Case Presentation
By: Dr. Sarah Al-Naki
Outline:
• Introduction
• Personal and demographic data
• Chief complaint and history of chief complaint
• Medical history and Socio-behavioral history
• Dental history, dental attitude, and home care regimen
• Clinical examination
• Intraoral examination
• Extraoral examination
• Special investigations
• Diagnosis
• Problem list and treatment options
• Treatment plan
• Patients file and consent forms
Introduction
Mrs. Z.A attended the dental clinic with a
complaint regarding her upper left 1st
molar.
Personal History &
Demographic Data
• Name: Z.A.
• Gender: Female
• Age: 25
• Nationality: Kuwaiti
Chief Complaint
• Patient’s own words: “I have severe pain at night, and my tooth is
broken”
History of Chief Complaint
• There was severe pain and sensitivity localized to tooth #26.
• Pain is spontaneous and increases at night.
• Triggering factors: cold and hot drinks, chewing/biting.
• Duration of pain: long duration a couple of minutes.
• Pain is not relieved with painkillers.
Medical History
• Medically fit and healthy
• Systems reviewed: Central Nervous System, Respiratory S.,
Cardiovascular S., Renal S., Immune S., Hematological.,
Gastrointestinal S., Endocrine S.
• No known allergy from any food or medication
• Not taking any medication
• Previous surgery or hospitalization: Gastric sleeve surgery
Socio-behavioral History
• Marital status: Married
• Occupation: College Student
• Education: High School Degree
• Nonsmoker and does not consume alcohol
• Para-functional habits: Bruxer and grinds at night
Dental History
Aspect of dentistry Comment
Frequency of dental visit Irregular
Last dental visit 4 years ago
Dental attitude Negative
Previous restorative therapy #16
Previous surgical therapy #37, #47
Previous endodontic therapy None
Previous periodontal therapy None
Previous prosthetic therapy None
Previous orthodontic therapy None
Home care regimen
• Uses a soft manual toothbrush
• Brushes 2 times daily (Morning and night)
• No specific technique of brushing but usually in a horizontal, right to
left motion.
• The toothpaste is fluoridated (1,450 ppm)
• Does not use any adjunctive oral health aids (mouth wash, floss)
Clinical examination
I. Extra-oral examination
II. Intra-oral examination
I. Extra-oral examination
FRONTAL VIEW LATERAL PROFILE VIEW
SMILE VIEW
I. Extra-oral examination
Extra Oral Examinations
General physical appraisal Normal
Face Facial asymmetry within normal range
Facial profile Slightly convex
Lymph node No abnormality detected
Muscles of mastication No pain or tenderness on palpation and examination
Mandibular movement No deviation, limitation or displacement
TMJ No pain or tenderness. No clicking or crepitus
Lip Competent lips
Smile time Average smile
II. Intra-oral examination
FRONTAL OCCLUSAL VIEW
RIGHT LATERAL VIEW LEFT LATERAL VIEW
II. Intra-oral examinations
MAXILLARY OCCLUSAL VIEW MANDIBULAR OCCLUSAL VIEW
II. Intra-oral examination
Soft Tissue
Lips Normal
Labial mucosa Normal
Buccal mucosa Normal
Tongue (dorsum and lateral side) Normal
Hard Palate Normal
Soft Palate Normal
Tonsils Normal
Frenum Normal
Floor of the mouth Normal
II. Intra-oral examination
Periodontal Examination
• Patient has good oral hygiene
• Gingival Mucosa
• Colour: Pale Pink/ with localised red margins
• Contour: blunt interdental papilla/scalloped
margins
• Consistency: Firm/resilient, soft/oedematous
in localised areas
• Texture: no stippling
• No Mobility or Furcation Involvement
• Basic Periodontal Examination (BPE):
2 2 2
2 2 2
II. Intra-oral examination
Periodontal Examination
Full Mouth Bleeding Score (FMBS): 50%
Full Mouth Plaque Score (FMPS): 74%
Dental Chart
extracted
Composite
restoration
Caries
Extracted
impacted
II. Intra-oral examination
Hard Tissue Examination
Occlusal maxillary view Occlusal mandibular view
Intraoral frontal view
II. Intra-oral examination
Hard Tissue Examination
Occlusal Assessment
• Both maxillary and mandibular dental arches are U-shaped
• No maxillary or mandibular midline shift
• Spacing of teeth between #12 and #13, #23 and #24
• Slight crowding in lower anterior teeth
• Previously extracted tooth #37, #47
• Caries of tooth #17, #15, #26, #27, #36, #35, #46
• Composite restoration on tooth #16
• Loss of space in lower posterior 2nd molar area due to eruption
of lower 3rd molars.
