History and examination

Pre & Post Operative

Photos

Denture design

Examination

Radiographs

Presenting complaint:•Pain from upper right quadrant•Change in the appearance of her face, teeth have ‘become smaller’ over time•Occasional bleeding gums•Difficulty chewing due to missing teeth in the lower arch

History of Presenting Complaint:•Mrs. LK had felt ‘sharp’ pain in her upper right quadrant which was felt whilst eating. The pain was not elicited on any specific foods, and she said it was the cold nature of foods (and not heat) that was causing the pain. The pain could not be localized, was short lasting and did not keep her up at night, nor did she require pain killers. She had felt this pain on and off for a few months and it did not seem to be worsening with time. She also reported no pain on biting.

Medical History:• Hypertension (controlled with Amlodopine and Benzofluoromethiazide)•Type II Diabetes (controlled with Metformin)•No known allergies

Dental History:•Has been attending King’s for a number of years. Her last dental visit was in 2012 with the hygiene therapy department for fillings •She has no outside GDP, and mainly attends when in pain (symptomatic attender)•Reported soreness in her cheeks on waking, however has never noticed herself grinding her teeth during the day or night

Social History:•Lives locally and is married with 2 children•Works for the NHS in administration•Mrs. LK is a non smoker and drinks on occasions

Diet:•2 main meals a day; lunch and dinner•Snacks on biscuits, cakes, occasionally fruits•Mrs. LK reported ‘chewing on chicken bones’ regularly•Tea with sugar once a day, peppermint tea and juices sometimes

Oral Hygiene:•Brushes twice a day with a manual toothbrush, fluoridated toothpaste•No other adjunctive aids were used

Tooth TTP EPT VALUE

MOBILITY SENSITIVE TO AIR

UR8 - 40 - -UR7 - 53 - +UR6 + 55 - +

UR1 (control)

- 47 - -

2 0 2

1 2 1

Plaque Score Graph

RBW: •Grade 2; cone-cut•Missing LR6 and LR7•Generalized horizontal bone loss of 5-10%•No radiolucencies indicating caries•Flattened cusp morphology indicating toothwear •Over eruption of the UR6&7

LBW: •Grade 2; cone-cut•Missing LL6 and LL7•Radio-opacity mesial to the LL8. Possibly a retained root of the LL7 after x/la. No pathology associated with the radio-opacity•Generalized horizontal bone loss of 5-10%•No radiolucencies indicating caries•Flattened cusp morphology indicating toothwear•Over eruption of the UL6

LCPA UR6&7:•Grade 1 image•No radiolucencies indicating caries•Unusual non-conical / non fused root morphology of the UR8•Radio-opacity distally to the UR8 indicating calculus deposits•No apical pathology present

Diagnoses

• Dentine hypersensitivity of the UR6 secondary to gingival recession. • Generalized moderate toothwear secondary to attrition and erosion• Missing teeth (LL6&7 and LR6&7)• Low caries risk

•Diet sheet•BEWE•BPE•Sensibility testing•Intra-oral photographs

Care Plan Management of Acute Pain:•Twice daily use of desensitizing toothpaste to control sensitivity on UR6. Adjunctive use of fluoride varnish

Prevention:•Oral hygiene instruction: Modified Bass technique to be shown to patient. To stress importance of daily interdental cleaning with TePe brushes, and demonstrate this to the patient. Advise to 'Spit, don't rinse‘ with excess toothpaste after brushing•Dietary advice – to limit sugar attacks to 4 times a day (at mealtimes where possible) and reduction in the intake of erosive foods and drinks•Generalized scale and polish

Definitive treatment:•Reassessment to check patient compliance with preventative advice•Composite build ups of upper 5-5 using the conformative approach. As the patient did not want an increase in OVD, a joint decision was made to only restore her upper teeth•It was emphasized that the composite restorations are a conservative form of treatment, involving minimal pulpal insult, and that debonding of a restoration would allow replacement in the same fashion•Fabrication of a lower partial cobalt-chrome denture

Review & Maintenance:•Monitor UR6 for symptoms. If desensitizing toothpaste & fluoride varnish does not work, then sealing the tooth with DBA will be tried•Monitor oral hygiene and diet•Regular review of plaque scores•Recall interval of 6 months

BEWE (total 13) 2 3 2

2 2 2

BPE

Extra Oral Examination:• TMJ – no deviation or clicks noted•Muscles of Mastication –No soreness on palpation of her masseter and temporalis muscles •Lips competent•No asymmetry or lymphadenopathyIntra Oral Examination:•Bilateral hyperkeratosis on the buccal mucosa however no other abnormalities detected on the tongue, floor of mouth, hard and soft palate or gingivae•Oral hygiene was fair; some visible plaque and calculus deposits were noted •Mildly restored dentition; few composite restorations•Missing lower left lateral incisor; congenitally absent? •Generalized tooth surface loss (TSL) on upper and lower arches•Upper midline diastema present (measuring 6mm) and spacing between the lower anterior teeth •Lower arch: Kennedy class 3 modification 1; with no history of a previous lower denture•Group function on left and right lateral excursions

CASE PRESENTATIONCANDIDATE NUMBER:

V14586MRS L K. 47 YEARS OLD

DENTAL CHART

Investigations and special tests

SENSIBILITY TESTS

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