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Your patient is Lesley Andrews who is a teacher. They are midway through root treatment with
another dentist in the practice who is on holiday today. The other dentist in the practice accessed
and dressed their upper left first molar tooth with calcium hydroxide and GIC last week.
Lesley has returned today for a 20 minute emergency appointment with you complaining that the
tooth is ‘broken in half’ and uncomfortable when chewing.
A colleague has just examined the patient now and found that the buccal wall of the upper left first
permanent molar has fractured just below the crestal bone level and feels the tooth is unrestorable
and has asked you to explain the situation to the patient. The buccal section is mobile but still
attached to the gingivae. There is no sign of infection and the GIC appears to be intact and sealing
the pulp chamber.
The patient is fit and well, has an otherwise complete and intact permanent dentition with no
recurrent or untreated caries. Oral hygiene is excellent. The patient has never smoked and drinks on
average 10 units of alcohol in a week.
Please discuss your findings and proposals for treatment with Lesley Andrews and answer any
questions or concerns they may have
Diagnosis: buccal wall of the upper 1st permanent molar has fractured just below the crystal bone
level
1. Leave and monitor (risk of inhalation of buccal wall/ fracture further/ pain/infection)
2. Remove buccal section and temporise tooth – review appointment with colleague to
xla/discuss treatment options
Not in pain from rct in pain as of the fractured cusp- tooth is fine but will need further treatment. Do
not want to rush the xla todayso can only remove the fracture
Why has it happened – big ccity- need to make big cavity to do endo. Strong forces on back teeth.
Tooth is weaker and lost proprioception so more likely to break
Xla is complicated- below the bone- cut in the gym. Simple surgical procedure. Can do xla with
experienced colleague
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Options to space fill. Leave. Denture. Bridge. Implant
Communication Scenario B
Jo Brown, a regular patient at the practice, has attended the surgery today with their 4 year old
daughter Sara. Sara is not present in the room, only the parent.
Your colleague has just carried out a full examination and history for Sara and taken bitewing
radiographs which show caries into dentine mesially on both lower first deciduous molars. The
marginal ridge is intact on both these teeth and the child is not having any pain. The other teeth are
all caries free and in class 1 occlusion with no crowding.
Your colleague has asked you to see this patient as they have another emergency patient waiting.
You have been asked to discuss the proposed treatment and most appropriate option to restore
Sara’s teeth with her parent and book them in for a further appointment.
Please discuss the diagnosis and proposed treatment with the parent and answer any questions or
concerns they may have.
Diagnosis: dental decay/caries into dentine mesially on both lower 1st deciduous molars
Short term:
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3. SSC
Long term:
Communication Scenario C
You are a Foundation Dentist working in a busy multi-surgery dental practice.
You have been asked to see Ali Cooper, a regular patient at the practice, who is booked in
with you as they have just fractured their denture.
The patient is complaining of a fractured upper full denture again; this is now the third time
in 6 months (been repaired twice already) that it has broken down the middle and it has
been feeling loose when chewing.
Reviewing the patient’s records shows that the denture was made 6 years ago and has only
been a problem recently. The two pieces of denture can be approximated accurately and
there are no missing pieces.
A full history and examination by your colleague has been carried out recently and found a
healthy mouth, the lower teeth are all present and caries free with sound restorations. They
noted there is a pronounced bony ridge (palatine raphe) in the midline of the palate with
some slight resorption of the alveolar ridges.
The patient is fit and healthy, smokes 10 cigarettes a day and drinks about 10 units of
alcohol in a week but has good oral hygiene.
Please discuss with the patient your findings, the short and long term management and
answer any questions or concerns he/she may have.
1. Repair with lab cold cure acrylic denture not strong enough – rebase
Long tern
- Get rid of torus prio to new denture -pre-prothestic surgery (refer into hospital)
- New denture (co f9r or avylocrv/ high impact acrylic
- Referal for implant
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Complaining -
Why giving me problems now – no teeth so bone resorbs, is this your first denture? Lower teeth
hitting and flexing the denture.