II. Intraoral Examination
Hard Tissue Examination
• Non Carious tooth surface loss on teeth #12, #11, #21, #22, #23
• Plaque and calculus accumulation
II. Intra-oral examination
Static Occlusal Assessment
Molar Relation Class I on left side
Class I on right side
Canine Relation Right crossbite
Left class I relation
Incisor Relation Right crossbite
Left class I relation
Overjet 1 mm
overbite 1 mm
II. Intra-oral examination
Dynamic Occlusal Assessment
Lateral excursion • Working side: Right/Left Canine
Guided Occlusion.
• Right Nonworking side: occlusal
interference from #12
• Left Nonworking side: No interference
Protrusive Guidance • Anterior Guidance with posterior
disocclusion
Special Investigation
I. Radiographic Examination
II. Endodontic Examination
III. Diet Analysis
IV. Carries Risk Assessment
I. Radiographic Examination
Extraoral Radiograph (Orthopantomogram)
OPG shows the following
• Normal bony outlines and
no apparent pathology
• Missing teeth #37, #47
• Caries tooth #26
• Impacted tooth #18
• Distoangular impaction of
tooth #28
• Restoration on tooth #16
Intra Oral Radiograph (Bitewings)
Right Bitewing
• #47 missing
• #16 restoration
• #14 distal caries
• #46 caries
• Proximal enamel lesions #15, #45, #46
• No bone loss
Intra Oral Radiograph (Bitewings)
Before emergency treatment 2 weeks after emergency treatment
• #37 Missing • #26 Extracted
• #26 grossly decayed
• #27 carious
• #35 distal caries
• Interproximal calculus
Intra Oral Radiographs (periapical)
• #35 distil caries • #26 grossly decayed caries
• #37 missing • #27 carious
• No periapical abnormality • No periapical abnormality
• Normal PDL spaces • Normal PDL spaces
II. Endodontic Examination
Tooth #26
a) Subjective findings: History of pain:
•History: pain started the days ago increases at night
•Intensity: severe
•Frequency: spontaneous
•Duration: long ( >10 seconds to minutes)
•Stimulating factors: cold/hot
•Relieving factors: not relieved by painkillers
b) Objective findings:
•Radiograph: grossly decayed
•Pain on percussion
•No pain on palpation
•No swelling/sinus tract
•No mobility
II. Endodontic Examination
b) Objective findings: Pulp and apical tests
Endodontic assessment of tooth #26
Tooth No. Pulp Test (End-Frost) Percussion Palpation
intensity Duration
25 Normal Normal Normal Normal
(Control)
17 Normal Normal Normal Normal
(control)
26 Severe >10 Severe Normal
(offending) seconds
Tooth #26
• Pulpal diagnosis: Necrotic pulp
• Periapical diagnosis: Symptomatic apical periodontitis
II. Endodontic Examination
b) Objective findings: Pulp and apical tests
Endodontic assessment of tooth #26
Tooth No. Pulp Test (End-Frost) Percussion Palpation
intensity Duration
34 Normal Normal Normal Normal
(Control)
45 Normal Normal Normal Normal
(control)
35 Severe >10 Mild Normal
(offending) seconds
Tooth #26
• Pulpal diagnosis: irreversible pulpitis
• Periapical diagnosis: Symptomatic apical periodontitis
II. Endodontic Examination
Tooth #35
a) Subjective findings: History of pain;
• History: on some occasions every other month
• Intensity: severe
• Frequency: intermittent
• Duration: >10 seconds
• Stimulating factors: hot/cold/sweets
b) Objective findings:
• Radiograph: distal caries
• Cold Test: severe pain lasting >10 seconds
• Mild pain on percussion
• No pain on palpation
• No swelling/sinus tract
• No mobility
II. Endodontic examination
b) Objective findings: Pulp and apical tests
Endodontic assessment of tooth #35
Tooth No. Pulp Test (End-Frost) Percussion Palpation
intensity Duration
36 Normal Normal Normal Normal
(Control)
45 Normal Normal Normal Normal
(control)
35 Mild Short Normal Normal
(offending)
Tooth #12
• Pulpal diagnosis: Reversible Pulpitis
• Periapical diagnosis: Normal apical tissues
• Non-milk extrinsic sugar • Anticariogenic
• Intrinsic sugar • acidogenic
III. Dietary Analysis
Friday Saturday Sunday Monday
Time Items Time Items Time Items Time Items
Breakfast 9:30 Tea with milk + 2 9:00 Tea with milk + 2 8:00 Tea + 2 spoon of 8:00 Tea + 2 spoon of
spoon of sugar. spoon of sugar. sugar. sugar.
2 Toasts 2 Toasts 1 egg with bread 2 Toasts
Snack _ _ _ _ _ _ _ _
Lunch 2:30 Rice and chicken 3:00 Rice and meat stew 2:00 Rice and lentil stew 1:30 Rice and chicken
stew with potatoes stew.
