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Pedodontic Case Study Group Presentations **Case Study Six - Chelsea ** Jessica, Nathan & Vivian

Chelsea is 18 years old and unemployed. She receives a Teen Dental Voucher and comes for a dental check up for the first time in 5 years because ‘it’s free’.

DUE DATE: Tuesday 14/9/2010

Prepare a 10-15 PowerPoint presentation on the case study which covers the following points: **__Description of patient and clinical presentation__** - Light pink attached gingiva with a change to dark-red colour at the muco-gingival junction particularly in the lower arch. - Appears to have loss of stipping, this can be seen around the lower anteriors where the gingival tissues appear 'rolled' at the CEJ. The rolled gingiva appear fluid filled with bulbous interdental papillae. - Attached gingiva has a darker tinge around the tooth, seen on the upper anteriors - possibly due to subgingival calc but will need to be confirmed in examination. - Has been referred as 'Mountain Dew mouth' by many dentists in America
 * Intra-oral**

- 18 year old patient appears to have full permanent dentition from what can be seen from the picture, however the picture does not show teeth beyond the first molars - axial inclination towards the distal of the 22 - upper right molars and upper left molars and 31, 32, 41, 42 appear to have demineralisation around the cervical margins due to plaque retained along the gingival margin and what looks like incipient lesions - 13, 23, 33, 34, 35, 43, 44, 45, 46 has obvious smooth surface cervical caries as the cavity appears to start at the cervical margin and extend down throughout the crown towards the occlusal edge - true labial surfaces of enamel on anterior teeth appear shiney and smooth - plaque retained on tooth surface especially along the gingival margins of the upper posterior teeth (though a better picture is needed) and plaque retention on the gingival margins of upper and lower anteriors. __**Etiology of the clinical problem**__ Brief summary of caries etiology - multifactorial disease: different factors playing a role in caries formation in conjunction with bacteria - Featherstone (2008) describes the caries process as a continuum resulting from many cycles of demineralisation and remineralisation. When demineralisation outweighs remineralisation on a surface of the tooth, it will result in caries occurring (Kidd 2005).
 * Hard Tissues**

- Throughout the day there is a significant exhange of ions which takes place between the tooth surface and the oral enviornment following each episode of eating and drinking (Mount & Hume, 2005). - This cycle of remineralisation & demineralisation is considered normal as demineralisation of apatite is rapidly reversed by a resevoir of calcium and phosphate ions stored in saliva. However, certain circumstances can cause demineralisation of apatite to exceed the bodys capacity to remineralise enamel and this accumulation of mineral loss in enamel and dentine is the first stages of caries (Mount & Hume, 2005). - Mount & Hume (2005) identify Dental Caries as a "continuing chronic loss of mineral ions from enamel crown or root surface stimulated largely by the presence of certain bacterial flora and their by-products" (Mount & Hume, 2005, p 21) - factors contributing to the initiation of caries lesions which found to exert most influence on both caries & erosion include: plaque accumulation & retention, frequency of carboyhydrate intake, frequency of exposure to dietary acids, natural protective factors of pellicl & saliva, and fluoride (Mount & Hume, 2005). - stability of oral environment in relation to tooth tissue is dependant on maintenance of homeostatic balance between the factors listed above.

Smooth Surface caries - we believe that the cause of the severe smooth surface caries in Chelsea's case is caused by dental erosion and severe tooth decay related to soft drinks - soft drinks contain high levels of acid and sugar which have both acidogenic and cariogenic potential resulting in dental caries and enamel erosion

- main cause of dental erosion include gastrointestinal, dietary and environmental acids - in Chelsea's case, the cause of dental erosion is most likely dietary acids this being mainly from soft drinks with high acid and sugar content - many studies have shown a positive relationship between caries and dental erosion and the consumption of soft drinks - the clinical situation presented is most likely the cause of a combination of erosion and dental caries - dental erosion is the chronic loss of dental hard tissues which is chemically etched away from the tooth surface by acid/chelation without the envolvement of bacteria [] - thus, dental erosion is a localised non-carious lesion that develops as a consequence of the chronic loss of dental structure caused by chemical action, with no bacterial involvement []

Gingivitis: Gingivitis is a periodontal condition caused by plaque accumulation and is characterised by changes in the colour, contour and consistency of the gingival tissues. This cause-effect relationship is observed clinically from four to fourteen days after plaque accumulation in the gingival sulcus. The two classifications of gingivitis are acute and chronic. Acute gingivitis is characterised by fluid filled connective tissue that results in swollen gingiva, which lasts for a short time. In contrast, chronic gingivitis is a condition that can last for months or years. When gingivitis is chronic the body may attempt to repair the damage caused by inflammatory mediators and the PMNs by forming new collagen fibres in the connective tissue. Excess collagen fibres leads to gingival tissues that are enlarged and leathery (fibrotic) in consistency. These signs are often accompanied by gingival tissues that are usually red or reddish blue, a gingival margin that is swollen and papillae that are bulbous, BOP and psuedopocketing. (Nield-Gehrig, J and Willmann, D, 2008, 'Foundations of Periodontics for the Dental Hygienist,' Lippincott Williams and Wilkins, Philadelphis, United States of America.)

