APLAN MILESTONE

3
Anish Amin
EXAMINATION
APPOINTMENT
 Male, 26 years old

 Irregular attendance, last attended in 2014 – lack of attendance is due to

anxiety which then turned into embarrassment about the patients own
oral health

 Reason for attendance: Patient decided they want to take ownership of

their dental health and improve confidence.

 Presenting complaint: No pain but overall dissatisfied with the way his
teeth look and decay on his back teeth
MEDICAL HISTORY

 No relevant medications
 No relevant conditions
 No relevant allergies
 SOCIAL
HISTORY
 Smokes e-cig daily, for the last 3 years

 Less than 14 units per week

 Occupation: Family business, works from home

 Diet: Frequent snacking, high in sugars. Sugar free

fizzy drinks
 DENTAL HISTORY

 Not seen by a dentist for over 9 years

 Brushes once a day, using a manual toothbrush and fluoride

toothpaste

 No interdental cleaning

 Rinses after brushing and occasional mouthwash

 Anxious with dental treatment – primarily needle phobic

CLINICAL EXAMINATION

EXTRA-ORAL EXAMINATION
 Lymph Nodes: Not swollen and tender
 TMJ: No issues noted
 Swelling/Tenderness: No issues noted
 CLINICAL EXAMINATION
BPE INTRA-ORAL EXAMINATION
 All soft tissues: No issues noted
3 1 2
 Tooth wear: Generalised moderate erosion and attrition
3 2 3
 Multiple broken down grossly carious teeth
 Multiple sites of buccal cervical caries
 Modified Plaque score:
 Missing LR5
45%
 Modified Bleeding  Occlusion:
score: 40%  Incisal: Class III
 Canine (RHS): Class III
 Canine (LHS): Class II ½ unit
 Molar (RHS): Class II ½ unit
 Molar (LHS): Class I
 Posterior open bite RHS and LHS
 Guidance (RHS) – Canine Guided
 Guidance (LHS) – Group function
No non working side interferences on both sides
SPECIAL
INVESTIGATIONS
 Endofrost
 Positive: UR6, UR3, UR2, UR1, UL1, UL2, LL4,
LL5, LL7, LR3
 Hyper-sensitive: UL3, LR6, LR7, UR5, LL6
 Negative: LR4, UL4
 Tender to percussion:
 UL5, UL6, UL7
 Mobility
 No mobility noted
 Radiographs
 Peri-apical radiographs taken of posterior quadrants
– root morphology, caries, peri-apical pathology, and
bone levels
PRE-OP
TOOTH
CHART
PRE-OP PHOTOGRAPHS R L
[ANTERIOR VIEW]
 PRE-OP
RADIOGRAPHS
 Diagnostically acceptable
 Diagnostically acceptable
 Teeth present UL3,4, 5, 6, 7, 8
 Teeth present UR4, 5, 6, 7
 Mild horizontal bone loss – slight reduction in
 Mild horizontal bone loss height of alveolar crest, areas of vertical bone loss
between UL5 & UL6
 Radiolucencies:
 Occlusal RL indicative of caries –  Radiolucencies:
UR6  Coronal Radiolucencies indicative of caries and
 Coronal structure is RL indicative of broken down teeth – UL4, UL5, UL6, UL7
caries and crown fracture, RL also  Peri-apical radiolucency around apex of UL6
present around apex of mesial root -
UR7  UL3 mesial coronal radiolucency indicative of
caries proximal to nerve

 PDL widening around UL5

 Diagnostically acceptable

 Teeth present LR4, 6, 7.  Diagnostically acceptable

 LR5 missing  Teeth present LL4, 5, 6, 7.

 Mild horizontal bone loss  Mild horizontal bone loss – slight reduction in height
of alveolar crest
 Radiolucencies:
 Radiolucencies:
 Occlusal RL indicative of caries –
 Occlusal RL indicative of caries – LL6, LL7
LR6
 Coronal structure is absent from LR4  RL limited to enamel indicative of early caries – LL4
indicative of fracture (d), LL5 (d)

 RL around apex of LR4 indicative of  No PDL widening or peri-apical pathology

caries or mental nerve
 R L
PRE-OP PHOTOGRAPHS
[ANTERIOR VIEW]
PRE-OP PHOTOGRAPHS R L
[OCCLUSAL VIEW]
 DIAGNOSIS AND PROGNOSIS

PERIODONTAL DIAGNOSIS TOOTH SURFACE LOSS

 Generalised Periodontitis, Stage 1,
Grade B, unstable, risk factors: e-
cigarette smoking
 Generalised mild erosion due to dietary reasons
 Attrition wear facets localised to lower anteriors due
to erosion and occlusion

EARLY CARIOUS LESIONS

REVERSIBLE PULPITIS
 LL4 (d)
 Guarded Prognosis = UL3
 LL5 (m)
 Good prognosis = LL6, LL7, LR6, LR7
CARIES PRESENT CLINICALLY
 UL3, UL4 (o), UL5, UL6, UL7 GROSSLY CARIOUS RETAINED ROOTS WITH
 LL6, LL7 SYMPTOMATIC APICAL PERIODONTITS
 LR3 (b), LR4, LR6, LR7  Poor Prognosis = UL5, UL6, UL7

 LL6, LL7 (b,o)

