Clinical Problem Solving in Dentistry


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Clinical Problem Solving in Dentistry

  1. 1. Examination Case • 1 Extraoral examination He is a fit and healthy-looking adolescent. No submental, submandibular or other cervical lymph nodes are palpable and the temporomandibular joints appear normal. Intraoral examinationA high caries rate The lower right quadrant is shown in Figure 1.1. The oral mucosa is healthy and the oral hygiene is reasonable. There is gingivitis in areas but no calculus is visible and probing depths are 3 mm or less. The mandibular right first molar is grossly carious and a sinus is discharging buccally. There are no other restorations in any teeth. No teeth have been extracted and the third molars are not visible. A small cavity is present on the occlusal surface of the mandibular right second molar. What further examination would you carry out?SUMMARY Test of tooth vitality of the teeth in the region of the sinus.A 17-year-old sixth-form college student presents at Even though the first molar is the most likely cause, theyour general dental surgery with several carious adjacent teeth should be tested because more than onelesions, one of which is very large. How should you tooth might be nonvital. The results should be comparedstabilize his condition? with those of the teeth on the opposite side. Both hot/cold methods and electric pulp testing could be used because extensive reactionary dentine may moderate the response. The first molar fails to respond to any test. All other teeth appear vital. Investigations What radiographs would you take? Explain why each view is required. Radiograph Reason taken Bitewing radiographs Primarily to detect approximal surface caries, and in this case also required to detect occlusal caries. Periapical radiograph of the lower right Preoperative assessment for first molar tooth, preferably taken with endodontic treatment or forFig. 1.1 The lower right first molar. The gutta percha point a paralleling technique extraction should it be necessary.indicates a sinus opening. Panoramic radiograph Might be useful as a general survey view in a new patient and toHistory determine the presence and position of third molars.ComplaintHe complains that a filling has fallen out of a tooth on the What problems are inherent in the diagnosis of caries inlower right side and has left a sharp edge that irritates his this patient?tongue. He is otherwise asymptomatic. Occlusal lesions are now the predominant form of caries in adolescents following the reduction in caries incidence overHistory of complaint the past decades. Occlusal caries may go undetected onThe filling was placed about a year ago at a casual visit to visual examination for two reasons. First, it starts on the fissurethe dentist precipitated by acute toothache triggered by hot walls and is obscured by sound superficial enamel, andand cold food and drink. He did not return to complete a secondly lesions cavitate late, if at all, probably becausecourse of treatment. He lost contact when he moved house fluoride strengthens the overlying enamel. Superimposition ofand is not registered with a dental practitioner. sound enamel also masks small and medium-sized lesions on bitewing radiographs. The small occlusal cavity in the secondMedical history molar arouses suspicion that other pits and fissures in theThe patient is otherwise fit and well. molars will be carious. Unless lesions are very large, extending
  2. 2. •2 1CASE A H I G H C A R I E S R AT E Fig. 1.2 Periapical and bitewing films. into the middle third of dentine, they may not be detected on bitewing radiographs. The radiographs are shown in Figure 1.2. What do you see? The periapical radiograph shows the carious lesion in the crown of the lower right first molar to be extensive, involving the pulp cavity. The mesial contact has been completely destroyed and the molar has drifted mesially and tilted. There are periapical radiolucencies at the apices of both roots, that on the mesial root being larger. The radiolucencies are in continuity with the periodontal ligament and there is loss of most of the lamina dura in the bifurcation and around the apices. The bitewing radiographs confirm the carious exposure and in addition reveal occlusal caries in all the maxillary and mandibular molars with the exception of the upper right first molar. No approximal caries is present. If two or more teeth were possible causes of the sinus, how might you decide which was the cause? A gutta percha point could be inserted into the sinus prior to taking the radiograph, as shown in Figure 1.1. A medium- or fine-sized point is flexible but resilient enough to pass along Fig. 1.3 Another case, showing gutta percha point tracing the the sinus tract if twisted slightly on insertion. Points are path of a sinus. radiopaque and can be seen on a radiograph extending to the source of the infection, as shown in another case in Figure 1.3. What temporary restoration materials are available? Diagnosis What are their properties and in what situations are they useful? What is your diagnosis? See Table 1.2. The patient has a nonvital lower first molar with a periapical Why is one molar so much more broken down than the abscess. In addition he has a very high caries rate in a others? previously almost caries-free dentition. It is difficult to be certain but the extensive caries is probably, in part, a result of the previous restoration. In view of the Treatment pattern of caries in the other molars, it seems likely that this The patient is horrified to discover that his dentition is in was a large occlusal restoration and the history suggests it such a poor state, having experienced only one episode of was placed in a vital tooth. It probably undermined the toothache in the past. He is keen to do all that can be done mesial cusps or marginal ridge. Three factors could have to save all teeth and a decision is made to try to restore the contributed to the extensive caries present only 1 year later: lower molar. marginal leakage, undermining of the marginal ridge or mesial cusps leading to collapse, or failure to remove all the How will you prioritize treatment for this patient? Why carious tissue from the tooth. Failure to remove all carious should treatment be provided in this sequence? enamel and dentine is a common cause of failure in amalgam See Table 1.1. restorations.