Why are the repairs failing- not dealing with the fit / weak spot on a repair/
Emergency : Repair – send to the lab as can repair it as they go together. Back iin 24 hours or call lab
to see if can get it sooner – might need to go without any teeth
Cocr frame – not cover the palate- lower teeth so can cope with flexing – thin metal – bit heavier
Monitor
Problems – lower natural teeth, causes upper denture to work harder – combination syndrome
Communication Scenario D
You are a Foundation Dentist working in a busy multi-surgery dental practice.
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Jamie Darwin, a regular patient at the practice, has attended the surgery today complaining
of a fractured upper left central incisor which is painful. The patient incurred this injury
accidentally at work yesterday evening.
Your colleague has asked you to see this patient as they have another emergency patient
waiting. Your colleague has taken a full examination and history including radiographs and
correctly diagnosed that the patient has a mesial incisal fracture of their upper left central
incisor which involves the pulp. The root appears intact and the tooth is hypersensitive to
temperature and is starting to ache.
The patient is fit and well, does not smoke and drinks a couple of alcoholic drinks at
weekends. Oral hygiene is good, and all the dentition is satisfactorily restored and healthy.
Please discuss the diagnosis and proposed treatment with Jamie and answer any questions
or concerns they may have.
Reversible pulpipotes- temperature
More conservative rebuild tooth
Irreversible- up all night
Diagnosis:
Mesial Incisal Fracture of the upper left central tooth which involves the pulp
Exposed pulp
Intact root- success rate good chev 95%
What if it doesn’t resolve – full root treatment
Short Term Treatment Options:
1. Do nothing
2. Initial extirpate for RCT (mature apical development)
3. Pulp capping – small pulp exposure – direct pulp cap with calcium hydroxide but
consideration should be given to partial pulpotomy especially if the exposure has
been present for many days.
4. Partial pulpotomy – preserve vitality of the tooth if the history does not suggest
irreversible pulpal disease. This can be performed up to 3 weeks after the injury
without significant problems. Need to remove pulp tissue until there is a fresh
wound and bleeding can be controlled. If pulpotomy approaches the CEJ consider
full extirpation.
5. Extract
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Mention guideline
Step ladder sending in how bad the nerve is and from what you told me the nerve is still
alive and we want to try and keep it alive. You are at this stage
We will know in a couple of days if it works and we can review you and consider other
options
Why is it painful? – exposed pulp sensitive to stimuli
Why is it hypersensitive to temperature?
If composite breaks – re do it or vener
If discoloured – bleach / tooth whitening
Why is it starting to ache?
What adverse effects are there for my tooth?
- Pulpal canal obliteration – hard tissue healing can result in partial or complete pulp
canal obliteration. These teeth usually remain vital. Unless signs of non-vitality are
notes these teeth can be monitored. The excess tertiary dentine often produces a
yellow colour to these teeth and cause a cosmetic concern. First line intervention
should focus upon vital tooth bleaching.
- Discolouration – following trauma blood products can be released coronally into the
dentine tubules leading to discolouration of the tooth. This is frequently associated
with a loss of vitality although, infrequently, maybe transient in the early stages of
healing. Bleaching is the initial treatment option in persistent cases.
- Root resorption – trauma tends to result in either external inflammatory or external
replacement resorption (ankyloses). Inflammatory resorption is driven by pulpal
necrosis and RCT should be initiated. Replacement resorption follows when the root
surface is so badly damaged that it becomes remodelled during skeletal turnover. It
is irreversible but can occur at different rates and frequently depends on the age of
the patient and growth development. In the growing patient, the tooth may become
infroccluded. If this occurs it should be decoronated and a prosthesis provided. This
is prevent problems with alveolar development. Though root resorption can present
challenges to endodontics and sometimes needs specialist level care, if suspected
first stage root canal treatment (full shaping) and dressing with calcium should still
be undertaken in primary care as delays in treatment can be catastrophic.
