Lisa Jordan

I have written down this file to help myself, friends and those who
have been through the same hardship of Ore. I am not expecting

anything back but if you find it of any benefit, I would be grateful if
you donate directly to the Royal Marsden in memory of a dearest
friend who I lost for horrible cancer. She was well looked after there,
please give what every you can afford and thank you for your
kindness and generosity.
Lisa Jordan
D.O.B 3-3-1965
Chief complaint I hate my denture
Lower acrylic denture given 6 months back. Loose since insertion. Patient can’t eat and
unable to speak. No clasp. teeth taken out 3 years ago, had bridge which was taken out
because it was infected. Had a chrome cobalt denture after that for 3 years which was
broken and replaced with this denture
Second complaint have pain on my upper teeth
Dull pain in UR4 for 3 days, pain came up at dinner 3 days ago, has a white filling on it given
three months back. Pain on biting and severity of pain is 6.
Dental history
Symptomatic attendee / last visit 3 months back for denture review and fluoride application
Previous dental treatment tooth extraction/amalgam filling
Brushing regime twice a day with electric tooth brush and Colgate toothpaste, no cleaning
aids.
Medical history
Asthmatic since childhood on salbutamol inhaler triggered by stress, cold and weather last
attack was 6 months’ back
Social history
Single lives alone and works at mark and spencer
Stress level is high grinds her teeth at night / front teeth sensitive to cold
Smokes 1-2 cigarettes day for 30 years
Sugar I have a sweet tooth, I eat a lot of chocolate
Alcohol consumption is 5 units of white wine per week
Acid intake is low
Expectation for treatment
Give me a metal denture
Get me out of the pain and save my tooth
When we get the file, we look at the patient’s name and age will give us some idea about
possible complaints. Radiograph report will be given to you in the file.
Ask patient to confirm personal details, ask patient if she is Miss or Mrs
Don’t write the address only number of house and postcode.
Good morning Miss Jordon my name is, I am one of the dentist here how are you today?
Sorry to hear you have this problem rest assured we will do something about it today.
How can I help you today?
Since when have you had that denture?
Is it your first denture?
Is it an upper or lower denture?
Is it a metal or plastic denture?
How many teeth does it replace?
Why were your teeth taken out?
Where you happy with it initially?
Did you attend your review appointment? Were there any changes made to your denture?
Any sharp edges?
Is it an immediate denture?
Does it have hooks on them? What about the teeth that hold the denture in place are they
broken?
is it loose when you eat or speak? Do you have a dry mouth?
How do you clean it? Do you take it out at night?
Do you have any other complaint?
Where is the pain exactly can you tell which tooth?
When did, the pain start? Is it the first time? What brings on the pain is it pain on biting or
hot and cold? Have you taken anything to relief the pain? Did it help?
Can you describe the pain for me?
Does it radiate to other areas?
Does it prevent you from sleeping?
Did you have any trauma to that tooth?
Do you have any temperature?
Did you have any treatment on that tooth? When and what?
Is there any swelling, salty taste or blister? What’s the severity of pain?
Do you have any other complaint?
Dental history
Do you visit your dentist regularly? When was the last time? What treatment did you have
done before?
How many times do you brush your teeth a day? What type of tooth brush do you use?
What type of toothpaste?
Are you happy with the appearance of your teeth?
medical history
I’ll need to ask you a few questions regarding your health in general just to make sure
everything is fine. Is that alright?
Are you generally fit and well?
Are you under the care of a specialist or GP for any medical condition?
Are you currently taking any drugs or medication which is prescribed or over the counter?
If yes-
● What medicines is that?
● What is the Dosage?
● How many times a day?
● Since when have you been taking it?
For what condition are you taking the medication?
● Other medications/ if patient does not remember the name of medication ask for
permission to contact his/her GP
A-Do you have any allergies? If yes, what?

A- Are you anaemic?
B-Do you have any breathing problems such as asthma?

● how long have you had it?
● Are you under the care of a GP or SP? Is it well controlled?
● Record patient medication with dosage, blue inhaler /salbutamol. Brown
inhaler/hydrocortisone 200mg.
B-Do you have any bleed problems? Do you bleed excessively after a cut?
C-Do you have any chest problems, angina or hypertension?
D—are you diabetic?
F- Have you had any fit, faints or block out in the past?
F-- Do you have a family history of any medical condition?
G-Do you have any tummy trouble(GASTRIC)e, or heart burns?
H- Have you been hospitalized in the past?
I- Do you have any blood infectious diseases such hepatitis B or C or HIV?
J- Do you have any skin, eye or joint trouble?
L-Ladies
● are you pregnant?
● Are you on any contraceptive?
● Are you periods regular? Do you bleed heavily?
K-do you have any kidney or liver problems?

S- have you had steroids in the past two years?
W- Do you carry any warning cards?
Do you have any concerns regarding your health which you would like to tell me about?
Do you smoke? How long have you been smoking? How many cigarettes do you smoke?
Do you consume alcohol? What type? And how many units per week
What are your expectations from the treatment?
Do you have any constrain?
Clinical findings
TEETH PRESENT
754321 1234567
7 4321 123 4 7
:
BPE 2-1-1/2-2-2
UNDEREXTENDED FLANGES OF THE DENTURE
NO CLASP PROVIDED ON LL7
IMPROPERLY DESIGNED CLASP ON LR7
DENTURE FINISHES AT A PONTIC LL6 WITHOUT ANY CLASP OR PLATE
DISTAL TO PONTIC LL6
NON-CARIOUS TOOTH SURFACE LOSS
Radiograph How does this request contribute to your making a

diagnosis
IOPA for UR4 To assess presence of caries, involvement of pulp and
periapical pathology
Provisional diagnosis Clinical symptoms/presentation (ascertained during the
history) that has led you to this provisional diagnosis
1- Unretentive lower denture Underextended flanges of the denture, no clasp
secondary to underextending provided on LL7, improperly design, history from
patient lose denture when eating and speaking.
2- Chronic periapical Dull pain on biting, history of trauma, fractured composite

periodontitis on UR4
3- Chronic generalized gingivitis Incidental finding BPE score 2-1-1/2-2-2
4- Dentine hypersensitivity Clinical examination, patient with bruxism habit, sensitivity

secondary to attrition on cold, patient is under stress
5- Overhang amalgam filling on Incidental From clinical examination
the UR5
6- Missing upper right 6 Incidental finding clinical examination
Investigation How does this request contribute to making your diagnosis

1- Examination of the denture To confirm fault of denture
2- Examination of denture To exclude any abnormality or pain on the ridge
baring area
3- OVD to confirm reduction in OVD
4- Vitality test to UR4 To assess vitality of the tooth
5- Percussion test on UR4 To confirm periapical involvement
6- Knight and smith index To confirm and assess amount of tooth surface loss and
provide a baseline record for future investigation
7- Examination of the TMJ and To assess involvement of TMJ and muscles of mastication
muscles of mastication
8- Dietary chart To analyse patient diet if high sugar intake
9- Plaque index To assess distribution of plaque and provide baseline
reference for future investigation
10- Bleeding index To assess amount of bleeding, presence of active
periodontal disease and provide future base line record for
further investigation
Result of investigation
NO TENDERNESS IN MUSCLES OF MASTICATION
LOSS OF OVD 1MM
14- VITALITY 80 ( NON VITAL)
SMITH AND KNIGHT TOOTH WEAR INDEX IS 2
Radiograph report
Type: is the IOPA

Side: upper right quadrant
Bone: level adequate
Teeth: 13, 14, 15
Restoration: restoration on 14,15
Caries: mesial caries on the 13/ caries under restoration on 14
Others: radiolucency around the apex of 14
Overhang on the 15
15 root Proximity to the maxillary sinus
Cone cut
Quality of film is 2
Immediate phase:
Educate the patient regarding all dental concerns
Give patient adhesive or chairside relining to improve looseness of denture
For UR4 Pulp extirpation, ledermix dressing and seal with temporary filling
Application of fluoride and prescription of desensitising fluoride tooth paste
Stabilization phase:
● For gingivitis give OHI, supra and sub gingival scaling
● Give patient option of treatment for denture repair denture, new acrylic or chrome
cobalt denture, bridge and implant
● Give patient treatment option for UR4 either RCT and crown or extraction
● Refer patient to GP for stress management and give night guard to prevent further
TSL
● Monitor TSL with photos and cast modules if habit stops and patient wants
treatment give option of composite, veneer and crown
● Caries removal on 13 and restoration placement composite or GIC
● Treatment of amalgam filling on 15 due to overhang: leave it as it is or replace.
● Replacement option of UR6 removable, bridge or implant .
● Dietary analysis and advice of reduce sugar consumption
● Smoking cessation advice
Preferred definitive:
Construction of new chrome cobalt partial denture
Root canal treatment for UR4 and pfm crown
consider this patient this patient, briefly describe what has led you into choosing this
overall care plan and the benefits (likely success, cost time ,ect)to the patient .
reline the denture…. improve the fit temporarily
new cast partial denture……. complies with wishes of the patient/less cost/patient already
accustomed to it.
pulp extirpation for UR4 brings patient out of pain
R.C.T …saves the natural tooth/implies with patient wishes
PFM after root canal on UR4 …gives security to the tooth and good aesthetic
Fluoride varnish …. relieves sensitivity
Bite guard…. protects teeth from further destruction
Consider this patient are there any potential disadvantages of this treatment
(complicated, high risk of failure, short life of restoration, ect) for this patient.
Relining denture fit might not improve
Cast partial denture more cost than acrylic/removable /compromise gum health
RCT UR4 10% failure risk and infection/fracture of file in canal
Bite guard require patient compliance
Would you provide all or part of the treatment for this patient yourself so which part or
parts? (give reasons)
Yes, all treatment in emergency /stabilization/ preferred definitive and maintenance phase
except restoration for upper and lower front teeth with crown
Would you refer the patient for all or part of the treatment? If so which part or parts and
to which specialist?
Part of treatment i.e restoration of upper and lower anterior with crowns to restorative
specialist as they require specialist skill restoration of so many teeth is beyond scope of
GDP.
Andy Jonsson
D.O.B 3.3.1971
Present complaint: ‘pain on my lower front teeth’
Pain started a month ago on the LL 12, achy pain (dull pain), pain on biting, teeth very
wobbly feels like they will fall out, bleeding gums, not bothered about the appearance of his
teeth and no family history
Other complaint: ’a lump on the roof of the mouth’
Patient had it for one year, hard, no pain ,no family history, seen gp for it advice was it will
resolve on its own, increasing is size slowly over two months , no numbness, no ulcer , no
discharge or bleeding , no altered sensation, did not have a trauma on it
Past dental history:

Irregular attendee afro British lives works abroad and attend appointments only when in the
country last appointment was year and a half for scaling
Previous treatment involved extraction, filling and a denture/cause of tooth loss was due to
periodontal disease.
Poor denture hygiene, takes the denture out at night
Brushes once in the morning with a manual tooth brush
Medical history:
Diabetic on metformin diagnosed 5 years ago, no history of hypoglycaemic attack in a dental
practice.
Hypertension on atenolol, simvastatin and aspirin.
Social history:
Works in a news channel/ married with three dependants
Smoker: quitted smoking 5 years ago, after diagnosis with blood pressure used to smoke 16
years ago,
Alcohol: couple of units over the weekend
Sugar intake low
Acid intake low
Notes:
Save the wobbly tooth
Not happy with denture patient wants a fixed option
Clinical findings:

Oral hygiene: fair
BPE
2 2 2
2 4 2

Missing LR 6,7,8 .... LL 6,7,8
Mobile 31,32
Provisional diagnosis Clinical symptoms/presentation (ascertained

during the history) what have lead you to this
diagnosis
1- Mobile lower left 1 and 2 secondary Diabetic patient, achy pain, mobile tooth, pain
to periodontitis on biting, gingival recession
2- Swelling on the palate of unknown Lump on the posterior part of the palate, no
aetiology pain, no bleeding no discharge, no altered
sensation, no ulceration ,
3- Generalized gingivitis and localised Incidental bpe
periodontitis secondary to diabetic 2 2 2
and fair oral hygiene 2 4 2
4- Replacement for denture Patient not happy with removable requested a

fixed option
5- Crown with defective margin metal Clinical examination, patient not bothered
bit showing with it
Radiograph How to assess this request contribute to your

making a diagnosis
1- IOPA for LL1 and LL2 To assess the amount of bone loss and
We use IOPA in score 4 for anterior periapical involvement
teeth not vertical bitewing
2- IOPA to the teeth next to the lump To rule out any connection to the lump
Investigation How does your request contribute to your

making a diagnosis
1- Full mouth 6 pocket point chart To assess amount of bone loss
2- Bleeding index To confirm active periodontal disease
3- Plaque index To assess distribution of plaque
4- Mobility index of LL1 AND LL2 To assess amount of mobility and done loss
5- Examination of the swelling To assess consistency and size of the lump
6- Examination of the denture To assess the denture for any fault
7- Examination of the denture baring To rule out any abnormality on the ridge
area
8- Vitality test for teeth adjacent to To assess vitality of teeth
swelling
9- Percussion test to teeth adjacent to To assess any periapical pathology
swelling
10- Body temperature To exclude any systemic involvement

Results:

LL1,LL2 grade 3 mobile
Swelling on palate -hard-2cm by 2cm
Teeth next to the swelling-vital- NAD
Denture satisfactory on examination
Multiple radiolucency in the mandible visible on the DPT provided
Body temp-normal

Radiograph is only for report writing. Its not related to the case
Radiograph: horizontal bitewing

Side: right side
Bone level: adequate
Teeth: partially 13,14,15,16, partially 17,44,45,46,47
Restoration: occlusal restoration on 16 and 46
Caries: occlusal on 17, mesio-occlusal on 15, distal on 14 and 13
Occlusal 47, disto-occlusal on 46, distal on 45, mesial on 44
Others: Nile
Film quality: 1
Medical link:
● Update medical history
● Stress free, short appointment
● Appointment early morning, avoiding meal time
● Remind patient to have medication and proper meal before appointment
● Patient is at risk of developing hypoglycaemic attack
● Possibility of bleeding patient on blood thinning medication
Immediate/emergency treatment:
Educate patient about all dental concerns
take impression with denture for addition of LL12
initial /Stabilization phase:

● for mobile teeth:
extraction of the mobile LL12 and insertion of immediate denture.
Give post extraction instruction and denture hygiene instruction.
● For gingivitis OHI, supra and subgingival scaling, root surface debridement and
possible referral to periodontal specialist
● Explain option of replacement for missing teeth
1-acrylic denture
2-chrome cobalt denture
3-implant supported denture
● Give option of new crown for defective crown
● Explain swelling on the lump and offer referral to maxillofacial for biopsy
● Referral for maxillofacial for multiple radiolucency
Preferred definitive:
Referral for maxillofacial for lump biopsy and management
Extraction of mobile teeth and give new chrome cobalt denture.
Long Term and Maintenance Treatment:

Recall every 3 months
Review healing of socket and periodontal condition
Reinforce OHI
Consider this patient this patient, briefly describe what has led you into choosing this
overall care plan and the benefits (likely success, cost time, ect)to the patient .
Extraction and immediate denture teeth are very mobile possibility of inhaling them
chrome cobalt new denture, CR/CO denture thin, light and patient is used to it.
Referral for biopsy to confirm diagnosis and prevent progression of swelling.
Control gum condition to prevent further progression
Consider this patient are there any potential disadvantages of this treatment
(complicated, high risk of failure, short life of restoration, ect) for this patient.
Long treatment, expensive and difficult for future addition of teeth.
Management for swelling might involve surgery bleeding, and swelling
Would you provide all or part of the treatment for this patient yourself so which part or
parts? (give reasons)
Yes will provide immediate, most of stabilization, follow up and long term maintenance
Would you refer the patient for all or part of the treatment? If so which part or parts
and to which specialist
Yes to maxillofacial for management of swelling on the palate not under the scope of a
GDP.
Rachel Aston
3-3-1965
Present Complaint and History: ‘pain in my mouth’

upper left hand side, pain non-localized, started six months ago, not first episode had pain before
but not that much bothered about it, pain when chewing on that side continues for 30 minutes,
didn’t need pain killer, throbbing pain, severity of 3-4, disturbs patient sleep, tooth not mobile, no
swelling or dental treatment done
Other Complaints and History: ‘food getting stuck on the upper right side’
On UR4, no pain only irritation, missing tooth, extracted 11 years ago, food gets stuck there, never
had a replacement there, patient wants a bridge to replace the tooth, patient is using a tooth stick to
remove the lodged food there.
Causes of food lodgement is TMPD…. T-treatment on that tooth due to filling or crown, M-missing
tooth-,P-periodontal, D-decay. Ask about all of them for full clear history.
Ask the patient about the cracked tooth on the 21, filling was placed years ago, patient is having no
sensitivity and patient wishes to replace it.
Past Dental History:
● Regular attendee last visit was last year
● Previous treatment involved restoration, denture and extraction due to decay patient was
on high sugar intake
● Patient brushes once a day with an electric tooth brush, does not use any cleaning aids
● Cleans denture once a day and does not use any cleaning solution, patient takes denture out
at night
Medical History:
● Patient fir and well
● Anaemia on iron, folate and tranexamic acid (IS GIVE FOR HEAVY BLOOD LOOSE AND HEAVY
MENSTURATION)
Social History:
● Teacher /married /no dependant
● Not a smoker and never smoked
● No alcohol
● Low sugar intake and low acid intake
Notes:
● Bring me out of pain
● Wants a bridge to replace the missing tooth
Clinical finding:
There is an enamel pearl related to UL6 part from this abnormality no other is found in that quadrant
BPE
2 2 2
2 2 2
Class 3 malocclusion
Teeth missing
5
876 67 8
Provisional Diagnosis Clinical symptoms/presentation (ascertained

during the history) that have led you to this
diagnosis
1- Apical periodontitis/irreversible Pain on biting, throbbing pain, non-localized, last for
pulpitis secondary to enamel pearl in few 30 minutes, disturbs patient sleep, no pain to
relation to UL6 hot and cold
2- Food lodgement secondary to missing Extracted tooth 11 years ago, drifting of adjacent
UR5 teeth into that space, patient complaining of food
lodgement
3- Fractured filling on the 21 From clinical photograph and patient history
4- Generalized gingivitis Incidental finding bpe
2 2 2
2 2 2
5- Class 3 malocclusion Incidental finding
6-
7-
8-

diagnosis
1- Periapical radiograph for UL6 To assess any pathology or periapical involvement
2-
3-
4-
5-
Investigation How does this request contribute to your making a

diagnosis
1- Vitality test for UL6,UR4,UR6 and 21 To assess vitality of teeth
2- Percussion test for UL6,UR4,UR6 and To assess any periapical involvement
21
3- Mobility index for UL6,UR4 and UR6 To rule out bone loss for the adjacent teeth
4- Plaque index To assess presence and distribution of plaque
6- Examination of denture To rule out any denture faults/routine examination
7- Examination of denture bearing area To rule out any abnormality /routine examination
8- Examination of the area of missing UR To assess the area for any abnormality
5

RESULTS OF INVESTIGATIONS:
UL6- VITALITY 80
DENTURE SATISFACTORY ON EXAMINATION
UR4 AND UR6 ARE VITAL AND HAVE DRIFTED INTO THE GAP OF
MISSING UR5.
THERE IS NOT MUCH SPACE TO PUT AN ARTIFICIAL TOOTH THERE
Please report on …shown in the box below. You will have the radiograph in your folder for
artefact. It’s not related to this case
Radiograph: Horizontal bitewing

Side: right side
Bone level: slight bone loss
Teeth: 17,16,15,14/44,45,47
Restoration:
Distal on 14, MOD on 15, three unit bridge on 16 and 17
On root of 14, three-unit bridge on 45 and 47
Caries: Nile
Others: Nile
Film quality: 1
● Medical link
Update medical history
Follow stress free and short appointment
Patient could be at risk of bleeding because she is taking tranexamic acid consulate GP before
invasive treatment
● Immediate /emergency treatment
Educate patient about all dental concerns
pulp extirpation and seal with temporary filling.
● Initial/ stabilization treatment
o Explain gingivitis to patient give O.H.I, supra and subgingival scaling
o For enamel pearl:
Refer to endodontist for RCT followed by referral to periodontist for enameloplasty if
required. Or extraction.
o Explain drifting of adjacent teeth in the missing tooth gap, space is not enough for
replacement option of treatment:
1. Do nothing and give instruction of using TEPE brushes to clean the area with hygienist
appointments
2. Explain referral to orthodontist to open the space then give option of replacement with
advantages and disadvantages for removable denture acrylic and chrome cobalt, fixed-fixed
conventional bridge, implant / warn patient that orthodontic will assess if patient is suitable
for such treatment due to age.
o Explain broken filling and give option of simple composite filling, veneer and crown.
o Ask for consent to contact patient GP to liaison regarding patients medical
condition
o Give denture hygiene instruction
● Preferred definitive
Referral to endodontist for RCT for UL6
No treatment for missing tooth
Composite restoration for 21
● Long term and maintenance treatment

Review work done, periodontal condition and restoration
Reinforce OHI and denture hygiene instruction
Considering this patient, briefly describe what has led you into choosing this overall treatment
plan (likely success, cost, time, etc) to the patient?
1-Referral to endodontist: alleviate pain, save natural tooth, high success rate
2-No treatment for missing tooth: simple and cost effective
3-Composite: cost effective, easy and no tooth structure to be removed
Considering this patient are there any potential disadvantages of this treatment (complicated, high
risk of failure, short life of restoration, etc) for the patient?
1-requires referral, long treatment and expensive with risk of breakage and lodgement of files and
perforation of root.
2-asthetic not corrected and continued food impaction in that area risk of caries in adjacent teeth if
patient does not clean the area regularly
3-can chip off or wear off and stains risk of sensitivity
Would you provide all or part of the treatment for this patient yourself? If so which part? (give
your reasons)
Yes, will provide all emergency and long term maintenance and part of stabilisation
Would you refer the patient for all or part of the treatment? If so which part or parts and to which
specialist?
Yes, to endodontist for RCT not under the scope of GDP complexity 3
Some notes:
How to explain enamel pearl to a patient? It is a small blob on the tooth we call it enamel pearl
which is part of the outer protective layer of the tooth which is in an uncommon place it contains in
some cases the nerve of the tooth causing irritation to the gums. It is not common but nothing to
worry about. Researches has shown that it has the tendency in 13% to cause tooth death for
unknown reasons. We will do RCT with specialist….and I can refer you a gum specialist to have it
grinded off we call that enameloplasty if he thinks it is necessary.
If patient insist on having a bridge?

