Introduction

My vocational training year served as an excellent opportunity for honing my clinical, communication and team working skills, as well as providing my first real insight and experience of working in a system that sometimes presents challenges to providing the best available care. The case I am about to recall was by far the most memorable and rewarding one that I’ve had the opportunity to work on in my, currently, short career spent in general practice.

Background and reasons for selecting the case

As a newly qualified and fresh-faced dentist, this patient presented early in my vocational training year and had struck a certain resonance with me, as they had attended university during the same time period as myself, having also moved there from a small town. As well as this they presented with one of the worst maintained dentitions – particularly for their age – I had seen, which would require a multidisciplinary approach to restore. For these reasons, I thought this patient would be an excellent example to discuss for my vocational training year case presentation, as well as providing an insight into what could be achieved and the limitations of supplying dental treatment on the NHS.

Presenting complaint and examination

The 23-year-old male presented in August 2018 for an emergency appointment as a new patient to the practice. His chief complaint was of pain from a tooth on the lower left. Pain had developed two weeks prior, occurred when food or the tongue was pushed into the tooth, no spontaneous pain, no associated tenderness to pressure and resulted in no disturbance of sleep. Medically, he suffered from migraines; taking Pizotifen and Sumatriptan when required. He was otherwise fit and well and a non-smoker. Clinical and radiographic (Figure 1) examination revealed tooth 35 had deep caries in close proximity to the pulp with no associated peri-radicular pathology. A diagnosis of caries and reversible pulpitis was established, gross caries were hand-excavated and a Kalzinol dressing was placed, with a plan for the patient to return for a full examination and appropriate special investigations.

He returned several weeks later – with pain from 35 having settled – when a full examination, bitewings, anterior periapicals (Figure 2), clinical photography (Figure 3), sensibility testing and plaque and gingival indices were completed, giving the following findings:

• Fully dentate with mesially impacted 38 and 48
• Gross caries, affecting all teeth with the exception of 31, 41, 42
• All teeth positive to ethyl chloride sensibility testing
• Generalised plaque deposits and bleeding on probing; Bleeding Score: 100% Plaque Score: 76%
• BPE: 1, 2, 3 / 1, 2, 3
• Class 3 edge to edge incisal relation with moderate lower arch crowding and12 and 22 in crossbite

• 

• 

• 

The dental and social history revealed that during his five years spent at university the patient almost never brushed his teeth and consumed one-to-two litres of full-sugar carbonated drinks per day. Since moving back home and starting work in the family business, his reported hygiene and diet habits had improved, brushing usually once daily and drinking less than one litre of fizzy drinks per day. From all these findings, diagnoses were established and a treatment plan was formulated.

These findings lead to the following diagnoses:

• Caries: 18 – 11, 21 – 28, 38 – 32 43 – 48
• Generalised gingivitis
• Generalised chronic periodontitis (Stage I, Grade A, currently unstable, no risk factors)

• 

• 

• 

• 

• 

• 

Treatment options discussed and plan agreed
Clinical and radiographic examination showed that all teeth – excluding the 8s – were restorable, although some to a greater degree than others. Because of this we agreed upon a restorative approach including surgical removal of all 8s under a general anaesthetic. The general anaesthetic was chosen by the patient to minimise time off work. The plan included:
• Oral hygiene instruction and diet advice
• Periodontal Treatment: Supra and subgingival scaling
• Caries Management: 17 – 11, 21 – 27, 37 – 32, 43 – 47
• Root Canal Treatment: 12, 13, 22, 33, 35, 43, 44
• Cast Post/core: 22
• Metal Ceramic Crowns: 22, 24, 35, 12, 13

On discussion with the patient, it was decided all treatment would be provided on the NHS and the plan was submitted for prior approval. All anterior and buccal lesions were to be restored with composite resin, but with the option of using a resin modified glass ionomer should moisture control not be amenable to composite placement. The root canal treatments were charted on teeth where caries removal was likely to result in pulpal exposure and/or loss of vitality. The crowns were charted with the plan to use direct restorations if there was sufficient tooth tissue remaining after caries removal.

This being the first large case I had ever sent for prior approval, it served as a steep learning curve in understanding the inner workings of the SDR and prior approval system, made even steeper by the change to a computerised approval system midway through. Because of this change and the extensive nature of the treatment plan, the time between initial submission and first approval was around four months.

