Team-Based Learning 4 Teams’ Responses,2023-2024

Team-Based Learning 4
2023-2024

Team Number: 5
Representative Name: Sarah Bkairat
University I.D.: U18101101

Facilitator Mark/
10
Professor
Ensanya
Dr.Mohannad
Dr.Zeina
Dr.Sunaina
Total
/40

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Team-Based Learning 4 Teams’ Responses,2023-2024

1. Analyze and interpret the information provided and identify the main features or
critical information presented in this scenario

Patient Background:
 Patient is a 51-year-old male.
 Chief complaint: sharp pain from his lower left quadrant.
 Aesthetics oriented: also wants to fix his teeth and improve his smile.

Periodontic:
 Patient is a heavy smoker (more than 10 cigarettes a day) for the past 15 years.
 Poor oral hygiene: Brushes once daily, doesn’t floss.
 Generalized supragingival and subgingival deposits seen on teeth #18 mesially, #44 and
#25 distally.
 Generalized recession, especially on teeth #15 and #18.
 3-4mm attachment loss except in the maxillary and mandibular posterior teeth.
 5-6mm attachment loss in teeth 37,38,47,48
 Heavy staining and calculus on his lower anterior teeth.
 Mobility of lower back teeth on both sides
 Grade 2 mobility of teeth #47, #48, #37 and #38.

Operative:
 Tooth #35: Deep Mesio-buccal caries as seen in the periapical radiograph. Caries which
appears to be on the mesial side of the tooth are possibly on the buccal surface since the
tooth is rotated. The caries concerning this tooth spears to be deep and close to the pulp.
 Tooth #34: Distal caries as shown in the periapical radiograph.
 Teeth #17, #24 and # 37: Occlusal caries as seen clinically.
 Tooth #25: Distal caries as seen on the bitewings.
 Tooth #11: Cervical caries as seen clinically.
 Tooth #37: Distal root caries as seen on bitewings.
 Teeth #31 and #41: Attrition as seen in clinical pictures.
 Teeth #47 and #48: Grossly carious teeth as seen clinically and in radiographs.
 Root remnants of teeth #16, #14, #22, #26 and #27.
 Crowding of lower anterior teeth and premolars which might affect the ease of oral
hygiene and create food stagnation areas. Moreover, crowding would complicate the
restorative treatment.

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Endodontic:
 The patient presented with a chief complaint of sharp pain in the lower left quadrant
(most probably #35)
 Tooth #35: Deep Mesio-buccal caries as seen in the periapical radiograph. Caries which
appears to be on the mesial side of the tooth are possibly on the buccal surface since the
tooth is rotated. The caries concerning this tooth spears to be deep and close to the pulp.
 Deep distal caries on #34 in close proximity to the pulp.
 The patient travels frequently, and this factor should be taken into account when
temporizing if endodontic treatment is pursued.

Prosthodontic:
 Missing teeth #12, #36 and #46.
 Root remnants of teeth #16, #14, #22, #26.
 The patient has PFM bridge that is supported with a crown on teeth #13 and #11 with
tooth #12 being the pontic, and #11 having a cingulum rest.
 Aesthetics oriented: also wants to fix his teeth and improve his smile.
 The lower anterior teeth and premolars display crowding, potentially impacting oral
hygiene and creating areas prone to food accumulation. This crowding poses challenges
for restorative procedures.
 The patient presents with a deep overbite, leading to reduced interocclusal space.
 Lower posterior teeth (#48, #47, #37, #38) exhibit grade 2 mobility, influencing decisions
regarding prosthodontic treatment and the selection of abutment teeth.
 #15 is distally tilted and supraerupted due to the absence of opposing teeth.
 Teeth #41 and #31: Slight attrition observed in clinical pictures.
 Teeth #47 and #48: Deep extensive caries rendering them non-restorable, as the caries
have extensively damaged the coronal part, extending beyond the bifurcation.