- Tooth loss and space loss – teeth having lost considerable amounts of tooth
structure or vitality may not survive in the long term and the patient needs to be
aware of this prospect. If a tooth is lost following trauma, then space can be lost
rapidly; particularly in young patients. Provision of a space maintainer or immediate
partial denture is crucial to prevent loss of space for futures prostheses or centreline
discrepancies.
SCRIPT:
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1. Hi, my name is Camilla. I’m the dentist who’ll be looking after you today.
2. Before we start, can I please just confirm your name and DOB?
3. How would you like to be addressed?
4. How are you? What brings you here today?
5. “pain”
6. SOCRATES
a. Site – can you point to which tooth is causing you the pain?
b. Onset – when did the pain start?
c. Character – can you describe the type of pain – dull ache, throbbing, sharp?
d. Radiate – does the pain radiate anywhere?
e. Associated symptoms – any associated symptoms, temperature, unwell?
f. Time -
g. Exacerbating/alleviating – anything make the pain better or worse?
h. Severity – on scale of 1-10, how painful is it?
7. Accident history
8. Okay, before I look in your mouth, may I ask you a few questions about your general
health?
9. I’m sorry if these questions seem long and irrelevant but it is in order for me to
ensure that I can treat you safely. I know my colleague may have been through these
questions already with you.
10. Are you generally fit and well?
11. Do you take any medication?
12. Do you have any allergies?
13. Have you had a tetanus check?
14. Do you smoke at all? Have you ever smoked?
15. Do you drink alcohol? How much on the weekend? (couple of drinks)
16. What job do you do? – are you able to take off work easily to receive dental
treatment?
17. How do you feel about getting dental treatment?
18. So what would you like from the appt today?
19. How did you find the appt with my colleague?
20. I’ve just taken a look in your mouth and I have pictures of the teeth in question here
21. Would you like me to explain my findings to you?
22. If at any point you think I’m going too fast or want to stop me to ask questions, feel
free to do so.
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23. From my findings, I have come to the diagnosis of what we call complicated enamel-
dentine fracture with pulp exposure.
24. So if you can imagine, the tooth has a hard outer shell that protects the soft inner
part. The soft inner part contains blood vessels and nerves that keep the tooth alive.
Bacteria/germs can spread from the outer surface of the tooth into the soft inside
part affecting the nerves and causing them to become inflamed. This is why you’re
experiencing pain.
25. If you can see on this black and white image taken of your tooth, here is the hard
outer layer of your tooth and here is the softer inner part called the nerve. You have
fractured/broken/chipped your tooth and it is exposing this nerve, softer inner part
which is why you are experiencing pain. Has the nerve begun to die?
26. Do you understand everything so far?
27. Would you like me to explain the treatment options available for you?
28. There are 5 options we can do:
29. So what we can do for you today to try to get you out of pain is remove any
bacteria/germs that is present, begin to remove the nerve by opening the tooth up
and to relieve the pressure. This will help reduce the pain experienced.
30. We can also place a little bit of medicine and put a tooth coloured temporary
material on top. This tooth however will require further treatment called root canal
treatment.
31. Pulp capping - direct pulp cap with calcium hydroxide but consideration should be
given to partial pulpotomy especially if the exposure has been present for many
days. Advantages and disadvantages….. can numb up – calcium hydroxide and GIC
32. Partial Pulpotomy - this involves removing the coronal (top) pulp tissue (nerve) that
is inflamed as a result of trauma. So we would isolate the tooth with a rubber sheet
and remove 2mm of the top of the nerve with a drill. The procedure aims to leave an
intact, vital apical pulp (alive bottom nerve). A medicament (ferric sulfate/MTA – can
discolour the tooth, setting calcium hydroxide or biodentine) is placed prior to the
placement of a coronal seal and then restore the tooth with filling/tooth fragment.
