CHIEF COMPLAINT:

I have a lot of broken teeth and I am here to get them fixed. My Upper right back teeth are loose.

HISTORY OF PRESENTING ILLNESS:

A 73 yo male presents with multiple fractured teeth (#3,#4,#14,#20,#29) in his mouth. They have been present for a long time. Mobile #2,#3 Patient has been negligent about his dental care . Discomfort on biting down and sensitivity to air pressure changes.

MEDICAL HISTORY:
Ill :

Hypertension since 10 years Neuropathy since 6 years (Burning sensation on the pressure bearing areas of the limbs) Hypercholesterolemia

Hosp : Yes (for the following) Surgeries:

Surgical removal of Clarks II Melanoma on the inner edge of his left outer ear 29 years back

MEDICATIONS:
Lisinopril/HCTZ 20/25 mg once a day since 4 years for HTN (under control) Atenolol 100 mg OD since 4 years Vytorin- 10/40 mg once a day since 3 years Lyrica 150 mg twice a day since 3 years Cymbalta- 60 mg OD since 1 year Tramadol- as an adjunct to neuropathic pain since a year Aspirin 81 mg once a day since 6 years Magnesium Oxide: preventive for kidney stones Vitamin D once a week Lovaza (Fish Oil) 1200 mg once a day Vitamin E supplements every alternate day

DENTAL HISTORY:

Caries Risk Assessment

Click to edit Master text styles Second level Third level Fourth level Fifth level

INTRA ORAL PICTURES :

OCCLUSAL VIEW :

MAXILLARY ARCH

MANDIBULAR ARCH

RIGHT LATERAL VIEW

LEFT LATERAL VIEW

PERIO CHARTING

7
7

ORAL FINDINGS:

Hard tissue : Amalgam restorations: #5 O,#14 DO,#15 MO,#15 DO,#16 DO,#30 MODBL,#32 O Composite: #7 DL, #9

ORAL FINDINGS CONTD:

Soft tissue : Gingiva: Inflamed, slightly bulbous contour Plaque Score : 70% Generalized Calculus Occlusion: Right canine Angle class: III Left Canine Angle class: II

PANORAMIC RADIOGRAPH:

RADIOGRAPHIC FINDINGS:
Generalized moderate Hz bone loss with Localized severe bone loss in relation to #2,#3,#16 No Periapical radiolucencies Furcation involvement : #2,3,30,32

HORIZONTAL BITEWINGS

PERIAPICAL RADIOGRAPHS

PROBLEM LIST/DIAGNOSIS: ASA Case type II Poor Oral hygiene : Generalized Moderate Chronic Periodontitis with Localized Severe Periodontitis

TREATMENT OBJECTIVES: Improve oral hygiene

Patient education and motivation (hygiene/nutritional) Control periodontal disease Remove the centric interference Restore Occlusion & Function Restore carious teeth and fractured teeth

PHASED TREATMENT PLAN

URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

PHASED TREATMENT PLAN

URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

NONE

PHASED TREATMENT PLAN

URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

Comprehensive oral eval Diagnostic casts SC/RP: All 4 quad Oral hygiene instructions Topical Fluoride varnish Occlusal adjustment Extract #2,3,16,32 #5 Amalgam restoration #7 DL, #8 MIFL, #9 MFL Composite restoration #4,#20,#29 Core build up amalgam

DIAGNOSTIC CASTS

POST EXTRACTION HEALINGand Use visual inspection, palpation,

radiographic assessment to assess healing Warn the patient of dry socket possibility and be prepared Allow 3-4 weeks for proper soft tissue recovery as to not interfere with the healing process before any impressions are taken Complete bone healing will take around 6-8 months

EVALUATION OF INITIAL THERAPY

EIT (4-6 weeks after initial tx) Ideal: pink, stippled, knife-edge gingiva, no BOP, decreased plaque score, no calculus, decreased PD and AL, decreased mobility
Newman, MG, Takei, H, Klokkevold, P, Carranza, F. (2006). Carranzas Clinical Periodontology. 10th Ed.

