Welcome to our world, enter the AEGD-2

Comprehensive Care II Treatment Plan Presented by

Captain Alfred G. Khallouf AEGD-2 Resident

Class of 2005

Introducing Our Patient

37 years old Male African-American Attitude-Positive Patient type- Indifferent

Historical Notes

Joined the USAF in Feb 1986, currently a MSgt Not married and has no children States that he is in good health and physically active Born and raised in Tx.

Subjective Findings

Chief Complaint: “My upper left tooth is sensitive to cold since I received a filling.” Denies any history of smoking, occasional social drinker Majority of his treatment was completed prior to PCSing here to Lackland in April of 2002. . Previously, he had been seen as a periodontal maintenance pt

Medical Hx. AF form 696

Medical / Systemic

Reports a history of High Blood Pressure, which is controlled by diet Currently under the care of a physician at WHMC for the high blood pressure.

B.P. is high normal for him. B.P. average: 131 / 89

Previous history of Acid reflux (no meds) Reports no known drug allergies

Med use, regimen, effects and concerns

HYDROCHLOROTHIAZIDE: - 25 mg once daily - Thiazide Diuretic - Management of mild to moderate hypertension. - Dental Tx. Concerns: No effects or Contraindications reported LISINOPRIL: -10 mg/day - ACE Inhibitor (Angiotensin-Converting Enzyme) - Tx. of hypertension, either alone or in combination with other hypertensive agents. -Dental Tx. Concerns: No effects or Contraindications reported

Oral Pathology

Oral Pathology

Pt. states that these lesions have been present for an unknown duration of time.

They have been there as long as he can remember. Pt states that occasionally his mouth becomes painful to very hot and spicy foods, which is only temporary, otherwise, it normally remains asymptomatic. These lesions were originally documented in July 1991, with no biopsy or follow up performed.

Oral PathologyMultiple asymptomatic, generalized erythematous yellowish-white patches bilaterally on buccal mucosa and tongue and inner aspect of lower lip.

Oral PathologyAlso a large asymptomatic pink smooth-surfaced papule about 7mm in diameter which was firm and non-fluctuant on inner aspect of lower lip. Lip lesion had been present for several years with no apparent change in size.

Oral PathologyDeep-fissured grooves on dorsal surface of tongue consistent with fissured tongue.

Oral Pathology

PRE-OPERATIVE DIAGNOSIS: A) Lip Lesion ● Irritation Fibroma ● Neuroma ● Papilloma

B) BUCCAL MUCOSA LESION ● Erythema Migrans ● Benign migratory stomatitis. ● Erosive lichen planus. ● Pemphigus ● Verruca Vulgaris

FINAL DIAGNOSIS: A) LEFT LABIAL MUCOSA: IRRITATION FIBROMA

B) LEFT BUCCAL MUCOSA: PSORIASIFORM MUCOSITIS (SEE COMMENT)

Comment: The histological findings, together with the submitted digital clinical images are consistent with ERYTHEMA MIGRANS

Restorative Findings

Caries risk: low Carious teeth: none Defective / Incomplete restorations: • #2 and 4- partially prepared, into enamel for

Resin-Bonded FPD • #14 has a large amalgam overhang, which

is sensitive to cold (skin refrigerant causes lingering pain which reproduces pts C.C.)

Anterior Dentition View

Maxilla

Max Right Sextant

1- Occlusal Amalgam 2- Occlusal Amalgam, with

partial prep for RR-FPD

Max Right Sextant

3- Missing 4- Occlusal Amalgam, with

partial prep for RR-FPD 5- Sealant

Max Anterior Sextant6- no treatment 7- no treatment 8- no treatment 9- no treatment 10- no treatment 11- no treatment

Max Left Sextant12- DO Amalgam 13- MOD Amalgam

Max Left Sextant14- Defective MODFL Amalgam Restoration Symptomatic, skin refrigerant cause lingering pain which reproduces pts. C.C.

Max Left Sextant15 OL Amalgam Restoration 16- missing

Mandible

Mand Left Sextant

17 – missing 18 – DO Amalgam 19 – OF Amalgam

Mand Left Sextant20 – Occlusal Pit Amalgam & Sealant 21 – Sealant

Mand Anterior Sextant22 – no treatment 23 – no treatment 24 – no treatment 25 – no treatment 26 – no treatment

Mand Anterior Sextant27- 6mm gingival recession on facial ● CT graft was first attempted in Oct 1999 ● CT graft failed for unknown reasons

Mand Right Sextant28 – No treatment 29 – Occlusal Amalgam & Sealant

Mand Right Sextant

30 – OF Amalgam 31 – MO Amalgam 32 – Missing

OK now, where are those residents?

