dental treatment problem list - patient sm

DR. ASHLEY MARKTREATMENT PLANNING BOARD PRESENTATION

15 Oct 10

Treatment Overview Statement

Patient chief complaint: “I’m missing several teeth and have decay in a lot of teeth. I just want to get that cleared up so I will have a full set of teeth.”I will address Patient S’s chief complaint through periodontal, restorative, orthodontic, and prosthodontic treatment. Restoration and preservation of his dentition will provide a mutually protected occlusion, restoring function and esthetics while addressing his chief complaint. Following maxillary and mandibular orthodontic treatment, his maxillary arch will be restored with crowns and two fixed dental prostheses (FDP). The mandibular arch will receive an implant supported removable dental prosthesis (ISRDP) to facilitate chewing on his left side. Patient S’s treatment will be completed in several phases.

Preparatory Phase

Patient S is a 34 year old high caries risk patient with generalized slight chronic periodontitis. He has smoked 1 pack per day (ppd) for 16 years and is currently undergoing smoking cessation. The preparatory phase of Patient S’s treatment begins with arresting the caries process through application of the Anderson Medical Model. Teeth #‘s 3,4,5,6,7,8,9,10,14,20, 28,&31 will be restored with glass ionomer provisional restorations. Tooth #9 will be endodontically retreated due to the presence of a radiolucent apical lesion, and deficient radiographic obturation. Patient S’s oral hygiene is poor, and he will undergo initial non surgical periodontal therapy with detailed oral hygiene instructions to treat his generalized slight chronic periodontitis. Periodontal re-evaluation of initial periodontal therapy and completion of the Medical Model will provide a treatment decision point. If there is non-compliance, I will fabricate maxillary and mandibular treatment partial dentures and use direct restorative materials to restore both arches. If Patient S demonstrates acceptable levels of oral hygiene and diet compliance at a 3 months re-evaluation, we will continue with the preparatory phase of treatment and initiate orthodontic treatment. An endosseous 1-stage implant will be placed approximately 3 months after the initiation of orthodontic treatment. If required, this implant will be used for orthodontic anchorage, and finally, to act as a supportive and retentive element for a mandibular Kennedy Class III RDP.

Corrective PhaseFollowing successful completion of the preparatory phase, I will commence with restoring Patient S’s dentition. Restoration of his maxillary arch will include PFM crowns fabricated for teeth #’s 3,6,7,8,9,10 and a PFM FDP from teeth #‘s 11-14. His mandibular arch will be restored using surveyed PFM crowns fabricated for teeth #‘s 21&28. A Locator abutment will provide support and retention for a mandibular Kennedy Class III RDP to replace extracted teeth #’s 18,19,20,29,30. A maxillary bruxism splint will be fabricated for him to wear at night.

Maintenance PhaseUpon completion of the corrective phase, Patient S will be placed on a three month trial maintenance program for one year followed by a 6 month recall after one year.!All treatment will be completed using universal precautions and personal protective equipment. All instruments will be autoclave sterilized. Other items and surfaces will be disinfected with Dispatch for a minimum of two minutes contact time.

Patient: SPatient Identification

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Chief Complaint“I’m missing several teeth and have decay in a lot of teeth. I just want to get that cleared up so I will have a full set of teeth”

Treatment Expectations“I think it would be easier to have dentures. Either a plate or implants and I like the way my front teeth look. ”

Medical/Systemic Overview General AppearancePatient S appears to be a well-nourished male in apparent good health

Family Medical HistoryFather: 52 years old; smoker 1 ppdMother: 52 years old; smoker 1ppdSiblings: 1 older brother; 36 years oldChildren: 3 children (15,13,10) – No medical issues

Family Dental HistoryFather: DentateMother: DentateBrother: DentateChildren: Dentate

Social HistoryMarital Status: MarriedAlcohol: 6 pack of beer/weekTobacco: 1 ppd for 16 years. Quit for 3 years and started start smoking again. Has quit smoking since 30 Aug 10. Patient referred to smoking cessation program.Physical Fitness: Fit

NutritionBreakfast: Coffee – Black

Lunch: Sandwich/ChipsDinner: Spaghetti, Pizza, BBQSnacks: Chips Fluids: Water/Diet Coke

Past Medical HistoryAllergies: Penicillin (unconfirmed - allergic event was 20 yrs. ago), NK food or latex allergiesHypertension: Patient was on antihypertensive medications prior to enlisting. He was ! instructed to stop HTN meds by recruiters in order to qualify to enlist.

Overall Health: Good

Current Medical StatusAllergies: Penicillin (unconfirmed - event was 20 yrs. ago), NK food or latex allergiesMedications! Loratidine - PO 10 mg - seasonal allergiesSocial: Non smokerHypertension: Patient’s BP is 153/84 (Stage 1 hypertension). Patient has been made aware of his BP and feels that smoking cessation will assist in decreasing his blood pressure.