I will refer you to a restorative specialist as I mentioned there is not enough space there. so, he will
assess you for this as it is out of my scope of practice. He is in a better position to advise you about
this treatment.
Mrs Jemma Nolin D.O.B 3-3-1953

Present Complaint and History: ‘denture has gone very loose’
Had denture two years and a half, first denture, teeth had been extracted due to periodontal
diseases, acrylic partial upper denture, looseness happed gradually 8 months ago, looseness
increased last month after abutment tooth broken UR5, no pain or sensitivity with sharp edges.
Denture not fitting anymore 4 days ago abutment tooth lost a crown with RCT UL5, no pain and
edges are sharp, denture had no clasps. Denture has been altered, front teeth removed and added
to the denture couple of months ago, Patient cleans denture once a week and is not wearing it now,
take denture out at night.
● Since when have you had the denture? Is it your first denture? Why did you have your teeth
removed?
● Is it an upper or lower denture? Does it replace all or some of your teeth? Is it a plastic or
metal denture?
● When did, the looseness happened? Is it sudden or gradual?
● For UR5: Is the abutment tooth wobbly or broken? What about the teeth that hold the
denture in place they have a filling on it? Is it broken? Which tooth is it? How did it break?
Any sharp edges? Any pain? any RCT?
● For UL5: Is the abutment tooth wobbly or broken? What about the teeth that hold the
denture in place do they have a filling on it? Do you have it with you? Is it broken? Which
tooth is it? How did it break? Any sharp edges? Any pain? any RCT?
● Does your denture have any hooks? Are they broken?
● Was your denture altered?
● How many times do you clean your denture? Do you take your denture out at night?
Other Complaints and History: no other complain
Irregular attendee-last visit a year ago, for front teeth extraction/implant supported complete lower
denture/crowns and RCT.
Brushes once a day in the morning using a manual tooth brush. No cleaning aids
Medical History:
DVT patient diagnosed 3 years ago, INR is usually 2.5 done two weeks ago on warfarin and
furosemide (diuretic)
When asking patient about INR test patient may not understand so ask about (prick test) it’s the
layman term of INR.
Social History:
Retired nursery teacher/married/ no dependent
Not a smoker, never smoked
No alcohol
Sugar intake low
Acid intake low
Stress level medium
Notes:
Patient wants replacement for denture
CLINICAL FINDINGS:
TEETH PRESENT
UR 2,3,5
UL1,2,4,5
OTHER INFO
BPE 2,3,2/---
UR5 FRACTURED AT GUM LEVEL
UL5 POST CORE CROWN DEBONDED

diagnosis
1- Unretentive upper denture for Loose denture, no clasps, fractured abutment and
multifactorial aetiology deboned crown on other abutment, addition of
teeth, looseness happened gradually but increased
within the last days
2- Fractured UR 5 History from patient, tooth fractured to gum line
3- Deboned post and core crown UL5 History from patient
4- Gingivitis with localised periodontitis Incidental finding and BPE 2/3/2
5-
6-
7-
8-

diagnosis
1- Intra oral periapical for UR5 and UL5 To assess any periapical pathology, assess bone
level and condition or RCT
2- Intra oral periapical anterior upper To assess level and type of bone loss
sextant
3-
4-
5-

diagnosis
1- Examination of the denture To exclude any denture faults
2- Examination of the denture baring to exclude any abnormality in the alveolar ridge
area
3- OVD To asses OVD
4- Vitality test to UR5 To assess vitality of the tooth
5- Percussion test UR5 & UL5 To assess any periapical involvement
6- Mobility test UR5 AND UL5 To assess any bone loss and degree of mobility
7- Plaque index To assess presence and distribution of plaque
artefact
Radiograph: IOPA
Side: left side
Teeth: 35,36,37
Restoration: occlusal on 36,37
Caries: mesial on the 36
Others: partially impacted 38
Film quality: 1
RESULT OF INVESTIGATIONS;

DENTURE DESIGN SATISFACTORY
DENTURE BEARING AREA - NAD
NO LOSS OF OVD
NO TENDERNESS IN MUCLE OF MASTICATION
BODY TEMP NORMAL
UR5 AND UL5 HAVE A SATISFACTORY RCT DONE
● Medical link
o Update patient medical history regularly
o Stress free, short appointment
o Patient should be reminded to take medication
o Refer for INR in case of invasive dental treatment
o Liaison with GP before invasive treatment
o Explain unretentive denture /chairside relining
o Smoothen broken teeth and seal with temporary filling
o Explain gingivitis and localized periodontitis, give OHI, supra and subgingival scaling and
root surface debridement
o Explain option of fractured tooth and deboned crown leave as it is, incorporate them in
an over denture ,post core crown or extraction
o Give option of a new denture acrylic/chrome cobalt adding the extracted teeth or
restore them and use them as abutment, over denture and implant supported denture.
o Give denture hygiene instruction
o Coping on abutment and use as support for over denture
Recall every three months
Review work done, periodontal condition and restorative work
Reinforce OHI and denture hygiene instruction
Patient is on warfarin avoid extraction possibility of bleeding, teeth are RCT avoid complicated
extraction, preserve ridge height and better support.
Expensive treatment, multiple appointment and denture is bulky compared to the original type.
Abutment teeth may become infected
your reasons)
Yes all emergency, and long term maintenance and most of stabilization
specialist?
Yes refer to prosthodontic for over denture not under the scope of a GDP (you can constructed a
overdenture treatment if you feel confident so referral is not necessary)
● Other preferred definitive option that can be done:

1-Refer to a prosthodontic for over denture.
2-post core crown on the upper 5s and new denture
3-construct an overdenture yourself
● You want to avoid extraction in this case and patient is at risk of bleeding and teeth are RCT
which will render them brittle so extraction will be complicated might need surgery and
bone removal. You should explain to the patient if they opt for this option you must refer
him/her for an INR first and will take further precaution by applying suture and pressure
gauze to stop bleeding. Explain extraction is not recommended and better avoided.
● How to explain post core crown to patient:
We can build the tooth with a post which is basically a nail in the tooth that will hold the crown. The
advantages you will restore your natural tooth but it has the tendency to come off.
● Explain the coping and over denture:
We can prepare the broken teeth in a special way as they already have a good rct. where the teeth
will have a small protection cap over it and it will be used as a male part and female part in the
denture that sits on top of it, this will give you a denture with better support, avoid removal of teeth
and preserving natural teeth the disadvantages is the cost, teeth might get infected and might
require a referral.

David Princeton
3-3-1972
Present Complaint and History: ‘Concerned about my looks’

Discolouration started 7 years ago, getting worse, milk teeth had no problem, no trauma, pain or
sensitivity or dental treatment. No family history. it is only on the teeth that show when I smile.
Patient consumes 7-8 cups of coffee, not much tea, patient consumes 30-35 units of red wine was
unemployed and stressed and now starting a new job as a manager at the national park. Patient
brushes once a day and uses corsodyl mouth wash every night. Not a smoker. I wish I can have teeth
as white as the crown that I have.
● Where is the discolouration? Which teeth are you concerned about?
● Since when have you noticed it?
● What about your milk teeth did they have the same problem? Any family history of the same
problem?
● Any history of trauma? Pain or sensitivity? Any dental treatment?
● How much tea or coffee or red wine do you have?
● Are you a smoker?
● How many times do you brush your teeth do you use any mouth wash?
Other Complaints and History: ‘painful tooth LR6’
Localized started a week ago, pain on eating does not; last for long only when eating, dull pain, no
radiation doesn’t interfere with sleep. Severity is 4, pain killers is helping, swelling no temperature
and discharge all over, mobile tooth, patient has bleeding gums and discharge all over the gums, bad
taste, family history. Children has mentioned bad smell in my mouth. 2 of my upper teeth are mobile
too. No space between the teeth
If the patient mentions he has pain on eating mainly this is because periodontal problems
● Where is the pain? When did it start? Any previous history of pain?
● What brings on the pain? How long does it last? Did you take any painkiller? did it help?
● What is the character of pain?
● Does it radiate? Interrupt your sleep?
● Any treatment on your tooth? Any trauma? any temperature?
● Any swelling? Salty taste or blister? What is the severity of pain on a scale of 10?
● Any mobility of the tooth?
Irregular attendee/last visit 3 years ago for the crown and RCT some fillings on the back teeth
Patient brushes with manual tooth brush
Medical History:
Fit and well
No allergy
Family history of diabetes
Social History:
Smoker: no
Alcohol 30-35 units of red wine
Sugar low
Acid low
Stress is high
Notes:
Wants white teeth
Don’t want to lose mobile tooth
Findings provided :
ALL TEETH PRESENT
BILATERAL CLASS 2 MOLAR OCCLUSION
BILATERAL CANINE GUIDANCE
Plaque and calculus deposits

Pus extruding from pocket of LR6
mobile UR7, UL7
BPE:
4 3 4
4* 4 3
UL1 has a post and core crown(patients past x-ray

provided)
diagnosis
1- Generalized external discoloration Poor oral hygiene, high coffee and red wine intake.
secondary to multifactorial aetiology Daily use of Corsodyl mouth wash. patient not
happy with appearance of teeth
2- Chronic generalized periodontitis with Family history, mobile teeth, furcation involvement,
furcation involvement BPE score, bad smell and taste, mobile UR7 ad UL7
3- Periodontal abscess on LR6 secondary Pain on eating, mobile, swelling, salty taste
to periodontitis
4- Radiolucency on UL1 incidental
5-
6-
7-
8-

diagnosis
1- Selective IOPA for 3,4 and * sextants To assess level and type of bone loss
2-
3-
4-
5-

diagnosis
2- Bleeding index to confirm active periodontal disease
3- Mobility index To assess mobility grade and bone loss
4- 6-point pocket chart To assess clinical attachment loss
5- Furcation index To assess level of furcation involvement
6- Percussion test UL1,LR6 To assess any periapical pathology
7- Body temperature and lymph node To rule out any systemic involvement
examination
8- Sensitivity test To assess vitality of the teeth
9- Dietary chart To analyse patient diet
RESULTS OF INVESTIGATION
ALL TEETH VITAL EXCEPT --UL1-RCT DONE + POST CORE CROWN
BODY TEMP NORMAL
BLEEDING INDEX 89%
PLAQUE INDEX 81%
LR6 GRADE 2 MOBILE, GRADE 2 FURCATION INVOLVEMENT
UR7, UL7 GRADE 1 MOBILE
artefact
Radiograph: intra-oral periapical radiograph

Side: right lower posterior
Bone level: sever vertical bone loss
Teeth: 45,46,47
Restoration: none
Caries: mesial on 45
Others: furcation involvement on 46
Film quality:1
● Medical link
o Update medical history
o Stress free and short appointment
o Explain periodontal abscess /scaling to drain the pus from periodontal pocket to relief pain
o Explain periodontitis and furcation involvement:
OHI/ supra and subgingival scaling, root surface debridement and referral to periodontist
o Option for LR6 either monitor or extract and give replacement option
o Explain cause of discoloration:
Advice on reduction in consumption of coffee and red wine/ stop use of Corsodyl mouth wash.
give option of scaling and polishing, teeth whitening, veneers and crown. Explain to option only
available option now is scaling and polishing, other option not available until periodontal
conditions is stabilized.
o Explain radiolucency on UL1 monitor as there is no pain
o Refer to GP for blood sugar level test and stress management
o Advice on alcohol limit
Tooth whitening after stabilization of periodontal condition.
Monitor LR6
o Recall every three months
o Review restorative and periodontal condition
o Reinforce OHI, alcohol limit
Teeth Whitening: quick and simple, cost effect, conservative treatment no tooth surface removed
and acceptable results
Monitor the LR6: restore natural tooth, comply with patient wishes after treatment tooth might
stabilize
Discolouration might reoccur if patient continue with same dietary habits, patient might be left with
sensitivity.
Monitor: tooth has poor prognosis, possible source of infection which might flare in the future casing
pain and swelling
your reasons)
Yes all immediate and follow up and most of stabilization
specialist?
Yes to periodontal specialist BPE score of 4* not under the scope of GDP
In this case avoid taking to the patient about sending him for a blood test in the medical link,
leave it to when you explain about periodontitis and how diabetes is link to this condition.
Address patient main concerns at this stage which is discoloration give patient all the option.
Give advantages and disadvantages for each option.
Scaling advantages do it in one go, remove all stains and deposit and cost effective
Scaling disadvantages can bring sensitivity and does not whiten the teeth
explain until we bring the gum condition I cannot offer you the rest of the options unless we
stabilize you gum disease.
Advice patient about periodontal abscess: caused by plaque and calculus which contain germs
these creeps along the tooth making a gap between the tooth and bone this is called a pocket.
Germs produce some harmful substance causing distraction of one accumulation of pus causing
swelling. What I will do today I will clean the pocket and that will calm the pain down.
As the tooth is wobbly because it has lost a lot of bone support around it success rate for it is
low the option is to monitor it the advantages we are saving the natural tooth the down side it
might flare up. The other option is taking the tooth out and give you a removable option, fixed
option will be given after the stabilization of gum condition if you like.
Regarding periodontitis explain it and show the link to family history and diabetes. Explain you
are doing referring to GP as diabetes runs in families and has a direct link on treatment.
Explain treatment of periodontitis is a tringle of three:
1-the dentist: giving advice on cleaning and polishing, correct mouth wash, hygienist
appointment and recalling you every three months
2-patient: should follow the advice given by keeping your teeth clean. I am sure you do not
want to lose your teeth
3-periodontal specialist (gum specialist) they will repeat the treatment that we have already
done plus some minor surgical procedures
MARK ROBINSON
DOB 3-3-1972
Present Complaint and History: ‘I am here to have a check-up’

As I am here I have a funny tongue for the last three months, no dry mouth, there is an ulcer on the
lateral right border of the tongue, it is 1cm in diameter. red and white in colour it is not increasing in
size. Patient had no trauma to the area but has a LR6 that is broken with an amalgam filling with RCT
which is broken for five years and no treatment was done for it since . patient is avoiding touching
the tooth with the tongue.no pain or discomfort from the tooth or ulcer. He has seen his GP who
prescribed Nystatin it did not help. GP tried to scrap it but it didn’t come off.no bleeding or discharge
atient’s wife has noticed he has lost weight and he is a heavy
from it or alteration in sensation. p
smoker and high alcohol intake.
● Since when have you noticed it?
● Is there any alteration in sensation or Any restriction in the movement of the tongue?
● Any funny taste or dry mouth?
● Is there any break in the skin? Where is it? Is it painful? Have you had it before? what is the
size? Is it getting bigger? What colour is it? any bleeding or discharge from it? Did you have a
trauma?
● Is there any broken filling or tooth near it? When did it break? Is there any pain from the
tooth? Does it have a RCT?
● Did you have any treatment for it? Can you scrap it off?
● Do you smoke? and have alcohol? Do you have a lump anywhere else? Have you lost
weight?
Other Complaints and History: ‘I have a denture lost it 7 months ago,’
Patient has an upper and lower denture no problem with upper denture but lower denture broken
both dentures acrylic partial dentures and he threw it away. interested in a new denture. Lost his
teeth for hypodontia, have a milk tooth present LRE which is wobbly. Cleans denture after ever meal
and takes it out at night.
● Is it a plastic or metal? Replacing all or some of your teeth? A top or a bottom denture?
● What happened to the bottom denture? When did that happen? Are you interested in a new
replacement? Did you like your denture? What about your top denture are you satisfied?
● How did you lose your teeth? do you have any milk teeth? are they wobbly?
● How many times do you clean your denture? Do you take it out at night?
Irregular attendee, brushes twice a day with a manual tooth brush no cleaning aid
Medical History:
Medically fit and well
Social History:
Motor mechanic/married/ 2 dependent
Smoking 30-35 cigarettes for the past 20 years
Alcohol 20-30 units/week mainly white wine
Sugar intake is low
Acid intake is low
Stress level is low
Notes:
Nothing

INFO PROVIDED;
LESION ON RIGHT LATERAL BORDER OF TONGUE HAS EVERTED MARGINS
BPE111-121
UPPER ACRYLIC DENTURE FOR MISSING UR 2,3 UL 3,4 --one clasp broken
LOWER DENTURE REPLACING LL6-
LRe MOBILE
EROSION VISIBLE
FRACTURED FILLING LR6-PICTURE PROVIDED

diagnosis
1- Traumatic ulcer in relation to the Non-healing ulcer for 3 months,1 cm in size, red and
lateral order of the tongue suspected white patch no pain, adjacent to a broken tooth
squamous cell carcinoma present for the last 5 years, cannot be scrapped off,
heavy smoker and alcohol intake, not responding to
previous treatment
2- Broken restoration in relation to LR6 History from patient
3- Mobile LE in secondary to hypodontia Patient diagnosed with hypodontia, history from
patient
4- Missing LL 6 Hypodontia, previous denture, broken, history from
patient, patient requested a replacement
5- Generalized gingivitis Incidental and bpe score
6- NCTSL secondary to erosion Incidental, high white wine intake
7- Broken clasp on upper denture incidental
8-
For erosion ask for BEWE/// For attrition ask for knight and smith
diagnosis
1- IOPA LR6 To assess quality of RCT and presence of any
pathological periapical involvement
2- IOPA for LRE To assess root condition and presence of permanent
tooth
3-
4-
5-

diagnosis
1- Examination of the ulcer To assess size and consistency
2- Palpation of lymph node To assess any systemic involvement
3- Percussion test LR6` to assess any periapical pathology
4- Mobility index LR6,LLE To assess the grade of mobility and bone loss
7- BEWE To asses NCTSL
8- Examination of the denture To assess any faults with denture
9- Examination of the denture baring To exclude any abnormalities
area

RESULTS OF INVESTIGATIONS;
Body temp-normal 36.7 deg C
MOVEMENTOF TONGUE-SATISFACTORY
LR6-RCT SATISFACTORY
LRe –grade 2 mobility. ROOTS RESORBED-NO PERMANENT TOOTH DETECTED UNDERNEATH

Radiograph is only for report writing practice. It’s not related to this case.
artefact
Radiograph: IOPA
Side: right side
Bone level: mild bone loss with sever bone loss around furcation of 46
Teeth: partially 44 and 47 ,45,46
Restoration: occlusal on the 46
Caries:
Others: widening of the PDL around the 46 and periapical radiolucency around the roots of 46
Film quality:1
● Medical link
o Update medical history records
o Explain non-healing ulcer to patient, urgent referral to maxillofacial for a biopsy and
management, advise on stopping alcohol and smoking
o Removal of filling on LR6 and placement of temporary
o Explain gingivitis OHI, supra and subgingival scaling
o Explain option of treatment for restoration LR6 composite, amalgam, onlay and crown
o Explain mobile LLE monitor or extraction and include in replacement for lower denture
acrylic partial denture CR/CO denture, conventional bridge and implant supported denture
or bridge
o Explain NCTSL and monitor with photographs and study casts
o Repair upper denture clasp
o Smoking cessation referral
o Alcohol limit advice
Referral to maxillofacial for biopsy and management of ulcer
Crown for LR6
Extraction of LLE and include in new acrylic partial denture
Review NCTSL, periodontal condition and restorative work done
Reinforce OHI, smoking and alcohol status
Ulcer: to reach a definitive diagnosis and start with a correct treatment plan.
Crown: good aesthetic, retention and protection for the RCT tooth
Extraction of LLE: poor prognosis, tooth might exfoliate to be included in the new acrylic denture
Ulcer: require referral to hospital and time consuming
Crown: cost and require multiple visits
Extraction: loss of natural tooth
your reasons)
Yes immediate, most of stabilization and long term
specialist?
Yes to maxillofacial for ulcer biopsy and management not under the scope of GDP
Things we need to high light in the presentation:
Do not mention the word cancer to the patient but show them that you are worried. if after
explaining the condition and patient is still hesitant about going for a biopsy and not bothered
address your concerns one way of doing that by mention three words seriously, nasty and
sinister for example:
I would advise you to take it more seriously, from the history that you have given, the colour
and shape it looks nasty. And as it has been there for quite a long time with the history of
smoking and alcohol I am suspecting something sinister. It has also not responded to the
treatment your GP prescribed so let’s explore it more for your peace of mind and my
satisfaction.
You had that sharp filling for five years and it has been irritating the area continuously which is
not normal with the smoking and alcohol it can turn into something nasty.
Explain biopsy and inform patient only way to confirm or rule out diagnosis.
Kate Williamson
DOB 3-3-1992
Present Complaint and History:’ my bridges came off please put it back’
My front teeth in the photos are false teeth, I had it for 2 ½ years replacing my 11 and 21, lost it in a
car accident when I was 12 the front teeth popped out and had a removable denture which I hated,
kids made fun of me. I am happy with my bridge because it is fixed the only problem it came out
many times before.
How long have you had the bridge?
Are you happy with it is it causing you any trouble?
How did you lose your teeth? when did you have an accident?
What replacement did you have before? How was your experience?
Other Complaints and History:’ my gums bleed ‘
My gums bleed, started 5 months back around my back teeth only although I take good care of my
teeth, family history my mother had a same problem, no mobility no gaps, no diabetes, moderate
stress not a smoker
Since when have you had this problem?
Is it all over your gums or to a specific area?
Have you noticed you gums shrinking or teeth becoming longer?
Any gaps? Any wobbly teeth? any bad taste or breath?
Any family history?
Are you diabetic? Smoker? Stressed?
Regular attendee, every 6 months, previous treatment involved bridges and filling, orthodontic
treatment done when she was 17 years old and happy with the result.
Brushes twice a day with an electric tooth brush daily use of mouth was and floss
Medical History:
Omeprazole for acid regurgitation for the past three years which is controlled now.
We should ask about sensitivity possible NCTSL, Do you have any sensitivity in your teeth? if you
do not ask patient will not give this information in exam
Social History:
Solicitor
Not a smoker and never smoked
Alcohol intake 7-10 unit of white wine
Sugar intake is low
Acid not fond of fizzy drinks but occasionally take fruit juice
Stress is medium starting a new job
Notes:
Want my bridge back now I have a meeting and cannot leave like this
Clinical findings