2. List any further suggested investigation(s) required

Periodontics:
 Thorough medical history should be taken and examination should be done to assess the
presence of modifying risk factors that implicate the periodontal and gingival status.
 Thorough periodontal history- oral hygiene habits (tooth brushing technique, type of
toothbrush and toothpaste utilized, sensitivity and halitosis) should be documented.
 Periodontal charting must be done to assess the periodontal grading and staging through
evaluation of the following factors:
 Gingival form, bleeding index, and plaque index to assess the gingival condition
 Periodontal charting:
o Asses pocket depth
o Clinical attachment loss
o Mobility grading
o Degree of furcation involvement

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 Assess the patient’s parafunctional habits

 Assess patient’s smoking history and patient’s motivation status to quit smoking.
 Assess the patient’s salivary flow rate.
 5A’s protocol includes (Ask Assess, Advise, Agree, Assist) to assess the patient’s
motivation to quit smoking.
 Assess prognosis of tooth #38 and 37 due to recession and mobility.
 Assess need of periodontal pre-prosthetic surgery/ treatment prior to any definitive
prosthodontic treatment.

Operative:
 History Taking
o General history of health conditions.
o Dental history.
o History of chief complaint, pain, trauma, parafunctional habits, dietary habits,
previous restorations, brushing & flossing habits.
o Smoking history.
o Assess patient compliance in regards to continuing treatment.
o Evaluate patient’s motivation in regards to smoking cessation.
 Comprehensive dental charting
o Extra-oral examination (symmetry, facial appearance & harmony, smile line)
o Intra-oral examination (presence of caries, occlusal wear and tooth structure
loss, quality of existing restorations, soft tissue examination). Proper Clinical
examination using a blunt explorer and adequate lighting to differentiate
cavitated active lesions from staining or arrested lesions. Scaling must be done
for some of teeth in question to determine the presence of carious lesions.
o Caries risk assessment
o Occlusal analysis
 Radiographs
o Bitewings and periapical imaging to assess presence of caries and quality of
existing restorations.
o Periapicals for lower anteriors.
o Periapical for teeth #11, #24, and #25
 Tailored investigations
o Assess the quality and success of the bridge (#13-11)
o Assess the restorability of #14, 13, 11, 22, 34, 35, 37.
o Assess the pulpal condition for teeth using cold test, palpation and percussion
on teeth #14, 13, 11, 22, 34, 35.
o Assess the prognosis of questionable teeth/root remnants #47, 48, 37, 38, 22,
16, 14, 26.
o Checking attrition sites for any exposed dentin or sensitivity (#31 and #41).

Endodontics:
o Gather adequate details regarding the patient's medical and dental history and history
of chief complaint.

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o Perform Extra-oral and intraoral examination to look for any intraoral swelling or
sinus tracts, assess for the presence of caries, fractures, and faulty restorations.
o Tooth #35 requires evaluation for the potential presence of an endo-perio lesion.
o Proper periapical x-rays should be taken for grossly carious teeth (#35, #34 and #43).
o Perform pulp vitality testing on teeth #34 and #35. Additionally, pulp testing on #13
and #11 if the PFM bridge is faulty and requires removal. If not, assess the tooth from
the lingual metal collar using EPT.
o Perform percussion and palpation tests on teeth #35, #34, #11, and #13 to assess the
periapical status.
o Establish the pulpal and periapical diagnosis for teeth #34, #35, #13, and #11 to
formulate a treatment plan.
o Assess restorability of teeth #34, #35, #13, and #11.
o Teeth #14, #22, #47 and #48 are evidently non-restorable.
o After determining the restorability of the teeth, use the AAE Endodontic Case
Difficulty Assessment form to determine the complexity of the case in case an RCT is
required and whether it requires a referral.

Prosthodontics:
o Ask about any medications that the patient is taking.
o Gather information on the patient's medical and dental history, family history, and
inquire about any parafunctional habits.
o Conduct an extraoral examination, including TMJ palpation, assessment of muscles
of mastication, jaw movement deviations, and evaluation for TMJ-related disorders.
o Perform a clinical examination of the teeth with appropriate lighting, utilizing a blunt
explorer for dental charting.
o Analyze occlusion due to the presence of an unstable occlusion from decreased
posterior support. Check for occlusal interferences, assess occlusal vertical
dimension, and look for signs of attrition, particularly on the lower central incisors.
o Inquire about any parafunctional habits and, if present, consider the patient's
psychological assessment.
o Evaluate interocclusal clearance and overbite, as these factors impact restorative and
prosthodontic work.
o Obtain periapical radiographs for abutment teeth (#13 and #11), checking the PFM
bridge for defects or secondary caries. Assess the restorability of teeth #13 and #11
after bridge removal.
o Record centric occlusion and maximal intercuspation due to multiple missing or
carious posterior teeth with decreased occlusal units. Consider using a Lucia jig as a
muscle deprogrammer.
o Take upper and lower impressions for diagnostic casts, positioning the upper cast
based on facebow registration on the articulator.