  3. 3. 3• 1 CASE A H I G H C A R I E S R AT ETable 1.1 Sequence of treatmentPhase of treatment Items of treatment ReasonsImmediate phase Caries removal from the lower right first molar, access cavity Essential if the tooth is to be saved and to remove the source of the apical infection. There is also preparation for endodontics, drainage, irrigation with sodium an urgent need to minimize further destruction of this tooth, which may soon be unrestorable. hypochlorite and placement of a temporary restoration The temporary restoration is necessary to facilitate rubber dam isolation during future endodontic treatment, and it will also stabilize the occlusion and stop mesial drift.Stabilization of caries Removal of caries and placement of temporary restorations in all To prevent further tooth destruction and progression to carious exposure while other phases of carious teeth in visits by quadrants/two quadrants treatment are being carried out.Preventive treatment Dietary analysis, oral hygiene instruction, fluoride advice Should start immediately and extend throughout the treatment plan, to reduce the high caries rate and ensure the long-term future of the dentition.Permanent restoration Will depend on what is found while placing temporary restorations Permanent restorations may be left until last; stabilization takes priority.Table 1.2 Temporary restoration materialsMaterial Examples Properties SituationsZinc oxide and eugenol pastes Kalzinol Bactericidal, easy to mix and place, cheap but not very strong. Suitable for temporary restoration of most cavities provided there is no Easily removed. significant occlusal load. Endodontic access cavities.Self-setting zinc oxide cements Cavit Harden in contact with saliva. Endodontic access cavities. Coltosol Reasonable strength and easily removed. No occlusal load.Polycarboxylate cements Poly-F Adhesive to enamel and dentine, hard and durable. Used when mechanical retention is poor. Strong enough to enable rubber dam placement when used in a badly broken down tooth.Glass ionomer including silver Chem-fil Adhesive to enamel and dentine, hard and durable. Good As polycarboxylate cements and also useful in anterior teeth.reinforced preparations Shofu Hi-Fi appearance. Ketac Silver How would you ensure removal of all carious tissue when a susceptible tooth surface. Denying the plaque flora its restoring the vital molars? substrate sugar is the most effective measure to halt the progression of existing lesions and prevent new ones forming. Removal of all softened carious tissue at the amelodentinal No preventive measure affecting the flora or tooth is as junction is essential and only stained but hard dentine can be effective. A further advantage of emphasis on diet is that it left in place. forces the patient to acknowledge that they must take Removal of carious dentine over the pulp is treated responsibility for preventing their own disease. differently. In a young patient with large pulp chambers there is always a tendency for the operator to be conservative but How would you evaluate a patient’s diet? this might be counterproductive if softened or infected Dietary analysis consists of two elements: enquiry into lifestyle dentine were left below the restoration. Very soft or flaky and into the dietary components themselves. Information dentine must always be removed. Slightly soft dentine can be about the diet itself is of little value unless it is taken in left in situ provided a good well-sealed restoration is placed context with the patient’s lifestyle. Only dietary over it. Deciding whether to leave the last layers of softened recommendations tailored to the patient’s lifestyle are likely dentine can be difficult and the decision rests to a degree on to be adopted. clinical experience. Pain associated with pulpitis indicates a need to remove more dentine or, if severe, a need for elective The diet record should include all the foods and drinks endodontics. Interpreting softened dentine in rapidly consumed, the amount (in readily estimated units) and the advancing lesions is difficult. The deepest layers are soft time of eating or drinking. through demineralization but are not necessarily infected and In this case it should be noted that the patient is a 17-year- may sometimes be left over the pulp. Also, bacterial old student. Lifestyle often changes dramatically between the penetration of the dentine is not reliably indicated by staining ages of 16 and 20. He may no longer be living at home and in rapidly advancing lesions. Removal of the last layers of may be enjoying physical, financial and dietary independence carious dentine may require some courage in deep lesions. from his parents. He may be poor and be eating a cheap More detailed information on caries removal is included in carbohydrate-rich diet of snacks instead of regular meals. problem 9, ‘A large carious lesion’. Long hours of studying may be accompanied by the frequent consumption of sweetened drinks. What is the most important preventive procedure for this Analysis of the diet itself may be performed in a variety of patient? Explain why. ways. The patient can be asked to recall all foods consumed Diet analysis. Caries requires dietary sugars, in particular over the previous 24 hours. This is not very effective, relying sucrose, glucose and fructose, an acidogenic plaque flora and as it does on a good memory and honesty, and is unlikely to