EDGE TO EDGE BITE

BPE
3 2 3
2 3 3

TEETH MISSING UR1, UL1
NCTSL
RESIN BONDED BRIDGE WITH WINGS ON 12,22
WINGS ON 22,12 ARE UNDEREXTENDED

diagnosis
1- Deboned resin bonded bridge History of deboning on multiple occasion, under
secondary to fault in design extended metal wing on 12 and 22, patient has an
edge to edge occlusion
2- Aggressive periodontitis Bleeding gums, bpe score
3 2 3
2 3 3
Family history, good oral hygiene, healthy young
patient
3- Edge to edge occlusion Incidental
4- NCTSL secondary to erosion Clinical examination, sensitivity, previous history of
acid regurgitation which is controlled,
5- Caries on LR 6 and 7 Incidental
6-
7-
8-

diagnosis
1- IOPA for score 3 sextants To assess leave and type of bone loss
2-
3-
4-
5-

diagnosis
3- Mobility index Ro confirm bone loss and
4- Vitality test To assess vitality and sensitivity of teeth
5- Examination of bridge bearing area To exclude any abnormality
6- Articulating study cast To examine occlusion
7- BEWE To assess erosion
8- Diet chart To analyse diet
9- Percussion testLR6,7,UR2&UL2 To exclude any periapical pathology
Radiograph is only for report writing-not related to the case

RESULTS OF INVESTIGATIONS
ALL TEETH VITAL
BLEEDING INDEX 83%
PLAQUE INDEX 15%
BEWE 11
-------------------------------------------------------------------------------
BEWE 0 – 2 no susceptibility
BEWE 3 – 8 low susceptibility
BEWE 9 – 13 medium susceptibility
BEWE ≥ 14 high susceptibility
artefact

Side: right side
Teeth:14,15,16,17,45,46,47
Restoration: Nile
Caries: distal on the 46
Others: coning off , upper teeth not showing accurately
Film quality: 2
● Medical link
o Explain causes of deboning bridge and cement back
o Explain NCTSL application of durphate 22600 ppm
o Explain aggressive periodontitis, give OHI , supra and subgingival scaling , root surface
debridement and refer to periodontal specialist
o Explain effect of edge to edge occlusion on replacement option and refer to orthodontic for
correction of occlusion
o Give option of replacement removable acrylic/CRCO denture, resin bonded bridge,
conventional bridge, implant with advantage and disadvantage.
o Give option of treatment of NCTSL direct veneer, indirect veneer and crowns
o Give dietary chart and advice on reducing consumption of white wine
o Explain caries on LR 6 and 7, excavate careis and temporary filling and option of amalgam
and composite for permanent restoration with advantages and disadvantages.
o Refer to periodontal specialist for treatment of aggressive periodontitis
o Referral to orthodontist for correction of occlusion
o Give a new resin bonded bridge, bridge with proper wing design
o After stabilization and correction of occlusion give patient implant
o Recall every 3 months
o Review restorative and periodontal treatment
o Reinforce OHI and dietary advice
Refer to perio, prevent progression of periodontal condition and restore patient natural teeth.
Refer to orth, correct patient occlusion for more suitable long term replacement
New resin bonded bridge, better design, given as an interim measure until occlusion and periodontal
is corrected,5-7 years life long
Implant, young patient, high success, last a life time
referral-long mulitiple visits, require referral and expensive.
New resin bridge, possible deboned
Implant, expensive, involve surgery and require referral
your reasons)
Yes all immediate, part of stabilization and longer term maintenance
specialist?
Referral to periodontist for Aggressive periodontitis not under the scope of GDP, complexity 3
Referral to orthodontist to correct occlusion not under the scope of GDP
Referral for implant not under the scope of GDP
Let me explain why you bridge is falling off:
First it has a faulty design the wing should extend all over the adjacent tooth and the way you are
biting the top and bottom teeth meet and tip off. in a normal bite this doesn’t happen as bottom
teeth close behind the upper teeth and that is why you bridge is coming off. we need to do
something about it. Is that clear?
For today I will glue the bridge back but keep in mind that it will come off again. So I can give you
couple of options either a removable plate which is acrylic or metal…….. etc , a new sticky bridge
which will have a proper design wing, but there is a possibility that they can come off . a fixed bridge
which has good aesthetic but we need to prepare the other two front teeth to give it enough
support and that puts the tooth under risk of death if it happens you will need further treatment.
Implant which has a high success rate and can last you a life time however if your bite is not
corrected then there will be a higher risk of failure for both implant and bridge, therefore I would
like to refer you to an orthodontist to have braces to correct your bite. I know you had this
treatment before and you are happy with it but if we don’t correct the bite you will keep having
problems with your replacements.
We can give you the new sticky bridge as an interim measure until your bite and gum disease is
corrected.
You mentioned your gums are bleeding, unfortunately you have an aggressive form of gum disease it
runs in families as you mentioned your mum had it and it is seen in those with excellent oral care but
you still get this disease as it is in your genes. I will refer you to a specialist so we control it and
prevent further progression.
your regurgitation reflex influenced the structure of your teeth, the stomach acid is very strong
which dissolves the enamel away. acid from food or drink will make it worse. you have mentioned
that it is under control which is very good, but you are still taking a lot of white wine which is high
acid so I will give you this diet chart to fill and we will highlight it next time. For the sensitivity, I will
apply fluoride gel on the teeth to stop it.
Notes we need to remember:
1- If patient says he doesn’t like the removable you still give it as an option to make sure you
show the examiner that you know.
2- Another treatment option that passed is as following:
New sticky bridge
Referral to periodontist
Referral to restorative specialist to construct a bridge of 6 units canine to canine and to
prevent the interference of edge to edge occlusion
this is two cases in one
Mr. Cole Walker
DOB 3-3-1989
Present Complaint and History: ‘pain on the UL1’
Localized pain, started 7 days, previous episodes, pain in continuous, pain on bite, dull pain, on the
RCT done twice and one apicectomy done 4 months ago, trauma patient was caught in a fight, sinus,
swelling patient had antibiotic of amoxicillin for five days’ course prescribe by GP. I want to get rid of
the tooth
Other Complaints and History: ‘pain on the UR side’
Non-localized pain, present for 3 days, first episode, pain to hot and cold lasts for few seconds, no
painkillers taken but when pain comes very sever, treatment done on that area a 4-unit bridge done
6 years ago, lost teeth due to accident
regular attendee/last visit 6 months/polishing, bridge and normal fillings
brushes twice a day with a manual tooth brush no cleaning aids
Medical History:
Epileptic on phenytoin for the last 7-8 years, diagnosed since childhood, triggered by noise, light and
stress, last seizure was a minor one 6 months ago because I missed my medication.
Social History:
Never smoked
Alcohol 3 units a week
Sugar intake low
Acid low
Stress low
Notes:
I had enough with this tooth take it out I don’t want to spend any more money on it.
I am getting married within 3 weeks save my tooth and bridge going away for a long honey moon 9
months
Clinical findings:
BPE
1 1 2
2 1 1

TEETH PRESENT
7 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 43 21 1 2 3 4 5 6 7 8
4-unit bridge replacing UR 5 & 6---- Pics show caries around the bridge margins on UR7
Draining sinus in relation to the labial UL1

diagnosis
1- Chronic preapical abscess secondary RCT twice, apicectomy 4 months, patient has dull
to failed RCT pain, swelling. Sinus and temperature
2- Reversible pulpitis under the bridge Sever pain under the bridge, doesn’t interrupt
secondary to caries patients sleep, last seconds, pain to hot and cold,
caries around leakage bridge on the margin of the 7
3- Generalized gingivitis Incidental finding
4-
5-
6-
7-
8-

diagnosis
1- IOPA for UL1 with GP for sinus track To assess RCT and any periapical pathology and
tracing determine the path of sinus
2- Horizontal bitewing for UR 4 and 7 To assess presence and extension of caries
3-
4-
5-

diagnosis
1- Vitality for UR 7 and 4 UL1 To assess vitality of the pulp
2- Percussion test To assess any periapical involvement
3- Mobility index To assess mobility and bone loss
4- Examination of the swelling To assess size and consistency of swelling
7- Temperature To assess systemic involvement
8- Lymph node examination To assess systemic involvement
PLEASE WRITE RADIOGRAPHIC REPORT ON THE XRAY WITH BRIDGE-ITS NOT RELATED TO
THE CASE ITS ONLY FOR REPORT WRITING PRACTICE
Results of investigations:
BODY TEMP 38.4 DEGREES
UR7-VITALITY 20
UR4- VITALITY 40
LR6- VITALITY 40
LR 7 VITALITY 40
UL1 - FLUCTUANT ABSCESS ON PALATAL ASPECT WITH A DRAINING SINUS LABIALLY
artefact
Radiograph: IOPA
Side: Left side
Bone level: Adequate
Teeth: 23,24,26, partially 27
Restoration: 3-unit bridge abutment 24 and 26 with pontic replacing the 35
Caries: distal to 23 under the retainer on 24 and 26
Others: proximity of roots of 26 to maxillary sinus
Film quality: 1
● Medical link
o Stress free short appointment
o Remind patient to take his medication
o Fits triggered by noise stress and light possible medical emergency
o For swelling incision on the palatal aspect and drain, pain killer and advice patient to
continue their antibiotic course prescribed by the GP.
o Removal of bridge and decay, application of temporary filling and temporary bridge/or
recement patients bridge if not damaged
o Gingivitis: OHI , supra and subgingival scaling
o For UL1: either save the tooth with re-apicectomy or take the tooth out and give option of
immediate denture , resin bonded ridge, conventional cantilever on the UR1 or implant.
o For UR 7 option of amalgam or composite
o For bridge: new bridge , crown on the abutment and removable partial denture or crowns on
the abutment and implant
o Extraction and resin bonded bridge as temporary and implant after healing
o New bridge to replace the upper posterior right bridge
o Review work done
o Reinforce OHI
Extraction and implant: tooth is of poor prognosis, alleviate pain and prevent further infections,
implant is high success rate, young patient no good periodontal condition not a smoker
R.B.B to restore aesthetic as temporary measure, fixed option and epileptic patient
New bridge: restore aesthetic and function, fixed option within patient’s time frame
1-Loss of natural tooth, expensive and long treatment, RBB possible of deboning, require a referral
2-expensive possible pulp necrosis
your reasons)
Yes all immediate and long maintenance and part of stabilization
specialist?
Yes refer to implantology’s for implant require special training and knowledge not under the scope
of GDP
For the painful front tooth, it is chronic periapical abscess which is infection around the tip of the
root and there is pus collection and that is why you are having the swelling and pain on biting. The
good thing is that pus is coming out through the blister and that is why you are not having sever
pain. On the top of your mouth there is a swelling which I will numb the area around it and make a
small cut to allow the drainage of pus and that should get you out of pain. I would advise you to
continue taking the antibiotic that you have. You can also have some pain killer and that should help
with pain.
I will review you after a couple of days to make sure the pain has subsided. For the treatment
options, you can either:
1- Save the tooth by having a re-apicectomy I know you don’t want to spend more on it but we
can give it a last try nothing replaces a natural tooth. However, is has a low success rate
because of previous failed treatment and I will have to refer you to a maxillofacial specialist
2- Or Have the tooth taken out and give you replacement options:
a) we take an impression and give you an immediate denture same day we take the tooth
out, you won’t be left with a gap but because your medical condition there is a risk of injury
or inhalation it.
b) we can give you a sticky bridge which is an artificial tooth attached to a wing that is glues
to the back of the tooth next to it. It is a fixed option and won’t interfere with your condition
but if the area underneath it gets infected it will be difficult to remove it
the previous options can be used as a temporary measure and after healing is completed we
can give you a fixed option that is:
● Conventional cantilever bridge which is two caps stuck together it will get the
support from the tooth next to it good aesthetic and retention but there is a
possibility after preparing the healthy tooth it might undergo death if that happens
further treatment is required
● Implant explain advantage and disadvantages
The sequence of treating a failed RCT: first RCT, RE-RCT, APICETOMY, RE-APICETOMY, EXTRACTION
The pain under your bridge is because of decay. The margins of your bridge are poor and food is
getting stuck there. To relieve you form pain I will have to take the bridge off. I might damage the
bridge or break the teeth underneath it. i will then remove the decay and place a temporary filling
and then place the bridge or make a temporary bridge and put it in place.
For the permeant treatment of the filling composite or amalgam.
For the replacement of bridge either:
1- a new bridge within the time limit.
2- Crowns on the teeth and removable again there is risk of injury or inhalation
3- Crowns on teeth and implant long treatment
there is another pain under the bridge, with irreversible pulpitis emergency treatment is going
through the bridge there is a possibility that the bridge or the tooth is damaged so will take some
x-rays to know the angulation but this bridge has poor margins it needs to be replaced.
The other option is to remove the bridge, remove the nerve and seal the tooth, then a temporary
bridge is placed on tooth until we finish the treatment we can give you a permanent replacement.
Another case is when there is a wobbly tooth the abutment tooth is wobbly because of periodontitis,
in this case you can section the bridge leaving the crown on the tooth and give replacement option
for the rest.
Richard Earl
DOB 3-3-1945
Present Complaint and History: ‘Loose upper denture’
Patient is denture wearer for more than 40 years, had 8 dentures before because dentures becomes
loose and teeth removed and added to it. had this denture for 4 years the denture is a metal denture
replacing all my teeth but two one has a clasp and the other is under the denture. It became slightly
loose for 2 years ago, 2 days ago, it became very loose I dropped it while I was cleaning it and the
acrylic part broke I don’t remember where I put it old age you know ! Denture has clasps which are
okay on the UL7 abutment, the other is a root which has a RCT that has a coping and I lost it. I don’t
clean my denture it looks okay to me and I don’t take it out at night I cannot sleep with I always wore
it at night.
Other Complaints and History: ‘I have a wobbly tooth’

LL7, wobbly for the last 3 years, gums are bleeding and always did I am not bothered about it, gums
shrinking down, gaps forming between my teeth, no family history, diabetes or stress
Irregular attendee
Brushes once a day with a manual tooth brush uses mouth wash occasionally
Medical History:
I visit HIV clinic was diagnosed 4 years ago, on the following medication Tenofovir, Zidovudine,
Abacavir and Lamivudine. (if the patient gives you a card with medication names write them down).
there are four patient who give you a card the HIV patient, the patient with a lump on the palate,
patient with bulimia and the loose denture with broken abutments.
You should ask when was the viral load checked? My viral was checked 2 weeks ago, and the people
at the clinic were very happy. (do not say sorry to the patient about HIV stay neutral)
Social History:
Not a smoker and never smoked.
Alcohol taken occasionally
Sugar low-moderate
Acid low
Stress moderate patient grinds his teeth
Notes:
I want you to fix my denture I have my nephews wedding which I don’t want to go without the
denture I want to have a nice smile, the wedding is 3 days
CLINICAL FINDINGS:
TEETH PRESENT .........UR3(ROOT PRESENT, RCT DONE) UL7
UR3 root present with RCT 7
7 4 3 2 1 12 3 4 7

BPE ---/2-2-4*
FLABBY RIDGE IN ANTERIOR MAXILLA
ATTRITION VISIBLE IN MANDIBULAR TEETH
ACRYLIC COPING LOST FROM ROOT OF UR3
Lost filling LL4
BUCCAL ACRYLIC FLANGE BROKEN FROM RIGHT POSTERIOR PART
This is the UL7

diagnosis
1- Unretentive denture secondary to Loose denture, history of accidentally dropping it
broken flange during cleaning happened suddenly
2- Generalized gingivitis with localised History of mobile tooth, bleeding gums and BPE
periodontitis score
3- NSTCL secondary to attrition Patient grinds their teeth does not take the denture
out at night
4- Flappy ridge in the anterior part of Incidental
maxilla
5- Lost coping on abutment Incidental
6- Lost restoration on the LL4 Incidental
7- Lower missing posterior teeth Incidental
8- UL 7 furcation involvement and gum Incidental
recession

diagnosis
1- Selective IOPA for posterior left To assess type and level of bon loss
sextant
2- UL 7 IOPA To assess type and level of bone loss
3-
4-
5-

diagnosis
1- Examination of denture To confirm denture fault
2- Examination of denture baring area To confirm abnormality on the ridge
3- Plaque index To assess plaque distribution
4- Bleeding index To confirm active periodontal condition
5- Mobility index To confirm bone loss and grade of mobility
6- 6-point pocket chart To confirm clinical attachment loss
7- Furcation index To confirm grade of furcation involvement
8- Knight and smith index To assess degree of TSL
9- Vitality test for LL4 To assess vitality of the pulp
10- Percussion test for LL4 To asses any periapical pathological
11- OVD To rule out any OVD loss
12- Articulating study cast To assess occlusion
RADIOGRAPH IS ONLY FOR REPORT WRITING PRACTICE
LOSS OF OVD 1MM
LL7 GRADE 2 MOBILE
RCT UR3 SATISFACTORY
UL7 gingival recession. Grade 1 furcation involvement
LL4 non-vital
BODY TEMP NORMAL
artefact
Radiograoph: DPT
Side:
Bone level: irregular bone loss,
sever around posterior teeth
Teeth:
3 2
7 4 3 2 1 1234 7
Restoration: crown on all teeth except the LL7 which has and occlusal restoration and RCT on LR7,
UR 3 and 2
Caries: nile
Others: nile
Film quality: 1
● Medical link
o Advice patient to take medication and visit HIV clinic regularly
o Take consent to liaison with HIV clinic
o Referral to HIV clinic for viral load check in case of extraction or minor surgery
o Educate the patient about the link of HIV and periodontal disease
o Follow stress free protocol during appointment
o Educate the patient regarding all dental concerns
o Take an impression with denture and send it to the lab for repair
o Temporary dressing on the UR3
o Fluoride varnish on attrition (only if patient has sensitivity this patient doesn’t)
o OHI, supra and subgingival scaling, root surface debridement and referral to periodontal
specialist
o Option of UR3 replace the coping and use as abutment or extract and include in replacement
option
o Refer to prosthodontic for window impression or to maxillofacial for removal of tissue
o Option of replacement for upper either upper acrylic denture, CR-CO denture, overdenture
and implant supported denture
o Option for lower replacement of LR 5,6 and LL 5,6 denture acrylic or CR/CO, bridge or
implant supported
o LL 7 monitor or extraction and add to replacement option
o LL4 extraction or RCT and crown
o Monitor TSL with photograph and study cast
o Give denture hygiene advice
o Referral to prosthodontic for upper new overdenture using UR3 as abutment, extraction of
UL7 and add it to denture
o Referral to periodontist
o Extraction of LL7 and give new lower acrylic denture
● Recall every 3 month
● Review periodontal condition, restorative work done and TSL
● Reinforce OHI and denture hygiene instruction
Over denture: maintain height of jaw, no surgery (only window impression), patient is HIV, poor
prognosis of the UL7, better retention, restore function and aesthetic
Referral to periodontist: to control periodontal condition and prevent progression of disease and
prevent natural teeth loss
New lower acrylic denture: to have a balance distribution of occlusion, stop overgrowth of flappy
ridge, poor prognosis of the LL7, further teeth can be added to the denture
Long treatment require referral, flappy ridge still exist might affect the retention of denture,
abutment tooth might get infected and need extraction at a later stage
Treatment is unreliable link to patient’s medical history needs compliance of patient
Acrylic denture is bulky, thick patient never had lower denture might find it difficult to adapt
your reasons)
Yes immediate, most of stabilization and long-term management
specialist?
Yes to prosthodontic for overdenture out of the scope of GDP and periodontist complexity 3

