1) This document presents a comprehensive treatment plan for an 63-year-old retired veteran with a history of back surgery and arthritis. 2) The plan addresses numerous carious and defective restorations, periodontal disease, missing teeth, and a lesion in the floor of the mouth. 3) The proposed treatment involves multiple phases including emergency extractions, restorative and endodontic work, fixed and removable prosthodontics, and periodic maintenance to improve the patient's oral health.

1. Welcome to the AEGD-2

2. Comprehensive Care
Treatment Plan Presented by
Captain Alfred G. Khallouf
AEGD-2 Resident
Class of 2005

3. Introducing Our Patient
63 years old
Male
African-American
Attitude-Positive
Patient type-
Philosophical

4. Historical Notes
Retired from USAF in
1984 as a MSgt
Married with 6 kids and
8 grandchildren and 2
great-grandchildren
States that he is in good
health and somewhat
active
Lived in San Antonio
area since 1982

5. Subjective Findings
Chief Complaint: “I have a bunch of
problems I want to fix.”
Denies any history of smoking
Sporadic dental tx. at a civilian dentist.
Other major concern is missing crown
from tooth # 7

6. Medical
History
AF Form 696

7. Medical / Systemic
History of back surgery to replace 2
cervical disks. Undergoing Physical
Therapy at WHMC
Seen at WHMC for Arthritis and high
B.P. which is controlled by medication
B.P. average: 138 / 88
Reports no known drug allergies

8. Medication
Aspirin 350mg daily
Celecoxib 200 mg twice daily
Effexor 75 mg once daily
Indocin 50 mg daily

9. Med use, regimen, effects
and concerns

10. Oral Pathology

11. Oral Pathology
Sinus Tract present
adjacent to # 30,
asymptomatic
Subgingival Caries
extending into pulp
Class II Furcation
involvement
Dx. Pulpal Necrosis w/
Chronic Apical
Periodontitis

12. Oral Pathology
5x2x3mm pedunculated
pink lesion with fingerlike
projections in the floor of
the mouth
Patient unaware of
asymptomatic lesion
Differential Diagnosis
● Squamous Papilloma
● Verruca Vulgaris
● Condyloma Acuminatum

13. Restorative Findings
Caries risk: High
Numerous Carious teeth and defective
restorations: #s 3-MODFL; 5-O; 6-F; 7-
missing crown; 8-MI; 9MID; 10-L; 11-F ;
12-MOD; 13-O; 14-MODL; 15-MO; 30-
MODFL; 31-MODFL; 32-O
Cervical abrasion/abfraction lesions:
Generalized

14. Anterior Dentition View

15. Maxilla

16. Max Right Sextant
1- Missing
2- Missing

17. Max Right Sextant
3- Defective MODL Amalgam restoration

18. Max Right Sextant
4- No treatment
5- Defective Occlusal Amalgam restoration

19. Max Anterior Sextant
6- Class V abrasion on Facial
7- Prior RCT completed greater than 10 years ago
with a missing crown

20. Max Anterior Sextant
8- Class IV chip, MI
9- Class IV chip, FIDL with a lingual amalgam

21. Max Anterior Sextant
10- Defective lingual amalgam
11- Class V abrasion on facial

22. Max Left Sextant
12- Defective MOD amalgam
13- Defective Occlusal amalgam

23. Max Left Sextant
14- Defective MODL Amalgam restoration and
Supraerupted

24. Max Left Sextant
15 Defective MO Amalgam Restoration and Supraerupted
16- missing

25. Anterior Dentition View

26. Mandible

27. Mand Left Sextant
17 – missing
18 – missing
19 – missing

28. Mand Left Sextant
20 – 2 small pit occlusal amalgams
21 – missing
22 – No Treatment

29. Mand Anterior Sextant
23 – no treatment
24 – no treatment
25 – no treatment
26 – no treatment
27 – no treatment

30. Mand Right Sextant
28- Existing Gold crown over 42 years
29- Existing MODL Amalgam with 2 pins

31. Mand Right Sextant
30- Defective MODFL Amalgam restoration
with a pin and associated periapical
pathology and sinus tract and furcation
involvement

