Dental Treatment Problem List - Patient SM

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  • 1. DR. ASHLEY MARKTREATMENT PLANNING BOARD PRESENTATION 15 Oct 10
  • 2. Treatment Overview StatementPatient chief complaint: “I’m missing several teeth and have decay in a lot of teeth. I just wantto 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, andprosthodontic treatment. Restoration and preservation of his dentition will provide a mutuallyprotected occlusion, restoring function and esthetics while addressing his chief complaint.Following maxillary and mandibular orthodontic treatment, his maxillary arch will be restoredwith crowns and two fixed dental prostheses (FDP). The mandibular arch will receive animplant supported removable dental prosthesis (ISRDP) to facilitate chewing on his left side.Patient S’s treatment will be completed in several phases.Preparatory PhasePatient 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 smokingcessation. The preparatory phase of Patient S’s treatment begins with arresting the cariesprocess 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 beendodontically retreated due to the presence of a radiolucent apical lesion, and deficientradiographic obturation. Patient S’s oral hygiene is poor, and he will undergo initial nonsurgical periodontal therapy with detailed oral hygiene instructions to treat his generalizedslight chronic periodontitis. Periodontal re-evaluation of initial periodontal therapy andcompletion 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 directrestorative materials to restore both arches. If Patient S demonstrates acceptable levels of oralhygiene and diet compliance at a 3 months re-evaluation, we will continue with the preparatoryphase of treatment and initiate orthodontic treatment. An endosseous 1-stage implant will beplaced approximately 3 months after the initiation of orthodontic treatment. If required, thisimplant will be used for orthodontic anchorage, and finally, to act as a supportive and retentiveelement for a mandibular Kennedy Class III RDP.Corrective PhaseFollowing successful completion of the preparatory phase, I will commence with restoringPatient S’s dentition. Restoration of his maxillary arch will include PFM crowns fabricated forteeth #’s 3,6,7,8,9,10 and a PFM FDP from teeth #‘s 11-14. His mandibular arch will be restoredusing surveyed PFM crowns fabricated for teeth #‘s 21&28. A Locator abutment will providesupport and retention for a mandibular Kennedy Class III RDP to replace extracted teeth #’s18,19,20,29,30. 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 trialmaintenance program for one year followed by a 6 month recall after one year.!All treatment will be completed using universal precautions and personal protectiveequipment. All instruments will be autoclave sterilized. Other items and surfaces will bedisinfected with Dispatch for a minimum of two minutes contact time.
  • 3. Patient: SPatient IdentificationxxxxxxxxxChief Complaint“I’m missing several teeth and have decay in a lot of teeth. I just want to get that cleared up so Iwill 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 myfront teeth look. ”Medical/Systemic OverviewGeneral AppearancePatient S appears to be a well-nourished male in apparent good healthFamily 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 issuesFamily Dental HistoryFather: DentateMother: DentateBrother: DentateChildren: DentateSocial HistoryMarital Status: MarriedAlcohol: 6 pack of beer/weekTobacco: 1 ppd for 16 years. Quit for 3 years and started start smoking again. Has quitsmoking since 30 Aug 10. Patient referred to smoking cessation program.Physical Fitness: FitNutritionBreakfast: Coffee – Black
  • 4. Lunch: Sandwich/ChipsDinner: Spaghetti, Pizza, BBQSnacks: ChipsFluids: Water/Diet CokePast 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: GoodCurrent 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 ofhis BP and feels that smoking cessation will assist in decreasing his blood pressure.Physical ExamHeight: 76”Pulse: 81 bpmWeight: 230 lbsBP: 153/84Resp rate: 14BMI: 28 Normal weight = 18.5–24.9 Overweight = 25–29.9Past Dental HistoryOverview: Patient S has had intermittent dental care prior to Active Duty (2 yrs ago) and it wasmainly on an emergent basis. All procedures were well tolerated.Oral HygieneBrushing: Electronic Sonicare Toothbrush once per dayFlossing: 3 times per week 4
