DTP Tips

You have to read Lisa Jordan file first by Dr Wasan so you can have better understanding of
these tips

1. When we get the file, we look at the patient’s name and age will give us some idea about
possible complaints. Radiograph report will be given to you in the file.

2. IOPA to the teeth next to the lump To rule out any connection to the lump(I do
not agree of having x-ray connection to teeth can be detected by vitality , percussion and
palpitation)

3. The Cause of food lodgement is TMPD….

T-treatment on that tooth due to filling or crown,
M-missing tooth-,
P-periodontal,
D-decay. Ask about all of them for a full clear history.

4. Anaemia on iron, folate and tranexamic acid (IS GIVE FOR HEAVY BLOOD LOOSE
AND HEAVY MENSTRUATION

5. How to explain enamel pearl to a patient?

It is a small blob on the tooth we call it enamel pearl which is part of the outer protective layer of
the tooth which is in an uncommon place on the root of the tooth. It is not common but nothing
to worry about, researches has shown that it has the tendency in 13% to cause irritation to the
core of the tooth and it to die for unknown reasons and in other cases it can cause irritation to
the gums.
We will do RCT with a specialist….and I can refer you to a gum specialist to have it grinded off.
We call that enameloplasty if he thinks it is necessary.
If a patient insists on having a bridge?
I will refer you to a restorative specialist as I mentioned there is not enough space there. so, he
will
assess you for this as it is out of my scope of practice. He is in a better position to advise you
about
this treatment.

6. When asking patient about INR test patient may not understand so ask about (prick test)
it’s the
layman term of INR.

7. You want to avoid extraction in this case and the patient is at risk of bleeding and teeth
are RCT which will render them brittle so extraction will be complicated and might need
 surgery and bone removal. You should explain to the patient that if they opt for this
option you must refer him/her for an INR first and will take further precaution by applying
suture and pressure gauze to stop bleeding. Explain extraction is not recommended and
better avoided.

8. How to explain post core crown to patient:

We can build the tooth with a post which is basically a nail in the tooth that will hold the crown.
The advantages are that you will restore your natural tooth but it has the tendency to come off.

9. Explain the coping and over denture:

We can prepare the broken teeth in a special way as they already have a good rct. where the
teeth will have a small protection cap over it and it will be used as a male part and female part in
the denture that sits on top of it, this will give you a denture with better support, avoid removal of
teeth and preserving natural teeth the disadvantages is the cost, teeth might get infected and
might require a referral.

10. Mnemonic for generalized discolouration : SOM RAT :

S: SMOKING
O: FOR ORAL HYGIENE AND BRUSHING
M: FOR MOUTHWASH
R; RED WINE
A: FOR CHILDHOOD ANTIBIOTIC AND SUPPLEMENT
T: FOR TEA AND COFFEE

11. Let me explain why your bridge is falling off: (Edge to edge explanation)
First it has a faulty design: the wing should extend all over the adjacent tooth and the way you
are biting the top and bottom teeth meet and tip off. In a normal bite this doesn’t happen as
bottom teeth close behind the upper teeth and that is why your bridge is coming off. We need to
do something about it. Is that clear?
For today I will glue the bridge back but keep in mind that it will come off again. So I can give
you a couple of options either a removable plate which is acrylic or metal…….. etc , a new sticky
bridge which will have a proper design wing, but there is a possibility that they can come off . a
fixed bridge which has a good aesthetic but we need to prepare the other two front teeth to give
it enough support and that puts the tooth under risk of death if it happens you will need further
treatment.
Implant which has a high success rate and can last you a lifetime however if your bite is not
corrected then there will be a higher risk of failure for both implant and bridge, therefore I would
I would like to refer you to an orthodontist to have braces to correct your bite. I know you had
this treatment before and you are happy with it but if we don’t correct the bite you will keep
having problems with your replacements.
We can give you the new sticky bridge as an interim measure until your bite and gum disease is
corrected.
 12. You mentioned your gums are bleeding, unfortunately you have an aggressive form of
gum disease. It runs in families as you mentioned your mum had it and it is seen in those
with excellent oral care but you still get this disease as it is in your genes. I will refer you
to a specialist so we control it and prevent further progression.