This is a quick outline of what you need to tell the patient. It is too long very difficult
to cover everything!!!
Thank you for waiting I have the results………
Let’s start with your medical history I might need to contact you HIV clinic to make sure
whatever treatment we decide on is safe for you, your safety is first,
Your denture is loose because it is broken I will take a mould with the denture send it to the lab
and make sure it’s ready on time before the wedding so you can attend with a confident smile.
Now this denture might not last you for long I have noticed you have a loose fold of gum tissue
there so I think it’s a good time to discuss all the options that we have, either acrylic/CO-CR,
overdenture and implant (explain link between HIV and implant).
I will refer you to prosthodontic to have a special mould made which does not involve a surgery
but the tissue will remain or refer you to a surgeon to have it removed but as you are HIV
positive I would like to avoid surgery.
You have an advance form of gum disease which is an irreversible condition it has a close link to
your medical condition which makes this disease more aggressive and that is why you are losing
many teeth,
Your LL7 is wobbly we can monitor it as we treat your gum condition it might stabilize saving a
natural tooth but looking at it has a poor prognosis. The other option is to take it out and add it
to the new replacement.
UL7 is of poor prognosis the gum and bone around it has shrunk if I keep it and give you the
replacement within a few years you will comeback complaining about it, so let’s deal with in
now and include it in the overdenture
The root you have has lost the small cap on top of it so I will seal it with temporary filling today
and later we can either place a new cap on it and save the natural tooth or have it taken out
but as it has a rct these teeth are very brittle and you might need a small surgery to have it
taken out which again we want to avoid.
Your lower teeth are missing we can give you a replacement for them and that will stop the
flabby ridge from growing options are …….
Talk about attrition and ask the patient to take the denture out and give denture hygiene
instructions. monitor it
You have a LL4 that has lost a filling the tooth is dead so we can either leave it, rct or extraction
This case also come with a patient who has prostate cancer and had radiotherapy there is no
link of his medical history to dental treatment.
Teresa Harper
08/04/1994
Present Complaint and History: ‘my gums are bleeding’

It started 3 months ago, around my upper front teeth, there is a soft swelling behind them. Swelling
is red in colour increasing in size appeared three months ago, No discharge but bleeding on touch,
not painful no tingling sensation, no pain in the teeth next to it or trauma, had a white filling placed
on the tooth next to it and swelling appeared around the same time. No body temperature and food
does not get stuck in it and no radiotherapy.
Other Complaints and History: ‘my teeth are sensitive’
It started 2-3 years ago, becoming worse, its generalized, they are sensitive to cold lasts for seconds.
Patient was diagnosed with acid reflex and GP stopped the omeprazole as condition is stabilized.
Patient is very concerned about healthy eating and takes 3-4 glasses of fresh fruit drinks. Patient had
no bleaching or orthodontic treatment. Patient does not grind their teeth and stress is low.
Causes of sensitivity are; erosion, attrition, abrasion, gum recession , bleaching
Since when have it started? Is it getting worse?
Is it sensitive to hot, cold or sweet? How long does it last?
Is it all over your teeth or to a specific area?
Do you grind your teeth? do you have any pain on the side of your face?
Do you have any tummy trouble or heart burn?
How much fruit juice or fizzy drinks do you take?
Do you think your gums are shrinking?
Regular attendee every 6 months
previous treatment involved composite filling/scaling and polishing
brushes twice a day with a manual tooth brush and Colgate tooth paste
Medical History:
Fit and well
In all medical histories, it is important to ask about family history and childhood illness
Social History:
Beautician therapist , loves her work, has a partner and no dependant
Never smoked
Alcohol no
Sugar is low
Acid lots of fruit juice
Stress is low
Notes:
I am worried about the swelling I want to make sure it is not cancer
Clinical findings:
All teeth present except 8s
Class 2 div 1
BPE 221-121
Interproximal overhang w.r.t composite restoration 21
Non-carious tooth surface loss
diagnosis
1- Localized gingival hyperplasia Patient complains from swelling appeared after
suspected pyogenic granuloma filling was placed, not painful, bleeds to touch, no
secondary to over hanged composite pain on the teeth adjacent to it, composite filling
restoration on 21 present
2- Dentin hypersensitivity secondary to Patient compliant of sensitivity, history of acid
erosion reflex, high acid intake and fruit intake
3- Generalized gingivitis BPE score
4- Class 2 division 1 incidental
5-
6-
7-
8-

diagnosis
1- Note required Will not add to diagnosis no need to expose the
patient to unnecessary radiation
2-
3-
4-
5-

diagnosis
1- Clinical examination of the swelling To assess size and consistency of the swelling
2- Body temperature and lymph node To exclude any systemic involvement
involvement
3- Vitality tests for 11 and 21 to assess vitality of pulp
4- Percussion test for 11 and 21 To assess any periapical involvement
5- BEWE To assess TSL
6- OVD To assess any OVD loss
7- Dietary chart To analyse patients diet
10- Articulating study models To assess occlusion
Investigation results:
Muscles of mastication- NAD

Body temperature- 37 degrees
All teeth vital
Loss of OVD 1mm
1mmx1mm Soft palatal swelling, bleeds readily with gentle manipulation
artefact
This radiograph is only for report do not include it in treatment plan, in exam any finding on this
radiograph should be included as incidental finding

Side: left side
Bone level: adequate no horizontal or angular bone loss
Teeth:24,25,26,27,35,36,37
Restoration: DO on 24, MO on 25, occlusal on 27/34 DO, DO on 36 and MO on 37
Caries: secondary caries on 25, badly carious 26, caries on 27,37 and 36
Others: nile
Film quality: 1
● Medical link
o History of acid reflex consult GP link to TSL

o Educate the patient about all dental concerns
o Remove the composite restoration and apply a temporary filling (in exam filling is okay only
overhang where you only remove the access and not change the whole filling) and localized
debridement for 11 and 21
o Apply durphate gel on 22600 ppm, to prevent sensitivity and give high fluoride tooth paste
and fluoride mouth rinse
o OHI, supra and subgingival scaling
o Reassess the pyogenic granuloma within 2 weeks, replace the filling on 21
o Monitor NCTSL with photograph and studying models
o Refer to restorative after stabilizing the NCTSL for restoring giving option is composite,
veneer or crowns with advantages, disadvantages and risk
o Dietary chart and dietary advice
o Monitor pyogenic granuloma and refer to maxillofacial if no signs or regression
o Referral to specialist for Composite restoration for TSL repair
o Review periodontal condition, TSL, restorative work and assess pyogenic granuloma
Removal of overhang and local debridement to help with regression of swelling
Monitor pyogenic granuloma can regress spontaneously, cost effect and simple
Varnish to stop sensitivity
Scaling and polishing to improve periodontal condition
Composite restoration for good aesthetic and cost effective
Composite- time consuming, can chip off or satin and cause sensitivity
Monitoring – swelling might not regress needs patient compliance
Scaling -can leave teeth with sensitivity
your reasons)
Yes, all immediate, most of stabilization and long term management
specialist?
Yes, to restorative specialist, TSL is generalized not under the scope of GDP
And to maxillofacial for biopsy and removal of pyogenic granuloma if it shows no signs or regression
The swelling you have is what we call a pyogenic granuloma it is nothing you need to worry
about. Our gums are very sensitive and they can get irritated easily. Now because the filling
that you has poor margin it caused upset to the gum which show as swelling and because it has
a lot of blood supply , it bleeds easily. You have also some tartar under the gum which is adding
to the irritation so what I will do today is …..
John Franklyn
04-08-1961
Present Complaint and History:’ I am in severe pain’

Left side of the skin on my cheek, pain never happens on right always on the left, horrible pain
electrical shock like pain, it comes and goes lasts for few seconds, the area is so sensitive the
slightest touch brings out the pain, pain is worse in the morning. It started suddenly when I was
shaving and it’s been there for 6 weeks now. And pain on shaving, washing my face or towel drying,
no pain from the teeth on that side or any treatment. No pain on sweet and does not disturb my
sleep. Haven’t had any treatment for it. I tired paracetamol but it didn’t help with the pain. I grind
my teeth and very stressed ,did not have any virus infection. Pain score 8-9.
Can you tell me where exactly is the pain?
Does it always come on the left side?
What sort of pain is it? throbbing dull electrical?
Is it there all the time or does it come and go? And how long does it last?
What brings on the pain? Is there any time of day where the attack is worse?
Can you relate it to something on how it started? What about towel drying?
How about the teeth on that side any pain or sensitivity>? Any treatment done on that tooth?
Do you get this pain on hot, cold or sweet?
Does it disturb your sleep?
Did you seek any medical advice for it? Did you take any pain killers?
Do you grind your teeth? are you stressed?
Any shingle or painful skin rash recently ? How would you score this pain from 1-10?
Other Complaints and History: none

Irregular attendee, can’t remember last appointment
Previous treatment involved scaling and polished teeth were removed because they were infected
because of decay
Brushes twice a day with a manual tooth brush and over the counter tooth paste, does not use
cleaning aids
Not anxious about visiting the dentist
Medical History:
Fit and well
Asthma diagnosed since childhood, taking salbutamol inhaler only, no steroids, triggered by stress
and cold weather, last episode a month ago, no attack history in a dental chair , controlled
Penicillin allergy
Social History:
Truck driver, married no dependants
Smoking: never smoked
Alcohol 12-20 unit per week cider and white wine
Sugar is low
Acid is high 2-3 cans of cola per day
Stress is high
Notes:
Please help me with the pain
Clinical findings:
Teeth present:
76 4 3 2 1 1 2 3 5 6 7
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
NCTSL
BPE
2 1 2
2 2 1

diagnosis
1- Facial pain suspected trigeminal Electric shock type of pain, pain when shaving or
neuralgia washing face, does not disturb sleep, painkiller
didn’t help, pain lasts few seconds, no pain in teeth
adjacent to it, pain lasts for few seconds
2- NCTSl multifactorial aetiology Patient is a grinder, under stress, high cider and
white wine intake,2-3 cans of cola/ day
3- Generalized gingivitis incidental
4- Missing UR4 UL5 History from patient extracted secondary to caries
5-
6-
7-
8-

diagnosis
1- NO RADIOGRAPH required Does not assess in diagnosis/no need to expose
patient to unnecessary radiation
2-
3-
4-
5-

diagnosis
1- Examination of the cranial nerve To assess nerve involvement
2- Examination of TMJ and muscles of To assess TMJ and muscle of mastication
mastication involvement
3- Vitality test to all teeth To exclude any odontogenic cause of pain and to
assess sensitivity
4- Percussion test on all teeth on the left To exclude any periapical involvement
side
5- OVD To assess OVD loss
7- Knight and smith index To assess TSL
8- Articulating cast To assess occlusion
9- Dietary chart To analyse diet
1 Plaque index To assess plaque distribution
0-
1 Bleeding index To confirm active periodontal disease
1-
Result of investigation:
Muscles of mastication NAD
Smith and night 2
BEWE is 9
EPT:
UL1:30/UL2:35/UL3:30/UL5:30/UL6:35/UL7:30
LL1:35/LL2:30/LL3:30/LL4:35/LL5:35/LL6:30/LL7:35
Radiograph not to be involved in the treatment planning
artefact
Radiograoph: IOPA
Side: Lower right posterior
Teeth:45,46,47
Restoration: RCT and crown restoration on 45,46,47
Caries: Nile
Others: radiolucency around the apex of 46, voids in the RCT of the distal root of 47, proximity of
477 to the inferior dental nerve
Film quality: 1
● Medical link
o Stress free appointment
o Bring salbutamol inhaler when attending appointment and avoid use of durphate
o Avoid any penicillin and ibuprofen
o Reassure patient and educate regarding all dental concerns
o Give palliative advice on avoid touching the trigger area
o Prescribe carbamazepine 100mg one tablet twice a day for 10 day , space out the medication
through the day
o Application of recaldent for sensitive teeth (not durphate patient is asthmatic)
o Dietary chart and advice on reducing cider, white wine and fizzy drink
o Give night guard to prevent grinding
o Refer to GP for stress management
o Referral to GP for maxillofacial carbamazepine blood test and liver function test to confirm
diagnosis and further management
o Prescription of high fluoride tooth paste 5000 ppm
o Monitor tooth surface loss with photographs and study cast
o After controlling TSL give option of composite build up, only or crowns
o Option of replacing UL5, UR4 removable acrylic denture, chrome cobalt denture, fixed -fixed
cantilever and implant with advantages and disadvantages
o Refer to maxillofacial for further investigation and management of facial pain
o Chrome cobalt denture to replace UR4, UL5
o Refer to a restorative specialist for Composite build up after stabilization of grinding habit
o Recall every 3 month
o Review pain, TSL, restorative work and periodontal condition
o Reinforce OHI and diet advice
Carbamazepine prescription: sever pain, diagnosis of Trigeminal neuralgia
Scaling and polishing: prevent deterioration of periodontal condition
Night guard to stop grinding habit
Recaldent to relieve sensitivity, patient is asthmatic
Composite build up cost effective and easy to repair
CR/CO denture to improve function and aesthetic
Carbamazepine need of further blood investigation and titrate of medication can interact with other
medication
Scaling might leave teeth sensitive
Composite can chip off
Cr/co more expensive than acrylic
your reasons)
Yes immediate, most of stabilization and follow up
specialist?
Yes, will refer to maxillofacial specialist for monitoring and managing the patient further
investigation is required
Trigeminal neuralgia is basically pain coming from a nerve the Trigeminal nerve is a major nerve that
supply most of your face. It is an uncommon condition usually affecting people in their 50s or 60s the
cause of this is yet unknow but it is believed that with age the elasticity and flexibility of blood
vessels decrease causing compression on the nerve which you perceive as pain. There are many
facial pains but why I incline more toward TN is the feature of pain that you have described.
To relieve you from pain I will prescribe you with a medication called carbamazepine for 10 day only
you should space the medication throughout the day. We need to keep an eye on how your body is
liking the medication as everyone reacts differently to it so I would like to refer you to a specialist as
the dose of this medication needs to be altered, he will run a few tests and see how your body will
respond to it .If you respond to the medication that will confirm our diagnosis .
In the meantime, avoid the triggering area when you leave the house make sure you wrap your face
with a scarf to protect it. If it is what I think it is an irreversible condition unfortunately the
medication will not treat it but it will reduce the number of attacks and severity
Claire smith
08/04/1943
Present Complaint and History: ‘not happy with my dentures’

Lower immediate acrylic partial denture was given same appointment the teeth were removed. One
of the Abutment on the right-hand LR3 side got decayed and infected a year ago, and need to be
removed tooth but not added to the denture, the denture is not broken, clasps on denture seem
fine, patient has dry mouth for two years has not seek medical advice but carrying a bottle of water
to keep his mouth moist. I clean my denture after every meal and keep it clean as advised by my
dentist, she takes them out at night and keep them in a container of water. I lost my teeth because a
few of them got wobbly if patient give history of teeth removed for periodontal problems ask
about Family history, Stress, Smoking and Diabetes and some got decayed.
Upper acrylic complete denture, patient had it for 15 years second set of denture. First was a
temporary denture. My upper denture is becoming loose over a period of time.no alterations done
to the denture, denture is not broken. Dentures making me look old.
Other Complaints and History: ‘my gums bleed’
Bleeds around all my teeth, bleed only on brushing it has been ongoing for a year and it’s the same
not getting worse, gums are not swollen, teeth are not becoming shorter, gums are not shrinking, I
never smoked am a little bit stressed, NO diabetes or family history of gum disease.
Irregular attendee last time 13 months ago, to remove the LR3, not anxious visiting the dentist
Brushes twice a day with Coalgate toothpaste
Medical History:
Diagnosed with scleroderma for two years if patient give you a card with medication on them write
them down as this card will be taken away
Scleroderma affects the collagen fibres, these patients usually have dry mouth or associated with
sjorgen syndrome. Patient usually complains of periodontitis
osteoarthritis since 5 year/taking gold medication for it
Dry eye why I am taking artificial eye drops/bought from boots over the counter/not seen my GP for
it
Hypertension /taking nicardipine/ controlled/last check was last week and my GP was very happy
with the results
Social History:
House wife lives with her husband and no dependant
Never smoked
Alcohol five units of red wine
Sugar is low I am trying to stop it since my teeth got decayed
Acid low
Stress is moderate
Notes:
Fix the denture for me and make them such they at least make me look younger
CLINICAL FINDINGS
Upper complete acrylic denture

Lower partial acrylic denture
Stained dentures
Missing teeth 11-18, 21-28, 31,32,33,41,42,43
Resorbed upper and lower ridges
BPE: -/2-3

diagnosis
1- Unretentive lower immediate partial Unretentive denture, abutment tooth LR3
denture secondary to multifactorial extracted a year ago, xerostomia and possible ridge
aetiology resorption
2- unretentive upper acrylic complete Unretentive from patient history, dry mouth and
denture secondary to multifactorial denture is 15 years’ old
aetiology
3- Localized gingivitis and periodontitis Bleeding gums, history of tooth lose secondary to
periodontal disease and BPE score -/2-3
4- Xerostomia secondary to possible History from patient dry eyes, osteoarthritis and dry
sjorgen syndrome subjected to further mouth
investigation
5- Stained denture Incidental, patient consume 5 units of red wine
weekly
6- Missing LR 3 Hasn’t been added to the denture
7-
8-

diagnosis
1- IOPA for lower left sextant score 3 BPE To assess the level and angulation of bone loss
2-
3-
4-
5-
diagnosis
1- Examination of the denture To assess any faults in denture
2- Examination of denture baring area To assess any abnormality on the ridges
3- OVD measure To assess any loss in the OVD
5- Oral hygiene index To assess level of oral hygiene and plaque
distribution
6- Mobility index To assess grade of mobility and bone loss
7- Saliva flow rate To confirm xerostomia
8- Candida swap To exclude any conidial infection
10- Dietary chart To analyse patient diet
Salivary flow rate 0.01ml/min
Do not involve this radiograph in treatment plan it is only for practice
artefact
Radiograph: IOPA
Side: right side
Bone level: mild horizontal bone loss
Teeth: 45,46,47
Restoration: Nile
Caries: root caries mesial on 47
Others: roller marks on film
Film quality: 2
● Medical link
o Short stress free appointment
o Advice on continuing medication as prescribed by GP
o Link between scleroderma and periodontitis and xerostomia on oral health
o Chair side relining for both upper and lower denture
o Give palliative for dry mouth: take frequent sips of water, increase fruits and vegetables in
diet, avoid dry hard food,( (patient has arthritis avoid giving her chewing gum))
o OHI, supra and subgingival scaling and root surface debridement followed by 6-point chart,
advice on using an electrical toothbrush
o Review dry mouth if palliative not helping advice on orthana artificial saliva and high fluoride
tooth paste 5000 PPM, and application of durphate 22600ppm if no improvement refer to
maxillofacial
o Refer to GP to rule out Sjorgen syndrome and stress management
o Give option for a new lower denture with the addition of the extracted lower abutment
option: acrylic/ cr-co/ bridge /implant supported denture with advantages and
disadvantages
o Upper denture: new acrylic denture or implant supported with advantages and
disadvantages
o Denture hygiene instruction
o Dietary advice and avoid red wine causes staining
o New upper acrylic denture
o New acrylic lower partial denture
o Review periodontal condition, xerostomia and restorative work
o Reinforce OHI, denture hygiene instruction
plan (likely success, cost, time ,etc) to the patient?
Relining the denture to improve retention temporarily
Lower acrylic denture further teeth could be added to it in the future
New complete acrylic easy to make and cost effective
Local measures for xerostomia to reduce difficulty in eating and speaking
Durphate and high fluoride tooth paste as preventive measure to decay
Scaling and polishing improve periodontal health and prevent progression of disease
Relining only helps temporarily
Local measures for xerostomia might not be effective
New acrylic denture bulky heavy and fragile can break easily
your reasons)
Yes, relining of denture, fluoride application, new lower denture and upper denture
specialist?
Yes, to maxillofacial in supplying patient with orthana lozenges does not help, out of the scope of
GDP
An immediate denture is given to replace you missing teeth and you are not left with a gap it also
works as a bandage to prevent bleeding of the wound. after the healing take place within the first
few months your bone and gums shrink and will have new measurements and that is why your
denture is not given. You have also mention that the tooth that supports your denture in place has
been removed and not added to your denture, the denture has lost all the support of it, in addition
your dry mouth is making the condition even worse.
Part of aging process is shrinkage of bone which effects the stability of the denture which in turn
supports you lips, hopefully with a new denture we can slightly improve that
Jessica Yardley
4-8-1986
Present Complaint and History: ‘there is a gap between my front teeth’