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o Capture bite registration for centric relation using dental wax or low-viscosity
material. Multiple CR records should be taken for verification, and the mounted cast
should be compared with clinical findings.
o Identify prognosis of following teeth: #14, #22, #37, #35, #34 and #47.
o Identify prognosis of questionable teeth: #16, #14, #22, #26, #48, and #47.
o Check the dimensions of missing spaces, considering their impact on the final
restoration size and type.
o Assess supracrestal connective tissue attachment in teeth requiring prostheses and
evaluate the need for crown lengthening.
o Assess remaining bone for implant feasibility, considering the need for bone
augmentation. Verify the maxillary sinus floor level in relation to the roots of current
posterior teeth or predicted apical area of the implant, with smoking cessation being a
relative contraindication for implant placement.

3. What are your dental diagnoses per discipline?

Periodontics:
 Generalized periodontitis staging and grading will be determined based on the periodontal
charting findings and proper bitewing x-rays to assess degree of bone involvement.
 Grade C has been selected due to the patient being an active smoker for the past 15 years and
smoking more than 10 cigarettes per day which acts as a periodontal risk modifier.
 Generalized periodontitis stage 4, grade C. Stage 4 has been selected due to the presence of
the following factors:
 Highest clinical attachment loss recorded is 5-6mm
 Involvement of complexity factors such as masticatory dysfunction, bite collapse, grade 2
mobility.
Operative:
 Teeth #16 #14 #22 and #26: Root remnants.
 Defective PFM bridge spanning from 13-11
o Open margins on the crown of #13.
o Cervical caries on the abutment #11
 Carious lesions on multiple teeth: 37 distally root caries and occlusal, 35 mesially, 25, 34
and 44 distally, 11 facially.
 Attrition involving the lower anterior teeth: 41 and 31
 High caries risk
 Teeth #48 and #47: Non-restorable carious teeth.

Endodontics:
The diagnosis of Teeth #34, and 35 depends on the results of periapical and pulp testing,
which may be symptomatic reversible or irreversible pulpitis, with or without symptomatic

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apical periodontitis. Additionally, the periapical diagnosis is influenced by the outcomes of

percussion and palpation tests conducted on all teeth.
 The likely offending tooth is #35, considering the patient's symptoms and the extent of
caries, the provisional diagnosis would be symptomatic irreversible pulpitis.
 Pulpal necrosis of #14 and #22 with asymptomatic apical periodontitis (asymptomatic as
the patient did not report any associated symptoms).
Prosthodontics:
 Teeth #46, #36, #12, #17, and #27: Missing teeth.
 PFM bridge #13 to #11: Defective bridge.
 The Kennedy classification for the upper arch is Class II Mod 2 prior to extractions. The
classification after extractions is Class II Mod 3.
 Teeth #14, #16, #22, #26, #47, #48: Non-restorable (root remnants, severe caries, and
broken crowns).
 The Kennedy classification for the lower arch is Class II mod I if #48 and #47 are
extracted. If teeth #37 and #38 are deemed hopeless, it would shift to Class I.
 Teeth #37, #38, #47, and #48: Grade 2 mobility.
 Crowding of lower teeth.
 Tooth #43: Labial proclination.
4. What is your dental treatment plan per phase?
Phase 1 (Urgent-Phase):
Endodontics:
 After proper investigation and diagnosing is carried-out, the treatment will depend upon
the diagnosis. If either tooth 34 or 35 (35 is most likely) was identified as the offending
tooth and diagnosed with irreversible pulpitis, the tooth will be accessed followed by pulp
extirpation and intracanal medicament placement, opting for ledermix. As for the
restoration placed during this appointment, we need to take into consideration the fact
that the patient is a frequent traveler, therefore we need to utilize the double-seal
technique; GIC will be used to restore tooth walls, followed by placement of Teflon in
the canal’s orifice, then cavit on top and finally GIC above.
 As for pain management, we should prescribe painkillers such as ibuprofen 400 mg to
600 mg 3 times a day for 2-3 days with paracetamol 325 to 500 mg 4 times a day for 2-3
days.