13. your regurgitation reflex influences the structure of your teeth, the stomach acid is very
strong which dissolves the enamel away. acid from food or drink will make it worse. you
have mentioned that it is under control which is very good, but you are still taking a lot of
white wine which is high acid so I will give you this diet chart to fill and we will highlight it
next time. For sensitivity, I will apply fluoride gel on the teeth to stop it.

14. Notes we need to remember:

1- If patient says he doesn’t like the removable you still give it as an option to make sure you
show the examiner that you know.
2- Another treatment option that passed is as following:
New sticky bridge
Referral to periodontist
Referral to restorative specialist to construct a bridge of 6 units canine to canine and to
prevent the interference of edge to edge occlusion.

15. For the painful front tooth, it is chronic periapical abscess which is an infection around
the tip of the root and there is pus collection and that is why you are having swelling and
pain on biting. The good thing is that pus is coming out through the blister and that is
why you are not having severe pain. On the top of your mouth there is a swelling which I
will numb the area around it and make a small cut to allow the drainage of pus and that
should get you out of pain. I would advise you to continue taking the antibiotic that you
have. You can also have some pain killers and that should help with pain.
I will review you after a couple of days to make sure the pain has subsided. For the
treatment options, you can either:
1- Save the tooth by having a re-apicectomy I know you don’t want to spend more on it but we
can give it a last try; nothing replaces a natural tooth. However, is has a low success rate
because of previous failed treatment and I will have to refer you to a maxillofacial specialist
2- Or Have the tooth taken out and give you replacement options:
a) we take an impression and give you an immediate denture same day we take the tooth
out, you won’t be left with a gap but because your medical condition there is a risk of injury
or inhalation it.
b) we can give you a sticky bridge which is an artificial tooth attached to a wing that is glues
to the back of the tooth next to it. It is a fixed option and won’t interfere with your condition
but if the area underneath it gets infected it will be difficult to remove it
the previous options can be used as a temporary measure and after healing is completed
we can give you a fixed option that is:l.
􀁸 Conventional cantilever bridge which is two caps stuck together it will get the
support from the tooth next to it good aesthetic and retention but there is a
possibility after preparing the healthy tooth it might undergo death if that happens
further treatment is required
􀁸 Implant explain advantage and disadvantages

The sequence of treating a failed RCT: first RCT, RE-RCT, APICETOMY, RE-APICETOMY,
EXTRACTION
The pain under your bridge is because of decay. The margins of your bridge are poor and food
is
getting stuck there. To relieve you from pain I will have to take the bridge off. I might damage the
bridge or break the teeth underneath it. i will then remove the decay and place a temporary
filling
and then place the bridge or make a temporary bridge and put it in place.
For the permanent treatment of the filling composite or amalgam.
For the replacement of bridge either:
1- a new bridge within the time limit.
2- Crowns on the teeth and removable again there is risk of injury or inhalation
3- Crowns on teeth and implant long treatment
􀂙 there is another pain under the bridge, with irreversible pulpitis emergency treatment is
going through the bridge there is a possibility that the bridge or the tooth is damaged so will
take some x-rays to know the angulation but this bridge has poor margins it needs to be
replaced it. The other option is to remove the bridge, remove the nerve and seal the tooth,
then a temporary bridge is placed on tooth until we finish the treatment we can give you a
permanent replacement.
􀂙 Another case is when there is a wobbly tooth the abutment tooth is wobbly because of
periodontitis, in this case you can section the bridge leaving the crown on the tooth and give
replacement option for the rest.
Then a temporary bridge is placed on tooth until we finish the treatment we can give you a
permanent replacement.
􀂙 Another case is when there is a wobbly tooth the abutment tooth is wobbly because of
periodontitis, in this case you can section the bridge leaving the crown on the tooth and give
replacement option for the rest.