Since childhood, no treatment done for it, it is getting bigger, the teeth next to it are not painful, I
have a crown on my UR1 and a rct the tooth was too discoloured, there is condition called
dentinogenic imperfecta runs in the family, I am not happy with the gap I am dreading to smile its
affecting my confidence . I don’t have any missing teeth only the ones that were removed.
● Where is the gap? Have you always had it? is it the same or getting bigger?
● How about the teeth on either side of the gap any pain or sensitivity? Any missing teeth?
● Any dental treatment done? Any rct? did you have braces? Any trauma to that area?
● Why was it discoloured u can see other teeth discoloured too?
Other Complaints and History: ‘all my teeth are sensitive’
Been like this for many years since childhood, sensitive to hot and cold especially cold, patient does
not grind no pain on the side of the face, no habits of nail biting, I use gentle force to brush my teeth,
I brush for I minute, no gastric reflex, acid intake is low, has 15-20 unites of white wine a week, tooth
are not getting shorter or longer, my gums are not shrinking down,
When patient has, sensitivity ask from what, where, how long does it last, grinding, acid intake,
acid reflex, abrasion,
‘my gums bleed ‘all over my gums started 6 months ago, all over my teeth, no shrinking gums,
started bleeding on brushing now it bleeds all the time no space in-between the teeth, some teeth
are getting wobbly especially back teeth and my UR1, no diabetes, no stress, never smoked, no
family history, no salty taste nor bad breath
Irregular dental attendee last visit was 2 years ago, /her denture needed repair, it is a partial acrylic
denture, my teeth were severely worn down because of dentinogenic imperfecta so they removed
them, had denture for 5 years was relined as it became loose now it does not fit me anymore, I
dropped my denture it doesn’t look like broken to me, it has clasp they are fine, teeth that hold the
denture in place are fine no problem with them. I clean my denture as instructed by the dentist after
every meal and soak in in a solution, and take my denture out at night and put it in a container of
water.
I brush my teeth 2 times a day with a manual tooth brush I use Colgate toothpaste and occasionally
use dental floss
Medical History:
Fit and well had radiotherapy for melanoma 6-7 years, treatment was on my left arm I am fine now
Family history of blood pressure
Social History:
Social worker, love my job, live with partner
Never smoked
Alcohol white wine 15-20 unites per week
Sugar intake is moderate, balanced diet
Stress is moderate, does not grind her teeth
Acid low
Notes:
Do something about the gap I hate my smile
Get me out of this sensitivity
No time or financial constrain
Clinical Findings:
Teeth present
7 4 3 2 1 1 2 3 4 7
7 6 5 4 3 2 1 1 2 3 4 567
BPE
3 4 3
3 4 3
Hairline fracture on upper acrylic denture
Carious LR3
UR1 Mobile

diagnosis
1- Midline diastema related to upper Patient complain of gap between their upper
central centrals, since eruption of adult teeth, gap getting
bigger, UR1 in mobile,
2- Generalized aggressive periodontitis BPE Score, mobile teeth, young patient good oral
hygiene measures, gums bleed spontaneously
3- Dentine hypersensitivity secondary to Complaint of sensitivity to hot and cold lasting for
dentinogensis imperfecta few seconds, and high white wine intake
4- Unretentive upper acrylic partial Loose denture, history of dropping denture, data
denture secondary to hairline fracture provided
5- Carious LR3 Incidental
6- Mobile UR1 Incidental and date provided (incidental)
7-
8-

diagnosis
1- Full mouth IOPA oral periapical To assess teeth for any periapical pathology, type
radiograph and angulation of bone loss and quality of RCT on
UR1
2-
3-
4-
5-

diagnosis
1- Measurement of diastemia To assess the size
2- Vitality test to 21 and 43 To assess vitality
3- Percussion test 11,21 and 43 To assess any periapical involvement
4- Palpitation of 11,21 and 43 To assess any periapical pathology
5- Plaque index To asses distribution of the plaque
6- Bleeding index To assess active periodontal disease
7- Mobility index To assess bone loss and mobility grade
8- 6 point pocket chart full mouth To assess clinical attachment loss
9- Examination of the denture To assess any faults
10- Examination of denture bearing area To assess any abnormality
11- BEWE and smith and knight index To assess TSL
12- OVD To assess any OVD loss
13- Diet chart To analyse sugar and acid intake
Midline diastema measuring 3mm
UR1 grade 1 mobile
Minimal plaque and tarter deposit, Satisfactory oral hygiene.
LR3 is vital
–ve TTP
U +ve heat test
+ve cold test
Do not involve this radiograph in the treatment plan in examine you will have to include it this is for
practice only
artefact
Radiograph: IOPA
Side: Lower right posterior
Bone level: sever angular bone loss with furcation involvement around the 46
Teeth: 44,45,46,47
Restoration: occlusal restoration on 46
Caries: distal to 46
Others: Nile
Film quality:1
● Medical link
o Apply fluoride varnish 22600 ppm to stope sensitivity and prescribe high fluoride tooth paste
5000ppm
o Chair side relining for the upper denture
o OHI, supra and subgingival scaling, RDS , full mouth 6 point pocket chart post initial
treatment
o Refer to GP to rule out blood pressure
o Dietary advice and reduction in consumption of alcohol
o Monitor the UR1
o Option of diastema after controlling periodontal problems: composite, veneer or crown on
the UL1 but size will not match/ remove or crown on UR1 and place new crowns on both
centrals might look big not natural/refer to orthodontic
o For denture lab relining, new removable acrylic or cobalt chrome (fixed options bridge or
implant only after stabilization of periodontitis)
o Excavate decay from LR3 and composite filling
o Refer to periodontitis for further comprehensive periodontal treatment
o Referral to orthodontist once periodontal stabilizes to close diastema
o Provision of new acrylic partial upper denture
o recall every three months
o review periodontal condition, denture and restorative work done
o reinforce OHI, denture hygiene instruction, diet advice and alcohol consumption
Fluoride application to prevent sensitivity
Refer to periodontist more complex treatment needed
Orthodontist to gain better aesthetic patient and closure of diastema
New acrylic denture cost effective and further teeth can be added
Composite filling good aesthetic and conservative
Refer might need long treatment and multiple visits expensive
Acrylic bulky, unhygienic and fragile
Composite can undergo polymerization shrinkage
your reasons)
Yes, treat sensitivity, part of periodontal treatment, new denture, repair old denture and other
restorative treatment
specialist?
Yes, periodontitis specialist for aggressive periodontitis complexity 3 not under the scope of GDP
Orthodontist for diastema closure out of my expertise
I know that you are here to discuss about your gap but I found a condition in your gums that
has a direct link to this gap becoming bigger and unless we stabilize your gum disease we will
not be able to do anything to it. the gum condition that you have is called aggressive
periodontitis, although you are taking good care of your teeth and there are minimal irritating
factors around your gums margins but unfortunately the type of gum disease can happen even
when you take good care of your teeth and there can be various reasons for this. Sometimes it
can run in families sometimes it is due to hormones or medical condition but it can also happen
for no obvious reason. We need to work hand in hand to prevent further damage, you need to
keep a meticulous oral hygiene and I will give your teeth a good clean to remove any hard
deposit and will be seeing you on a regular basis every three month and will referral to a gum
specialist.
Once this gum condition is stabilized we can close the space in-between your front teeth cause
if the foundation is weak how can we build on top.
The gap in between your front teeth there can be reasons for it. it can be genetic but what
worries me is that it is getting bigger because of this gum condition. The supporting structure
around the tooth is compromised and the tooth loses the support around it and becomes
wobbly and tend to move and that is probably what’s happening in your case. So for you front
wobbly tooth we will monitor it and after the gum treatment hopeful it will stabilize
The options of treatment for that gap is to remove the crown on the right side and make a
bigger crown and mask the gap with some more treatment on the left tooth which could be a
filling , veneer or crown which is a less invasive treatment matching the filling and veneer with
the crown will be difficult and if you go for a crown it will look chunky and unnatural however if
you decided to go for this treatment we will try our best to make them look as natural as
possible. Keeping in mind your young age we can refer you to a specialist is braces to close the
gap by means of hooks and chains.it will give you good results but it is a long treatment …ect,
but this is only possible once the gum condition stabilises.
Sensitivity is because the condition that runs in your family this effects the second layer of your
tooth called the dentine which work as a cushion to support the above protective layer the
enamel. Because the dentin is defective the enamel is wearing off very quickly and this exposes
the dentine and that is why you have the sensitivity. You are also consuming a lot of white wine
which is very acids and this wears off your teeth at a faster rate. Your alcohol limit is above that
recommended by the national health body I would suggest if you could keep it below 14 units
which will benefit your health in general. I will apply fluoride …ect and if you are worried about
the appearance I can refer you to a specialist who can mask the colour.
Talk about the decay, and denture emergency treatment and option of stabilization if you give
bridge you should refer to a specialist.
Treatment of mobile teeth:
Grade 1 monitor
Grade 2 monitor or extract
Grade 3 extract if posterior in emergency if anterior in stabilisation to make an immediate
denture.
Stacey Bevier
08-04-1942
Present Complaint and History: ‘I hate my denture’

My denture has a good fit, I had it 8 months ago it is my first denture had a bridge before and one
tooth got infected and removed it they gave me an upper partial acrylic denture and a crown, the
denture is replacing some of my front teeth which I lost because they became wobbly.it is painful at
the corner of my mouth (around the canine) I can’t taste food and it makes me gag it has been like
that from day one I never liked it. I have attended the review appointment no alteration was done
and the dentist said I need to give it time to get used to it. the gag is getting better but the pain is
still there it is a very achy dull sort of pain it always there and gets worse at night. The denture is not
broken or have sharp edges. For the pain, I am taking codeine over the counter for 5 months. Pain is
very bad that I can’t keep wearing it because of pain. My teeth don’t meet when I talk or eat and I
can’t close my lips together. I do have a dry mouth it’s been there for few months I did not seek any
treatment I am just drinking a lot of water and going to the loo more often. the denture has hooks
which are fine the denture was not given to me straight after my teeth were removed. I clean my
denture following the instructions given by my dentist and soak it in a solution and put it in a
container with water.
Ask all the questions related to denture plus the following:
When you close, your mouth does your lips meet?
Do your teeth meet more often when you eat or speak?
Other Complaints and History: ‘pain in the UL 5’
It has been a week, first time, sharp pain on cold lasts for few seconds it is getting worse comes and
goes, doesn’t it affect sleep, severity is 6 no swelling, no trauma no temperature. The tooth has a cap
and it is not root filled, not taking any medication for this as pain disappears quickly, doesn’t radiate
Regular attendee last visit 3 months ago
I had the bridge, teeth removed, the cap and denture I am not anxious seeing the dentist
Brushes once a day with a manual tooth brush no cleaning aids
Medical History:
Asthma since childhood on salbutamol well controlled no steroids or nebuliser haven’t had an attack
in ages triggered by cold weather and stress never had an attack in a dental clinic
Hiatus hernia diagnosed 8 years controlled taking Gavscon my teeth are not sensitive
Fibromyalgia diagnosed 5 years ago, taking diazepane, fluoxetine and paroxetine. It is controlled but
pain comes and goes
Social History:
Retired live with husband no dependant
Never smoked
Drinks 15-20 units of alcohol
Sugar is low and balanced diet
Acid is low
Stress is high
Notes:
Please give me my bridge back and get me out of pain
CLINICAL FINDINGS:
Denture satisfactory on examination
Teeth missing UL2, UL3, UL4
UL5 –crown has faulty crown margins
BPE 233/232
Mobile UR, UL1
diagnosis
1- Denture intolerance secondary to Patient not happy with denture since it was given,
fibroma cannot taste the food, pain worse in the evening,
dry mouth
2- Reversible pulpitis to UL5 secondary Sharp pain to cold lasts for seconds, poor margins of
faulty crown the crown, no RCT,
3- Xerostomia Since 3 months, stressed taking codeine, uses the
rest room a lot
4- Chronic generalized periodontitis BPE score, history of extracted mobile teeth
5- Mobile UR1 and UL1 secondary to Incidental
periodontitis
6-
7-
8-

diagnosis
1- IOPA for all bpe sextants of score 3 To assess type and angulation of bone loss, any
periapical involvement , caries extension and
proximity to pulp
2-
3-
4-
5-
diagnosis
1- Examination of the denture and To assess any fault to the denture or abnormality of
denture baring area the ridge
2- Measure OVD To assess any OVD fault
3- Examination of TMJ and muscles of To assess involvement of both
mastication
4- Vitality test UR1, UL1,UL5 To assess vitality
5- Percussion test UR1, UL1, UL5 To assess any periapical involvement
6- Palpitation UR1, UL1, UL5 To assess any periapical involvement
7- Salivary flow rate To confirm xerostomia
8- Plaques index To assess plaque distribution
10- Mobility index To assess bone loss and mobility grade
12- Dietary chart For diet analysis
RESULTS OF INVESTIGATION:
Denture design satisfactory
No loss of OVD
UL1 & UR1 are grade 1mobile
Cervical caries w.r.t UL5
EPT 40
TTP -ve
Salivary flow rate 0.1ml/min
UR1 and UR2 grade 1 mobile
RADIOGRAPH IS NOT RELATED TO THE CASE.ITS ONLY FOR REPORT WRITING.
artefact
Radiograph: IOPA
Side: lower right posterior
Bone level: sever angular bone loss involving furcation of 46 and 47
Teeth: 45,46,47
Restoration: Nile
Caries: mesial on the 46
Others: widening of periodontal ligament on both 46 and 47
And slight overlapping of the crown interproximal
Film quality:2
● Medical link
o Asthmatic patient avoids prescribing NSAID, and avoid triggering factor
o Advice patient to bring inhaler next appointment
o Take all medication as prescribed by GP
o Educate patient regarding all dental concerns
o Remove the crown, excavate caries Ca(OH)2 dressing and temporary crown
o Prescription of paracetamol 500mg *2 four times a day
o Palliative treatment for dry mouth sips of water, suck on ice, increase vegetable and fruit
intake avoid hard food (do not give this patient chewing gum it increases the work of
muscles and increases pain)
o OHI, supra and subgingival scaling, root surface debridement and 6-point pocket chart for
sextants score of three post initial treatment
o Monitor mobile teeth
o Review patient for pain and dry mouth and prescription of saliva orthana if symptoms still
exists
o Refer to GP for stress management and blood glucose measure to rule out diabetes
o Advice on alcohol limit
o Application of fluoride without varnish (patient is asthmatic)
o Option of replacement for upper teeth Co/Cr denture or fixed option after stabilization of
periodontal condition fixed-fixed bridge or implant supported bridge or denture
o Option of crown for UL5 metal or PFM or include in the replacement option
o Use a Cobalt/chrome denture as an interim measure
o PFM crown for UL5
o After stabilization of periodontitis refer for implant supported bridge
o If xerostomia measure still exists refer to OMFS
o Review periodontal status, restorative work done, xerostomia
o Reinforce OHI, denture hygiene instruction and alcohol consumption
plan (likely success, cost, time ,etc) to the patient?
Excavate caries and temporary filling: to relief pain, GIC releases fluoride
Stop codeine: improve dry mouth
PFM: good aesthetic better margin
Chrome cobalt: easy to use, thin and light does not exert too much pressure on muscles
Implant: fixed option high success rate
Periodontal treatment: to improve gingival health
PFM further destruction of tooth risk of pulp necrosis
Cobalt chrome expensive and can deteriorate the periodontal condition
Implants: expensive involves a surgery
your reasons)
Yes, periodontal treatment, PFM , CO/CR denture and follow up
specialist?
Yes to implantologist not under the scope of GDP
We will give you frequent breaks during the treatment because the last I wont to do to you is tier
your muscle and give you pain. Please bring your inhaler with you, and we will avoid anything that
can trigger your asthmatic attack. Please stop the codeine as it can be the cause of dry mouth you
are having and I would suggest using paracetamol instead. Please ask for medical advice before you
take any medication as you are taking a couple of medications and some of these don’t like each
other and can put you in a bigger trouble.
Coming to the denture, I have had a look at the denture I can’t see anything wrong with it. the only
thing I can think of is the medical condition you are suffering from. Fibromyalgia is a medical
condition where your muscles get worked up very quickly and your body preserve that as pain. The
pink denture needs muscle control to stay in place and as the day passes the muscles get used, over
worked and tired and you perceive this as pain. Ideally anyone with fibromyalgia they should receive
fixed option but because of a gum condition that I have pick on I cannot offer you this option unless
we control your gum condition. the only option I have for you now is a removable metal denture,
these dentures take support from the teeth and do not require as much muscle control as the pink
denture. But these dentures may have an adverse effect on the gum condition you have. Give fixed
option fixed-fixed bridge this will be a long span so I will need to refer you to a restorative specialists
and implant.
Explain periodontitis, we also pick some teeth that are loose but it is still a grade one and hopefully
after the treatment of your gums it will stabilise and have a good grip. Explain treatment. You are
complaining of dry mouth and going to the rest room a lot and these are symptoms related to
diabetes therefore I would like to refer you to your GP to have a blood test done to make sure you
are fine. Diabetes have a direct effct on your gum condition
Regarding your upper left 5 which has a poor margin, germs has crept in and caused decay. The good
thing that it has not extended to the centre of the tooth and we call this reversible pulpitis. For today
I will remove the decay and apply a dressing and temporary filling and cap we will monitor it for 2
weeks if no pain then we can give you a new crown but if you come back with pain that means we
need to do a RCT for that tooth and a cap on top or extract the tooth.
Brianna Slater
04/08/1976
Present Complaint and History: ’uncomfortable feeling in my gums’ if patient comes with a
swelling, lump or uncomfortable feeling always ask about the adjacent teeth are they okay painful or
do they have any dental treatment on them, this case patient will either complain of uncomfortable
heavy feeling of the gums or achy itchy gums. The patient sometimes said she had the crowns
because of erosion in other cases she said she had fluorosis.
I had it for one year into on the front upper jaw on the right side not getting any worse didn’t have
any treatment of it, I have caps from 13-23 with some of them have RCT but I don’t know which
ones, I had crowns 8 years ago, because my teeth started to wear off. I don’t grind my teeth but they
are wearing off because of a medical condition of bulimia 18 years ago, when I was a teenager it is
sort of controlled but I haven’t seen my GP for very long time. I was happy with them but now they
are stained. I smoke 20 cigarettes for the last 20 years, I take 5 units of red wine per week and use a
Corsodyl mouth wash I have been using it for 6 month got it over the counter, not into tea and
coffee. No trauma to the area or sharp teeth there.my gums are bleeding for the last 6-8 months
ago, it’s the same not getting any worse.
Other Complaints and History: ‘my filling on the back teeth are chipping off’
I have silver filling on my back-right teeth they are chipping off had them for many years, it been a
couple of months no pain or sensitivity from the teeth but there is sharp edges causing irritation to
the tongue and cheek, no skin breakage or any white or red patches any injury no parafunctional
habits
Very irregular attendee-last visit 3years back cleaning and a filling. I am not anxious visiting the
dentist
I brush twice a day with a manual tooth brush occasionally use floss / when patient mention they use
mouth wash ask which one? If Corsodyl ask for how long and was it prescribed by the dentist?
Medical History:
Fit and well
No allergies
Bulimia/ taking Prozac for many years now, last episode of vomiting was 6 months ago, haven’t seen
my GP for ages
Social History:
I work in marks and spencer I love my job I live with my lovely partner no dependents
Smoker 20 cigarettes for 20 years
Alcohol 6 units red wine
Sugar low
Acid is low
Stress is low
Notes:
Help with the uncomfortable feeling
Clinical Findings:
Teeth present:
7 6 5 4 3 2 1 1 2 3 4 5
7 6 5 4 3 2 1 12 3 4 6 7
PFM: 13-23, 34, 44

No RCT: 11, 12, 23
Internal Resorption 11
Periapical radiolucency12
Defective crown margins 13,34
Fractured amalgam fillings 16,17,46
Cross bite on the right side (this was given in may 2017 exam) and patient had a small gingival
enlargement size 3x2 mm around the 12. it is not included in the diagnosis and treatment plan of
this case.
Decayed 25
BPE score
2 1 2
2 1 2
Non carious tooth surface loss- erosion

diagnosis
1- Uncomfortable felling on the gums Heavy gums, crowned teeth no RCT and data
secondary to periapical radiolucency provided
related to 12 and internal resorption
related to 11
2- Stained crowns History from patient, smoker, red wine and Corsodyl
mouth wash
3- 13 and 34 defective crown margin Clinical finding
4- Fractured amalgam restoration on Patient complaint of chipping filling, old fillings,
16,17 and 47 irritation to cheeks and tongue
5- Decayed 25 Data provided
6- Chronic generalized gingivitis History from patient bleeding gums over 6 months
and BPE score
7- NCTSL secondary to erosion Patient is bulimic, history of worn down teeth and
clinical finding
8- Missing 26,27,35 incidental

diagnosis
1- IOPA periapical for 11,12,13 To assess periapical area, bone level and any
abnormality
2-
3-
4-
5-

diagnosis
1- Vitality test to 11,12,13,16,17,46,25 To assess vitality of the tooth
2- Percussion test to all anterior upper To assess periapical involvement
teeth,16,17,25,46
3- Palpitation of all anterior upper To assess periodontal involvement
teeth,16,17,25,46
5- Plaque index To assess distribution of the plaque
7- Dietary chart To assess patient sugar and acid intake
8- Examination of crown To assess any fault in design
9- Examination of edentulous area To assess any abnormality on the ridge
EPT ETHY WAR PERCU
LCHL N SSION
ORID GUTT
E A
TEST PERC
HA
11 40 -ve -ve +ve
12 80 -ve -ve +ve
13 +ve
16 30 +ve +ve -ve
17 30 +ve +ve -ve
25 25 +ve -ve -ve
34 -ve
46 30 +ve +ve -ve
artefact
Radiograoph: horizontal bitewing