Endodontic Findings14- defective restoration ● Large Amalgam overhang ● Symptomatic: skin refrigerant causes lingering pain, which

reproduces pts. C.C. ● No positive findings to apical palpation, percussion and biting

and no periapical pathology ● Periradicular Dx: Normal ● Pulpal Dx: Irreversible Pulpitis

AF form 935Periodontal

Charting

AF form 935, Maxilla

AF form 935, Mandible

Periodontics

Initial Modified O’Leary score was 76% plaque free surfaces PD: 1-5 mm BOP: 15 of 25 teeth Mobility: physiologic Diagnosis: ● Localized chronic severe periodontitis involving tooth #27. ● Localized chronic moderate periodontitis involving #s 1, 13-15, 18,

19 ● Generalized Gingivitis and moderate plaque present

Etiology: 1) Plaque 2) Calculus CT graft was first attempted in Oct 1999 for #27. CT graft failed for unknown reasons.

Periodontics: Prognosis

Short term: ● Overall: Good ● Individual: Fair #27

Long term: ● Overall: Good ● Individual: Guarded/Fair # 27

Perio Maintenance: Every 3-4 months

OrthodonticsNo Maxillary Anterior crowding apparent Midline discrepancy: mand 1mm to the left Mesial / Facial rotation of #22 Slight Mandibular Anterior crowding Pt. states he is not interested in Orthodontic Tx. Dental Class I Malocclusion

OcclusionAngle class I molar on left side Class I premolar on right side ● #3 extracted several years ago

#1 Non-opposing No need to alter plane of occlusion

Oral Surgery

Oral SurgeryExtraction of #1 - malposed and not in function or occlusion Biopsy intra-oral lesions under local anesthesia

Prosthodontic

Prosthodontics

Missing teeth: # 3, 16, 17, 32 Single crown: # 14 3-unit Fixed Partial Denture: #’s 2 – 4 ● #2 – 7/8th crown ● #3 - pontic ● #4 – 3/4th crown

Treatment Plan by Phase

I. Emergency Care ● RCT #14, address pts. chief complaint

II. Medical / Systemic ● HBP controlled by diet and Medication

Treatment Plan by Phase

III. Diagnostic / Initial Therapy ● Medical Model and Caries Control

● Pt has no caries or restorative procedures planned ● OHI- Brushing & Flossing ● Extract #1 (Disease control) ● Biopsy Intra-oral lesions

Treatment Plan by Phase

IV. Re-Evaluation ● Check O.H. and Pt. Compliance ● Re-chart 935 ● Assess Key Teeth # 2, 14 & 27

V. Corrective Surgical ● Orthodontics:

● Discussed with pt. ● Pt. does not desire any Tx.

Treatment Plan by Phase

V. Corrective Surgical ● Periodontics

● #14 - crown lengthening ● #15 - Distal Wedge ● #27 – CT graft with lateral pedicle graft

Treatment Plan by Phase

V. Corrective Surgical ● Single Crown

● #14 - Full Gold Crown

● 3-unit Fixed Partial Denture ● #2 – 4

● #2 – 7/8th crown ● #3 – pontic ● #4 – 3/4th crown

Treatment Plan by Phase

Nightguard / Occlusal Guard

VI. Maintenance ● Re-evaluation ● Perio Recall every 3-4 months

Tooth by Tooth Treatment Plan

1: Extraction 2: Abutment for a 3-unit FPD 3: Pontic (Hygenic or Bullet shaped) 4: Abutment for a 3-unit FPD 5: No Treatment 6: No Treatment 7: No Treatment 8: No Treatment 9: No Treatment 10: No Treatment

Tooth by Tooth Treatment Plan

11: No Treatment 12: No Treatment 13: No Treatment 14: RCT, Amalgam build up, Crown Lengthening

and Gold crown 15: Distal Wedge 16: Missing

Tooth by Tooth Treatment Plan

17: Missing 18: No Treatment 19: No Treatment 20: No Treatment 21: No Treatment 22: No Treatment 23: No Treatment 24: No Treatment 25: No Treatment

Tooth by Tooth Treatment Plan

26: No Treatment 27: CT graft with possible lateral pedicle graft 28: No Treatment 29: No Treatment 30: No Treatment 31: No Treatment 32: Missing

Alternative TX. Plan

Maxilla ● Implant to replace #3 ● Single unit crowns #2 and 4 versus ● Posterior composites #2 and 4 Mandible ● If pt chooses not to undergo a 2nd CT graft

surgery to correct recession, monitor #27 for continued recession

Everybody, out of the Residency