Treatment carried out
The first phase of treatment included caries management, periodontal treatment, and oral hygiene and diet advice. The latter was also covered at the examination appointment and a marked improvement in gingival health and plaque control could be noted on the patient’s return for treatment. Caries management represented the bulk of the treatment required, this included: the use of glass ionomer as an intermediate restoration in multiple buccal lesions where composite wasn’t viable as an immediate restorative material, two pulpal exposures on teeth 24 and 46 – both rinsed with chlorohexidine and dressed with direct pulp caps of calcium hydroxide and resin-modified glass ionomer cores – and most notably, no teeth showing indication for root canal treatment.

Figure 3: Pre-operative

• 

• 

• 

• 

• 

Once caries management was complete and all intermediate glass ionomer restorations were changed for composites, the treatment plan was reassessed. Ethyl chloride sensibility testing was repeated on teeth that had been approved for pre-emptive root canal treatments; all of which were found to be positive. From this the following changes were made to the treatment plan and re-approval was applied for:

• All RCTs and 22 cast post/core were removed
• 46 amalgam restoration changes to a metal shell crown due to more extensive caries than anticipated
• 12 and 13 metal-ceramic crowns were changes to direct composite restorations
• 47mo amalgam changed to 47mob amalgam
• 27do amalgam changed to 26dob amalgam

Then began phase two of the treatment, which included crown preparation and cementation for teeth: 22, 24, 35, and 46. For 24 and 46, after pulpal exposures, there was a three month waiting period to ensure neither became symptomatic or non-vital.

The final phase of treatment included periodontal re-evaluation, clinical photographs (Figure 4) and consideration of long-term maintenance. Post-treatment plaque and gingival indices showed a plaque score of 24% and bleeding of 35%, with only one pocket greater than 4mm in the six-point pocket chart. The patient showed great motivation from the start which made for ideal conditions for placement of composite restorations close to the gingival margin at the caries management phase. His motivation wavered past this initial phase; however, the need for long term maintenance was enforced throughout the treatment. This resulted in a marked improvement which can be observed in the final clinical photographs. There were still some areas of marginal gingival inflammation that can be noted; this was partly due to some rough eqi-gingival restoration margins that were corrected. The patient’s fizzy drink consumption had also dropped dramatically, reporting only drinking two glasses per week, having changed to mostly water. He was placed on a three-month recall interval to ensure periodontal health was being
maintained, with the plan of being moved to a six-month recall once stable.

Benefits to the patient

The patient noted a considerable aesthetic improvement to his smile as well as a functional benefit, feeling confident to eat without risk of damage to decayed teeth. He also described feeling less lethargic with much more energy since cutting down his high sugar diet, as well as a cleaner feeling mouth through brushing two times per day and use of interdental brushes almost every day.

Figure 4: Post-Operative

• 

• 

• 

• 

• 

Conclusions and learning from the case

This case proved to be an invaluable learning experience for me, both in improving my clinical skills, as well as gaining a more complete understanding of providing dental care within NHS Scotland.

The latter included learning to work within the SDR, the prior approval process and the limitations of treatment that can be provided on the NHS. It was also very rewarding to see the patient’s change in attitude to oral hygiene have a positive effect on his life as a whole, not just limited to the mouth. It helped me realise the importance of treating every patient with a holistic approach, to ensure they can achieve the maximum benefit from the treatment you provide.

There were some areas that on reflection of the case could have been improved upon. I feel these can be broken down quite well into limitations of my own ability/knowledge and limitations of treatment provided on the NHS.

Limitations of my own treatment:

• Upper left posterior periapical more appropriate radiograph than left bitewing
• 35 shade not great match; patient not concerned or interested in remake
• Periodontal health; ultimately patient driven but hoped to see better resolution by end of treatment
• Consider veneer technique for more seamless margins on anterior composites
• A longer waiting period of six to twelve months may have been more appropriate before reassessing vitality of 24 and 46 pulp exposure and placing crowns.

Limitations of NHS:

• Direct composite less destructive method than metal shell crown for 46
• Four months wait between applying for prior approval and it being passed
• Intermediate glass ionomer restorations not financially feasible if working as an associate
• Large anterior direct composite restorations time consuming and not remunerated well; likely to result in placement of crowns when less destructive option available.

Overall, I thoroughly enjoyed working on this case and found it a pivotal learning experience in my vocational training year, showing what could be achieved on the NHS and that my initial scepticism wasn’t completely founded.

It was also rewarding to be able to see the treatment all the way through, from initial examination to maintenance and recall; giving the opportunity to thoroughly reflect on the treatment as a whole, a luxury not always afforded at an undergraduate level.

Robbie McLeish, BDS (Glas)

Tags: clinical, examination, recall