Side: right
Teeth:13,14,15,16,17,,44,45,46,47
Restoration: occlusal on 16 and 46
Caries: oclussal on 13,14,15,17,44,45,46,47
Others: 17 and 47 badly broken down
Film quality: 1
● Medical link:
o Advise patient to keep taking her medication
o For 11 and 12 pulp extirpations, apply dressing and temporary filling
o Smoothen sharp edges of 16,17,46
o Fluoride varnish
o Refer to GP to re-evaluate bulimia
o Smoking cessation advice
o Advice on changing alcohol preference
o Stop use of chlorohexidine and advice on use fluoride NAF o.o5% mouth wash
o Polish stained crowns (need to check) or give new crowns
o Excavate caries on 25 and option of composite or amalgam filling
o crowns on 13 and 34 PFM or metal crowns
o For 11 and 12 either RCT drilling through the crown or extraction immediate denture and
replacement option after healing is completed
o New restoration for 16,17 and 46 options are amalgam, composite, onlay ,inlay or crowns
with advantages and disadvantages
o Replacement option for missing teeth 26,27 and 35 either removable denture acrylic or
cobalt chrome or fixed implant supported denture or bridge for upper or implant or bridge
for low
o Monitor TSL with photos and studying cast
o Referral to endodontic specialist for RCT on 11 followed by composite filling
o RCT for 12 and composite filling
o Provision of new PFM crowns on 13 and 34
o Amalgam filling for 25
o Provision of onlys for 16,17 and 46
o Once bulimia and NCTSL is controlled refer to restorative specialist for composite build up to
restore TSL
o Review all dental work done
o Reinforce OHI, smoking and alcohol advice
Smoothing of sharp edges to stop irritation
Pulpectomy to alleviate pain
RCT high success, save natural tooth
Only good protection of tooth and aesthetic
Replacement of new crown better aesthetic
Scaling to improve periodontal health
Long expensive treatment, patient compliance required, amalgam not aesthetic, new crowns
destructive possible pulp necrosis
your reasons)
Immediate, most of stabilisation and follow up
specialist?
Will refer to endodontic specialist internal resorption is a complexity 3 out of my scope and will refer
to restorative specialist after controlling bulimia for composite build up to restore the TSL a
generalized condition of out my experts
Regarding your complaint about the itchiness in your gums after running some investigation there
are a couple of thing that I have found which maybe the cause:
1-the front tooth on the right side if you look at the x-ray there is a black shadow which we call
internal resorption which means the centre of the tooth has the nerve and vessels which keep the
tooth alive it also has protective cells and sometimes these cells get damaged because of injury or
previous dental treatment and can sometimes happen for no reason at all. so, these cells misbehave
and start eating the tooth from inside the good thing that we have picked it at this stage where is
haven’t damaged lots of your tooth structure if we don’t do anything about it will only get worse, to
save the tooth we need to clean the tooth from inside to get rid of that part giving you a dressing
and temporary filling. Follow that you have 2 option first is save the tooth by means of doing a rct
advantage/disadvantage and risks because the tooth has been eaten away from the inside I must
refer you to a specialist in rct to have the treatment done to make sure you get the best treatment
available. The other option is remove the tooth and give you on the same day a plastic denture as a
temporary measure so you are not left with a gap and go out with a confident smile. After the
healing is completed we can discuss a permanent replacement option. Advantages /disadvantage
risk.
2-the other thing I have found is what we call it….. black shadow in close proximity to the tip of the
root, this happens in teeth with a caps and no never treatment done it happens in 1 in every 5,this
cause irritation to the centre of the tooth and infection which spreads through the root to the under
lying tissue and that could be the cause of heaviness in your gums. it might not cause you any pain
at the moment but if we leave an infection it can flare up giving you pain and swelling. Explain
emergency and give option of treatment after. The good news that cap is good and we can go
through the crown it will be cost effective and less invasive or we can have the crown taken off but
there is a risk of fracture of the tooth…..
You have been complaining about staining on you crown this is causes by various factors smoking
causes stains and the same for red wine I would advise you to quit smoking and change your
preference of alcohol. The use of a Corsodyl mouth wash is known to satin your teeth as well as
alternating the taste sensation, this type of mouth wash should only be used for two week. I would
suggest you use a fluoride mouth wash instead. We can polish these crown or give you new crowns
Anne bird
04-04-1963
Present Complaint and History:’ I have a painful tooth’
On my lower left jaw tooth number 7, pain has been there for 5 day it is the first time, pain is to
sweet and cold last for 15-30 minutes, pain on biting and especially when opening the mouth. Pain
came up when I was having dinner I bit on something hard. Pain is throbbing pain it is the same not
getting worse but couldn’t sleep last night. I had a silver filling 6-8 months ago, it was replaced in the
past because it was broken once and had decay under the filling. I don’t know if the filling is
fractured but there are no sharp edges. I don’t grind my teeth.
Ask pain history questions then add the following:
Is the pain when you bite hard or when opening your mouth?
Do you think the filling is fractured? Any sharp edges? Have you bitten anything hard?
Other Complaints and History:’ pain in front of my ear’
The pain is in front of my ear on the left side of my face I had it for 5-10 years.it it achy pain worse in
the morning and at night. pain comes and goes, I have had several occasions where I heard I clicking
noise when opening my mouth. I went to the GP and he put me on amitriptyline. I paid a visit to the
dentist saw too, gave me this horrible plastic plate I hate it makes me gag I suppose to wear it on my
top jaw but I never do and I don’t know where it is now. I had no trauma to the area. The pain I have
travels to my neck shoulders and jaw. My teeth are getting shorter and they are sensitive. I don’t
know if I have a white line on my cheek or indentation on my tongue.
After asking about pain ,
Ask about associated symptoms such as clicking noises, trismus and linea alba and scalloped tongue
Regular attendee -last time one year ago -night guard was given
Previous treatment involves restoration, scaling and polishing, RCT and crown
Brushes twice a day with a manual tooth brush and I don’t use any cleaning aids but I use Colgate
tooth paste
Medical History:
Fit and well
No allergy
On amitriptyline for the last 2-3years for stress management .
Social History:
I don’t have a job I lost it couple of months ago, and that is stressing me out, I single with no
dependants
I never smoked
Alcohol 10 units of white wine
Balanced diet sugar level is low
Acid is low
And stress is high
Notes:
Help me with this pain
CLINICAL FINDINGS:
All teeth present
BPE 101/110
NCTSL
Inappropriate FGC margins on 17
Horizontally impacted 38, 48
Partially lost filling and crack Visible on 37
LR4,5,6 root canal treated
diagnosis
1- Irreversible pulpitis secondary to CTS Pain is throbbing last for 15-20 minutes, pain on
37 releasing bit started when eating something that
was hard, pain started 5 days ago, had an amalgam
filling that was replaced few months ago, pain to
sweet and cold
2- Facial arthromyalgia Pain on left side of face in front of the ear, pain is
achy for 10 years, treatment has not help, patient
on antidepressant. Pain
3- NCTSL secondary to attrition Patient is a grinder, scalloped tongue, teeth getting
shorter, sensitivity , white wine
4- Generalised gingivitis Incidental BPE score
5- Poor margins on FGC on 17 Incidental
6- Impaction of 58 and 38 incidental
7-
8-

diagnosis
1- IOPA for 37 To assess extension of broken tooth and crack, any
periapical pathology
2-
3-
4-
5-

diagnosis
1- Tooth sleuth test 37 To assess CTS
2- Vitality test 37,17, To assess vitality
3- Percussion test 37,17 To assess any periapical pathology
4- Palpitation test 37,17 To assess any periodontal involvement
5- Mobility test 37,17 To assess any bone loss or mobility
6- Examination of TMJ and muscles of To assess involvement of TMJ and muscles of
mastication mastication
7- Interincisal measurement To assess any trismus
8- Knight and smith index To assess TSL
9- OVD to assess OVD loss
12- Examination of crown on 17 To assess crown for any faults
RESULTS OF INVESTIGATIONS;
BITEWING IS FOR RADIOGRAPH REPORTING
LL7 EPT 30
TTP –ve
Tooth sloth test +ve
Cold test +ve
Heat test –ve
LR4, LR5, LR6, UR7 root canal fillings satisfactory
Tenderness in Muscles of Mastication Especially Temporalis and Masseter
Crack on LL7 extending into pulp
High occlusal forces on the mesio-palatal cusp of LL7
Body Temperature: 37
artefact
Radiograph: Horizontal bitewing

Side: left
Teeth:24,25,27,34,35,36,38
Restoration: mesio-occlusal on 26, disco-occlusal on 36 occlusal on 37
Caries: distal on 25
Others: Nile
Film quality:1
● Medical link
o Short stress free appointments to avoid stressing the patient and tiring his muscles and jaws
o Continue taking medication as prescribed by GP
o Apply and orthodontic band around 37, extirpate the pulp, dressing and temporary filling
o Local palliative treatment for Facial arthromylagia
o Prescription of ibuprofen 400mg three times a day for 5 days
o Application of varnish 22600 ppm
o OHI and give patient high fluoride tooth paste 5000 ppm and NaF 0.05% mouth wash
o Advice on changing alcohol preference
o Reassess Facial arthromylagia
o Reinforce facial arthromylagia palliative advice and provide a lower jaw night guard
o 37 option of rct and FGC or extraction and replacement option
o Monitor TSL with with photographs and cast
o When grinding habit and TS is controlled refer to specialist for composite build ups, veneer,
crowns or onlay
o Monitor impacted 48 and 38
o 17 monitor or replace with a PFM or FGC
o RCT on 37 followed by FGC
o Referral to Oral Maxillofacial for facial arthormylagia if pain does not resolve
o Referral to restorative specialist for restoring TSL for composite build ups after stopping
grinding habit
o Review all work done
o Reinforce OHI and palliative l0cal measures for facial arthromylagia
o Othrodontic band: to prevent propagation of the crack
o Pulp extirpation: to alleviate pain
o RCT: high success rate and saving the natural tooth
o Metal crown: conservative and cost effective
o Palliative measures: relief from pain
o Night guard: break the habit of grinding and prevent further TTSL
Long multiple appointment, expensive, FGC anaesthetic and RCT risk of breakage of files
Would you provide all or part of the treatment for this patient yourself? If so which part?(give
your reasons)
I will provide immediate, most of stabilization and follow up
specialist?
Restorative specialist for full mouth rehab and oral maxillofacial for facial arthomylagia
The reason you are having this pain is because of the crack so when you bit the cracked parts are
moved away from each other but when you open your mouth the parts snap together and that is
why you feel the pain.
The pain on the side of your face is called facial arthromylgia and its coming from your jaw and
muscles on the side of your face which help to open and close your mouth although I do understand
you have mentioned that you do not grind your teeth some people do grind but they are unaware of
it. why I am more inclined that you do grind your teeth is the pattern, location and type of the pain.
People who grind are more likely to have cracks in their teeth. these muscles need to relax from the
use all day long the time they relax is when you sleep but because you grind your teeth your muscles
don’t get time to relax and are under constant tension which you perceive as pain.
You also mentioned that your teeth are shorter is because they rub against each other and the main
reason for this is stress I hope everything goes well with your job hunt. I would suggest referring you
back to your GP to review your stress medication that you are taking and that should help. i will give
you a a night guard I know you had one before which you had befor but I will make you a lower one.
This will protect your teeth and break the grinding habit.
Richard Hughes
D.O.B 04-08-1965
Present Complaint and History: I am here for a check-up.

my upper front tooth on the left is stained. It happened a year ago, and it is getting worse, no pain
on the tooth, I had an accident a year and a half ago in the swimming pool and my tooth was
fractured and had a white filling done. no RCT is done on that tooth, did have any help for it when it
became discoloured, no pain on biting or sensitivity but I am having a salty taste and pink spot
behind that tooth. The tooth is becoming greyish in colour. no swelling not fond of tea and coffee
love red wine and I don’t use mouth wash.no temperature
Other Complaints and History: my lower right tooth is discoloured as well
I had a RCT and white filling done 2 years ago, never had pain after the treatment, no swelling or
pink spot. my tooth got infected and decayed. tooth colour is getting darker for 6 months and
getting worse
Regular attendee, last visit 1 ½ years had the filling done
Not anxious about dentist
Previous treatment white filling and RCT
Brushes once a day with a manual tooth brush no cleaning aids used
Medical History:
Hepatitis B- 3 years ago on lamivudine, adefovir, telbivudine and entecavir. Viral load was done
2weeks ago although I don’t remember the numbers but the anticoagulant clinic people were very
happy with my results
Allergic to penicillin and latex
Social History:
Truck driver enjoys his job but it does get stressful at times, married and no dependant
Smokes 5 a day for 16 years
Alcohol 10 units, red wine per week
Balanced diet and sugar is low
Acid a lot of squash 1-2 litre and energy drinks a day to keep me going
Stress is medium and I am not grinding my teeth
Notes:
Great if you could fix the stains on my teeth although I am not very bothered about it, it will be great
if you could make them look like the rest of my teeth
No constrain regarding time or finance
Clinical findings:
IN THE PICTURE: Imagine this was only a composite filling impinging the pulp without rct!
Teeth present:
7 6 5 4 3 2 1 1 2 3 4 5 6 7
7 6 5 4 3 2 1 1 2 3 4 5 6 7
Draining sinus on 21
BPE scores:
2 2 2
2 2 2
NCTSL Erosion more pronounced on occlusal surfaces of back teeth
diagnosis
1- Intrinsic stains on 21 secondary to Tooth becoming darker becoming grey in colour
multifactorial aetiology after a trauma, composite filling, no RCT, red wine
2- Chronic periapical 21 secondary to Sinus, bad taste, history of trauma, bad taste and
pulp necrosis salty and bad breath
3- Intrinsic staining on 41 secondary to Gradual discoloration, happened after RCT
RCT
5- NCTSL secondary to erosion Incidental, clinical photos and history of high acid
intake
6-
7-
8-

diagnosis
1- IOPA with long cone gutta percha for To assess periapical pathology, bone support and
21 extension of sinus
2- IOPA on LR1 To assess quality of RCT
3-
4-
5-

diagnosis
1- Vitality test 21 To assess vitality of the tooth
2- Percussion test 21 and 41 To assess periapical involvement
3- Palpitation 21 and 41 To assess periodontal involvement
4- Mobility 21 and 41 To assess bone level
5- Body temperature and palpitation of To assess any systemic involvement
lymph nodes
9- OVD To assess OVD loss
1 Dietary chart To analyse patient diet
0-
1 Articulating cast To assess occlusion
1-
Periapical radiograph is only for report writing and not related to this case
UL1 Non-vital, TTP +ve
LR1 NAD, TTP –ve
artefact
Radiograph: IOPA
Side: posterior lower right
Bone level: mild bone loss around premolar
Teeth:43,45,46,47
Restoration: mesio-occlusal on 46 and disto-occlusal on 45
Caries: nile
Others: fractured file lodge in the apical third of the root on 45 with radiolucency at the apex and
widening of the lamina dura
Film quality: 1
● Medical link
o Advise patient to continue medication as prescribed by GP
o Avoid penicillin and latex possible anaphylactic shock
o Consult GP if invasive treatment required possible bleeding and check viral load
o Application of varnish fluoride 22600 ppm on NCTSL, prescription of high fluoride tooth
paste 5000 ppm and NaF 0.05%
o Extirpate the pulp apply dressing and seal with temporary filling
o OHI, supra and sub gingival scaling
o Advice on changing preference of red wine and reducing acid intake
o Stress management advice
o Monitor TSL with photographs and study casts
o UL1 extraction and immediate denture, explain permanent option removable and fixed after
healing or RCT and PFM crown
o LR1 internal and external bleaching, veneer and crown
o After stabilization of NCTSL refer to a specialist for composite build ups, onlays or crowns
o UL1 RCT and crown PFM
o LR1 internal and external bleaching
o NCTSL refer to restorative specialist for composite build ups
o Review TSL, work done and periodontal status
o Reinforce OHI , smoking Cessation and dietary advice
Scaling to improve periodontal condition
RCT save natural tooth and high success rate
PFM crown protect RCT and good aesthetic
Bleaching cost effective and simple conservative treatment
Scaling can cause sensitivity
Rct long expensive treatment
Internal bleaching unreliable results and sensitivity
your reasons)
Yes, all immediate and follow up and most of stabilization
specialist?
To restorative specialist after NCTSL is stabilized
There are many causes for this discolouration it could be because of the trauma you had. The centre
of the tooth the nerve and vessels that keep the tooth alive these are sensitive to the slightest
irritation can cause it to go dead and when the blood breaks down the by-products seep through the
inner core to the middle part of the tooth the dentine and it reflect the greyish colour .this tooth has
a white filling and these filling get stain easily also you habit of red wine drinking and smoking is
adding to this problem and I would suggest changing your preference and stopping smoking and this
is adding to the problem.
Because this tooth is dead it has cause infection that has travelled along the root to the surrounding
structure that hold the tooth in place producing the germs there has grown there and produced
nasty substance which we call pus and the collection of it is called an abscess, the bodies way to fight
it is to through it out and that is why you have the pink spot where pus is discharged and that is
why you are having that bad taste and breath. I know its not giving you any pain but leaving an
infection in place can give you trouble.
Maggie Smith
04-08-1986
Present Complaint and History: I moved to the area recently and I am here to register and have a
check-up only. I do not have any concerns
Other Complaints and History:
I visit my dentist regularly last time was 6 months ago, I have tooth number 12, is giving me
infections so I went to my dentist and he gave me antibiotics. now, I have no pain or sensitivity there
is no treatment or RCT done on that tooth. But when pain comes I have pain on biting, salty taste,
swelling and bad taste and sometimes I have a pink spot.
Previous dental treatment involves filling, scaling veneer but recently I have noticed they are
growing they make me look like Buggs bunny the are on my front two teeth one on the right and the
other one the left I had them for three years now and was very happy with them at the beginning.
and it been about a year, I have noticed that my veneers are growing and getting bigger I had a
trauma when I was 8 years old (to some candidates she said 8 years ago,). I fell on my face and my
two front teeth popped out and they put them back in place. There was no treatment done and
slowly and gradually they started to go darker so they gave me these veneers which were made in
the lab. No RCT done, no pain or sensitivity.
My gums are bleeding it has been like that for a year and a half and is getting worse. my gums are
red and I am not sure if they have shrunk but these veneers are definitely growing.
Brushes twice a day with a manual tooth brush no cleaning aid used.
Medical History:
Fit and well
Microgynon contraceptive pills -been on for years
Rheumatoid fever as a child but I am fine now not taking any medication
Social History:
Work at the super market, single with no dependant
Smokes 5-7 cigarettes a day for the last 9 years
Alcohol in 15 units per week red wine
Sugar intake is medium take a balanced diet
Acid not fond off
Stress low, does not grind her teeth of have habits of biting nails or pencil
Notes:
I don’t have any I just want to register with you as I said
Clinical findings:
All teeth present.
BPE Score: 222/212
11,21 have calcified canals and open apex
NCTSL
In exam the canals were completely blocked

diagnosis
1- unaesthetic veneer Patient complains of veneers getting longer,
happened within a year patient thinks she looks
like Buggs Bunny
2- 11 and 21 calcified canals and open Data provided and history of avulsion
apexes secondary to trauma
3- Recurrent chronic periapical abscess Recurrent history of infection, pain, swelling, bad
in regards to 12 secondary to trauma breath salty taste, repeated antibiotic prescription
4- Chronic generalized gingivitis Bleeding on brushing getting worse, teeth getting
longer, gum rescission, BPE score
5- NCTSL secondary to erosion Hight alcohol intake and clinical finding provided
6-
7-
8-
diagnosis
1- IOPA for 11, 12 and 21 ( use of long To assess teeth, periapical and periodontal tissue
GP cone if sinus exists )
2-
3-
4-
5-

diagnosis
1- Vitality test 11,12,21 To assess vitality of the pulp
2- Percussion test 11,12,21 To assess periapical pathology
3- Palpitation of 11,12,21 To assess any periodontal involvement
4- Mobility test 11,12,21 To assess any bone loss
5- Body temperature and lymph node To assess any systemic involvement
involvement
6- Plaque index To assess distribution of the plaque
8- Gum recession index To assess gum rescission
10- Examination of veneer To assess design
11- Dietary chart To analyse high acid and sugar in diet
11, 12, 21, non-vital.

