CLINICAL CASE REPORT example

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1 EDINBURGH DENTAL INSTITUTE CLINICAL CASE REPORT example

2 MSc in dental primary care case report exemplar The following example is from our database of coursework examples. It represents an acceptable standard to pass the assessment. When considering an example students should always look at the content, standard of presentation and detail of the description or reflection. When preparing their own piece of coursework for assessment they should look for ways that they could improve on the example and strive for the highest possible standard.

3 History: Presenting complaint Lost post and crown from tooth #23 and would like it recemented before a certain social occasion that day. She would also like to improve the appearance of her front teeth as she feels they have got shorter with old age. History of presenting complaint Patient has had some of her crowns come out on multiple occasions over the past few years. She is also aware that she may be grinding her teeth at night but is unsure if this is causing the crowns to get loose. She occasionally wakes with headaches and her husband has heard dreadful sounds in the middle of the night from her teeth! There is no pain associated with this problem in #23 however she has started to feel some tenderness under it when she pushes up on the tooth. Previous Medical History No relevant medical conditions, allergies or medications recorded. Previous Dental History Attends the dentist only when something goes wrong. However this happens quite often meaning the patient has undergone multiple extractions and a lot of restorative work. She is partially edentulous and wears a denture in the upper arch. She reports that she has never discussed preventative measures with a dentist or had the causes of her dental problems explained to her in the past. She had crowns and root treatment placed in the #23 in 2006 and #25 in She had root treatment carried out on the #16 in She has had her back teeth refilled on multiple occasions due to the fillings leaking or breaking. Occasionally wears an old ill-fitting partial denture. Social History Retired teacher. Non smoker and non- drinker of alcohol. Has had some stress in her life recently looking after her unwell over 90 year old mother who lives over 70 miles from the patient. Admits that her diet isn t always great as she can consume a lot of sugary snacks especially biscuits and hard boiled sweets. Her diet history uncovers frequent intake of fruit juices and apples and white wine which all have low PH values. Habit Patient is a nocturnal bruxist and aware that her jaws are quite tense during the day suggesting stress related wakeful bruxism.

Dental Hygiene Brushes twice a day most of the time but sometimes forgets to brush at night time and can leave the upper denture in at night time. Uses a fluoride toothpaste.

4 Dental Hygiene Brushes twice a day most of the time but sometimes forgets to brush at night time and can leave the upper denture in at night time. Uses a fluoride toothpaste. Doesn t floss or use interdental aids. Examinations and records: Extra Oral TMJ: Slight click in the left and right TMJ. Asymptomatic. Maximum opening greater than 40mm. Lymph and glands: No swelling or abnormality detected. Facial: Symmetrical, slight class 2 skeletal profile. Smile assessment Medium lip line (75-100% of upper tooth crown visible with the interdental papillae), good smile width, acceptable smile arc, wider buccal corridor space on the right side. Dental and facial midlines are not coincident as upper has drifted to the left side.21 appears to have a different hue as well as the crowns in the upper left quadrant. Exposed crown margins have resulted in a poor aesthetics here. The tooth form is irregular from previous toothwear with tooth proportions being less than ideal. Gingival biotype appears to be thicker with levels around the upper labial segment being close to symmetrical. Extra-oral photographs

5 Intra-oral Soft tissue No abnormality detected Salivary function- Appears to be within normal range. Periodontal: Basic Periodontal Examination X

6 Pocket charting

Dentition and charting Teeth present 7 6 3 2 1 1 3 5 7 8 5 4 3 2 1 1 2 3 5 Unerupted teeth-none Existing Restorations- Amalgam: 17 DOB, 16 MODP, 27 DO, 28 O, 44 O, 45 OL Composite: 13 D, 35 OB, 31 B

7 Dentition and charting Teeth present Unerupted teeth-none Existing Restorations- Amalgam: 17 DOB, 16 MODP, 27 DO, 28 O, 44 O, 45 OL Composite: 13 D, 35 OB, 31 B Glass ionomer: 45 B Existing Prosthesis: porcelain fused to metal crowns 23 and 25 (both post retained.) Mobility: Tooth 23 is Grade 2 mobile - 1mm to 2 mm of horizontal movement (using Miller s index 1 ) 1 Davies S.J., Gray R.J., Linden G.J., James J.A., Occlusal considerations in periodontics. Br. Dent. J., 191 (11), pp Tooth mobility can be recorded using Millers index: i.- up to 1mm of movement in a horizontal direction ii.-greater than 1mm of movement in a horizontal direction iii. - greater than 2mm of horizontal movement and vertical movement possible.

