Download ODRP 726 – Lab 2 Patient: Ms. Donna S. Students in Group: Age

ODRP 726 – Lab 2
Patient:
Age:
Gender:
Chief Complaint:
Ms. Donna S.
39 years old
Female
Toothache
Students in Group:
Health History: Questions are from this quarter Lecture 3 and 4 Developing the Tx Plan and Acute Phase of Tx
Questions the students should ask
Any recent hospitalizations, surgeries or major medical
problems?
Currently being treated by a physician?
Any heart or breathing problems?
Any allergies to medications, food or other substances?
Any bleeding problems?
Any joint replacements?
What prescribed or OTC medications, or herbs are you
taking?
If female – Are you pregnant or taking birth control pills?
What do you do for exercise?
Do you have any other health problems?
Answers
Yes – right knee replacement four years ago. No history of
previous joint infections. Doctor has not said she needs
antibiotic premed.
Yes for diabetes
No
No
No
Right knee replacement
Glucotrol
No
Walk three times/week
No
Additional Information related to specific medical conditions: Questions from textbook: Pickett
Questions the students should ask
What type of diabetic?
What have your recent blood sugar levels been?
How often do you check your blood glucose levels?
How often does your doctor check your blood glucose
levels?
What was your most current A1c?
Do you heal slowly or have frequent infections?
When was your last meal?
Did you take your medication today?
Have you experienced hypoglycemia recently?
How many episodes of hypoglycemia have you had this
week?
Have you had any problems during dental treatment?
Answers
Type II for 4 years
They have been a little high, between 100-130
Check blood sugars 4 times each day
Every 3 months
It was 6.5% two months ago.
Not that I know of.
This morning before I came to this appointment
Yes
Yes, just yesterday
One
No although I might need to stop and have a snack if the
appointment is long.
History of Chief Complaint: Questions from last quarter handout – Lecture 7 Chief Complaint and Dental History
Questions the students should ask
Tell me about your problem
How long has this been going on?
On a scale of 1-10, how bad is the pain?
Where is the pain?
What does it feel like?
Answers
I have a toothache
On and off for several months
Today it’s about a 3. It can be a 10 sometimes
On the lower left (points to tooth # 20)
Throbbing pain, it gets worse when I lie down. Cold really
Has this happened before, if so how did you make it go
away?
Have you had fever or swelling?
hurts it, but not biting.
When it hurts, I just take ibuprofen. That usually helps.
Not recently. I did before I had the root canal on the molar
on the lower left.
Clinical Findings: Questions from this quarter handout – Lecture 3 and 4 Developing the Tx Plan and Acute Phase of Tx
Information the students should request
General evaluation – overall health status
Vital signs
Oral cancer screening (extraoral/intraoral exam)
Exam of area of concern
Contiguous soft tissue and teeth
TMD examination
Which radiographs are required
Radiographic findings
Endodontic testing
Periodontal probing
Examination information
Patient appears healthy
BP 118/72 Pulse 72 Resp 18/min Temp 99.3
No abnormal findings
#18, 19 and 20 have large amalgam restorations. #19 is grayish
in appearance. The DL cusp has been replaced by amalgam. #20
has a large mesial carious lesion with subgingival decay. Open
margin present on the distal of #19, with recurrent decay. Open
margins on all three teeth.
Salivary flow appears normal.
Within normal limits
PAX and bitewings
#20 M D3 recurrent with existing MOD amalgam. Decay appears
at or below alveolar bone height.
#21 D recurrent and M D2-D3 recurrent with existing MOD
amalgam
#19 existing root canal filling, D open margin or decay, periapical
radiolucency on mesial root,
#18 Existing # MO amalgam with D2 recurrent decay
Tested all 4 posterior teeth
Cold: #20 +++, #18 ++
Heat: #20 ++
EPT: #18 56, #20 23, #21 44
Percussion: None
Palpation: None
Biting: None
Generalized 3-4 mm ppd
Additional Questions
When was the root canal done on #19?