16. Do not say sorry to the patient about HIV stay neutral

17. Thank you for waiting. I have the results………

Let’s start with your medical history I might need to contact you HIV clinic to make sure
whatever
treatment we decide on is safe for you, your safety is first,
Your denture is loose because it is broken I will take a mould with the denture send it to the lab
and make sure it’s ready on time before the wedding so you can attend with a confident smile.
Now this denture might not last you for long I have noticed you have a loose fold of gum tissue
there so I think it’s a good time to discuss all the options that we have, either acrylic/CO-CR,
overdenture and implant (explain link between HIV and implant).
I will refer you to prosthodontic to have a special mould made which does not involve a surgery
but the tissue will remain or refer you to a surgeon to have it removed but as you are HIV
positive
I would like to avoid surgery.
‘’You have an advance form of gum disease which is an irreversible condition it has a close link
to your medical condition which makes this disease more aggressive and that is why you are
losing many teeth,
Your LL7 is wobbly we can monitor it as we treat your gum condition it might stabilise saving a
natural tooth but looking at it has a poor prognosis. The other option is to take it out and add it
to the new replacement.
UL7 is of poor prognosis the gum and bone around it has shrunk if I keep it and give you the
replacement
within a few years you will comeback complaining about it, so let’s deal with in now
and include it in the overdenture
The root you have has lost the small cap on top of it so I will seal it with temporary filling today
and later we can either place a new cap on it and save the natural tooth or have it taken out
but as it has a rct these teeth are very brittle and you might need a small surgery to have it
taken out which again we want to avoid.
Your lower teeth are missing we can give you a replacement for them and that will stop the
the flabby ridge from growing options are …….
Talk about attrition and ask the patient to take the denture out and give denture hygiene
instructions.
monitor it
You have a LL4 that has lost a filling the tooth is dead so we can either leave it, rct or extraction

18. This case also comes with a patient who has prostate cancer and had radiotherapy;
there is no link of his medical history to dental treatment.

19. Causes of sensitivity are; erosion, attrition, abrasion, gum recession , bleaching, scaling

20. In all medical histories, it is important to ask about family history and childhood illness

21. in exam filling is okay only overhang where you only remove the access and not change
the whole filling.

22. The swelling you have is what we call a pyogenic granuloma. It is nothing you need to
worry about. Our gums are very sensitive and they can get irritated easily. Now because
the filling has poor margin it causes upset to the gum which shows as swelling and
because it has a lot of blood supply , it bleeds easily. You also have some tartar under
the gum which is adding to the irritation so what I will do today is …..
 23. Trigeminal neuralgia is basically pain coming from a nerve. The Trigeminal nerve is a
major nerve that supplies most of your face. It is an uncommon condition usually
affecting people in their 50s or 60s the cause of this is yet unknown but it is believed that
with age the elasticity and flexibility of blood vessels decrease causing compression on
the nerve which you perceive as pain. There are many facial pains but why I incline more
toward TN is the feature of pain that you have described. To relieve you from pain I will
prescribe you with a medication called carbamazepine for 10 day only you should space
the medication throughout the day. We need to keep an eye on how your body is liking
the medication as everyone reacts differently to it so I would like to refer you to a
specialist as the dose of this medication needs to be altered, he will run a few tests and
see how your body will respond to it .If you respond to the medication that will confirm
our diagnosis . In the meantime, avoid the triggering area when you leave the house
make sure you wrap your face with a scarf to protect it. If it is what I think it is an
irreversible condition unfortunately the medication will not treat it but it will reduce the
number of attacks and severity

24. wobbly if patient give history of teeth removed for periodontal problems ask about Family
history, Stress, Smoking and Diabetes

25. if patient give you a card with medication on them write them down as this card will be
taken away

26. Scleroderma affects the collagen fibres, these patients usually have dry mouth or are
associated with sjogren syndrome. Patients usually complain of periodontitis.

27. If patient has arthritis avoid giving her chewing gum

28. An immediate denture is given to replace your missing teeth and you are not left with a
gap. It also works as a bandage to prevent bleeding of the wound. After the healing
takes place within the first few months your bone and gums shrink and will have new
measurements and that is why your denture is loose. You have also mentioned that the
tooth that supports your denture in place has been removed and not added to your
denture, the denture has lost all the support of it, in addition your dry mouth is making
the condition even worse.
Part of ageing process is shrinkage of bone which effects the stability of the denture which in
turn supports you lips, hopefully with a new denture we can slightly improve that