EVALUATION OF INITIAL THERAPY Depending on the periodontal defects/problems following

course of action is applied :

Mild

1. 2.

1. Further Sc/RP 2. Local Antibiotics 3. Peridex, Chlorhexidine mouth rinse

Severe

Further Sc/RP Surgery

PHASED TREATMENT PLAN

URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

Determine level of patient compliance and oral hygiene Determine the healing of extraction site #2,3,16,32 Reinforce nutritional counseling and OHI Check for new carious lesions and marginal integrity of existing restorations Continue 3 month perio recall Assess gingival health and inflammation Calculate plaque score, amount of calculus, full mouth probing depths and assess bleeding on probing

EVALUATIVE PHASE
Results we would like to see prior to Reconstructive Phase

Significant improvement of Oral Hygiene Post Extraction/Surgery Healing without complications

Caries control and periodontal health stability Adequate Bone Levels

IS IT TIME TO MOVE Decide if ODCT has been successfully completed : AHEAD ?

1. If yes, proceed to reconstructive phase 2. If no, go back to ODCT to improve areas in need of further treatment

PHASED TREATMENT PLAN

URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

CVC Gold crown for #4,14,20,29,30 Implant supported CVC crown for #1

DIAGNOSTIC WAX UP

k to edit Master text styles ond level Third level Fourth level Fifth level

PHASED TREATMENT PLAN

URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

Maintain Periodontal recalls every 6 months Repeat Bitewings every 12 months .Check for any secondary decay. Fluoride varnish every 6 months Check margins of all fixed prosthesis at 6 month recall appointments. Endodontic recall of all endo treated teeth (if any) every 6 months.

COST BREAKDOWN
URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

$0

$ 1170 (possible additional $651 for endo)

$ 0

$ 4126

Varies with every appointment

TOTAL COST : $5296 (TENTATIVE)

Due to Cost factors/systemic factors/anatomical factors; Implant supported crown for #19 can be excluded from the final reconstructive plan. #19 can be left unreplaced Advantages: No surgery, No waiting period for the implant healing, Decreased maintenance required on patients part, Saves money

ALTERNATIVE TREATMENT PLAN#1

COST BREAKDOWN
URGENT ODCT EVALUATIVE RECONSTRUCTIVE MAINTENANCE

$0

$ 1170 (possible additional $651 for endo)

$ 0

$ 2500

Varies with every appointment

TOTAL COST : $3670 (TENTATIVE)

ALTERNATIVE TREATMENT PLAN#2

If the patient does not want any fixed treatment options (cost factors/others) then : Extract #4,14,20,29 Substitute with a U/L Removable Cast Partial Denture. Upper: Kennedys Class II Mod I Lower: Kennedys Class I Mod I

RPD DESIGN

ADVANTAGES & PreventsDISADVANTAGES extensive surgical procedure for

an implant. Could be done in about 2 mos. vs 6-8 mos. for an implant supported crown and other fixed crowns. Would make flossing and maintaining oral hygiene easier Detection of secondary caries easier Definitely a cost effective option BUT : will involve stresses on abutment

COST BREAKDOWN
URGENT ODCT $1240 vs $1170 EVALUATIVE RECONSTRUCTIVE MAINTENANCE

$0

$ 0

$ 790 vs $ 4126

Varies with every appointment

TOTAL COST : $2030 (TENTATIVE)

ALTERNATIVE TREATMENT PLAN#3

DO NOTHING That is, no implants, no fixed options, no RPD Core build up #4,14,20,29 without crowns. Only Advantage: Saves Money Disadvantages : Poor oral health Decreased Periodontal health

WHOLE IDEA OF COMPREHENSIVE DENTAL CARE IS

COST BREAKDOWN
URGENT ODCT $1170 EVALUATIVE RECONSTRUCTIVE MAINTENANCE

$0

$ 0

$0

Varies with every appointment

TOTAL COST : $1170 (TENTATIVE)

TIONS ??? QUES