Wear: BEWE 2 index Grade 2-16, 11, 21, 32, 31, 41, 42, 35 Grade 1-13, 33, 43, 12, 27, 45 Caries: 35 buccal, Endodontic status: 23 (failing-periradicular radiolucency, symptomatic, multiple occasions

8 Wear: BEWE 2 index Grade 2-16, 11, 21, 32, 31, 41, 42, 35 Grade 1-13, 33, 43, 12, 27, 45 Caries: 35 buccal, Endodontic status: 23 (failing-periradicular radiolucency, symptomatic, multiple occasions with loss of crowns with exposed root filling, inadequately obturated canal.) 16 and 25: root treated. 17 and 21: +ve to thermal testing (Endofrost) Occlusion Static: Class 1 incisor. Class 2 canine right side, Class 1 canine left side. Poor posterior support. Small number of contacts. RCP is not coincident with ICP. Freedom in centric occlusion present. Overbite of 2mm with an overjet of 3-4mm. Dynamic: Canine guidance on both sides. Interferences were recorded on the16 (mesiobuccal cusp) and 45 during working side excursion. Mandible deviates slightly to the left and forwards from the premature contact in RAP into ICP. Red - Lateral excursion Blue- Intercuspation 2 Bartlett D., 2010 BEWE -A proposed system for screening tooth wear Br.Dent. J., 208, pp No erosive wear 1-Initial loss of surface texture 2-Distinct defect, hard tissue loss <50% of the surface area 3-Hard tissue loss >50% of the surface area

9 Casts (coated in a cyanoacrylate resin for protection from frictional wear) (with RCP marked) Maxillary study cast Mandibular study cast

10 Intra-oral photographs Anterior view with teeth in occlusion Anterior view with teeth apart

11 Maxillary occlusal view Mandibular occlusal view

12 Buccal view Right side Buccal view- Left side

Red articulating paper mark on the distobuccal cusp of the 16 shows the retruded contact position after the patient was manipulated into retruded axis position (RAP) by bimanual mandibular

13 Red articulating paper mark on the distobuccal cusp of the 16 shows the retruded contact position after the patient was manipulated into retruded axis position (RAP) by bimanual mandibular manipulation. This was the first point of contact in RAP which results in a mandibular slide into the patient s habitual intercuspation position (ICP). Anterior view of protrusive excursion showing contact with 11,21 with 41,31,and 32 with their corresponding wear facets

14 Lateral excursion to the left side showing canine guidance off the mobile 23. Lateral excursion to the right side shows contact and canine guidance with the 13. There is a working side interference on the 16 buccal cusp.

15 Radiographs Orthopantomogram Intraoral bitewing radiographs

16 (i) (ii) (iii) Periapical radiographs of (i) 45 and 44, (ii) 16 and 17 and (iii) 35.

17 Occlusal analysis Teeth Present Fractured teeth or those with cavitation: #16- Mesiobuccal cusp to amalgam fractured #35- Caries around the composite restoration buccally #45- Caries under a glass ionomer restoration mesiobuccally. #13- Caries on distal surface Degree of Restoration: Upper Lower 17- Large amalgam restoration (DO) 35- Composite (OB) - Rotated 16- Large amalgam (MOP) 44- Amalgam (Occ) 23- Root canal treated, post and crown 45- Amalgam (MO) 25- Root treated post retained crown with glass ionomer (Buccal) 27- Amalgam (Occ) 28- Amalgam (Occ) Tooth Wear Attrition: The areas of wear appear to be mostly confined to the occlusal and incisal surfaces. There are matching polished surfaces or facets on the contacting surfaces. Cusp height has been reduced with flattening of the