29. When patient has, sensitivity ask from what, where, how long does it last, grinding, acid
intake, acid reflux, abrasion
30. I know that you are here to discuss your gap but I found a condition in your gums that
has a direct link to this gap becoming bigger and unless we stabilise your gum disease
we will not be able to do anything about it. the gum condition that you have is called
aggressive periodontitis, although you are taking good care of your teeth and there are
minimal irritating factors around your gums margins but unfortunately the type of gum
disease can happen even when
you take good care of your teeth and there can be various reasons for this. Sometimes it
can run in families, sometimes it is due to hormones or medical conditions but it can also
happen for no obvious reason. We need to work hand in hand to prevent further
damage, you need to keep a meticulous oral hygiene and I will give your teeth a good
clean to remove any hard deposit and will be seeing you on a regular basis every three
months and will refer you to a gum specialist.
Once this gum condition is stabilised we can close the space in-between your front teeth
because if the foundation is weak how can we build on top.
The gap in between your front teeth can be a reason for it. it can be genetic but what
worries me is that it is getting bigger because of this gum condition. The supporting
structure around the tooth is compromised and the tooth loses the support around it and
becomes wobbly and tends to move and that is probably what’s happening in your case.
So for you front wobbly tooth we will monitor it and after the gum treatment hopeful it will
stabilise
The options of treatment for that gap is to remove the crown on the right side and make
a bigger crown and mask the gap with some more treatment on the left tooth which could
be a filling , veneer or crown which is a less invasive treatment matching the filling and
veneer with the crown will be difficult and if you go for a crown it will look chunky and
unnatural however if you decided to go for this treatment we will try our best to make
them look as natural as possible.
Keeping in mind your young age we can refer you to a specialist in braces to close the
gap by means of hooks and [Link] will give you good results but it is a long treatment
…ect, but this is only possible once the gum condition stabilises.
Sensitivity is because the condition that runs in your family affects the second layer of
your tooth called the dentine which works as a cushion to support the above protective
layer the enamel. Because the dentin is defective the enamel is wearing off very quickly
and this exposes the dentine and that is why you have the sensitivity. You are also
consuming a lot of white wine
which is very acidic and this wears off your teeth at a faster rate. Your alcohol limit is
above that recommended by the national health body. I would suggest if you could keep
it below 14 units which will benefit your health in general. I will apply fluoride …ect and if
you are worried about the appearance I can refer you to a specialist who can mask the
colour.
Talk about the decay, and denture emergency treatment and option of stabilisation if you
give bridge you should refer to a specialist.
31. Treatment of mobile teeth:
Grade 1 monitor
Grade 2 monitor or extract
Grade 3 extract if posterior in emergency if anterior in stabilisation to make an immediate
denture.

32. Another case where the patient doesn’t have fibromyalgia but has an increase in the
OVD and the patient will give the following answers on top of the above is very bad that I
can’t keep wearing it because of pain. My teeth do meet when I talk or eat and I can’t
close my lips together

33. Do not give this patient chewing gum it increases the work of muscles and increases
pain)

34. Patient with mouth opening problem: We will give you frequent breaks during the
treatment because the last thing I want to do to you is tear your muscle and give you
pain.
35. Please bring your inhaler with you, and we will avoid anything that
can trigger your asthmatic attack. Please stop the codeine as it can be the cause of dry
mouth you are having and I would suggest using paracetamol instead. Please ask for
medical advice before you take any medication as you are taking a couple of
medications and some of these don’t like each other and can put you in bigger trouble.

36. Coming to the denture, I have had a look at the denture and I can't see anything wrong
with it. The only thing I can think of is the medical condition you are suffering from.
Fibromyalgia is a medical condition where your muscles get worked up very quickly and
your body preserves that as pain. The pink denture needs muscle control to stay in place
and as the day passes the muscles get used, overworked and tired and you perceive
this as pain. Ideally anyone with fibromyalgia they should receive fixed option but
because of a gum condition that I have pick on I cannot offer you this option unless
we control your gum condition. The only option I have for you now is a removable metal
denture, these dentures take support from the teeth and do not require as much muscle
control as the pink denture. But these dentures may have an adverse effect on the gum
condition you have. Given a fixed option fixed-fixed bridge this will be a long span so I
will need to refer you to a restorative specialist and implant.

37. Explain periodontitis, we also pick some teeth that are loose but it is still a grade one and
hopefully after the treatment of your gums it will stabilise and have a good grip. Explain
treatment. You are
complaining of dry mouth and going to the restroom a lot and these are symptoms
related to diabetes therefore I would like to refer you to your GP to have a blood test
done to make sure you are fine.
 38. Diabetes have a direct effect on your gum condition
Regarding your upper left 5 which has a poor margin, germs have crept in and caused
decay. The good thing is that it has not extended to the centre of the tooth and we call
this reversible pulpitis. For today I will remove the decay and apply a dressing and
temporary filling and cap. We will monitor it for 2 weeks if there is no pain then we can
give you a new crown but if you come back with pain that means we need to do a RCT
for that tooth and a cap on top or extract the tooth.

