the proposed treatment plan at initial appointment?

A
  1. OHI, diet advice, referral to perio dept DONE
  2. UR5m+d caries = restore DONE
  3. UL5m caries = restore
  4. UL4d caries = restore
  5. UL6o amalgam deficiency = restore DONE
  6. UL7m amalgam overhang assess DONE
  7. Specialist opinion regarding edentulous area LR6 (discussed with pt the edentulous area LR6 and informed them that gingivitis must stabilize before crown/ bridgework can be considered)
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25
why did you refer to perio?
due to BPE codes of 3 and 4
26
why are you restoring caries?
to halt the progression of disease protect the pulp from caries prevent further damage restore the tooths function and appearance
27
why do you want to assess the amalgam overhang?
with advice from a different clinician, I was advised that you should not interfere with an amalgam overhang if it is cleansable, to avoid the risk of devitalising the tooth. Although, I assumed amalgam overhang should be removed as they create a plaque trap for bacteria to harbor in. This puts the patient at risk of secondary caries and gingivitis in the area.
28
what was completed at the first CONS (assessment) appt?
dental chart and BPE PMPR supragingival USS lower quadrants UR5d restored OHI delivered
29
why did you do supragingival PMPR lower quadrants on the first appt?
BSP guidelines for BPE code 3 = initial periodontal therapy and review in 3 months with localised 6ppc in involved sextants - removed risk factors (plaque retentive factors) only lower quadrants done due to time constraints
30
how did you restore UR5d?
caries removal with a tunnel prep matrix band flowable composite composite
31
what initial OHI was delivered?
toothbrushing - modified bass technique flossing advice diet advice regarding sugar intake
32
why did you use a rubber dam when restoring UR5 m+d?
practice for skill moisture control - especially for blood isolated and clean working field moisture interferes with the bonding of composite and blood will stain it
33
what was completed at the initial perio appt?
6ppc: due to BPE codes 3 plaque and bleeding full mouth supra gingival PMPR USS
34
what were the findings from the 6ppc?
pockets of 4mm and 5mm found plaque upper 40.6% plaque lower 84.6% bleeding upper 37%
35
what do you do now that you have found 4mm and 5mm pockets on the 6ppc?
continue with step 1 of the BSP guidelines for periodontitis
36
what is step 1 BSP?
Building foundations for optimal tx outcomes: 1. explain disease, risk factors and treatment alternatives, risks and benefits including no tx 2. explain importance of OH, encourage and support behaviour change for OH improvement 3. reduce risk factors including removal of plaque retentive factors, smoking cessation and diabetes control interventions 4. provide individually tailored OH advice with ID cleaning 5. select recall period
37
how did you tailor your OHI to your patient?
instructed with use of TePe brushes, focusing on areas where there are pockets and caries informed pt of the importance of fluoride in toothpaste advised pt not to rinse after brushing - if he wants to use mouthwash, to do so during the day/ before brushing
38
what was the purpose of the second perio appt?
1 month recall to assess OH - plaque scores and assess sites 4mm or more for site specific subgingival PMPR
39
did your pts OH improve?
yes - now uses F containing oral B toothpaste with manual toothbrush 2xday and uses floss harps daily - all 4mm checked and none are 4mm anymore - plaque scores reduced significantly: 10% reduction for uppers 73% reduction lowers = overall plaque 21.5%
40
considering pts OH improving and none of the 4mm sites present anymore, what now?
full mouth supragingival PMPR with USS and OHI redelivered pt can now be put on maintenance care - 3 month recalls
41
how did you treat the secondary caries underneath the amalgam on UL6?
removed part of the amalgam caries removal new part amalgam placed
42
what are the causes of secondary caries?
defective restoration - allows for microleakage where saliva and bacteria can enter initial active decay not removed poor marginal seal patient factors - high caries risk
43
what periodontal guidelines were followed?
diagnosis: British Society of Periodontology (BSP) 2018 classification of periodontal diseases treatment: BSP UK clinical practice guidelines for the treatment of periodontal diseases
44
what does BSP state a 'currently stable' patient shows?
- BOP <10% - PPD
45
how does BSP classify a patient 'currently in remission'?
- BOP >/= 10% - PPD
46
how does BSP classify a patient 'currently unstable'?
- PPD >/= 5mm or - PPD >/=4mm and BOP
47
what future treatment is needed in cons?
restore UL4d and UL5m caries caries removal UL4d first to then visualise the UL5m
48
what further treatment is required in perio?
3 month review - bleeding scores??? for a new diagnosis - BPE again
49
how would you restore the gap LR6?
fixed cantilever bridge LR5 post core and crown - it is currently root treated but lacking tooth structure, it has enough for a 1mm ferule and GP is 10.5mm long so can have a 7mm post ceramic??? emax???
50
why would you use emax for a bridge?
it is a strong ceramic - high flexural strength good aesthetics durable and resistant to stain biocompatible emax crowns require less tooth prep
51
why didnt you take periapicals for perio diagnosis?
we had already taken BWs in cons for assessment of caries no severe bone loss - all bone loss can be seen on the bitewing
52
describe microbiology in health/ gingivits?
- Bacteria mostly gram +ve aerobic and saccharolytic (breaks down carbohydrates for energy) - Streptococcus, Actinomyces, and Capnocytophaga species - Maybe black stained Prevotella
53
describe microbiology in periodontitis ?
orange complex bacteria are found in periodontitis there is a shift to red complex as the disease progresses, and these bacteria are most commonly found at the base of the pocket
54
