Libyan International Medical UniversityFaculty Of Dentistry

Comprehensive Dental Course

Clinical Case Presentation July 2013

Presented by :

Ziad S. Abdul Majid

NO : 19

Biographical data & chief compliant

51 years old Libyan female.

Married, teacher & lives in Buhdyma/Benghazi. Chief Complaint :

The patient want to replace her missing teeth.

History of present complaint : She did multiple extractions due

to caries & the last extraction done since 4years without complications.

Medical& Dental history

Medical History:

Diabetes Mellitus type II : 7 years ago.

Last Fasting blood sugar was 125 mg/dl.

Last HBA1C was 1 month ago = 7.4 %.

Last physical exam  April/2013.

Metformin 500mg

Aspirin 75 mg

Simvastatin 20mg

Medications

Past Dental History

H/O multiple teeth extractions due to caries without any complications.

H/O endodontic treatment & fixed prosthesis, restorations due to caries.

Oral Hygiene Practice :

Tooth brush: Yes

Brushing method : Horizontally

Any other orophysiotheraputic aids :

No

Kind of Dentrifice

used : Crest

Any other No

Smoker No

Others :

Oral Habits : Nail Biting. Diet : 3 meals daily, snacks in between, 2-3 cups

of coffee daily.  Patient Attitude: Extremely motivated But she is

not regular dental attender .

Clinical Examination

Extra-oral

Examination Intra-oral

Examination

Extra-Oral :

She is slightly overweight, a fit & healthy looking, with no obvious facial asymmetry, no submental, submandibular or other lymph nodes are palpable.

the tempromandibular joint appears normal with no clicking, crepitus, tenderness or deviation in the mouth opening with no masticatory muscles tenderness.

The Lips are competent.Initial vital signs : BP : 123/82 mmHg BPM : 79 RES : 18

INTRA-ORAL Examination

INTRAL-ORAL :

The soft tissue ( Oral Mucosa ) is healthy & normal. Her OH is fair there is soft deposits , stains ,

calculus & no Halitosis .

Decayed Missing Filled

12,21,34,42,43

14,15,16,17,23,24,25,27,35,36,37,46,

47

13,22,26

DMFT= 21

Intra Oral findings:

No objective or subjective sign of parafunction :

Attrition , Abrasion ,Erosion. There is slight crowding in the lower anterior area. No loss of proximal contact. No TFO, cross bite , open bite, deep bite .

Gingival Status

Maxillary Region :

Max. Left Posteriors

Max. AnteriorsMax. Right Posteriors

red Pale pink - Color

rolled margin Scalloped, rolled margin, blunt IDP

- Contour

Normal Normal - Size

Soft& Edematous Soft& Edematous - Consistency

- Present - Stippling

Apical to CEJ Coronal to CEJ - Position

Present Present - Bleeding on Probing

Absent Absent - Exudation

Mandibular Region :

Man. Left Posterior

Man. AnteriorMan. Right

PosteriorPale pink Pale pink Pale pink Color

Scalloped, rolled margin, blunt IDP

Scalloped, rolled margin, blunt IDP

Scalloped, rolled margin, blunt IDP

Contour

Normal Normal Normal Size

Soft& Edematous Soft& Edematous Soft& Edematous Consistency

Absent Absent Absent Stippling

At CEJ At CEJ At CEJ Position

Present Present Present Bleeding on Probing

Absent Absent Absent Exudation

Periodontal Examination

1 1 1 1 1 0 1 0 1 1 0 1 1 1 1 CAL

3 2 2 2 2 2 2 2 2 1 0 1 2 2 2 PD

5 6 6

2 2 2

2 2 1 1 0 1 1 1 1 1 1 1 1 1 1 CAL

2 2 1 1 0 1 1 1 1 1 1 1 1 1 1 PD

4 4 4

2 1 2

2 2 1 1 1 1 1 2 2 2 3 3 3 3 4 4 4 4 3 2 2 1 1 1 1 1 2 CAL

2 2 1 1 1 1 1 1 1 1 2 1 1 1 2 2 2 2 3 2 2 1 1 1 1 1 2 PD

1 0 0 1 1 0 1 1 2 1 2 1 1 2 1 1 1 1 1 1 1 1 0 1 1 1 1 CAL

1 0 0 1 1 0 1 1 2 1 2 1 1 2 1 1 1 1 1 1 1 1 0 1 1 1 1 PD

Other Periodontal findings:

Mobility

•41,31 ,Grade I

Recession

•42,41,31,32,26

RADIOGRAPHIC EXAMINATION

Extra-oral

panorama

IOPA IO-Bitewing

Bone: •Mild to moderate generalized

bone loss.•Normal trabecular pattern.•No bone pathology.•Normal anatomical structures.

Teeth: •Tooth # 22 rotated .

•RCT, intra-radcular & coronal coverage radiopauqe rest. related to tooth # 13. •Proximal radiolucency related to tooth # 12, 21,42,43. •Tooth # 26 restored by a radiopaque rest. with a radiolucent shadow underneath the prox. Rest.

IOPA

Tooth # 12 ,13

Tooth # 21

Tooth # 42,43

IO- Bitewing

Tooth # 34

Diagnostic casts

Supplementary tests :

Palpation

Percussion

Vitality test ( EC )

Tooth #

Normal Normal Respond 12

Normal Normal Respond 21

Normal Normal Respond 42

Normal Normal Respond 43

Final

Diagnosi

s

Diagnosis :

Severe generalized chronic periodontitis . Reversible pulpitis (class III DC ) related to

tooth #12, 21, 42, 43. Dentinal caries (class II DC ) related to

tooth # 34. Recurrent caries related to tooth # 26.

Treatment plan

Aims & objectives of treatment :

Address patient’s chief complaint. Maintain good oral hygiene. Restore occlusion, form, function, and esthetics. Educate and motivate the patient. Eliminate active disease and prevent future oral

disease. Maintain gingival and periodontal health. Long term maintenance.

Extraction of tooth # 26 :

Justification for extraction :

Heavily restored, recurrent

caries, gingival

recession, severe

attachment & bone loss,

surpra-eruption.

Compromised tooth as long term

abutment

PRELIMANERY PHASE :

PHASE 1 THERAPY: OHI ; patient education,

motivation . Diet counselling . Scaling & root

debridement . Restoration of the caries

teeth. Topical fluoride application.

Diet sheet analysis:

Instructions

given

Condition : # 12 : class III

TTT Proposed : IPC + Composite

restoration

Condition : # 21: class III

TTT Proposed : IPC + Composite

restoration

Condition : # 42 & 43 : class III

TTT Proposed : IPC + Composite

restoration

Condition : # 34: class II

TTT Proposed : Composite

restoration

Perio ttt & polishing

Topical fluoride application

PHASE 2 THERAPY (surgical phase) : Not indicated ; BUT may indicated in the

revaluation of periodontal therapy.

PHASE 3 THERAPY (Restorative

phase) :

Replacement of the missing teeth : Treatment options : 1-implants & implant supported fixed

bridges.2- implant supported overdenture. 3- overdenture. 4- upper & lower chrome cobalt partial

denture with distal extension. 5- upper & lower acrylic partial

denture with distal extension .

CLINICAL PROCEDURES :

Phase 4 therapy : Periodic rechecking for: Plaque and

calculus . Recall and maintenance every 6 month .

Post treatment photographs :

Frontal view

Lateral view

Occlusal view

Prognosis & conclusion :

Chronic periodontitis is characterized by low grade chronic inflammation that may remain silent in diabetics causing damage that is not locally limited but may extend systemically.

Diabetes is associated with an increased risk of developing inflammatory periodontal diseases, and glycemic control is an important determinant in this relationship.

Patient’s commitment to oral hygiene will be a major factor in long term prognosis.

Regular VT required for the restored teeth with IPC to evaluate the outcome and success of ttt.

Thank you