39. If a patient comes with a swelling, lump or uncomfortable feeling, always ask about the
adjacent teeth. Are they okay, painful or do they have any dental treatment on them? In
this case patients will either complain of uncomfortable heavy feeling of the gums or
achy itchy gums. The patient sometimes said she had the crowns because of erosion, in
other cases she said she had fluorosis.

40. When a patient mentions they use mouthwash, ask which one? If Corsodyl ask for how
long and was it prescribed by the dentist?

41. Cross bite on the right side (this was given in the May 2017 exam) and patient had a
small gingival enlargement size 3x2 mm around the 12. it is not included in the diagnosis
and treatment plan of this case.

42. Regarding your complaint about the itchiness in your gums after running some
investigation there are a couple of thing that I have found which maybe the cause:
1-the front tooth on the right side if you look at the x-ray there is a black shadow which we call
internal resorption which means the centre of the tooth has the nerve and vessels which keep
the tooth alive. It also has protective cells and sometimes these cells get damaged because of
injury or previous dental treatment and can sometimes happen for no reason at all. so, these
cells misbehave and start eating the tooth from inside the good thing that we have picked it at
this stage where is haven’t damaged lots of your tooth structure if we don’t do anything about it
will only get worse, to save the tooth we need to clean the tooth from inside to get rid of that part
giving you a dressing and temporary filling. Following that you have 2 options. First is saving the
tooth by means of doing an rct advantage/disadvantage and risks because the tooth has been
eaten away from the inside. I must refer you to a specialist in rct to have the treatment done to
make sure you get the best treatment available.
The other option is remove the tooth and give you on the same day a plastic denture as a
temporary measure so you are not left with a gap and go out with a confident smile. After the
When healing is completed we can discuss a permanent replacement option. Advantages
/disadvantage risk.
2-the other thing I have found is what we call it….. black shadow in close proximity to the tip of
the root, this happens in teeth with a caps and no never treatment done it happens in 1 in every
5,this cause irritation to the centre of the tooth and infection which spreads through the root to
the under lying tissue and that could be the cause of heaviness in your gums. it might not cause
you any pain
at the moment but if we leave an infection it can flare up giving you pain and swelling.
Explain
emergency and give the option of treatment after. The good news that cap is good and we can
go
through the crown it will be cost effective and less invasive or we can have the crown taken off
but
there is a risk of fracture of the tooth…..
You have been complaining about staining on you crown this is causes by various factors
smoking
causes stains and the same for red wine I would advise you to quit smoking and change your
preference of alcohol. The use of a Corsodyl mouthwash is known to stain your teeth as well as
alternating the taste sensation, this type of mouthwash should only be used for two weeks. I
would suggest you use a fluoride mouthwash instead. We can polish these crowns or give you
new crowns.

43. Crack tooth syndrome case

Ask pain history questions then add the following:

Is the pain when you bite hard or when opening your mouth?
Do you think the filling is fractured? Any sharp edges? Have you eaten anything hard?

44. The reason you are having this pain is because of the crack so when you bite the
cracked parts are moved away from each other but when you open your mouth the parts
snap together and that is why you feel the pain.
The pain on the side of your face is called facial arthromyalgia and it's coming from your jaw and
muscles on the side of your face which help to open and close your mouth although I do
understand you have mentioned that you do not grind your teeth some people do grind but they
are unaware of it. Why I am more inclined to grind your teeth is the pattern, location and type of
the pain. People who grind are more likely to have cracks in their teeth. These muscles need to
relax from the use all day long. The time they relax is when you sleep but because you grind
your teeth your muscles don’t get time to relax and are under constant tension which you
perceive as pain. You also mentioned that your teeth are shorter because they rub against each
other and the main reason for this is stress. I hope everything goes well with your job hunt. I
would suggest referring you back to your GP to review your stress medication that you are
taking and that should help. I will give you a nightguard. I know you had one before but I will
make you a lower one. This will protect your teeth and break the grinding habit.
45. There are many causes for this discoloration. It could be because of the trauma you had.
The centre of the tooth the nerve and vessels that keep the tooth alive these are
sensitive to the slightest irritation can cause it to go dead and when the blood breaks
down the by-products seep through the inner core to the middle part of the tooth the
dentine and it reflect the greyish colour .this tooth has a white filling and these filling get
stain easily also you habit of red wine drinking and smoking is adding to this problem
and I would suggest changing your preference and stopping smoking and this is adding
to the problem. Because this tooth is dead it has cause infection that has travelled along
the root to the surrounding structure that hold the tooth in place producing the germs
there has grown there and produced nasty substance which we call pus and the
collection of it is called an abscess, the bodies way to fight it is to through it out and that
is why you have the pink spot where pus is discharged and that is why you are having
that bad taste and breath. I know its not giving you any pain but leaving an infection in
place can give you trouble