32. Mand Right Sextant
31- Defective MODFL Amalgam restoration
with 2 pins
32- Existing occlusal Amalgam restoration and also is
supraerupted and not in occlusion

34. Endodontic Findings
3- defective restoration
● Asymptomatic
● No positive findings to palpation, percussion
● Endo Ice and EPT response WNL
● Recurrent Caries
● Periradicular Dx: Normal
● Pulpal Dx: Normal

35. Endodontic Findings
7- crown missing since June 2003
● Obturation radiographically and clinically
acceptable
● No contamination noted
● Asymptomatic- No positive responses
● Gutta Percha short about 2 mm
● May require retreatment for adequate post
length
● Periradicular Dx: Normal
● Pulpal Dx: Pulpless

36. Endodontic Findings
14 and 15
● Supraerupted
● Asymptomatic
● Re-establish Occlusion
● Calcified Canals beginning
to form
● Periradicular Dx: Normal
● Pulpal Dx: Normal

37. Endodontic Findings
29- Asymptomatic
● No positive findings to palpation, percussion
● Endo Ice and EPT response WNL
● Abutment tooth for a 3-unit FPD
● Periradicular Dx: Normal
● Pulpal Dx: Normal

38. Endodontic Findings
30- asymptomatic
● Sinus Tract present with sensitivity to palpation
● Subgingival Caries extending into pulp
● Class II Furcation involvement
● Periradicular Dx: Chronic Apical Periodontitis
● Pulpal Dx: Pulpal Necrosis
● Nonrestorable: to be extracted

39. Endodontic Findings
31- Defective restoration
● Recurrent decay
● No positive findings to palpation, percussion
● Asymptomatic
● Endo Ice and EPT response WNL
● Abutment tooth for a 3-unit FPD
● Periradicular Dx: Normal
● Pulpal Dx: Normal

40. AF form
935
Periodontal
Charting

41. Periodontics
Modified O’Leary 42%
PD: 1-6mm
BOP: 15 of 25 teeth
Mobility: Cl I #30
Diagnosis:
● Localized Chronic Moderate Periodontitis: #11-15,
31.
● Localized Chronic Severe Periodontitis: #3, 30, 32
● Generalized Gingivitis
Etiology: 1) Plaque 2) Calculus

42. Periodontics: Prognosis
Short term:
● Overall: Fair
● Individual: #30 and 32- Hopeless
Long term:
● Overall: Fair
● Individual: Questionable # 3 and 15
Perio Maintenance: Every 3-4 months

43. Orthodontics
Mand Ant. crowding about 3 - 4mm
Midline discrepancy: mand 2 - 3mm to the left
Pt. states he is not interested in Orthodontic Tx.

44. Occlusion
Angle class I molar on right side
Class I premolar on left side
Loss of VDO due to missing # 17, 18, 19 and 21
Supraerupted # 14, 15, 32
TMJ: Asymptomatic

45. Oral Surgery

46. Oral Surgery
30- nonrestorable
32-malposed and not in function or occlusion
Lesion in F.O.M.

47. Prosthodontics

48. Prosthodontics
Missing teeth: #1, 2, 16, 17, 18, 19, 21
Single crowns: #3, 7, 14, 15,
3-unit Fixed Partial Denture: #’s 20 – 22, 29 - 31
Mandibular Removable Partial Denture replacing
missing teeth #’s 18 & 19

51. Treatment Plan by Phase
I. Emergency Care
● Extract # 30 & 32
● Biopsy lesion in F.of M.
II. Medical / Systemic
● Consult with Physician for Contraindications
● High Caries Protocol and Dietary Counseling