12 tender to percussion
periapical radiolucency in relation to 12 seen on radiograph
BEWE Score 14
artefact
Side: left and right
Teeth:14,15,16,17,23,24,25,26,27,37,36,35,34,44,45,46,47,
Restoration: occlusal on 17,16,15,24,25,26,27,37,37,34,45,46,47
Disto-occlusal on 35
Caries:15,25,35,45,46
Others: cone off
Film quality: 2
● Medical link
o Liaison with GP regarding rheumatoid fever
o Application of fluoride varnish 22600 ppm , prescribe high fluoride tooth paste 5000 ppm
o 12 Pulp extirpation, dressing and temporary filling
o Alcohol reduction advise and change of preference
o Dietary advice reducing acid and sugar
o NCTSL monitor with photographs and study cast until controlled
o 12 RCT and PFM crown or Extraction and immediate denture
o 11 and 21 rct and pfm crown referral to specialist or extraction and immediate denture
o NCTSL composite build up, onlay or crowns
o 12 RCT and PFM
o 11 and 21 referral to endodontic specialist for RCT followed by PFM ///extraction and
immediate denture is also a passing treatment plan
o Referral to restorative specialist for restoring NCTSL with composite build up
o Review periodontal condition and restorative work done
o Reinforce OHI, dietary advice and smoking cessation
Fluoride varnish, to prevent any sensitivity
Pulp extirpation, to prevent pain flare up
RCT, save the natural teeth
PFM crown good aesthetic and protection to the tooth
Composite build up, cost effective and less destructive
Scaling improve periodontal health
RCT risk of breaking file, success rate is low open apex
PFM destructive treatment may weaken tooth structure
Composite may chip off or stain
your reasons)
yes, fluoride application, pulp extirpation, RCT, PFM
specialist?
Yes, endodontic specialist calcifies canal complexity 3 and restorative specialist composite build up
to restore TSL
Coming to your concern regarding your veneers becoming big I have pick up a condition in you gums
which I would like to talk about because the gum condition could be causing you veneers looking
bigger. It is an inflammation of the gums we call it gingivitis luckily it is an initial stage and can be
reversed (take about plaque ect …). These veneers have caused irritation to the gum and the gums
has shrunk and you can see the edge of the veneer and the root of the tooth, that is why your front
teeth are getting bigger as these veneers can’t increase in size they are not a living thing. (Take
about the treatment of gingivitis)
Another thing is the root of these teeth have not developed completely as you mention you had an
injury and popped out and this has caused the tooth to die and that is why it couldn’t complete its
development if you look at the tip of the root it is open it should be closed like the tip of a cone ,
the inner part of the tooth that houses the nerve and the vessel is usually soft again because of the
injury it has become hard and solid. I do understand that it is causing you no pain but I may bring
you in pain and infection in future so these teeth need to be treated to save the tooth you need have
a RCT done where I need to refer you to an endodontist who is a specialised in nerve treatment. he
will clean the centre of your tooth place a tooth friend material to try and close the tip of the root
we call this apexification and after that will complete the nerve treatment (give advantages save
natural tooth, disadvantages the success rate is normally 90% but it is considerably reduced in your
case) or extraction and immediate denture.
The tooth that gets infected every now and again has a condition called chronic periapical abscess,
the trauma had an effect in irritating the nerve and that tooth is now dead and this is a source of
infection which has spread along the tooth to the surrounding structure that hold the tooth in place.
The germs there produce toxic product we call this pus a collection of it is called abscess and that is
why you have this bad taste and breath from time to time. I know it is not giving you any pain now
but as you mentioned it has done so many times in the past to stop it you need a RCT or extraction
and immediate denture.
It is very important that the foundation of these teeth which are the root is strong cause we need a
strong structure to build on it so we won’t be able to do anything for the veneers unless we treated
the root of these teeth.
Patient might become upset and tell you they do not want to register with you anymore he came for
a check-up and now you want to extract his teeth tell the patient, I understand that you are worried
and concerned but I have a professional duty towards you. For your own benefit I have to point out
anything wrong and explain to you all the treatment options with the advantage and disadvantages
so you ca make up your mind and at the end it is your decision to take the treatment on and we are
here to help.
Fiona Brown
D.O.B 08-04-1936
Present Complaint and History:’ Not happy with my denture’
It is a lower plastic denture that replaces my back teeth on both sides. I had it 8 months ago my
teeth were decayed and had to be removed it is my first. I was very happy with it initially but slowly
and gradually it became loose. The teeth that hold the denture in place are fine nothing wrong with
them and have no fillings.my denture have hooks and they are fine nothing wrong with them either.
My denture was given the same day my teeth wear removed and no alteration or addition of teeth
to them. I rinse my denture after a meal and I don’t put it in a solution, I sleep with it in my mouth
cause if I don’t I and get a head ache. I can’t eat or speak with it it makes me conscious. I have an
upper denture which is fine am very happy with it is a metal denture that replaces some of my teeth
I had it since the 70s.yesterday when I was cleaning my denture I dropped it and it broke in two
pieces. I don’t have it with me I chucked it in the bin.
Other Complaints and History: ‘my teeth are sensitive ‘
It is all over my teeth but mainly the front teeth. my teeth are getting shorter and sensitive to cold
and hot which last for few seconds. I do grind my teeth but I have no pain on the side of my face. I
do have heart burns and I take gaviscon for it, it is self-prescribed I haven’t talked to my GP about it.
I am trying to adopt a healthy life style and I am talking a lot of orange juices and oranges they are
healthy you know. I am not fond of fizzy drinks.
I visit my dentist irregularly, I had a RCT and dentures
I brush twice a day with a manual tooth brush and colaget toothpaste. the tooth brush is a medium
bristle one. I floss occasionally and use aqua fresh mouth wash
Medical History:
Medically I am fit and well
No allergies
Been diagnosed with blood pressure 5 years ago, on Ramipril seen my GP 2 weeks ago and he is
happy my condition is controlled
I was hospitalized for removal of pituitary gland,10-15 years ago because I was diagnosed with
acromegaly , I take prednisolone 1mg
Social History:
Retired, I am widowed with no dependants
Alcohol intake is 15 units per week mainly white wine and cider
Sugar is high and I do take a balanced diet
Acid is high
Stress if high since I lost my husband
Notes:
Give me a nice denture
No constrain
Clinical Findings:
BPE:
2 2 2
2 2 2
Teeth Present:
7 4 3 2 1 1 2 3 4
4 3 2 1 1 2 3 4
Missing Teeth: UR 5,6
UL 5,6,7
LR 5,6,7
LL 5,6,7
Carious UR7, LL3
LR4 Root canal treated
Periapical radiolucency w.r.t LR4
Acrylic blobs on occlusal surface of upper co-cr partial denture.
diagnosis
1- Lower immediate acrylic partial Patient complain of her denture loose, immediate
denture unretentive secondary to denture given 8 months ago, gradual looseness,
ridge resorption
2- Dentin-hypersensitivity secondary to Patient complains of sensitivity to cold lasting for
NCTSL primarily erosion and attrition few seconds, increase acid intake of oranges and
orange juices, cider and white wine, patient is
stressed and grinds her teeth, heart burn on
gavscon
3- Carious UR7,LL3 Data provided
4- Periapical radiolucency in relation to Data provided
LR4
5- Acrylic blobs on upper CO/CR denture Data provided
6- Denture stomatitis Clinical finding, poor denture hygiene, wears
denture at night
8- Missing teeth UR5,6,7 UL5,6,7 Data provided

diagnosis
1- No radiograph required Will not help with treatment plan
2-
3-
4-
5-

diagnosis
1- Examination of upper denture To assess any fault design
2- Examination of upper and lower abnormality on denture bearing area
denture baring area
3- Measurement of the OVD To assess OVD loss
4- BEWE To assess TSL erosion
5- Smith and knight index To assess TSL attrition
6- Vitality test UR7 ,LL3, LR4 Ta assess vitality of the tooth
7- Palpitation of UR7 ,LL3, LR4 Ta assess any periodontal involvement
8- Percussion of UR7 ,LL3, LR4 To assess any periapical involvement
9- Candida swab To assess any candida infection
12- Diet chart To assess amount of acid and sugar
Loss of OVD 1mm
Poor rct LR4
Poor oral hygiene, Plaque and calculus deposits on teeth and on denture
Candida test positive confirming candidiasis
artefact
Radiograoph:IOPA
Side: left side
Bone level: no horizontal or angular bone loss
Teeth: 33, 34
Restoration: restoration on 33
Caries: nile
Others:RCT on 33 with radiolucency around the apex of 33
Film quality: 1
● Medical link
o Stress free short appointments
o Advice on taking medication
o Consult GP in case of invasive treatment in case steroids dose need to be doubled
o Application of fluoride varnish 22600 ppm
o Advice on use of 5000 ppm fluoride tooth past
o Denture hygiene instruction and advice on removing denture at night
o Prescription of miconazole 80g, 24mg on denture fitting surface four times a day for 7 days
o Review denture stomatitis
o Reduction in acid and sugar consumption
o Refer to GP for stress management and control on acid reflex
o Advice on removing denture at night
o Monitor TSL with photos and study casts
o Options for lower and upper jaws new removable denture acrylic or CO/Cr, implant
supported denture
o Carious LL3, UR7 excavate caries and temporary filling, permanent option is amalgam or
composite
o Failed RCT, if no pain monitor, or refer for re-RCT or extraction and replace
o After stabilizing TSL give option of composite build up, veneer, onlays or crowns
o composite restoration on the LL3
o Amalgam restoration on the UR7
o Refer to Endodontist for a RE-R.C. T
o refer to restorative specialist to correct TSL for composite build ups
o new CO/CR DENTURE upper and lower
o Review work done restorative treatment and periodontal condition, review denture
stomatitis
o Reinforce OHI, dietary advice,
Varnish……………………….to stop sensitivity
Re-RCT…………………………to save natural tooth
Composite filling…………. Aesthetic
Amalgam filling……………durable
CO-CR denture……………. thin and light
Scaling………………………….improve gingival health
Long treatment, multiple, expensive treatment. RE-RCT reduced success rate, composite might chip
and stain
your reasons)
I will diagnose, treat denture stomatitis, remove caries, scaling, OHI, dietary advice, Monitoring/ I
will refer cause part of the treatment was away
specialist?
Yes, to endodontist specialist for re-RCT and restorative specialist for composite TSL
These are only highlights of the case you will need to elaborate more on them involving options,
advantages , disadvantages , risks and monitoring.
Regarding your denture that is broken although you mentioned that you throw it away, let me
explain why that denture is loose. This denture has been given to you as a temporary measure to
replace your missing teeth, maintain function and works as a bandage to prevent bleeding and
infection to the wound. after the healing process of your wound is completed your gums and bones
shrink and they don’t fit the same to the denture and that is why the denture was loose. we have to
think about replacement option such as removable denture or implant supported. Taking new sizes
that will fit with that denture so hopefully you will be happy.as we are making a new lower denture
and you had your upper denture for a while I think its time to have it changed, those teeth on the
denture has been worn off any some plastic has been added to them to give them some height .this
might affect recording the bite for your lower denture so there will be no use of making a lower new
denture without a upper one. The options are the same as for the lower replacement.
Tooth is formed of three layers an outer protective layer called the enamel and the inner sensitive
layer called the dentine, what the acid does too your tooth it weakens and melts away the strongest
layer in your body exposing the under-lying layer the dentine and that is why you have this
sensitivity. The acid is coming from various sources such as the orange juice or the fruit although
they are healthy they are still acids. Also, you are taking white wine and cider which has the same
effect. You have also mentioned that you are having acid reflex which you are taking gaviscon for it.
the acid from the stomach is very acidic and is making the condition worse. Normally when you have
something acid the saliva corrects any damages that happened but in your case because are taking
too much acid your saliva can’t catch up with the repair process.
Another thing is that you mentioned that you grind your teeth and this is speeding up the process of
losing your tooth structure. When you grind your teeth, your upper teeth rub against the lower and
it grinds away the tooth structure. You mentioned that you are stressed so I would like to refer you
to your GP have a chat with them they have many ways to reduce your stress which will help your
grinding too. Another thing that I would suggest is to take your denture out at night this will also
prevent your grinding habit. I have also noticed a condition under your upper plate the area is red
and sore are you aware of it? this is a condition called denture stomatitis it happens in those who
wear upper dentures and don’t clean them regularly. Not taking you denture out at night is adding
to this problem as your gums are not having any time to breath and relax imagine you sleeping with
your shoes on how would you feel? I know you mentioned that you get headache when you take it
out but lets start with small steps take it out for some time and slowly increase it until you get to the
stage that you can leave it out whole night, for this condition I will give you …….
Miss Daisy Walter

D.O.B 2.3.1998
Present Complaint and History: pain on the lower left side
Pain on the last tooth on my lower right side started 5 days ago. It’s not the first time it’s the second
time. It happened 6 months now it’s getting worse. Pain is sharp and sever, constant pain. Pain
killers are not helping couldn’t sleep because of pain. I have a swelling, no fever but I do have bad
breath and taste in my mouth. I cannot open my mouth widely. Had treatment for it before visited
my dentist and he prescribed antibiotic for me, my tooth is partially covered with gum and it is not
wobbly. No decay on the tooth, scale of pain is 8 and did not take any pain killers this time.
Other Complaints and History: my denture is not fitting well
It’s an upper denture, plastic, replacing some of my teeth. I lost my teeth in a car accident 3 years
ago. This is my first denture, was happy with it at beginning but now it’s becoming loose. looseness
happened gradually 2 months ago. But couple of days ago it became looser. Lost a cap on the tooth
next to the denture on the right side, the tooth is not wobbly and not sensitive. I don’t know if I have
a RCT done. The denture has hook which are fine
Irregular attendee, last visit 6 months ago for the prescription of antibiotic
I brush twice a day with a manual tooth brush and don’t use dental floss or mouth wash
Medical History:
fit and well no allergies
asthmatic patient, since childhood on both blue and brown inhalers, controlled, asthma triggered by
stress and cold weather never had an attack in a surgery before.
Social History:
I am smoker 5 cigarettes a day
Alcohol 2-3 units a week
Sugar intake is medium
Acid intake a lot of fizzy drinks
Stress is very high and I am grinding my teeth at night
Notes:
Fix my denture and sort out the pain
No time constrains
Clinical findings:
BPE SCORE
1 0 1
2 0 1
Distal caries on 47
Partially erupted 48
Teeth missing 11,12,14,21,22
Lost crown on upper right canine

diagnosis
1- Pericoronitis on lower right wisdom Sever pain, swelling, difficulty in opening the mouth,
swelling, bad taste and breath, scale of pain is 8
2- Unretentive upper partial acrylic Denture loose gradually 2 months ago, denture
denture secondary to multifactorial given three years ago, couple of days abutment
tooth lost crown on the UR3
3- Generalized gingivitis Based on BPE data provided
4- Caries on 47 distally Incidental
5- NCTSL secondary to multifactorial Patient has high level of stress, grinds her teeth and
aetiology high fizzy drink intake
6- Lost crown on UR3 History from patient
7-
8-

diagnosis
1- Sectional DTP for the right side Limited mouth opening, to assess type and
angulation of impaction, extension of caries on the
47(the 47 is an incidental finding if it was on
another side I would not have asked for x-ray as
everyone is saying no x-ray for incidental finding
),and assess periapical region for 13 and if any RCT
has been done and the quality of it
2-
3-
4-
5-

diagnosis
1- Temperature and lymph node To assess systemic involvement.
palpitation
2- examination of the swelling To assess size and consistency
3- Interincisal measurement To confirm trismus
4- Examination of the denture and To assess any faults in denture or abnormality in
denture bearing area denture bearing area
5- Ovd To assess OVD loss
6- Vitality test for 13 and 47 To assess vitality of the tooth
7- Percussion test 13 and 47 To assess any periapical involvement
8- Examination of muscles of To assess involvement of both
mastication and TMJ
10- Dietary chart To analyse diet for sugar and acid
11- Oral hygiene index To assess level of oral hygiene
Results of the investigation:
Electric pulp testing :

47-60
46-35
45-35
25-25
Percussion test:
47 negative
25 negative
13 negative/ it is RCT
Decrease in the interincisal opening
Temperature is 38
artefact, do not include the finding of this x-ray in your treatment plan here. In the exam you will
include it
Side: left side
Teeth:24,25,26,27,34,35,36,37
Restoration: Oclussal on 27
DO on 24,35,36
MO on 25,37
Caries:25,26,27,36,37
Others:nile
Film quality: 1
● Medical link
o Advice patient to bring their own salbutamol inhaler next visit
o Avoid NSAID
o Irrigation of the area with chlorohexidine solution
o Give patient amoxicillin 400mg *3 times a day for 5 days
o Give patient paracetamol 500mgx2 *4times a day for 5 days
o Rinse with a warm salty water rinse three times a day, spend couple of seconds on that area
when brushing
o Place a temporary filling on 13
o Reline the denture or use denture adhesive as temporary measure
o Denture hygiene advice
o Dietary advice on reduction of fizzy drink intake
o Review 48 and refer to maxillofacial for surgical extraction with NICE guidelines
o Give patient night guard with magnesium powder
o Monitor TSL with photos and cast, restore aesthetic after stabilizing
o Recaldent as a preventative measure
o for 13 pfm crown or extraction and added it to the new replacement option
o for upper denture: new partial denture acrylic or CR/CO
fixed-fixed conventional bridge
implant supported bridge or denture
o removed decay on 47 and temporary restoration discuss permanent treatment either RCT or
extraction
o Refer to maxillofiacial for extraction of 48
o Place post and core on 13
o Replace missing teeth with implant supported denture after stabilizing grinding habit
o 47 RCT
o Review restorative treatment, gingival health,
o Reinforce dietary advice, denture hygiene advice and smoking cessation advice
Antibiotic to treat infection and alleviate pain and swelling
Application of fluoride as preventative measure
Night guard to stop parafunctional habits
PFM crown to restore 13
Implants young patient and high success rate
Extraction of 48 within NICE guideline
Rct to save natural tooth
Long treatment, multiple appointment, expensive treatment, implant involves surgery, rct has risk of
breakage of files, involves surgery , bleeding ,swelling , and infection possible side effect for surgery
your reasons)
Yes, I will do all emergency, most of stabilization and follow up
specialist?
Yes to maxillofacial for extraction of 48 require surgery out of my scope of practice
Refer to implantologist after stabilising grinding habit out of my scope of practice
Olivia smith
3.3.1990
Present Complaint and History: ’’Terrible pain on lower jaw’’

On the lower left back tooth, I think it is my last back tooth. I had the pain for one week and it’s the
third time I have it a year and a half, 6 months ago and now. I had some antibiotic for it in the past
my dentist said it is my wisdom tooth. The pain is throbbing pain, continuous, paracetamol is not
helping at all. Pain is spreading to my head and neck its giving me a bad head ache its getting bad I
am feeling feverish. It’s not interrupting my sleep but I cannot eat on that side. Unable to open my
mouth. There is a swelling and bad taste and smell. Food is getting impacted there and its very
painful to clean it from there. Severity of pain is 8.
Other Complaints and History: ‘’my teeth are sensitive’’

It’s all over my teeth but specially in my back teeth, its sensitive to cold last for few minutes, my
teeth are not getting longer, I use gentle force when brushing my teeth with a medium tooth brush,I
don’t have any heart burns, no teeth whitening ,I love cola I take 7-8 cans a day. I don’t grind my
teeth.
Regular attendee, last appointment 6 months ago, for the infection
I had braces in the past when I was 17 very happy with the treatment. I also had a RCT and a cap on
my front tooth which now has a metal bit showing there is no pain on that tooth
I brush twice a day with a manual tooth brush, I don’t use any cleaning aid
Medical History:
Family history of VwD, I am under investigation to see if I have it too
No allergy
Taking mycrogynon for 4 years
Social History:
I work in the supermarket enjoy my job
Alcohol is 5 units per week, I mix
Sugar intake is low
Acid is high
Stress is low
Notes:
Please get me out of pain
Clinical finding:
Teeth present
8765321 1235678
87654321 12345678
Linea alba on the right cheek
BPE score
1 2 1
1 1 1
NCTSL especially with relation to upper right molars

diagnosis
1- Pain secondary to pericoronitis related History of pain, third episode, difficulty in opening
to LL8 the mouth, patient is feverish, bad taste and smell,
food impaction, throbbing pain and radiating to
other areas,
2- Dentine hypersensitivity secondary to Generalized sensitivity to cold last for few minutes,
erosion high acid intake
3- Anaesthetic UL1 crown history from patient, getting brown
5- Linea alba on the right cheek Incidental finding
6-
7-
8-

diagnosis
1- Sectional DTP To assess angulation of impaction, proximity to IDN,
patient has trismus unable to open his mouth
2- IOPA for 21 To assess quality of RCT/been advised by others not
to ask for x-ray if not a major concern but in this
case I do not agree with it as patient is concerned
3-
4-
5-

diagnosis
1- Examination of the area and swelling To assess size and consistency
2- Body temperature and lymph node Systemic involvement
3- Interincisal measurement To confirm trsmus
5- OVD To assess level of OVD loss
6- Dietary chart To analyse diet
8- Bleeding index To confirm active periodontal condition
9- Examination of TMJ and muscles of To assess involvement of both
mastication
1 Examination of linea alba To assess shape , form , size and consistency
0-
All teeth are vital
Painful lymph node
Fever 38.1 degrees
artefact
Radiograoph: dental panoramic tomography

Side: nile
Bone level: no bone loss
Teeth: all teeth present
Restoration: nile
Caries: nile
Others: mesio-angular impaction of all wisdom teeth, lower wisdom near IDN
Film quality:2
● Medical link
o Stress free short appointments
o Liaise with GP regarding VwD , risk of bleeding in case of invasive treatment
o Educate regarding all dental concerns
o Local debridement of the LL8 and rinse with warm salty water
o Metronidazole 400 mg83 time for three days avoid alcohol
o Ibuprofen 400mg *4 times a day for 5 days/ or paracetamols in case of contraindication of
NSAID less side effect
o Varnish 22600ppm
o Review patient after 5 days for pain and temperature
o Dietary advice on reducing acid intake
o Give high fluoride tooth paste 5000 ppm
o Monitor TSL with photos and study cast
o After stabilization resort with composite build up, onlay , veneer or crown
o 21 monitor or PFM
o Monitor linea alba
o Refer to maxillofacial surgeon for extraction of LL8 in guidance with NICE
o Composite build up for TSL
o Refer to maxillofacial for biopsy of linea alba
o New PFM crown on 21
o Review pain, TSL , periodontal condition and restorative work
o Reinforce dietary advice and OHI
Antibiotic for relief of systemic involvement
Extraction prevent further episodes
Composite cost effect and aesthetically acceptable
New crow better aesthetic
Long treatment, require surgery possible bleeding and infection risk of IDN damage, composite can
chip off or stain,
your reasons)
Yes, I will do local debridement, scaling polishing, monitoring TSL, composite build up and new
crown
specialist?
Yes, to maxillofacial specialist for extraction of LL8 and biopsy of linea alba not under my scope of
practice
Linea alba: have you noticed that white line on the side of your right check. Do you have the
habit of biting your cheek? It nothing to worry about it happens because you have the habit of
biting your cheek. We will keep monitoring it try to avoid biting your check and keep
meticulous oral hygiene. If we find that it is not resolving I will need to refer you to a specialist
to have it checked with a biopsy. (linea alba has to be examined with biopsy as it can be
something sinister this is a passing or failing thing in the exam DO NOT IGNORE ANY WHITE
PATCH not responding always investigate to be on the safe side)
Laura Chadwick
8.04.1996
Present Complaint and History: ’my teeth are loose’’
It’s my 2 front lower teeth they have been loose for the last 6-7 months and getting worse. I did not
have a trauma to the area. My gums don’t bleed and my teeth are not getting longer and I don’t
have any dental treatment on them and they are not causing me any pain but I can’t bite properly if I
ever try it starts moving. I don’t know if they are my baby teeth you can tell me. well those two teeth
are smaller than the rest of my teeth. I don’t have any other small teeth. I do have missing teeth in
my mouth in fact there is a condition that runs in my family called hypodontia.
When asking about mobile teeth follow TMPD, T for trauma, M for milk teeth and missing teeth ask
the patient if she thinks the teeth are smaller, P for periodontal problem and D for dental treatment.
The actor will not tell you if they are baby teeth so ask if patient thinks teeth are smaller than the
rest
Other Complaints and History: ’I have a gap in between my front top teeth’’
The gap has always been there, it’s not increasing in size.no pain or sensitivity or dental treatment
on the teeth next to it. I had braces when I was 17 I am not happy with the treatment they were able
to close the gaps on the back sides but could do anything regarding the front part. I don’t have any
more gaps. The gap between makes me conscious and I don’t like to smile. I wore this plate after
words for a year. No family history and no extra teeth.
Patient say they could close the back gaps but they couldn’t do the front. That means there is no
relapse of orthodontic treatment.