18 occlusal inclined planes. This all suggests attritional tooth surface loss which is caused by the physiological wearing away of tooth structure from tooth contact. There is dentine exposure in the more severe areas of wear with an obvious reduction of clinical crown height. Along with the evidence that this patient is performing wakeful bruxing as well as nocturnal or sleep bruxism, it can be concluded that attrition plays the most important role in tooth surface loss. Erosion: Although the areas of tooth surface loss don t typically demonstrate erosive type lesions, it is prudent to acknowledge that the patient s increased acid intake is exacerbating the degree of tooth wear from attrition by softening the tooth substance by chemical dissolution. Abrasion: Abrasion which is the physical wear of teeth by a mechanical process independent of the occlusion does not appear to play a big role in her oral health. Her brushing technique appeared satisfactory and certainly not overzealous. She was using a soft Curaprox tooth brush which is more gentle on the tooth surface and less likely to cause wear. She didn t show any signs of notching or unexplained wear on her incisors from any habits. Abfraction: The buccal cervical surface of tooth 34 appears to have been repaired by composite resin in the past. This may have been caused by caries but possibly could have been caused by eccentric occlusal loading of this rotated tooth leading to adverse tensile and compressive forces in the cervical area leading to loss of the enamel.

Available Clinical Crown height (using ACE (anterior clinical erosive) classification by Vailati and Belser 3 ) Class 2 (minimally exposed dentine) - 13 12, 33, 43 Class 3 (distinctly exposed, < 2mm

19 Available Clinical Crown height (using ACE (anterior clinical erosive) classification by Vailati and Belser 3 ) Class 2 (minimally exposed dentine) , 33, 43 Class 3 (distinctly exposed, < 2mm incisal edge loss) 21, 32, 42 Class 4 (> than 2mm incisal edge length lost) 11, 31, 41 Prognosis of dentition: Poor- The # 23 has a very poor prognosis. It is symptomatic with a periradicular radiolucency and a poorly obturated root filling. The post and core is poorly fitting and has been uncementing on multiple occasions. It has very little remaining tooth structure for an adequate ferrule effect. The tooth is being used for canine guidance on lateral mandibular excursions to the left side. Guarded- 17- Extensive restoration with positive response to vitality testing. Monitoring needed for change to pulp status in possibly stressed pulp. 16- Extensive restoration, root canal obturation not ideal. No mobility, palpation or percussion response, sinus presence or radiographic evidence of periradicular pathology. Occlusal interferences exist here leading to failure of previous restorations. 25- Extensively restored tooth with root treatment and post/core crown. 35- Large composite restoration with possible stressed pulp and need for future root treatment. Good 13, 12, 11, 21, 27, 28, 33, 32,31,41,42,43,44,45. 3 Vailati F, Belser U C. Classification and treatment of the anterior maxillary dentition affected by dental erosion: the ACE classification. Int J Periodontics Restorative Dent 2010 :30:

1 PVS placed on bite fork and excess detail removed with a scalpel

20 With the casts in the articulator Recording the relationship between the maxillary and mandibular teeth to the hinge axis: Fig.1 PVS placed on bite fork and excess detail removed with a scalpel leaving only cusp tips an incisal edges Fig.2 Anterior reference point marked Fig.3 Facebow set up

21 Fig. 4 Transfer jig secured before removing earbow piece Lucia jig with a incisal contacts marked with red articulating paper Lucia jig with interocclusal record of pink moyco beauty wax and relined with zinc oxide and eugenol

22 Upper cast mounted using Kerr s snow white type 2 plaster. Casts articulated with interocclusal record RCP is reproduced on the articulated casts.

The casts have been mounted at a vertical position of 5mm.

The contact point I recorded clinically matched the contact point recorded on the articulator.

The ICP was poorly supported because of the lack of posterior teeth and horizontal stability because of the worn nature of

The discrepancy between the RCP and ICP was measured by the vertical and horizontal component: The Vertical component was

23 The casts have been mounted at a vertical position of 5mm. I found the mandible relatively easy to manipulate into RAP after using bimanual mandibular manipulation technique. The contact point I recorded clinically matched the contact point recorded on the articulator. The casts slide down the wear facet on 16 into ICP. The ICP was poorly supported because of the lack of posterior teeth and horizontal stability because of the worn nature of the remaining supporting teeth. The discrepancy between the RCP and ICP was measured by the vertical and horizontal component: The Vertical component was measured by the reading at the incisal pin with the casts first in ICP and then in their retruded relationship to and was found to be 2mm. Retruded contact position incisal pin Intercuspation position on incisal pin The horizontal component was measured to be about 2 mm as the right condyle moves forward from its housing and the left stays in the same position. RCP: Right side Left side

ICP: Right side Left side The larger the horizontal discrepancy that exists, the more grinding or adjustment is needed to correct and in order to distalise the mandible.