Phase 2 (Control Phase or nonsurgical phase)

Periodontics:
 Supragingival and subgingival scaling followed by root planning if needed (according to
periodontal chart).
 Prescribe desensitizing toothpaste

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 Proper oral hygiene instructions

 Patient education must be implemented regarding toothbrushing technique (advise and
demonstrate modified bass brushing technique by using an ultrasoft toothbrush and
desensitizing toothpaste.
 5A’s protocol includes (Ask Assess, Advise, Agree, Assist) to assess the patient’s motivation
to quit smoking. This should be followed by the 5R protocol which includes Relevance Risk
Reward Roadblocks and repetition if the patient isn’t motivated to quit smoking.

Operative:
 Teeth #13 and #11:
 Remove the PFM bridge of teeth #13 and #11 and check the restorability for both
teeth; check if there is endodontic involvement, the ferrule effect and if a crown
lengthening is needed along with post and core.
 If it is indicated for endodontic treatment, it should be done then temporized with
a provisional crown.
 If it is non restorable extraction should be done (extractions in phase 3).

 Cervical caries of teeth #11 and #33 should be removed and restore with GIC to control
the caries.
 teeth #25 distally, #23 mesial, #24 oclussaly, #17 occlusal, #25 distally, and #37
occlusally and distally, caries should be removed and restore with GIC to control the
caries.
 PRR for teeth that have deep grooves or superficial caries.
 Extensive caries on mesial of distal of #34, therefore:
o Selective removal of caries should be done (then place GIC to control to
insure the tertiary dentin formation)
o If endo treatment is indicated, then we should treat the tooth:
 temporize it with GIC (if the final restoration is direct restoration)
 temporize it with provisional crown if the final restoration is indirect
restoration.

 application of fluoride for sensitivity and reduce the caries risk

 Provide oral hygiene and nutritional instructions and consultations.
 Fabricate a night guard or hard occlusal splint to manage occlusal trauma, if present, and
prevent further damage in case of parafunctional habits.

Endodontics:
 Continuation of the initiated endodontic treatment on either tooth #34, #35 or both.
Biomechanicl preparation of the canals will be done with intermittent use of 5% NaOH

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and saline irrigation followed by placement of intracanal medicament. The temporization

will also be done according to the double-seal technique.
 If symptomless, obturation of either tooth 34, 35, or both.

Prosthodontics:
1. Identify and address risk factors.
2. Patient education is crucial, especially if mechanical wear is
present, with or without erosive factors.
2. Provide oral hygiene instructions, advising the patient to brush gently with a soft brush.
Capture bite registration for centric relation to facilitate wax-ups for teeth and the creation of
temporary crowns.
Remove the defective bridge on #11 and #13, if applicable. Assess and address defects in PFM
restorations, considering restorability, ferrule effect, crown lengthening, endodontic treatment,
and post and core requirements. Place a temporary crown if endodontic treatment has
commenced.
5. Evaluate the restorability of teeth #11 and #13, considering proper periapical, vitality,
abutment restorability, and the type of indirect restoration.
7. Explore the potential for a shortened dental arch, although unlikely given the patient's limited
occluding units (2 or 3).
8. Apply fluoride to address sensitivity and reduce the risk of caries.
9. Reassess the possibility of achieving a shortened dental arch, considering the patient's limited
occluding units.
10. Fabricate a night guard or hard occlusal splint to manage occlusal trauma, if present, and
prevent further damage in case of parafunctional habits.
11. Non-restorable teeth will be extracted in phase 3 of the treatment, following scaling and oral
hygiene control to minimize complications such as dry socket.