PULP NECROSIS WITH ASYMPTOMATIC APICAL PERIODONTITIS
MISSING TEETH
 Guarded prognosis = LR4, UL4
 LR5
 TREATMENT

ACUTE STAGE
 The patient has not attended a dentist for the past 8 years.
 Presented with multiple broken down and decayed teeth, he was not in pain.
 TREATMENT
PREVENTION STAGE
 Based on the patients dental history, current OH regimen, diet and high level of decay

 Advised patient to start brushing twice a day using an electric toothbrush and demonstrated
the correct technique.
 Advised using single tufted toothbrushes to target gums and broken down teeth to clean away
debris.
 Advised using interdental brushes and what sizes to use
 Provided a diet sheet to the patient to record what they ate and when (3 days with 1 day
including a weekend)
 Prescribed duraphat 5000ppm fluoride containing toothpaste.
 TREATMENT
STABILISATION STAGE

 Supra and sub gingival debridement

 Extraction of teeth with a poor prognosis
 UL5, UL6, UL7
 Removal of caries and stabilisation with GIC
 UL3, LL6, LL7, LR6, LR7
 Extirpation and dressing with ledermix
 LR4, UL4
 TREATMENT
REVIEW FOLLOWING 3 MONTHS

 Following prevention, oral hygiene advice, and stabilisation of the dentition

 Plaque scores improved from 45%  30%

 Bleeding scores improved from 40%  20%
 BPE score
3 1 1 The deep pocket on the UR sextant was between UR5 and UR6 where pt struggles to
1 2 1 keep clean due to crowding
 RADS: TREATMENT IN
WORKING LENGTH PA
DETAIL
MASTER CONE FIT PA POST OBTURATION PA

o Diagnostic o Diagnostic o Diagnostic

o Teeth present: LR6, LR5
o 25 file reaches apex of distal canal
o Est WL from PA:
o D canal: 20.5mm, MB canal: 21, ML
canal: 20mm
o Verified with apex locator:
o D canal: 19.5mm, MB canal: 20, ML
canal: 19mm
o *Radiograph deleted for WL PA for Mesial
canals
o Teeth present: LR6, LR5, LR4
o WaveOne primary GP points reach working
length and no extrusion out the apex.
o No adjustments made to cone before
placement
o No voids, good apical seal
o Teeth present: LR6, LR5, LR4
o GP is well condensed, no voids or perforations
present
o D canal GP is slightly short of apex but
o Coronal radiopacity indicative of GIC
restoration
SOCRATES TO ESTABLISH DIFFERENTIAL
DIAGNOSIS
 Site: LR6

 Onset: Since a week

 Character: Constant dull ache previously the pain was not constant

 Radiation: No radiation, localised to the area

 Association: No associations noted

 Time: Pain is mostly constant not fixed to a particular time

 Exacerbations or Relieving factors: Exacerbated by eating, sweets and relieved by

pain killers but only for a while

 Severity: 6/10
 FINAL POST-OP RADIOGRAPH
FOLLOWING DEFINITIVE RESTORATION

RADIOGRAPHIC REPORT
 To assess for root morphology, caries, peri-
apical pathology, and bone levels
 Diagnostically acceptable
 Teeth present LR4, LR5, LR6
 Mild horizontal bone loss
 LR6:
 Well condensed GP
 No voids
 Distal 1mm short of apical
constriction but no perforation of
constriction present
 Coronal radiopacity indicative of
composite restoration
 No distal overhang present,
restoration well sealed to tooth.
POST OP
TOOTH
CHART

LR6 root treated and

DO composite placed
 POST-OP
PHOTOGRAPHS

AFTER OCCLUSAL
ADJUSTMENT AND
POLISHING
 REFLECTION

What went well?

 Shaping process and identification of working length went well with minimal assistance
needed.
 Despite the stress of the situation, I was able to correct the coronal perforation while
making the access cavity and continued with the procedure."
 Use of mouth prop during long appointments prevented post-op trismus and facilitated
access to the tooth.
 Improving speed with rubber dam use and happy with final restoration.
 Good conversation with patient regarding prognosis, risks of not having indirect
restoration, and treatment consent process.
 Photography skills helped identify areas for improvement and allowed for objective
evaluation of work.
REFLECTION - CONTINUED

What didn’t go well?

 Difficulty identifying canals as they were presented buccally, leading to perforation of

the lingual aspect of the crown.
 Treatment required three visits due to struggling to complete it in a timely manner, an
area for improvement.
 Need to develop a habit of removing GP points cleanly to avoid compromising the bond
of the core and restoration.
 GP point distally was shorter than the master cone PA, something to be more aware of
in the future.
 Difficulty with fitting the endo ring PA holder around the clamp.
 REFLECTION - CONTINUED

What I learned from this case?

 Canals may not always follow textbook versions due to wear and attrition, but I learned
about the laws of orifice location which I now apply to access cavities.

 "To assess perforations during access cavity preparation, I can use my apex locator. If
beeps, it’s probably external tissue and therefore a perforation.

 I learned not to use a normal PA holder for working length radiographs, as the patient can
bite down on files. Instead, I use GP to assess WL with a normal PA holder.
 REFERENCES

 Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor. J Endod. 2004

Jan;30(1):5-16. doi: 10.1097/00004770-200401000-00002. PMID: 14760900.

 Ng YL, Mann V, Gulabivala K. Tooth survival following non-surgical root canal

treatment: a systematic review of the literature. Int Endod J. 2010
Mar;43(3):171-89. doi: 10.1111/j.1365-2591.2009.01671.x. PMID: 20158529.
THANK YOU!