46. Coming to your concern regarding your veneers becoming big I have picked up a
condition in your gums which I would like to talk about because the gum condition could
be causing your veneers looking bigger. It is an inflammation of the gums we call it
gingivitis luckily it is an initial stage and can be reversed (take about plaque ect …).
These veneers have caused irritation to the gum and the gums has shrunk and you can
see the edge of the veneer and the root of the tooth, that is why your front
teeth are getting bigger as these veneers can’t increase in size; they are not a living
thing. (Take about the treatment of gingivitis)
Another thing is the root of these teeth have not developed completely as you mention
you had an injury and popped out and this has caused the tooth to die and that is why it
couldn’t complete its development if you look at the tip of the root it is open it should be
closed like the tip of a cone, the inner part of the tooth that houses the nerve and the
vessel is usually soft again because of the injury it has become hard and solid. I do
understand that it is causing you no pain but It may bring you in pain and infection in
future so these teeth need to be treated to save the tooth you need have a RCT done
where I need to refer you to an endodontist who is a specialised in nerve treatment. he
will clean the centre of your tooth place a tooth friend material to try and close the tip
of the root we call this apexification and after that will complete the nerve treatment (give
advantages save natural teeth, disadvantages the success rate is normally 90% but it is
considerably reduced in your case) or extraction and immediate denture.
The tooth that gets infected every now and again has a condition called chronic
periapical abscess, the trauma had an effect in irritating the nerve and that tooth is now
dead and this is a source of infection which has spread along the tooth to the
surrounding structure that holds the tooth in place. The germs there produce toxic
products. We call this pus a collection of it is called abscess and that is why you have
this bad taste and breath from time to time. I know it is not giving you any pain now
but as you mentioned it has done so many times in the past to stop it you need a RCT or
extraction and immediate denture.
 It is very important that the foundation of these teeth which are the root is strong
because we need a strong structure to build on it so we won’t be able to do anything for
the veneers unless we treat the root of these teeth.
Patient might become upset and tell you they do not want to register with you anymore.
He came for a check-up and now you want to extract his teeth, tell the patient, I
understand that you are worried and concerned but I have a professional duty towards
you. For your own benefit I have to point out anything wrong and explain to you all the
treatment options with the advantages and disadvantages so you can make up your
mind and at the end it is your decision to take the treatment on and we are here to help.

47. For sensitivity follow the [Link].

W for where is it sensitive
W for what is it sensitive to
W for when is it sensitive
T for tummy trouble and heart burns
A for acid intake alcohol, fruit and fizzy drinks
G for grinding and parafunctional habit

