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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
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