Phase 3 (Pre-prosthetic Phase):

Periodontics:
- Strategic extractions for teeth 37, 38, 47, and 48 may be implemented if it favors the
prosthodontic treatment and the concept of a short dental arch is considered or GTR
surgery can be considered to improve the patient’s periodontal condition. However, the
smoking status of the patient should be appropriately evaluated and the patient must quit
to prevent poor surgical outcomes

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- The restorability of tooth 14 should be assessed. If restorable then crown lengthening or

gingivectomy (will be determined according to the periodontal status of the tooth (degree
of pocket depth& and bone involvement) to increase the height of the clinical crown and
improve the crown-to-root ratio.
- Conduct procedures like pocket reduction surgery to help patient properly maintain his
oral hygiene.
- Regenerative techniques to promote tissue regeneration.
- Consider soft tissue grafting or osseous surgery for gingival recession or bone reshaping.
Operative:

 Re-evaluation of the control phase.

 If teeth (#16, #14, #22, #26, #47 and #48) were unrestorable then extraction should be
done.
 Post and core for #13 #34 and #35 (if needed)

Endodontics:
 Evaluation of control phase.

 Prosthodontics:
 1. Reassess the control phase.
 2. During this stage, implant placement, specifically the insertion of the fixture without
the abutment, may proceed if it aligns with the treatment plan and the patient refrains
from smoking.
 3. Consider crown lengthening as a pre-prosthetic procedure for necessary abutment
teeth, such as tooth #13 and #11.
 4. If teeth (#16, #14, #22, #26, #47 and #48) were unrestorable then extraction should be
done. phase three of the treatment, following scaling and meticulous oral hygiene control
to prevent complications like dry socket.

Phase 4 (Definitive-Phase):
Operative:
 Remove the GIC and restore it with composite for each of the following teeth:
 Tooth #11: Remove the GIC in the cervical area and replace it with composite,
where for the lingual, PFM cingulum rest can be removed followed by caries
excavation (if present). Restore the lingual with composite or we can make a rest
for the PFM or prepare it as an abutment.
 Mesial of #23
 Occlusal of #24

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 Distal of #25
 Occlusal of #17
 Distal of #37

 #35 and #34:

If teeth #35 and #34 are indicated for direct restorations, then composite will be placed in
the mesial of #35 and distal of #34.
If teeth are indicated for indirect restoration then it can go for ceramic onlay, indirect
composite only, or a crown depending on the extent of caries damage.
 Fabricate another night guard or occlusal splint that accommodates the newly fabricated
restorations.

Prosthodontics:
 Install new Metal Ceramic bridges or an all-ceramic bridge as a 3-unit bridge between
teeth #13 to #11, contingent on the bridge's condition.
 Consider placing a fixed FPD in the upper arch to replace missing teeth, with a
removable partial denture in the lower arch. This option may involve extensive
preparation on healthy upper arch teeth.
 Explore implants, particularly if the patient is willing to quit smoking and has sufficient
bone, for optimal aesthetic results. Implants can replace missing teeth up to the second
premolar region in both arches, with endodontically treated teeth restored using indirect
restorations or full crowns.
 Contemplate removable partial dentures as a treatment option if the patient is unwilling to
quit smoking or undergo surgical procedures. Teeth requiring crowns and acting as
abutments should have surveyed crowns.
 Discuss the possibility of a Shortened Dental Arch (SDA) after extracting all non-
restorable mandibular and maxillary posterior teeth. This option reduces the burden of
operative and prosthodontic work. If opting for SDA, consider replacing teeth #14 and
#22 with implants and restoring tooth #13 with a crown or FPDs after extracting the
remaining posterior teeth.

Phase 5 (Maintenance-Phase):
Periodontics:
 Revaluate periodontal and gingival status by redoing the periodontal charting,
gingival forms plaque, and bleeding indices.
 Periodontal maintenance: scaling and root planning
 Revaluate and reinforce oral hygiene instructions
 Assess patient’s motivation status in regards to quitting smoking
Operative:

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 Oral hygiene re-evaluation, and motivation of the patient.

 Dental charting and bitewings.
 Re-evaluation of restorations.
 Reassess caries risk.
 Reinforcement of oral hygiene instructions.

Prosthodontics:
 Reassess and motivate oral health.
 Review prosthetic treatment effectiveness through clinical and radiographic evaluations.
 Strengthen patient education on avoiding parafunctional habits.
 For those opting for Shortened Dental Arch (SDA), evaluate patient function and occlusal
stability.
 If implants were inserted, evaluate the secondary stability.

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