Comprehensive Care Treatment Plan Presentation | Dr. Alfred Khallouf

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