__**Factors which may have contributed to the situation**__

Combination of many things: -lack of mechanical cleaning - therefore lack of fluoride - TP. - DIET - unemployed - unable to afford proper diet.Water consumption? poor diet Ussume lives alone?? -This then ties to social status and risk factors associated with... - Social stress may lead to salivary problems?? It affects agglutins in saliva preventing aggregation of bacteria, therefore not swallowed. - Education and lack of knowledge on oral health

__**Further information you would/might need to help arrive and a diagnosis and aid in treatment planning**__ - Bitewings, for any interproximal caries and has not been to the clinic in 5 years - Diet diary - Private or public clinical setting - Does Chelsea have a health care card or private health insurance? - Blood test - ascorbic acid levels (any vitamin def?) - Diagnostic tools to perio/gingivitis (detect pockets, sub/supra calc, BOP) decal lesions/caries (good air/light), erosion

__**Treatment plan which reflects a holistic approach to the care of the patient**__ -Diet counceling -Oral hygiene instruction - TBI, fluoride importance, flossing -xrays - bitewings -remineralisation of incipient lesions on anterior teeth and remineralise as other caries as possible -CHX gel or mouth wash? -CR on the smooth surface caries -scale and clean?

Appt 1: - Exam - extra/intraoral - MHU - BWs - LHS and RHS - Diet conseling (Fl water, sugary/acidic foods and drinks), diet diary - OHI (focusing on TBI - spit not rinse - Assess motivation levels? (attended as it was free) - Scale and clean (be careful aroung cavitated carious lesions) - APF treatment paint on with cotton bud REFERENCE or Duraphat application - Advise brushing twice a day with Neutrofluor 5000 (spit not rinse) possible CHX mouthwash (lightens bacterial load and used to treat ginigivitis) eg Curasept - use in conjunction with TBI (if pt is willing and can afford it) - advise pt on interaction on pt with CHX and fluoride - REFERENCE

Appt 2: - Review OHI, review diet diary (suggest changes) - Review ginigival tissue conditions - less inflammation? BOP? any reformed calc? plaque retention? - Assess remineralisation - when lesions have partially arrested place Fuji 2 (more aesthetically pleasing) restorations on cavitated lesions (Upper Quadrant - Tooth Inflitration). - Explain to pt that restorations are not permanent and will break down relatively quickly over time with a bad diet (consumption of acidic/sugary foods/drinks) and bad OH - (express the need to change habits) but will help strengthen tooth stucture when fluoride is applied (continual use with Neutrofluor 5000).

Appt 3: - Review restorations - any breakdown? erosion? - Review diet and OHI - Review ginigival tissue conditions - less inflammation? BOP? - If pt has been compliant - improved oral condition (less gingivitis, no new carious lesions, carious lesions appear to be more remineralised), continue with restoration of lower arch. Ask pt what she would prefer ie: LHS & RHS block together in one appointment or over two appointments restoring LHS & RHS seperately

Appt 4: - Review restroations etc - Review diet & OHI - Paint on duraphat on all tooth surfaces - thorough dental examination on each visit 3monthly recall until no longer able to be treated under SADS - Give pt information on how to apply for a local community dentist (public system) & go on a waiting list for a dental check-up - try to get pts OH patterns and diet in good shape before pt can no longer be seen under SADS - Diet councelling - reduce amount of acidic & sugary drinks; ensure pt fully understands the consequences of OH behaviours and diet on teeth

__**Provides an evidence base for their diagnosis and treatment planning**__

[] [] [] [] [] [] Nield-Gehrig, J and Willmann, D, 2008, 'Foundations of Periodontics for the Dental Hygienist,' Lippincott Williams and Wilkins, Philadelphis, United States of America. Featherstone JDB, 1999. ‘Prevention and reversal of dental caries: role of low level fluoride’, Community Dent Oral Epidemiol, vol.27, pp.31–40. Kidd EAM, 2005. Essentials of Dental Caries, 3rd Ed. Oxford University Press, UK.