Regular attendee, last appointment one year ago, regular check-up.
Past treatment scaling and polishing orthodontic treatment
Brushes twice a day with an electrical tooth brush, no cleaning aids
Medical History:
No allergies
Not pregnant
Has been hospitalized for aortic valve surgery when she was 4 years old. Not taking any medication
and visit her cardiologist every three years.
Social History:
I work in the supermarket and I do enjoy my job
Not a smoker never smoked
No alcohol
Sugar is low
Acid is low
Stress in moderate to high
Notes:
I want a better smile and my friend told me about this sticky bridge which she recommended and I
want more information about it
I have no financial or time constrain
Clinical finding;
Oral hygein satisfactory
BPE Score
0 0 0
0 0 0
Mobile LLA and LRA
Decayed LR 6.

diagnosis
1- Retained mobile LLA, LRA secondary to Teeth mobile, no pain or sensitivity, teeth smaller
hypodontia than the rest history of hypodontia
2- Midline diastema secondary to Complain about a gap, in front teeth, history of
hypodontia hypodontia, history of ortho treatment that did not
help
3- Decayed LR6 Incidental finding
4-
5-
6-
7-
8-

diagnosis
1- Dental panoramic tomogram To assess presence of any permanent teeth, assess
the roots and bone level
2-
3-
4-
5-

diagnosis
1- Vitality for LR6, UR1,UR2 To assess vitality
2- Mobility index LLA,LRA To assess grade of mobility
3- Percussion UR1,UL1,LR6 To assess any periapical involvement
4- Palpitation UR1,UL1,LR6 To assess any periodontal involvement
5- Examination of diastema To assess size
6- Articulation cast To assess occlusion
7- Examination of muscle of mastication To excluded involvement of any
and TMJ
8-
Results of investigation:
Diastema measure 2.2mm
LRA mobility grade 1
LLA mobility grade 2
Teeth missing UR2,UL2,LL1,LL2
artefact
Radiograoph: sectional dpt

Side: left side
Bone level: no bone loss
Teeth: 28,27,26,38,37,36
Restoration: occlusal on 26 and 36
Caries: distal on 37
Others: mesio angular impaction of 38
Film quality: 2
● Medical link
o Liaise with GP regrading aortic valve deficiency
o Explain all dental concerns to patient
o Refer to GP for stress management or advice on palliative measures such as yoga and other
relaxing activities
o Mobile teeth, monitor or extraction and immediate denture or a RBB as temporary
o After healing give option of removable denture, RBB, fixed -fixed bridge, implant
o For diastema monitor, build up, veneer or crown, or refer to orthodontist to increase size of
the gap then give option of bridge or implant
o Remove decay on LR6 temporary filling, amalgam or composite
o Extraction of LLA LRA and immediate denture
o Excavation of caries on LR6 and composite
o Refer to orthodontic for closure of diastema and creation of space to replace UR2,UL2
o After healing and ortho refer for implant replacement
o Review restorative work and diastema relapse
Mobile deciduous teeth of poor prognosis
Immediate denture will replace teeth temporarily
Orthodontic treatment better results to make more space for replacement
Implant has high success rate
Composite aesthetically acceptable
Requires referral, long treatment require patient compliance and meticulous oral hygiene,
composite can chip of and stain, implant expensive and involve surgery
your reasons)
I will provide part of the treatment, extraction, immediate denture, follow ups and referrals
specialist?
Referral to orthodontic specialist and implant specialist not under the scope of my practice.
This case comes in exam as retained upper AS and missing laterals or retained c in both cases the
treatment plan is like the above.
Explain that : you have your baby teeth because of hypodontia which is a condition that runs in
families, it also involve missing the adult teeth. these baby teeth are trying to catch up with the adult
teeth next to it when you bite so it has lost a lot of bone support around it and that is why it is
wobbly. We can monitor these teeth but the looseness will increase and these teeth will need to
come out eventually
Patient will insist on not wearing an immediate denture as it is for old people give the patient the
option of a RBB as a temporary measure and make her aware that after healing the gums will shrink
and a gap will appear so it is a temporary measure.
Regarding the ortho treatment, I will refer you to have braces to close the gap between the front
teeth and make more space to give you a replacement of the missing teeth you have on either side.
Billy Carley
8.5.1955
Present Complaint and History: ‘’ I have pain in my mouth’’
It is on the back teeth on the left side I cannot tell which one it is exactly.it started 2 weeks ago and it
is the first time I have that pain. Pain is on cold last for I minute. I don’t have pain on biting and the
pain is sharp pain severity is 7. I did not use any pain killers. Pain is only in that area and not
interrupting my sleep. No trauma or decay but I have few crowns, fillings and RCT because of either
decay or my teeth got infected. I am happy with the treatment done. no swelling, salty taste or
mobility
Other Complaints and History: ‘’teeth on the left side have sharp edges ‘’
It is on my upper and lower jaw, broken teeth and filling it hurts my tongue and cheek so I just try to
avoid it.it happened 2 months ago.no blister or soreness
*my tooth number 4 on the left side is causing me pain, throbbing pain started a week ago. Pain
more on hot last for 2-3 minutes, no pain on biting. Pain is not spreading interrupting my sleep. I had
a silver filling there which I lost 2 years ago and was not replaced. no swelling salty taste or
temperature severity of pain is 6-7.no mobility
*my teeth are sensitive.it started long time ago, I have noticed them getting longer, sensitive to cold
last for few seconds.my gums are not bleeding but I was diagnosed with a very bad gum disease
before it is okay now. I did not lose any teeth for gum problem. And no family history of gum disease
I don’t visit the dentist regularly but I see my hygienist every 3 months and she is happy with my gum
condition. I have not spoken to her about the sensitivity
I brush twice a day with an electronic tooth brush and Colgate tooth paste and I do floss daily but
don’t use mouth wash
Medical History:
COPD- diagnosed 5 years ago, taking salbutamol for 7 months, before that I was on the brown
inhaler. I have been hospitalized 2 years ago for COPD and been on oxygen supply for 2 months.
Episodes are provoked by stress and cold.
No allergies
Social History:
Retired dental technician- enjoying my retirement
Smoke: no, I used to smoke all my life 20 cigarettes a day but I did quite 5 years ago
Alcohol: red wine 10 units /week
Sugar low
Acid low
Stress medium
Notes:
Please get me out of pain
Clinical findings:
All teeth are present
Extrinsic staining on teeth
BPE score of
1* 1 *1
1 2 1
Fractured distopalatal cusp on 26
Fractured mesiolingual cusp on 36
Dislodged filling on 34

diagnosis
1- Reversible pulpitis related to 26 and Sharp pain, pain to cold last for 1 minute no
36 secondary to fractured cusps radiation no temperature or interruption of sleep,
broken cusps on 26 and 36
2- Irreversible pulpitis on 34 secondary Throbbing pain last for few minutes mainly to hot,
to dislodged amalgam restoration interruption of sleep, lost filling 2 years ago no
replacement
3- Sharp edges on 26 and 36 secondary History from patient, avoiding touching it with his
to fractured cusps tongue, causing pain
4- Generalized gingivitis with localised Bpe score, history of periodontal disease
furcation involvement
5- Dentin hypersensitivity secondary to History of sensitivity and BPE score, patent noticed
gingival recession teeth getting longer
6- Extrinsic stains Data provided
7-
8-

diagnosis
1- IOPA for 34,36 and 26 To assess proximity to pulp, presence of caries, any
periapical involvement
2- IOPA for sextant with * To assess level and type of bone loss and furcation
involvement
3-
4-
5-

diagnosis
1- Vitality test for 34,36,26 To assess vitality of the pulp
2- Percussion test for 34,36,26 To assess any periapical involvement
3- 6-point pocket chart full mouth To assess clinical attachment loss
6- Furcation index To assess grade of furcation involvement
7- Mobility index To assess mobility grade
8- Recession index To assess level of gum recession
LL6 EPT 30
UL6 EPT30
LL4 EPT 80
Body temperature 37 degrees
artefact
Radiograoph: IOPA
Side: posterior left
Bone level: mild bone loss around 35, crestal bone not present
Teeth: 35,36,37
Restoration: occlusal on 36
Caries: none
Others: none
Film quality: 2
● Medical link
o Bring inhaler next appointment
o Treatment will be carried out in the most comfortable position for patient ,
o Take medication as prescribe by GP
o Update medical history if any changes
o Explain all dental concerns to patient
o Remove filling from 26 and 36, smoothen sharp edges and apply Ca(OH2) and temporary
filling
o 34 pulp extirpation dressing and temporary filling
o Paracetamol 1g*4 times a day for 5 days
o Apply Recaldent for sensitivity
o O.H.I, supra and subgingival scaling, RSD and referral to periodontal specialist
o Diet advice, change preference of red wine link to discolouration
o Review 26,36 if no pain gives option of amalgam build up, composite build up, onlays or
crown
o For 34 root canal treatment or extraction and replacement option either removable denture
acrylic or CO-CR or fixed bridge or implant
o Desensitising tooth paste
o After stabilizing gingivitis give option of teeth whitening
o Onlay for 26 and 36
o RCT and PFM crown on 34
o Refer to periodontal specialist for comprehensive periodontal treatment
o Review periodontal health and restorative work
o Reinforce OHI
Removal filling and dressing to stop injuring the cheek and tongue and alleviate pain
Pulp extirpation and dressing to alleviate pain
Recaldent to stop sensitivity
Scaling and polishing to improve periodontal health
Rct to save natural tooth
Onlay provide protection to the tooth
Pfm good aesthetic
Expensive, multiple appointment, require patient compliance, RCT failure 10%, pfm destructive
your reasons)
I will provide part of the treatment scaling RCT, PFM, onlay, scaling and polishing and will follow up
with patient examination
specialist?
Yes, will refer to periodontal specialist for comprehensive periodontal treatment, not under the cope
of my practice
This case come at least once every year, COPD patient you should not lie them down it will start an
episode of breathing difficulty. Patient should be treated in an upright position.
The sensitivity that you have is because of your gum have shrunk. This has happened because some
bone has melted away due to the gum problem you had. when the level of bone moves down the
gums moves with it exposing the roots of the tooth which is covered with a thin protective layer
cementum which can be washed away very easily exposing the underlying dentine the sensitive layer
and that’s why you are having sensitivity.
Your gum condition has reached a point where the roots have lost a lot of support around it, I would
recommend referring you to a specialist in gum disease to have further treatment done they can use
artificial bone around the tooth and some surgery to cover the root of your teeth.
Mr John Luke
8.4.1963
Present Complaint and History: ’’I am here for a regular check-up’’
When I spit there is blood and it is disgusting. it is all over my gums started 2 years ago maybe it’s
getting worse, my gums are red and shrank down as my teeth are getting longer and sensitive to
cold. I do have this bad smell and taste in my mouth, I am not sure if there is any pus I had wobbly
teeth in the past but didn’t lose any. now none of my teeth are wobbly. I don’t think we have family
history of gum disease, I am not diabetic.
Other Complaints and History: ‘’I have an ulcer ‘’
I had them for a week now, it’s been on and off for the last 4 years but last year it started come
more often, the only treatment I use is bonjela. First it was only one now there are 2 under my
tongue on the floor of my mouth very small maybe 1mm in diameter. I don’t have any other ulcer
anywhere else on my body, it is causing me discomfort when I eat. they heal within 2 weeks with no
scar. no bleeding or discharge from it and no alteration in sensation. I did not have a trauma and no
sharp teeth around it. Positive family history father has the same problem. I am a vegetarian and do
not talk any supplements.
My teeth are stained, they started few years ago. It’s all over my teeth and its becoming worse. I
don’t like tea and coffee.
Irregular attendee only when have symptoms, not anxious about dental appointments
Last visit three years ago for regular check up
Previous dental treatment crowns, filling and scaling and polishing
Brushes twice with an electric tooth brush, use mouth wash Corsodyl for 4 years was not prescribed
by my dentist I use it for the bad smell I have.
Medical History:
No allergies
Palpitation was diagnosed 2years ago, was prescribed furosemide but I stopped taking it as I feel
better and don’t need the medication, my GP didn’t advise me to stop it but I feel better.
Furosemide can cause ulceration )
Family history of diabetes I have not checked it but I watch my food and don’t do sugar because I
know it’s in the family.
Social History:
I am a truck driver, I enjoy my job but it gets too much sometimes. I live with my lovely wife and no
dependents
Smoking not a smoker and never smoked
Alcohol 12units/week red wine
Sugar is low
Acid is low
Stress is high and I do not grind my teeth
Notes:
Please treat this ulcer it is causing so much discomfort and help me with the bleeding it is disgusting
No time or financial constrain
Clinical finding:
BPE score
4 3 4
4 3 4
*
3 pinpoint ulcers on the floor of the mouth
Pus discharge from the pocket of 41
All teeth present
Generalized gingival recession

diagnosis
1- Generalized periodontitis with Bleeding gums, generalized, gum recession, teeth
localized furcation involvement sensitive, halitosis , bad taste, BPE score
2- Recurrent aphouthus ulcer 3 ulcers, 1mm in size, floor of the mouth, previous
episodes heal with 2 weeks, causing discomfort,
positive family history, vegetarian no supplement
3- Generalized extrinsic discolouration Stains generalized, red wine and use of Corsodyl
mouth was
4- Dentine hypersensitivity secondary to Sensitive to hot and cold last for seconds,
gingival recession generalized gum recession
5- Periodontal abscess related to 41 pus discharge for pocket , incidental finding
6-
7-
8-

diagnosis
1- Full mouth IOPA To assess level and type of bone loss
2-
3-
4-
5-

diagnosis
1- Full mouth 6-point pocket chart To assess the level of CAL
4- Mobility index To assess grade mobility
5- Furcation index To assess grade of furcation involvement
6- Miller index To assess level of gingival recession
7- Vitality test 41 To assess vitality of the tooth
8- Percussion test 41 To assess any periapical involvement
9- Examination of ulcer To assess size and number
10- examination of stained teeth To assess stained teeth
11- Body temperature To exclude systemic involvement
Results of investigation:
41 is vital and negative to percussion
No teeth mobile
Poor oral hygiene with plaque and calculus deposit
artefact
Do not include findings of the radiograph in treatment plan in exam you will include it
Radiograph: sectional DPT

Side: right
Bone level: bone level adequate
Teeth:17,16,15,14,13,12,47,46,45,44,43
Restoration: oclussal on 17 and 47, DO on 15, MO on 16 , crown and rct on 46
Caries: none
Others: roots of 17,16,15 in the maxillary sinus, radiolucency on the mesial root of 46
Film quality: quality is 2 slight overlapping in the interproximal area between upper molars
● Medical link
o Advise on not stopping or taking medication without GP consent.
o Liaise with GP regarding palpitation
o Apply varnish to 22600 ppm of fluoride
o Local debridement around 41 for drainage pus
o Palliative advice for ulcer, continue use of bonjela , benzydamine mouth wash, salty warm
rinse and avoid spicy and crunchy food
o Stop use of Corsodyl mouth wash
o O.H.I, supra and subgingival scaling, RSD , 6 point pocket chart , refer to periodontal
specialist for comprehensive periodontal treatment
o Review ulcer after a week if it does not heal refer for biopsy
o Refer to GP for blood glucose test, full blood count and prescription of supplement
o Palliative management for stress or refer to stress counselling management
o Prescription of 5000ppm of fluoride and NaF of 225ppm fluoride mouth wash
o Advice on changing preference of alcohol red wine cause discolouration
o After stabilizing periodontal give option of teeth whiting or veneers
o Refer to periodontal specialist for comprehensive periodontal treatment
o If ulcer does not heal refer to oral and maxillofacial for biopsy and management
o Tooth whiting after stabilizing periodontal condition
o Reinforce O.H.I
o Review ulcer, periodontal condition, stress and restorative work
Local debridement to drain pus and prevent flare of pain
Periodontal treatment to improve gingival health
Blood test to exclude any underlying condition of ulcer or gum disease
Long treatment requires patient compliance therefor treatment results of periodontal treatment is
unreliable, whiting can leave patient with sensitivity
your reasons)
I will do part of the treatment, immediate management, scaling polishing, O.H.I, review ulcer and
local measures, referral and whiting
Under the scope of my practice
specialist?
To restorative specialist for comprehensive periodontal treatment patient is a complexity 3
To oral maxillofacial if no healing of ulcer for biopsy and management
Not under the scope of my practice

Lisa Jordan

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I have written down this file to help myself, friends and those who

have been through the same hardship of Ore. I am not expecting

A-Do you have any allergies? If yes, what?

B-Do you have any breathing problems such as asthma?

● Are you on any contraceptive?

● Are you periods regular? Do you bleed heavily?

K-do you have any kidney or liver problems?

Radiograph How does this request contribute to your making a

2- Chronic periapical Dull pain on biting, history of trauma, fractured composite

4- Dentine hypersensitivity Clinical examination, patient with bruxism habit, sensitivity

Investigation How does this request contribute to making your diagnosis

Type: is the IOPA

Past dental history:

Provisional diagnosis Clinical symptoms/presentation (ascertained

4- Replacement for denture Patient not happy with removable requested a

Radiograph How to assess this request contribute to your

Investigation How does your request contribute to your

Radiograph: horizontal bitewing

initial /Stabilization phase:

Long Term and Maintenance Treatment:

Present Complaint and History: ‘pain in my mouth’

Provisional Diagnosis Clinical symptoms/presentation (ascertained

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

Radiograph: Horizontal bitewing

● Long term and maintenance treatment

If patient insist on having a bridge?

Mrs Jemma Nolin D.O.B 3-3-1953

Provisional Diagnosis Clinical symptoms/presentation (ascertained

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

● Other preferred definitive option that can be done:

​Present Complaint and History: ‘Concerned about my looks’

Plaque and calculus deposits

UL1 has a post and core crown(patients past x-ray

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

Radiograph: ​intra-oral periapical radiograph

Present Complaint and History: ‘I am here to have a check-up’

Investigation How does this request contribute to your making a

NO TENDERNESS IN MUSCLES OF MASTICATION

LRe –grade 2 mobility. ROOTS RESORBED-NO PERMANENT TOOTH DETECTED UNDERNEATH

EDGE TO EDGE BITE

Provisional Diagnosis Clinical symptoms/presentation (ascertained

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

Radiograph​: horizontal bitewing

Provisional Diagnosis Clinical symptoms/presentation (ascertained

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

Other Complaints and History: ‘I have a wobbly tooth’

Provisional Diagnosis Clinical symptoms/presentation (ascertained

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

Present Complaint and History​: ‘my gums are bleeding’

Radiograph How does this request contribute to your making a

Investigation How does this request contribute to your making a

Muscles of mastication- NAD

Radiograph: ​horizontal bitewing

● Immediate /emergency treatment

Present Complaint and History:​’ I am in severe pain’

Other Complaints and History​: none

Provisional Diagnosis Clinical symptoms/presentation (ascertained

Radiograph How does this request contribute to your making a

Present Complaint and History: ‘Concerned about my looks’

Radiograph: intra-oral periapical radiograph

Radiograph: horizontal bitewing

Present Complaint and History: ‘my gums are bleeding’

Radiograph: horizontal bitewing

Present Complaint and History:’ I am in severe pain’

Other Complaints and History: none

Present Complaint and History: ‘there is a gap between my front teeth’

Present Complaint and History: ‘I hate my denture’

Present Complaint and History: I am here for a check-up.

Present Complaint and History: ’’Terrible pain on lower jaw’’

Other Complaints and History: ‘’my teeth are sensitive’’

Radiograoph: dental panoramic tomography

Radiograph: sectional DPT