Physical ExamHeight: 76” Pulse: 81 bpmWeight: 230 lbs BP: 153/84Resp rate: 14 BMI: 28

Normal weight = 18.5–24.9 Overweight = 25–29.9

Past Dental HistoryOverview: Patient S has had intermittent dental care prior to Active Duty (2 yrs ago) and it was mainly on an emergent basis. All procedures were well tolerated.

Oral HygieneBrushing: Electronic Sonicare Toothbrush once per dayFlossing: 3 times per week

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Oral PathologyExtra Oral ExamLymphadenopathy: No tender or enlarged lymph nodesThyroid: No swelling or masses detected Muscle Palpation: No tender muscles detected

TMJ ExamNoises: None detectedMaximum Opening: 45 mm Protrusive: 3 mmRight Lateral Excursion: 10 mm Left Lateral Excursion: 12 mm

Intra Oral ExamLips: WNLCheeks: WNLBuccal Mucosa: WNLRidges/Gingiva: WNLPalate: WNLTongue: WNLFloor of the Mouth: WNLOral Cancer Screen: Negative

Restorative:Caries Risk Assessment: High

≥ 2 Lesions in the past 3 yearsPoor oral hygieneModerately high CHO diet (Monster soda BID during deployment)Irregular dental visits

Carious Lesions:#4 DO#6 Bu#7 MDLiBu#8 MLi#9 MLiBu#10 DLi#31 Bu Pit

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Defective Restorations:#3 MOBu Amal#5 O Amal#8 DLiBu Comp#9 DLiBu#10 MLi#14 MOLi Amal#21 O Amal#28 DOLi Comp

Missing Teeth #’s: 3rd molars (1,16,17,32) & #’s 2,12,13,15,18,19,20,29,30

EndodonticsSymptomatic teeth: NilEndodontically treated teeth: #9History:The initial endodontic treatment of tooth #9 was completed at age 12 and retreated due to discoloration when the patient was 17 y.o. Tooth #9 is currently asymptomatic.Radiographic interpretation: A periapical radiograph of tooth #9 shows a previously endodontically treated #9 with a non metallic restorative material in the access opening and in the mesial/distal of the tooth. A carious lesion was present in mesial and distal of #9 and was restored with a GI restorative material (Sep 10). The crestal bone appears to be intact and the PDL space is continuous until the apex, where a radiolucent lesion is faintly visible. Tooth #9 appears to be a single canal obturated with a radiographically dense core material surrounded by a less radiopaque material.

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PeriodonticsGingival Quality: ! Maxilla: Generalized erythematous marginal gingiva, blunted papilla with some ! stippling! Mandible: Generalized knife-edged papillae, healthy coral pink color with stippling ! presentOral Hygiene Status: Poor to Moderate oral hygienePlaque Assessment Scoring System (PASS) score: 15% Plaque free surfaces Probing dePatienths ≥4mm: #10 DBu & MBu #11 Bleeding on Probing: Teeth #‘s 3,4,5,6,7,8,9,10,11,14Calculus: Moderate calculus mandibular incisorsRecession: Miller Class I - Buccal surface of #’s 22, 27, 28 Keratinized Gingiva: : Generally 4-5 mm on both mandibular and maxillary arches

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CLINICAL FINDINGSCLINICAL FINDINGSCLINICAL FINDINGSCLINICAL FINDINGSCLINICAL FINDINGSCLINICAL FINDINGS

TOOTH # PERCUSSION PALPATION PROBING COLD TEST MOBILITY(MILLER)

3 Negative Negative ≤4mm Normal 0






9 (RCT’d) Negative Negative ≤4mm No response 0

10 Negative Negative 4mm Normal 0

11 Negative Negative 4mm Normal 0











Clinical Attachment Level: Teeth #’s 22 - 4mm, 27 - 4mm, 28 - 4mmClassification of Periodontal Disease: Generalized slight chronic periodontitis

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Orthodontics

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Caucasian Patient

SNA 82°±2° 81°

SNB 80°±4° 78°

ANB 2°±2° 3°

Witts M-1/F 0±2mm 3mm

A-N⊥ 1mm±2.5mm 2.5mm

Pg-N⊥ M 0mm±2mmF -2mm±2mm

10mm

F.H.R 60-64% 60%

MP-FH M 23°±4°F 24°±4°

30°

MP-SN 32°±5° 37°

SGn-FH 59°±3° 70°

U1-SN 104°±6° 99°

U1-PP 112°±6° 107°

U1-A⊥ 5mm 4mm

U1-NA 22°±4 18°

U1-NA 4mm 3mm

L1-NB 25°±4° 29°

U1-NB 4mm 6mm

U1-L1 131°±6° 132°

L1-MP 93°±7° 92°

U1-Lip 2mm±1mm 0

NLA 100°±10° 108°

FCA -11°±4° -12°

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HORIZONTAL RADIOGRAPHIC BONE