52. Treatment Plan by Phase
III. Diagnostic / Initial Therapy
● Medical Model and Caries Control
● OHI- Brushing & Flossing
● Extract Hopeless teeth
● Endo- Retreat RCT # 7prn and other RCT prn
● Sc/RP- site specific # 3,11-15, 28-32
● Operative/Restorative

53. Treatment Plan by Phase
1 & 2: No Treatment – not to be replaced
3: Possible RCT with Full Gold Crown & Crown
lengthening prn
4: No Treatment
5: Replace with Occlusal amalgam
6: Replace with Glass Ionomer or composite
7: Retreat RCT prn for post length, Cast Post & Core and
PFM crown
8: Replace with Composite
9: Replace with Composite
10: Replace with lingual composite

54. Treatment Plan by Phase
11: Replace with Glass Ionomer or composite
12: Replace with MOD amalgam with enameloplasty
to adjust occlusion prn Class V abrasion, replace
with Glass Ionomer or composite
13: Replace with occlusal amalgam
14: Intentional RCT prn to allow for crown (Full Gold)
due to supraeruption and re-establish occlusion
15: Intentional RCT prn to allow for crown (Full Gold)
due to supraeruption and to re-establish occlusion
16: No Treatment

55. Treatment Plan by Phase
17: No Treatment
18: Replace with Denture tooth from RPD
19: Replace with Denture tooth from RPD
20: Abutment tooth for a 3-unit FPD &
Wrought wire clasp and distal rest
21: Replace with pontic from 3-unit FPD
22: Abutment tooth for a 3- unit FPD &
Cingulum Rest for RPD 23: No Treatment
23: No Treatment
24: No Treatment
25: No Treatment

56. Treatment Plan by Phase
26: No Treatment
27: No Treatment
28: Mesial Rest for RPD
29: Abutment tooth for a 3- unit FPD with a mesial rest for
an RPD & possible RCT prn
30: Extract and replace with Pontic from 3-unit FPD
31: Abutment tooth for a 3- unit FPD & Cast ½ round clasp
from distal and distal rest with possible RCT prn
32: Extract and not to be replaced

57. Treatment Plan by Phase
IV. Re-Evaluation
● Check O.H. and Pt. Compliance
● Re-chart 935
● Assess Key Teeth # 20, 22, 29 & 31
V. Corrective Surgical
● Ridge Augmentation prn
● Orthodontics: which pt. does not desire
● Prosthodontics

58. Treatment Plan by Phase
Single Crowns
● #3, 14 and 15- Full Gold Crown
● #7- Porclein Fused to metal
3-unit Fixed Partial Denture
● #20 – 22: Pier Abutment Survey Crowns
● #29 – 31: Pier Abutment Survey Crowns

59. Treatment Plan by Phase
Mandibular Partial Denture
● Kennedy classification II, modification I
● Major Connector: Lingual Plate
● Clasp Assembly # 20 and 31
● #20: Wrought wire clasp and distal rest
● #22: Cingulum Rest (indirect retainer)
● #28: Mesial rest
● #29: Mesial rest
● #31: Cast ½ round clasp from distal and distal rest
● Denture Teeth replacing # 18 and 19

60. Treatment Plan by Phase
Nightguard / Occlusal Guard
VI. Maintenance
● Re-evaluation
● Perio Recall every 3-4 months

61. Alternative TX. Plan #1
Maxilla
● Extract teeth # 14 and 15
Mandible
● Do NOT fabricate an RPD
● Keep the pt. in only 2nd premolar occlusion
on the left side

62. Alternative TX. Plan #2
Maxilla
● Extract teeth #3, 14 and 15
● Fabricate RPD replacing teeth # 3, 14 & 15
Mandible
● Single unit Survey crowns for teeth #29, 31
● Fabricate an RPD to replace teeth # 18, 19
and 30

63. Alternative TX. Plan #3
Extract # 30 and fabricate a bilateral
distal extention removable partial
denture if we are not able to save # 30.

64. They say 2 heads are better
than one

65. What I feel like now