  4. 4. •4 1CASE A H I G H C A R I E S R AT E give a representative account. Relying on memory for more be beneficial to use a weekly fluoride rinse as well. This could than 24 hours is too inaccurate. be continued for as long as the diet is felt to be unsafe. The most effective method is for the patient to keep a written Oral hygiene instruction is also important, but may be record of their diet for 4 consecutive days, including 2 emphasized in a later phase of treatment. It will not stop working and 2 leisure days. The need for the patient to caries progression, which is critical for this patient, and there comply fully and assess their diet honestly must be stressed is only a mild gingivitis. and, of course, the diet should not be changed because it is being recorded. Ideally the analysis should be performed Assuming good compliance and motivation, how will you before any dietary advice is given. Even the patient who does restore the teeth permanently? not keep an honest account has been made more aware of The mandibular right first molar requires orthograde their diet. If they know what foods to omit from the sheet to endodontic treatment and replacement of the temporary make their dentist happy, at least the first step in an restoration with a core. Retention for the core can be educative process has been made. provided by residual tooth tissue, provided carious How will you analyse this patient’s 4-day diet sheet destruction is not gross. The restorative material may be shown in Figure 1.4? What is the cause of his caries packed into the pulp chamber and the first 2–3 mm of the susceptibility? root canal. If insufficient natural crown remains, it may be supplemented with a preformed post in the distal canals. The Highlight sugar-rich foods and drinks as in Figure 1.4. distal canal is not ideal, being further from the most Note whether they are confined to meal times or whether extensively destroyed area, but it is larger. they are eaten frequently and spaced throughout the day The other molar teeth will need to have their temporary as snacks. The number of sugar attacks should be counted restorations replaced by definitive restorations. Caries and discussed with the patient. Also note the consistency of involved only the occlusal surface but removal of these large the food because dry and sticky foods take longer to be lesions has probably left little more than an enamel shell. cleared from the mouth. Sugared drinks taken immediately Restoration of such teeth with amalgam would require before bed are highly significant because salivary flow is removal of all the unsupported, undermined enamel leaving reduced during sleep and clearance time is greater. Identify little more than a root stump and a few spurs of tooth tissue. foods with a high hidden sugar content because patients Restoration could be better achieved with a radiopaque glass often do not realize that such foods are significant; examples ionomer and composite hybrid restoration. The glass ionomer are baked beans, breakfast cereals, tomato ketchup and ‘plain’ used to replace the missing dentine must be radiopaque so biscuits. that it is not confused with residual or secondary caries on The diet sheet shows that the main problem for this radiographs. A composite linked to dentine with a bonding patient is too many sugar-containing drinks, and frequent agent would be an alternative to the glass ionomer. snacks of cake and biscuits. Most meals or snacks contain a high sugar item and some more than one. The other typical Figure 1.5 shows the restored lower first molar 2 months cause of a high caries rate in this age group is sweets, after endodontic treatment. What do you see and what especially mints. long-term problem is evident? What advice will you give the patient? There is good bone healing around the apices and in the bifurcation. Complete healing would be expected after 6 The principles of a safer diet are shown in Table 1.3 (p. 6). months to 1 year at which time the success of root treatment Dietary advice is almost always provided using the health- can be judged. belief model of health education. However, it is well-known As noted in the initial radiographs, the lower right first molar that education about the risks and consequences of lifestyle, has lost its mesial contact, drifted and tilted. This makes it habits and diet is often ineffective. It is important to judge impossible to restore the normal contour of the mesial the patient’s likely compliance and provide dietary advice surface and contact point. The mesial surface is flat and there that can be used to make small but significant changes is no defined contact point. In the long term there is a risk of rather than attempting to eradicate all sugar from the diet. caries of the distal surface of the second premolar, and the As the diet improves, the advice can be adapted and caries is likely to affect a wider area of tooth and extend extended. further gingivally than caries below a normal contact. The Advice must be acceptable, practical and affordable. In this area will also be difficult to clean and there is a risk of case the patient has already suffered serious consequences localized periodontitis. Tilting of the occlusal surface may also from his poor diet and this may help change behaviour. favour food packing into the contact unless the contour of The patient must be made aware that damage to teeth the restoration includes an artificially enhanced marginal continues for up to 1 hour after a sugar intake. The ridge. explanation given to some patients may be no more than this This tooth may require a crown in the long term. Much of the simple statement. Many other patients can comprehend the enamel is undermined and the tooth is weakened by concept (if not the detail) of a Stephan curve without endodontic treatment. A crown would allow the contact to difficulty. have a better contour but the problem is insoluble while the The patient should be advised to use a fluoride-containing tooth remains in its present position. Orthodontic uprighting toothpaste. During the period of dietary change it would also could be considered.