LOSS


LOSS


LOSS

10% 10% 10%

10% 15% 10%

} 5mm

20mm

OrthodonticsAngle Classification: " Molar - Left and Right- Unable to determine! Canine - Left and Right - Class ISkeletal: Class I skeletal ANB =3°Overbite: 0% " " " Overjet: Tooth #8 - 1mm, Tooth #9 - 2mmMidlines:" Maxillary: Coincident with facial midline! Mandibular: 2mm right deviation of maxillary midlineWear Pattern: Moderate wear Mx/Md anterior teeth, Occlusal wear facets on Mx/Md ! posteriorParafunctional Habits: Nocturnal bruxism

Analysis of Diagnostic RecordsAlignment and Symmetry:" Maxillary Arch: U-shaped arch, posterior right segment spacing, missing teeth #12/13 ! Mandibular Arch: U-shaped arch, missing teeth #’s: 18,19,20,29,30; diastemas between ! ! anterior teeth, #21/28 distally tipped, #31 mesially tipped! Bolton analysis: 3-3: -0.6 mm discrepancy in the maxillary arch

Facial Esthetics:! Smile: Shows approximately 5mm max anterior tooth structure! Profile: Convex profile, Slightly obtuse nasolabial angle! Lip Competence: Competent

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OcclusionAngle Classification: " Molar - Left and Right- Unable to determine! Canine - Left and Right - Class IOverbite: 0% " " " Overjet: Tooth #8 - 1mm, Tooth #9 - 3mmWear Pattern: Moderate wear Mx/Md Anterior teeth, Occlusal wear facets on Mx/Md ! posteriorParafunctional Habits: Nocturnal bruxismExcursive Movements: " Right lateral md movement:! ! Working side: #31/3 and incisors" Left lateral md movement: " " Working side: Incisors! ! Non working side interference: #31/3! Protrusive movement: #31/3Crossbite: Posterior right side & #6/27SupraeruPatiention: Tooth #14

ProsthodonticsNon-restorable teeth: NoneMissing teeth to be replaced: " Max Arch: #12,13 " Md Arch: #18,19,20,29,30Mutually protected Occlusion: NoAnterior Guidance: NoResidual Ridge defects: " Allen Cl A #12-13" Allen Cl C #20-17 and #29-30Cross Bite: Posterior right side & #6/27Short Clinical Crowns: ! Ant mx teeth #‘s 6-11! Posterior teeth #’s: 14, 20, 28Vertical Dimension of Occlusion (VDO): No loss of VDO" VDO was evaluated with three different techniques:! Freeway Space: 3mm (Points measured from tip of nose to chin at rest and at maximum ! ! ! ! intercuspation)! Phonetics: (Letter F/S/60-66): WNL! Corners of the mouth: Not turned downwards and no history of angular cheilitis

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Esthetics (priority based on the patient’s chief complaint)

Edentulous space:! Lack of dentition (left mx posterior) when the patient smiles

Anterior Mx Teeth ! Shape: Short anterior maxillary clinical crowns! ! Tooth #8: 6mm (inciso-gingival)/8mm (mesio-distal)! ! Tooth #9: 8mm (inciso-gingival)/8mm (mesio-distal)! Shade: Previously endodontically treated tooth #9 has lower value relative to adjacent ! ! teeth!! !

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19 Years Old

Problem List by Discipline

Chief complaint:

“I’m missing several teeth and have decay in a lot of teeth. I just want to get that cleared up so I will have a full set of teeth”

Medical/systemic: Uncontrolled Stage 1 Hypertension

Restorative:

" Carious Lesions:! ! #4 DO! !! ! #6 Bu! ! #7 MDLiBu! ! #8 MLi! ! #9 MLiBu! ! #10 DLi! ! #31 Bu Pit" Defective Restorations:! ! #3 MOBu Amal! ! #5 O Amal! ! #8 DLiBu Comp! ! #9 DLiBu! ! #10 MLi! ! #14 MOLi Amal! ! #21 O Amal! ! #28 DOLi Comp

Endodontics: Tooth #9 - Previously endodontically treated tooth with asymptomatic apical ! periodontitis

Periodontics: Generalized slight chronic periodontitis

Orthodontics: Supraerupted tooth #14, mandibular diastemas, midline discrepancy

Occlusion: No mutually protected occlusion, no anterior guidance

Prosthodontics: Several edentulous spaces, parafunctional habit (bruxism)

Esthetics: Left mx edentulous ridge; short clinical ant max crowns, discolored tooth #9, md diastemas

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dental treatment problem list - patient sm

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