Snack 6:00 Tea with milk + 2 6:00 Tea with milk + 2 5:30 Tea with milk + 2 5:30 Tea + 2 spoon of
spoon of sugar spoon of sugar spoon of sugar sugar
Chocolate cake
Dinner 9:00 Rice and chicken 9:30 Rice and meat stew 9:00 Rice and lentil stew 8:30 Toast and cheese
stew
Snack _ _ _ _ _ _ _ _
Dietary Analysis
• A Diet sheet was given to the patient to record her diet for four consecutive days. To
record different eating habit routines; 2 workdays and 2 weekend days were charted.
• The time of each meal or snack was recorded.
• High sugar intakes are highlighted to the patient.
• The patient consumes sugar once during mealtime and once during snack time in the
afternoon.
• She snacks regularly between breakfast and lunch time, neither does she snack after
lunch time.
• Though sugar attacks are restricted to 2 times a day the patient is of moderate risk to
caries.
• The patient was advised to eat a healthy balanced diet and to incorporate fruit and
vegetables and to cut down on sugar intake.
Dietary Recommendation
• Patient consumes extrinsic sugars more than 2 times a day, she was
advised to restrict her sugar intake to mealtimes.
• NMES (Non-Milk Extrinsic Sugars) must not exceed 60g per day and should
provide no more than 10% of the total energy in diet.
• Intrinsic sugar consumption along with starchy/fibrous foods must be
increased to 5 portions/pieces of fruit and vegetables per day.
IV. Caries risk assessment
Treatment planning
I. Problem list and treatment options.
II. Diagnosis and differential diagnosis
III. Treatment objectives
IV. Final integrated treatment plan
V. Treatment Execution
I. Problem list and treatment options:
Problem list Treatment option
High caries risk • Patient education and oral hygiene instructions
• Dietary advice
• Professional fluoride application
Generalized calculus, plaque deposits, and bleeding on • Patient education and oral hygiene instructions
probing • Brushing technique demonstration and use of
dental floss
• Dietary advice
• Full mouth scaling and polishing
• Monitor
#12: Caries (Necrotic pulp) • Nonsurgical root canal treatment + core build
up + 1 unit fixed dental prosthesis
• Extraction:
• Surgical implant placement + fixed
dental prosthesis
• Fixed dental prosthesis (3-unit
bridge)
• Removable partial prosthesis
• Extraction without replacement
I. Problem list and treatment options
Problem list Treatment plan
Irregular Dental Visits • Case presentation, patient education and
motivation about the benefits of regular dental
visits
Caries on teeth #13 and 23 • Direct composite restoration
Caries on teeth #34, #35, #37, #47 • Direct composite restoration
• Amalgam restorations on tooth #37, #47
Arrested caries on tooth #47 mesially • Case presentation and patient education
• Monitor
• Fluoride application
• If cavitated, restore with direct composite
restoration
I. Problem list and treatment options
Problem list Treatment plan
Mesioangular impaction of tooth #38 • Surgical extraction
• No treatment
• Monitor
Missing tooth #46 • Implant supported prosthesis
• Fixed dental prosthesis (3 unit bridge)
• Removable dental prosthesis
• No treatment
White spot lesion • Patient education and motivation
• Fluoride application
• Monitor and review
• Bleaching
II. Diagnosis and differential diagnosis
1. Dental caries as shown in chart.
2. Endodontic diagnosis:
• Tooth #26 : necrotic pulp with symptomatic apical periodontitis.
• Tooth #35 : irreversible pulpitis with symptomatic apical periodontitis
3. Periodontal diagnosis: Generalized dental biofilm induced gingivitis.
4. White Spot Lesion:
• Enamel demineralization
• Dental fluorosis
• Enamel hypoplasia
III. Treatment objectives
• Management of chief complaint ( tooth #26)
• Behavioral management and modulation
• Patient education and motivation:
• Oral hygiene and its influence on dental caries and periodontal health
• Tooth brushing technique demonstration; use of appropriate toothbrush (soft) and the importance of
interdental cleaning (use of dental floss)
• Importance of diet and its role on caries activity
• Importance of regular dental visits and checkup
• Management of periodontal health/and prevention protocol (fluoride application)
• Restoration of carious teeth
• Restoration of root canal treated tooth with fixed dental prosthesis
• Replacement of missing tooth (implant supported fixed dental prosthesis)
• Management and monitoring of white spot lesions
• Regular recall, maintenance and review
IV. Final integrated treatment plan
• Phase 1 (Disease control phase):
• Case presentation and patient motivation
• Oral hygiene instructions and brushing technique demonstration
• Dietary analysis and advice
• Full mouth scaling, polishing and fluoride application
• Initiate pulp therapy: #12 (pulpectomy)
• Restoration of teeth #13, #23, #34,#35,#37,#47 (direct composite resin
restoration)
• Monitor of arrested caries: #47 mesially
• Monitor of white spot lesions
Patient's files and consent
forms
Thank you