  • 5. Oral PathologyExtra Oral ExamLymphadenopathy: No tender or enlarged lymph nodesThyroid: No swelling or masses detectedMuscle Palpation: No tender muscles detectedTMJ ExamNoises: None detectedMaximum Opening: 45 mmProtrusive: 3 mmRight Lateral Excursion: 10 mmLeft Lateral Excursion: 12 mmIntra Oral ExamLips: WNLCheeks: WNLBuccal Mucosa: WNLRidges/Gingiva: WNLPalate: WNLTongue: WNLFloor of the Mouth: WNLOral Cancer Screen: NegativeRestorative:Caries Risk Assessment: High ≥ 2 Lesions in the past 3 years Poor oral hygiene Moderately high CHO diet (Monster soda BID during deployment) Irregular dental visitsCarious Lesions:#4 DO#6 Bu#7 MDLiBu#8 MLi#9 MLiBu#10 DLi#31 Bu Pit 5
  • 6. Defective Restorations:#3 MOBu Amal#5 O Amal#8 DLiBu Comp#9 DLiBu#10 MLi#14 MOLi Amal#21 O Amal#28 DOLi CompMissing Teeth #’s:3rd molars (1,16,17,32) & #’s2,12,13,15,18,19,20,29,30EndodonticsSymptomatic teeth: NilEndodontically treated teeth: #9History:The initial endodontic treatment of tooth #9 was completed at age 12and 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 previouslyendodontically treated #9 with a non metallic restorative material inthe access opening and in the mesial/distal of the tooth. A cariouslesion was present in mesial and distal of #9 and was restored with aGI restorative material (Sep 10). The crestal bone appears to be intactand the PDL space is continuous until the apex, where a radiolucentlesion is faintly visible. Tooth #9 appears to be a single canalobturated with a radiographically dense core material surrounded bya less radiopaque material. 6
  • 7. 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 surfacesProbing dePatienths ≥4mm: #10 DBu & MBu #11Bleeding 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, 28Keratinized Gingiva: : Generally 4-5 mm on both mandibular and maxillary arches CLINICAL FINDINGS TOOTH # PERCUSSION PA L PAT I O N PROBING COLD TEST MOBILITY (MILLER) 3 Negative Negative ≤4mm Normal 0 4 Negative Negative ≤4mm Normal 0 5 Negative Negative ≤4mm Normal 0 6 Negative Negative ≤4mm Normal 0 7 Negative Negative ≤4mm Normal 0 8 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 14 Negative Negative ≤4mm Normal 0 21 Negative Negative ≤4mm Normal 0 22 Negative Negative ≤4mm Normal 0 23 Negative Negative ≤4mm Normal 0 24 Negative Negative ≤4mm Normal 0 25 Negative Negative ≤4mm Normal 0 26 Negative Negative ≤4mm Normal 0 27 Negative Negative ≤4mm Normal 0 7 28 Negative Negative ≤4mm Normal 0 31 Negative Negative ≤4mm Normal 0
  • 8. Clinical Attachment Level: Teeth #’s 22 - 4mm, 27 - 4mm, 28 - 4mmClassification of Periodontal Disease: Generalized slight chronic periodontitis 8
  • 9. Orthodontics 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±2mm 10mm F -2mm±2mm F.H.R 60-64% 60% MP-FH M 23°±4° 30° F 24°±4° 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 9 NLA 100°±10° 108° FCA -11°±4° -12°
  • 10. H O R I Z O N TA L R A D I O G R A P H I C B O N E LOSS 10% 10% 10% 10% 15% 10% } 5mm 20mm 10
  • 11. 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 bruxismAnalysis 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 archFacial Esthetics:! Smile: Shows approximately 5mm max anterior tooth structure! Profile: Convex profile, Slightly obtuse nasolabial angle! Lip Competence: Competent 11
  • 12. 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 #14ProsthodonticsNon-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 12
  • 13. Esthetics (priority based on the patient’s chief complaint)Edentulous space:! Lack of dentition (left mx posterior) when the patient smilesAnterior 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!! ! 19 Years Old 13
  • 14. Problem List by DisciplineChief complaint:“I’m missing several teeth and have decay in a lot of teeth. I just want to get that cleared up so Iwill have a full set of teeth”Medical/systemic: Uncontrolled Stage 1 HypertensionRestorative:" 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 CompEndodontics: Tooth #9 - Previously endodontically treated tooth with asymptomatic apical! periodontitisPeriodontics: Generalized slight chronic periodontitisOrthodontics: Supraerupted tooth #14, mandibular diastemas, midline discrepancyOcclusion: No mutually protected occlusion, no anterior guidanceProsthodontics: Several edentulous spaces, parafunctional habit (bruxism)Esthetics: Left mx edentulous ridge; short clinical ant max crowns, discolored tooth #9, mddiastemas 14