48. Regarding your denture that is broken although you mentioned it is loose, let me explain
why that denture is loose. This denture has been given to you as a temporary measure
to replace your missing teeth, maintain function and works as a bandage to prevent
bleeding and infection to the wound. After the healing process of your wound is
completed your gums and bones shrink and they don’t fit the same to the denture and
that is why the denture was loose. We have to think about replacement options such as
removable dentures or implant support. Taking new sizes that will fit with that denture so
hopefully you will be [Link] we are making a new lower denture and you had
your upper denture for a while. I think it’s time to have it changed, those teeth on the
denture have been worn off and some plastic has been added to them to give them
some height. This might affect recording the bite for your lower denture so there will be
no use of making a lower new denture without an upper one. The options are the same
as for the lower replacement.
Tooth is formed of three layers an outer protective layer called the enamel and the inner
sensitive layer called the dentine, what the acid does to your tooth it weakens and melts
away the strongest layer in your body exposing the under-lying layer the dentine and
that is why you have this
sensitivity. The acid is coming from various sources such as the orange juice or the fruit
although they are healthy they are still acids. Also, you are taking white wine and cider
which has the same effect. You have also mentioned that you are having acid reflux
which you are taking gaviscon for.
The acid from the stomach is very acidic and is making the condition worse. Normally
when you have something acid the saliva corrects any damages that happened but in
 your case because you are taking too much acid your saliva can’t catch up with the
repair process.
Another thing is that you mentioned that you grind your teeth and this is speeding up the
process of losing your tooth structure. When you grind your teeth, your upper teeth rub
against the lower and it grinds away the tooth structure. You mentioned that you are
stressed so I would like to refer you to your GP and have a chat with them. They have
many ways to reduce your stress which will help your grinding too. Another thing that I
would suggest is to take your denture out at night this will also
prevent your grinding habit. I have also noticed a condition under your upper plate: the
area is red and sore. Are you aware of it? this is a condition called denture stomatitis it
happens in those who
wear upper dentures and don’t clean them regularly. Not taking your denture out at night
is adding to this problem as your gums are not having any time to breath and relax.
Imagine you sleeping with your shoes on, how would you feel? I know you mentioned
that you get headache when you take it out but let’s start with small steps take it out for
some time and slowly increase it until you get to
the stage that you can leave it out for the whole night, for this condition I will give you
…….

49. Linea alba: have you noticed that white line on the side of your right check. Do you have
the habit of biting your cheek? There Is nothing to worry about because it happens
because you have the habit of biting your cheek. We will keep monitoring it, try to avoid
biting your check and keep meticulous oral hygiene. If we find that it is not resolving I will
need to refer you to a specialist to have it checked with a biopsy. (linea alba has to be
examined with biopsy as it can be something sinister this is a passing or failing thing in
the exam DO NOT IGNORE ANY WHITE PATCH not responding always investigate to
be on the safe side)

50. When asking about mobile teeth follow TMPD, T for trauma, M for milk teeth and missing
teeth ask the patient if she thinks the teeth are smaller,
P for periodontal problem and
D for dental treatment.
The actor will not tell you if they are baby teeth so ask if patient thinks teeth are smaller
than the rest
51. Patients say they could close the back gaps but they couldn’t do the front. That means
there is no relapse of orthodontic treatment.

52. This case comes in exam as retained upper AS and missing laterals or retained c in both
cases the treatment plan is like the above.
Explain that : you have your baby teeth because of hypodontia which is a condition that
runs in families, it also involves missing the adult teeth. These baby teeth are trying to
catch up with the adult teeth next to it when you bite so it has lost a lot of bone support
around it and that is why it is wobbly. We can monitor these teeth but the looseness will
increase and these teeth will need to come out eventually
Patients will insist on not wearing an immediate denture as it is for old people to give the
patient the option of a RBB as a temporary measure and make her aware that after
healing the gums will shrink and a gap will appear so it is a temporary measure.
Regarding the ortho treatment, I will refer you to have braces to close the gap between
the front teeth and make more space to give you a replacement of the missing teeth you
have on either side.

53. This case comes at least once every year, COPD patients should not lie to them down it
will start an episode of breathing difficulty. Patients should be treated in an upright
position.
The sensitivity that you have is because your gum has shrunk. This has happened
because some bone has melted away due to the gum problem you had. when the level
of bone moves down the gums moves with it exposing the roots of the tooth which is
covered with a thin protective layer
cementum which can be washed away very easily exposing the underlying dentine to
the sensitive layer and that’s why you are having sensitivity.
Your gum condition has reached a point where the roots have lost a lot of support
around it, I would recommend referring you to a specialist in gum disease to have further
treatment done they can use artificial bone around the tooth and some surgery to cover
the root of your teeth.
54. Furosemide can cause ulceration

55. If a patient had a mobility of grade 1 we will only do scaling and polishing without
sectioning or changing the bridge.
Better to avoid replacement with removable option and warn patient regarding possible
injury during fit
Implant can be given after the wedding and healing is over.
Explain to the patient about localised periodontitis and furcation involvement of abutment
tooth and prognosis is very low.

Good Luck