  5. 5. John Smith4 day diet analysis sheet for................................. Thursday Friday Saturday Sunday Time Item Time Item Time Item Time Item 7.00 2 cups of tea 7.30 4 chocolate biscuits Before breakfast with 2 sugars tea with 2 sugars sausages 8.30 banana 8.00 chocolate puffed rice pitta bread breakfast cereal Breakfast 8.30 ketchup 1 glass cola drink tea with 2 sugars 1 glass cola drink 10.30 4 slices toast 9.20 9.30 mug hot chocolate 11.00 1 slice cherry cake hot chocolate packet crisps and peanut butter Morning can of diet cola drink 1 piece cake 11.15 chocolate bar turkey salad 1.00 pm 2 pieces cheese on 1 slice cake 1.00 pm fish pie 12.30 12.30 sandwich toast, garlic sausage tea with 2 sugars 1 glass cola drink Mid-day meal 1 glass cola drink 1 slice cake tea with 2 sugars 1 glass cola drink 4.00 pm fizzy drink 4.30 pm ham 3.00 pm sausages, beans, 2.00 pm tea with 2 sugars chocolate bar 1 piece cake toast. 1 biscuit Afternoon 1 slice cake tea with 2 sugars an orange 4.30 pm 1 piece cake 1 can cola drink tea with 2 sugars 5.00 pm 1 glass cola drink 6.00 pm bar of chocolate salad, garlic burger and chips 8.00 pm spaghetti bolognaise 9.00 pm fish and chips, peas Evening meal 6.00 pm sausage, ham, 7.30 pm 1 can of cola drink ice cream 1 cola drink coleslaw sausages tea with 2 sugars 9.30 pm Evening 10.30 pm crisps 1 glass fizzy drinkFig. 1.4 The patient’s diet sheet. A H I G H C A R I E S R AT E 5• 1 CASE
  6. 6. •6 1CASE A H I G H C A R I E S R AT E Table 1.3 Dietary advice Aims Methods Reduce the amount of sugar Check manufacturers’ labels and avoid foods with sugars such as sucrose, glucose and fructose listed early in the ingredients. Natural sugars (e.g. honey, brown sugar) are as cariogenic as purified or added sugars. When sweet foods are required, choose those containing sweetening agents such as saccharin, acesulfame-K and aspartame. Diet formulations contain less sugar than their standard counterparts. Reduce the sweetness of drinks and foods. Become accustomed to a less sweet diet overall. Restrict frequency of sugar intakes to meal Try to reduce snacking. When snacks are required select ‘safe snacks’ such as cheese, crisps, fruit or sugar-free sweets, such as mints or chewing gum times as far as possible (which not only has no sugar but also stimulates salivary flow and increases plaque pH). Use artificial sweeteners in drinks taken between meals. Speed clearance of sugars from the mouth Never finish meals with a sugary food or drink. Follow sugary foods with a sugar-free drink, chewing gum or a protective food such as cheese. Why not simply extract the lower molar? Extraction of the lower right first molar may well be the preferred treatment. The caries is extensive, restoration of the tooth will be complex and expensive and problems will probably ensue in the long term. The missing tooth might not be readily visible. To a large degree the decision will depend on the patient’s wishes. If he would be happy with an edentulous space, the extraction appears an attractive proposition. However, if a restoration is required, a bridge will require preparation of two further teeth. A denture-based replacement is probably not indicated but an implant might be considered at a later date. Any hesitancy or uncertainty on the patient’s part might well influence you to propose extraction. Another factor affecting the decision is the condition and Fig. 1.5 Periapical radiograph of the restored lower first molar. long-term prognosis of the other molars. If further molars are likely to be lost in the short or medium term it makes sense to conserve whichever teeth can be successfully restored.