what are the orange complex bacteria?
fusobacterium nucleatum prevotella intermedium campylobacter rectus
55
what are the red complex bacteria?
porphyromonas gingivallis tanarella forsythia treponema denticola
56
what bacteria is associated with very aggressive periodontitis?
aggregatibacter actinomycetemcomitans
57
how does gingivitis convert to periodontitis?
- the plaque biofilm causes gingivitis by inducing an inflammatory host response - the inflamed gingivae create a small pocket which is an ideal environment for bacterial colonisation - there is low levels of oxygen in the gingival pocket which favours growth of obligate anaerobes - these obligate anaerobes are associated with the progression of perio disease
58
what is the plaque biofilm?
a diverse microbiome in a muco polysaccharide matrix - it can be removed by brushing
59
what is calculus?
calcified deposits from mineralisation of plaque
60
where does the mineral content of supragingival calculus derive from?
saliva most often found opposite the openings of salivary ducts i.e., upper 6/7 area (Parotid/Stensons duct) and lingual surface of lower anteriors (subman/ sublingual/ Whartons duct)
61
how long does it take for supragingival calculus to form?
2 weeks
62
where does the mineral content of subgingival calculus derive from?
gingival crevicular fluid
63
how long does it take for subgingival calculus to form?
many months
64
what effect does calculus have on periodontal disease?
it is a plaque retentive factor, allowing bacteria to accumulate and promoting inflammation
65
describe the pathogenesis of the initial perio lesion ?
gingivae appear clinically healthy 24 hours: vasodilation of gingival tissues 2-4 days: increase in gingival crevicular fluid and antibodies released
66
describe the pathogenesis of the early perio lesion?
1 week: clinical erythema - lymphocytes and neutrophils predominate - fibroblasts degenerate and collagen breaks down - subgingival biofilm develops
67
describe the pathogenesis of the established lesion?
clinically red, swollen gingivae which bleeds easily - neutrophils predominate and junctional epithelium converts to pocket epithelium *may remain the same for months/ years OR convert to an advanced lesion
68
describe the pathogenesis of the advanced perio lesion?
apical migration of the JE = formation of true pocket loss of connective tissue attachment and alveolar bone
69
what is the purpose of the BPE?
It determines what further examination is required and therefore provides a direction of the next phase of treatment
70
explain a BPE?
Examination of every tooth apart from third molars. - WHO probe used and walked around gingival margins - Highest score per sextant is recorded - Probe is walked around the sulcus with a probing force of 20-25g
71
what are the BPE scores?
SCORE 0: pockets <3.5mm, first black band completely visible SCORE 1: pockets <3.5mm, first black band completely visible - BOP SCORE 2: pockets <3.5mm, first black band completely visible - BOP - Calculus SCORE 3: pockets 4/5mm, black band partly visible SCORE 4: pockets >6mm, black band not visible
72
why do you clean root surfaces?
- to remove subgingival plaque, calculus and other plaque retentive factors - to decontaminate the superficial cementum, by removing endotoxin - to produce a root surface which is biologically acceptable = epithelial attachment and formation of LJE - to enable a certain degree of gum shrinkage - to facilitate resolution of gingival inflammation
73
what is the healing of a pocket?
reduction in probing depth and absence of BOP following treatment
74
what treatment allows for the shrinkage of gingival tissues? and how long does this take to have an effect?
supragingival PMPR and removal of plaque - results in reduced bacterial challenge to host - changes occur within 1-2 weeks
75
describe the formation of the long junctional epithelium?
RSD and disruption of sub gingival biofilm will create a root surface that is compatible with the formation of long junctional epithelium. The attachment of epithelium begins within a few days of RSD. Maturation of gingival and periodontal collagen fibres then follow and takes 3 months. This results in a tightening of the gingival cuff, reduced mobility and further pocket elimination.
76
why do we not prove/ re-instrument within 3 months of subgingival PMPR
it may distrupt the healing process
77
what are the factors that lead to caries?
diet (sugar substrate) tooth (susceptible surface) time bacteria in biofilm
78
what are the modes of action of fluoride?
inhibit demineralisation antibacterial strengthens enamel promotes remineralisation
79
how does fluoride inhibit demineralisation?
bacterial in dental plaque produce acid that can dissolve the minerals in tooth enamel. Fluoride helps slow down this process by interfering with the ability of bacteria to produce acid
80
how does fluoride enhance remineralisation?
Fluoride enhances tooth remineralisation by accelerating the growth of fluorapatite crystals on the partially demineralized sub-surface crystals in the carious lesion. Fluoride adsorbs into this surface and attracts calcium ions
81
how does fluoride strengthen enamel?
fluoride ions interact with calcium and phosphate, found in enamel, to form a stronger compound Fluorapatite. Fluorapatite is more resistant to acid attacks and helps prevent the enamel from dissolving.
82
explain fluorides antibacterial action?
The use of fluoride lowers the PH. Bacteria will therefore use more energy to maintain a neutral PH. Therefore, will have less energy left to grow and reproduce and generate acid polysaccharides.
83
Why are people using non-fluoride toothpaste?
- Concerns about overexposure and fluorosis - Preferences and beliefs; people believe fluoride toothpaste is redundant, fluoride-free toothpaste aligns with their natural or holistic lifestyle choices, many query the safety of fluoride.

Module 8 (34 decks)

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