How do you feel about this tooth?
About a year and a half ago.
I would like to keep my teeth if possible.
Case Presentation to Instructor:
Medical conditions of concern:
Knee replacement 4 years ago, no history of previous joint infections. Patient is not at risk for joint infection. No
antibiotic premedication recommended.
Type II Diabetic. Fair to Good control. Patient is at slightly increased risk for infection and slow healing.
Medication: Glucotrol – only adverse effect is chance of stress-induced hypoglycemia. Patient is at high risk for
hypoglycemia during dental treatment. Plan is to have patient eat just before coming to her appointments and bring a
snack with her.
Dental Conditions of Concern:
#20 is tooth of concern. Pt reports level 3 pain at this time, goes to 10. Ibuprofen helps. Endo testing confirms patient
history: Increased sensitivity to cold with lingering. Increased sensitivity to heat with no lingering. No tenderness to
percussion, palpation, biting. Caries appears to be at or below bone level on the mesial. Diagnosis: Irreversible pulpitis
secondary to gross caries. Tooth does not appear to be restorable based on inadequate biologic width. Treatment
options: extraction or root canal treatment, core build-up and PFM if crown lengthening is possible. If tooth is extracted
it should be replaced with FPD or implant.
Patient would like to save tooth if possible, which depends on crown lengthening.
Recommended treatment for today: 1) Pulpectomy and caries removal to determine extent of decay 2) refer to
periodontist for evaluation for crown lengthening. 3) Recommend comp oral eval prior to definitive treatment of # 20
since it appears that the patient has many deep caries lesions, and treatment may need to be prioritized.
Treatment Plan Presentation to Patient
You came in today because of a toothache on the lower left. You said that it is painful all the time, but especially to cold,
which causes increased pain that lingers.
What I found was a very deep cavity on the second premolar, tooth #20. Additional tests reveal that this tooth has
irreversible pulpitis, which means that the pulp is inflamed, and that it can’t heal from this situation, which is due to the
deep decay. The x-rays show that the decay is at or below the bone surrounding the tooth.
The tooth cannot be restored when decay is this deep. There is a possibility that this tooth can have “crown
lengthening” or “root extrusion” which would allow restoration of the tooth. A periodontist would need to evaluate the
tooth and determine if this tooth is a candidate for crown lengthening. Root extrusion involves rapid movement of the
tooth to move it out to a better position, using a wire appliance.
If neither of these procedures can be done, the tooth will need to be extracted and replaced by an implant or a fixed
partial denture.
If crown lengthening or root extrusion can be done, the tooth will need to have root canal treatment to remove the
inflamed pulp tissue which will be replaced by a filling material. The tooth will be weaker now due to the loss of tooth
structure, so after the root canal, the tooth will need to be built up so that it will have a good foundation for the final
restoration, a crown. The only alternative to a root canal is extraction.
Common risks of root canal treatment are pain, swelling and infection after treatment. You may also have muscle
soreness. There may be undesirable complications which might result in the tooth requiring additional treatment,
including re-doing the root canal filling or extraction.
If the tooth does not have root canal treatment or extraction, the infected pulp could result in a serious systemic
infection. The tooth will continue to break down until there is nothing left but the root in the gums.
I recommend that we remove the pulp today and place a temporary filling. This will greatly reduce or eliminate the
toothache pain. I will also reduce the height of the tooth to insure that it is not traumatized by the opposing teeth.
Please remember that this treatment is only a temporary situation. If you do not return for the final restoration, the
tooth will become infected again will lead to pain and infection.
We will set up an appointment for you to see the periodontist about the crown lengthening. Before making a final
decision on the treatment for this tooth, I recommend that we do a thorough examination of your oral condition. I
noticed during my brief examination that you have several other teeth that have missing restorations and/or deep
decay. I’d like to determine what all your dental needs are now, so that we can better determine whether it makes
sense to spend the time and money to restore this one tooth.