Dental update 2003: 30:416-422 In the intercuspal position The Intercuspal position has few contacting teeth as it has poor posterior support and stability.

24 ICP: Right side Left side The larger the horizontal discrepancy that exists, the more grinding or adjustment is needed to correct and in order to distalise the mandible. A smaller horizontal with a large vertical difference is easier to adjust if trying to provide more freedom. Alex Milosevic, Occlusal splints, analysis and adjustment. Dental update 2003: 30: In the intercuspal position The Intercuspal position has few contacting teeth as it has poor posterior support and stability. The upper occlusal plane is distorted by the tilting and overeruption on 17 and rotated and supra-erupted 27.The lower occlusal plane is flattened by tooth surface loss and lacks supporting molar teeth. There is no space between the anterior teeth to rebuild the worn teeth. Fortunately, when the mandible is brought into retruded contact position, there is space now to rebuild the anterior teeth. In excursive movements Anterior guidance comes from canine guidance bilaterally and off the 13, 11 and 21 during protrusive excursion. The 16 produces a working side interference in lateral excursion on the mesiobuccal cusp guide plane. The amalgam restoration on the 16 is shaped and sloped torwards the mesial aspect to allow the slide of the teeth from RCP into ICP. Its interference on working side excursion has likely led to fracture of the mesiobuccal cusp and restoration.

25 Diagnosis and Treatment options Diagnoses Partially Edentulous Heavily restored Dentition High caries risk Chronic mild generalised periodontitis with some localised moderate sites of bone loss. Wakeful and nocturnal bruxism causing attrition with an erosive component detected through diet enquiry Failed 23 root filling with perir-adicular inflammation, uncemented post/core and crown and with a very poor prognosis. Inadequate root obturation of the 16 Caries present in 13, 35 and Fractured cusp and inadequate amalgam restoration Management Patient s expectations: The patient s main reason for attending the dentist over the last few years has been to repair relatively new dental work or recement her crowns. The patient says she is concerned about the short worn looking appearance of her teeth. Her lower incisor teeth appearance particularly bothers her as she feels they look like little tombstones and is embarrassed by them. She is prepared to retreat many teeth again if it means she can rebuild these teeth as many of her previous dentists told her that nothing could be done and any attempt to put fillings on her front teeth has quickly failed. She says she would be happy to wear an occlusal splint, dentures and extract teeth if necessary. The patient is concerned about the financial implications of extensive treatment but would be interested in exploring all options and prepared to invest time & money if the result gives her improved appearance and the longevity of the dental work is better than previous attempted treatments.

26 Aims of treatment The aim of treatment is to correct the traumatic occlusal relationships & restore the severely worn lower incisor teeth and the appearance of the upper anterior teeth. The posterior teeth need to be restored into a stable relationship and I want to improve the amount of support and stability between the posterior dentition. Treatment Options Conformative approach Option 1 Leave everything as it is and provide treatment only to stabilise the gum disease and caries. Extraction of 23. Not really an option as this doesn t address patient s expectations and is likely to lead to a continuation of occlusal and aesthetic problems. Option 2 Maintain the ICP position but after initial stabilisation work, using a conformative approach to restoring the anterior teeth with composite resin but maintaining the occlusal relationships. -This requires some further tooth reduction to the incisors to create space to accommodate the composite filling It won t increase the size of the teeth and protect occlusion but only serve to protect the worn teeth in the short to medium term. Reorganising approach Provisional treatment plan Stabilisation 1. OHI 2. Diet advice: Reducing sugar intake and acidic foods. 3. Advice on stress management and habit control to reduce wakeful grinding. Explanation of occlusal splint after treatment for nocturnal bruxism. 4. Non-surgical periodontal treatment with root surface instrumentation, scaling and correction of any plaque retentive factors where possible.

