comprehensive care treatment plan presentation | dr. alfred khallouf
TRANSCRIPT
Welcome to the AEGD-2
Comprehensive Care Treatment Plan Presented by
Captain Alfred G. Khallouf AEGD-2 Resident
Class of 2005
Introducing Our Patient
63 years old Male African-American Attitude-Positive Patient type- Philosophical
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
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
Medical History AF Form 696
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
Medication
Aspirin 350mg daily Celecoxib 200 mg twice daily Effexor 75 mg once daily Indocin 50 mg daily
Med use, regimen, effects and concerns
Oral Pathology
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
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
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
Anterior Dentition View
Maxilla
Max Right Sextant
1- Missing 2- Missing
Max Right Sextant
3- Defective MODL Amalgam restoration
Max Right Sextant
4- No treatment 5- Defective Occlusal Amalgam restoration
Max Anterior Sextant6- Class V abrasion on Facial 7- Prior RCT completed greater than 10 years ago
with a missing crown
Max Anterior Sextant8- Class IV chip, MI 9- Class IV chip, FIDL with a lingual amalgam
Max Anterior Sextant10- Defective lingual amalgam 11- Class V abrasion on facial
Max Left Sextant12- Defective MOD amalgam 13- Defective Occlusal amalgam
Max Left Sextant14- Defective MODL Amalgam restoration and
Supraerupted
Max Left Sextant15 Defective MO Amalgam Restoration and Supraerupted 16- missing
Anterior Dentition View
Mandible
Mand Left Sextant
17 – missing 18 – missing 19 – missing
Mand Left Sextant
20 – 2 small pit occlusal amalgams 21 – missing 22 – No Treatment
Mand Anterior Sextant
23 – no treatment 24 – no treatment 25 – no treatment 26 – no treatment 27 – no treatment
Mand Right Sextant28- Existing Gold crown over 42 years 29- Existing MODL Amalgam with 2 pins
Mand Right Sextant30- Defective MODFL Amalgam restoration
with a pin and associated periapical pathology and sinus tract and furcation involvement
Mand Right Sextant
31- Defective MODFL Amalgam restoration with 2 pins
32- Existing occlusal Amalgam restoration and also is supraerupted and not in occlusion
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
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
Endodontic Findings
14 and 15 ● Supraerupted ● Asymptomatic ● Re-establish Occlusion ● Calcified Canals beginning
to form ● Periradicular Dx: Normal ● Pulpal Dx: Normal
Endodontic Findings29- 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
Endodontic Findings30- 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
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
AF form 935 Periodontal Charting
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
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
OrthodonticsMand Ant. crowding about 3 - 4mm Midline discrepancy: mand 2 - 3mm to the left Pt. states he is not interested in Orthodontic Tx.
OcclusionAngle 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
Oral Surgery
Oral Surgery30- nonrestorable 32-malposed and not in function or occlusion Lesion in F.O.M.
Prosthodontics
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
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
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
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
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
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
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
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
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
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
Treatment Plan by Phase
Nightguard / Occlusal Guard
VI. Maintenance ● Re-evaluation ● Perio Recall every 3-4 months
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
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
Alternative TX. Plan #3
Extract # 30 and fabricate a bilateral distal extention removable partial denture if we are not able to save # 30.
They say 2 heads are better than one
What I feel like now