ICS Case

Presentation
Pauline Tran
DDS 2020
 Meet my patient
• Female, 56 years old
• CC: ”I need a check up. I haven’t been to the dentist in a
while.”
• HH: Hypertension
• DH: Pt has not been to the dentist in 2 years
Intraoral Photos
FMX
 Radiographic Findings
• Missing teeth: #1, 5, 14, 16, 17, 18, 30, 31, 32
• Bone levels: generalized moderate horizontal bone loss
• Pathology: none noted
• Status of existing restorations: #7 D recurrent caries, #9
M & D recurrent caries
• Endo treated teeth: #20, 29
• Calculus noted
Perio Chart (Maxillary)
Perio Chart (Mandibular)
 Periodontal Findings
• Pocket depths: 3-4 mm, attachment loss up to 5 mm in
some areas
• Class I mobility: #22, 25
• Plaque Index: 1.2
• Etiology: bacterial plaque, calculus, crowding
• Diagnosis: generalized moderate chronic periodontitis
• Prognosis: Fair
Hard Tissue Chart
 Caries Risk Assessment
• pH: 7
• ATP meter reading: 8463
• Overall caries risk: High
• Etiology: High bacterial count, poor OH
• Disease indicators: new/progressing visible cavitations or radiolucencies
into dentin, restorations for caries in the last 3 years
• Diagnosis: ongoing caries disease
• Treatment recommendations: High fluoride toothpaste (5000 ppm)
 Medical Risk Assessment
Hypertension
• Controlled or uncontrolled?
• Medications? None in this case
• Refer patient to her physician for evaluation and anti-
hypertensive medications to prevent potential
hypertensive crisis
 Treatment Plan
Urgent Care:
• #13 – severely fractured, large area of exposed dentin
• Vitality testing
• Determine if restorable or not
• If not, extract tooth
 Treatment Plan
Disease Control:
• Extract #13 if deemed unrestorable
• 4 quadrants of SRP w/ re-evaluation in 4-8 weeks
• Remove & treat all recurrent decay and new carious
lesions (#4, 7, 9, 11, 12), buildup for #4
• Meanwhile, pt is using high fluoride toothpaste twice daily
 Treatment Plan
Reconstructive:
• Orthodontic intrusion of molars to open up VDO
• Crown #4 LD
• Place implants for #5, 13, 14, 30 (first molar occlusion)
 Treatment Plan
Maintenance:
• Place pt on 4 month recall
• Continue use of high fluoride toothpaste for high caries
risk

Treatment time: +3 years

Cost: +$10,000
 Alternative Treatment Plans
Alternative 1 Alternative 2
• RPD instead of implants • After disease control
after ortho intrusion phase, leave missing gaps
• Treatment time: ~2 years as is

• Cost: $6,000 • Treatment time: 2 months

• Cost: $1,000
 RBA & Informed Consent
Discussion
• Orthodontic intrusion can be a slow and long process, relapse can occur
• Benefit: Ortho will help correct plane of occlusion and make room for fixed &
removable prostheses
• Pt may need a sinus lift and/or bone grafts to place implants
• With implants, there is always a risk of failure and retreatment may be
needed
• Benefit: Implants avoid the hassle of wearing a removable appliance that needs to
be cleaned nightly
• Leaving missing gaps as is = least costly option, but less stable occlusion
 Evidence Based Dentistry
Management of Hypertensive Patients
• Collect detailed medical history including: family history of cardiovascular
disease & HTN, antihypertensive tx history, severity of condition, complications
• Pts w/ HTN have a higher risk of experiencing adverse effects in the dental
chair
• Measure BP at the beginning of each appt
• For hypertensive crisis (>180/110), postpone tx, refer pt to physician
immediately
Chaudry, Swantika, Ritika Jaiswal, and Surender Sachdeva. “Dental considerations in cardiovascular patients: A practical perspective.”
Indian Heart Journal. Volume 68. Issue 4 (July-August 2016): Pages 572-575).
 Evidence Based Dentistry
Dental implants for the periodontally compromised partially
edentulous patient…
• No significant differences in short-term & long-term implant survival
for pts with a hx of chronic perio vs periodontally healthy pts
• Pts with chronic perio may have greater long-term probing depths,
peri-implant marginal bone loss, and incidence of peri-implantitis
Karoussis, Ioannis K., Sotirios Kotsovilis, Ioannis Fourmousis. “A comprehensive and critical review of dental implant prognosis in
periodontally compromised partially edentulous patients.” Clinical Oral Implants Research. Volume 18. Issue 6 (December 2007):
Pages 669-679.
Thank you!