27 5. Extraction of the 23. Addition of tooth to old denture as short term measure. 6. Caries removal in 13, 35 and Review treatment options and teeth with a guarded prognosis. Pre-restorative phase 8. Articulated study models and wax-ups of the lower anterior teeth in the retruded contact position. Wax-up of the upper anterior teeth to rebuild the worn teeth and diminutive 12 which incorporates smooth anterior guidance. 9. Silicone index to be constructed and composite resin build-ups of the anterior teeth 12, 11, 21, 33, 32,31,41,42 and Full coverage crowns of the 17, 16 and 35 to restore the correct occlusal relationships in RCP, remove interferences and allow for space in the edentulous areas for replacement teeth. Direct onlay made from a lab wax up or an indirect onlay for the rotated and overerupted 27 to improve occlusal relationships with future lower antagonist. Occlusal surfaces to be constructed in metal where over-preparation of the tooth is of concern. 11. Provision of upper and lower cobalt chrome dentures or implant supported prosthesis to increase contacts, support and stability in this new ICP. 12. Stabilisation splint provision

28 Reflection This was an interesting case that presented a number of challenges. The patient was very cooperative and understanding. I was initially very pessimistic about being able to achieve retruded axis position by mandibular manipulation so I was pleasantly surprised when the patient reached the reproducible position of RCP in their hinge axis relatively quickly. I felt that because the patient allowed me to manipulate the mandible so easily, I was able to get a good feel for what I am looking for with patients and it increased my confidence in my ability to perform mandibular manipulation. I spent quite a bit of time watching the jaw move into this hinge axis rotation and verify it s reproducibility. I was worried that my lack of confidence would be a deterrent from recording these positions in my future practice so achieving the correct position gave me that backing I needed that this process actually works and not just something to read about!. I do recognise however that there will be patients that will be more difficult to find RAP in future. The inter-occlusal record with the wax and zinc oxide and eugenol (ZOE) was new and challenging because I have been used to using more convenient and quick materials like polyvinyl siloxane. On my first attempt, it took a lot of time using this method as I was unsure of the preparation, handling and management of the wax. I also found it hard to hold the wax in place while manipulating the jaws back into the correct position. The zinc oxide paste was messy and I used far too much meaning I had to carefully remove the excess detail afterwards. On my second attempt at this interocclusal record, I was quicker and better able to handle the wax from my mistakes first time around and I was much less generous with the ZOE paste, placing very small amounts around the cusp tip indentations only. Over the last few weeks my knowledge of materials used and the principles behind selecting the most appropriate material have changed considerably. I have a better appreciation for the ideas of vertical support and horizontal stability as well as a greater awareness of the flaws that can be introduced into a record by the use of an interocclusal record. My days of squirting PVS bite registration material around the whole arch regardless of the clinical scenario are now at an end!

29 This case was only my second ever attempt at creating records of this type and I carried out all the labwork myself. It was very time consuming and daunting but having completed the process and learning where the challenges lie, I am sure it will get easier and quicker as my handling skills and experience increases. Once the casts were mounted on the articulator, I could see the benefit it gave me in further assessing the patient s occlusion and the extra dimension it gave me for beginning the treatment planning. I was impressed to see the space that suddenly appeared when the patient hit the retruded contact position but equally surprised to see how the jaw position changed as it slid in to ICP. This allowed me appreciate how the occlusion has had such a damaging impact on the patients teeth. The jaw relations then allowed me plan for a wax-up of the anterior teeth and plan for indirect restorations of the remaining posterior teeth and the space restoration. The facebow record was something that I had said goodbye to at the end of my days in dental school and expected never to see it again. I assumed it was irrelevant and unnecessary to general dental practice as I had been told by my fellow colleagues at the time. I have developed an appreciation of the function and importance of the facebow in relating the upper cast to the hinge axis three dimensionally over the past 10 weeks. While I have not managed to begin the restorative phases for this patient yet, I can definitely say that it has allowed me a more in depth understanding of this patients problems and I feel I can approach it in a more organised and confident manner.

Dzakovich Conclusions

Dzakovich Conclusions Definitions Attrition Tooth wear resulting from contact between opposing teeth. Erosion A gradual tooth-surface loss process caused by an electrolytic or chemical mechanism without bacteria being involved.