Success rate – Fuks 92.7% in 1997 and 96.4% Ibricevic, 2003, Cvek partial pulptomy.
Advantages and disadvantages…..
33. The other option to do today would be to extract/ remove the tooth and that would
also provide immediate relief but then you would have a gap at the front of your
mouth which we would need to fill.
34. The last option is to do nothing – but as the nerve is exposed, bacteria and germs
can spread further inside the middle of the tooth causing the nerve to die and
causing further infection.
35. So there are 3 long term options for the future of this tooth
36. The first is what we call a root canal treatment, followed by a filling.
37. Do you know what this is?
38. This is a procedure where we remove the infected nerves and blood vessels that run
at the centre of the tooth. The tooth is cleaned, shaped and dressed with medication
to allow the tooth to settle. The tooth can then be permanently filled. RCT is usually
successful, however, if the infection comes back, the tx can sometimes be repeated.
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This procedure is time consuming and may require a number of visits. You will then
need a filling following the rct to protect the tooth from breaking (or we can attach
the tooth fragment back on, think about veneer/crown later in the future).
39. Is everything clear?
40. Alternatively, another option is to take the tooth out, followed by space filling
options for the gap.
41. Finally, you have the option of just leaving the tooth and monitoring it however that
is far from ideal as the tooth will suffer from further infection and pain.
42. You don’t have to make a decision today and you can have a think about it for as
long as you need.
43. I can book you in for a review appt in a week after you’ve had a think about it?
44. And then book a follow up in 6-8 weeks following RCT for another clinical and
radiographic assessment and 1 year following RCT.
45. Here are some leaflets that outline the tx options we’ve discussed today just because
I know I’ve overwhelmed you with information today.
46. From today to help you, have soft food for 1 week, maintain optimal oral hygiene,
brushing 2 X day and interdental cleaning, CHX mouth wash may help you reduce
plaque accumulation, avoid participation in contact sports.
47. Do you have any questions?
48. So to summarise…
49. Refer to GP for tetanus check
50. Okay that’s great, are you happy for me to start?
Root canal treatment is usually successful, however, if the infection comes back, the
treatment can sometimes be repeated. You will need a restoration following the root canal
treatment to protect the tooth from breaking (filling, tooth fragment, veneer or crown).
The overall success rates for primary endodontic treatment, re-treatment and
surgical treatment were 86.02%, 78.2%, and 63.4% respectively after at least four
years follow-up (Eleman & Pretty, 2011).
However, studies show that survival rates for primary endodontic treatment can
extend up to 98% (Friedman & Mor, 2004)
Benefits
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Chance of failure
File breakage or perforation
Increased risk of tooth fracture due to the removal of tooth bulk and devitality - so
the tooth so may need a ‘cap’ (crown).
Discolouration
Consequences of no treatment
• Band 2: 59.10
• Band 3: £256.50 (if placing veneer or crown too)
• 12 months guarantee*
Simple information
Benefits
Risks/drawbacks
Consequences of no treatment
Cost
• Band 2: £59.10
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Gap options:
a) Bridge: RRB which is basically a fake floating tooth which is attached to the tooth next to
it via a metal wing. The metal wing will be on the part of the tooth that doesn’t show. This
may require some shaving of the tooth next to.
• Adv: simple prep with minimal tooth loss, usually don’t need to be numbed up and
easy to clean.
• Disadv: chance of wing coming off and metal can sometimes shine through.
• Costs: £256.50 – band 3
• Survival: 80% of them last for about 10 years
b) Implant: a screw that is placed in your bone on which a fake tooth is attached.
c) Denture: plate made from either metal or plastic that has a false tooth attached to it
which you would take out
Pulpotomy
Benefits:
Risks:
Pulp Capping
Benefits:
Risks:
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