CASE PRESENTATION

Dr. M.Arsalan ZubairMDS Trainee (Semester II)

Operative Dentistry DepartmentDow Dental College

DUHS

PATIENT’S PERSONAL DATA

• Age: 43 years• Sex: Female• Address: Nazimabad

PRESENTING COMPLAINT Patient presented with the complaint of dark yellow staining of

her teeth

HISTORY OF PRESENTING COMPLAINT

Discolored teeth were present since her school age.

With more discussion with patient she revealed that her school water was not good.

MEDICAL HISTORYNon significant

FAMILY HISTORYNon significant

DENTAL HISTORY Extraction Root Canal treatment

6,8

7,8 6

CLINICAL EXAMINATION

• Teeth present:

• Teeth Missing:

• Carious Teeth:

7,5,4,3,2,1 1,2,3,4,5 6,7,8

8,7,6,5,4,3,2,1 1,2,3,4,5,6

8,7,6

7,8

5 ,7

INTRA ORAL EXAMINATION

SITE AND SIZE CLASSIFICATION

1 2

4 3

5(class 1) 7 (Class 1)

Periodontal ExaminationPocket Depths

11 0.5 0.5 0.5 0.5 0.5 0.5

12 0.5 0.5 0.5 0.5 0.5 0.5

13 0.5 0.5 0.5 0.5 0.5 0.5

14 2 0.5 1 2 0.5 1

15 2 0.5 0.5 2 0.5 0.5

17 2 0.5 0.5 2 0.5 0.5

No: F(Mes) Mid Distal P(Mes) Mid Distal

21 0.5 0.5 0.5 0.5 0.5 0.522 0.5 0.5 0.5 0.5 0.5 0.523 0.5 0.5 3 0.5 0.5 324 2 0.5 3 2 0.5 325 2 2 2 2 2 226 2 0.5 3 2 0.5 327 5 3 5 5 3 528 3 3 3 3 3 3

31 0.5 0.5 0.5 0.5 0.5 0.5

32 0.5 0.5 0.5 0.5 0.5 0.5

33 0.5 0.5 3 0.5 0.5 3

34 0.5 0.5 0.5 0.5 0.5 0.5

35 1 0.5 3 0.5 0.5 3

36 0.5 0.5 0.5 0.5 0.5 0.5

41 1 0.5 0.5 1 0.5 0.5

42 0.5 0.5 0.5 0.5 0.5 0.543 3 0.5 2 3 0.5 244 1 0.5 0.5 1 0.5 0.5

45 0.5 0.5 3 0.5 0.5 3

46 1 0.5 1 1 0.5 1

47 3 0.5 3 3 0.5 3

48 3 2 2 3 2 2

Examination of Occlusion

• Group Function on left side

• Group Function on Right side

Plaque and Gingival index

A film of plaque adhering to the free gingival margin and adjacent area of the tooth, which can not be seen with the naked eye. But only by using disclosing solution or by using probe

No plaque

Moderate accumulation of deposits within the gingival pocket, on the gingival margin and/ or adjacent tooth surface, which can be seen with the naked eye

Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin.

No inflammation

Mild inflammation, slight change in color, slight edema, no bleeding on probing.Moderate inflammation, moderate glazing, redness, bleeding on probing

Severe inflammation, marked redness and hypertrophy, ulceration, tendency to spontaneous bleeding

0

1.

3

2

1.

3

2

0

• On the basis of above criteria the plaque status was “2” because plaque was observed with the naked eye and gingival status was given score 1 because mild inflammation was seen and also bleeding on probing was there but not on all teeth it was only observed in 27

• No mobility of tooth was observed

• After reviewing the periodontal status it is observed that there are dark yellow or brownish stains just like circular lines on the facial surfaces of upper anterior teeth

• Stains are also observed on buccal surfaces of posterior tooth as well, directed gingivally

• Stains are also observed on the lower anteriors as well

• Stains are more towards the gingival third and interdentally on the facial surface of both sides.

• When the inner surfaces of upper and lower arches are observed these stains are also present

• Clinically there is no surface loss of the enamel or pitting of the surface.

• Attrition is seen in posterior teeth

• During further discussion with patient which revealed that these stains were present since her school life. Her school was in Punjab and the water was not good

• After brushing many times these stains were not cleaned

Investigation

DIFFERENTIAL DIAGNOSIS

• Fluorosis

• Amelogenesis Imperfecta

• Molar incisor hypomineralization

• Enamel Hypoplasia

• Early decalcification due to caries

Comparison

Enamel Hypoplasia• Enamel hypoplasia stain

relatively clear, and are parallel to the ridge line enamel.

• Enamel hypoplasia can occur in a single tooth or a set of teeth

Dental Fluorosis• Dental fluorosis as a long-

term damage, so the patches were scattered in a cloudy pattern, and not in a well defined pattern

• Dental fluorosis occurs in most teeth, particularly in the maxillary anterior teeth .

J Clin Exp Dent. 2009. Dental fluorosis: Exposure, prevention and management

• Tooth Colour generalized Yellow

• Tooth size Small

• Tooth Shape is also changed

• Enamel leads to attrition which leads to loss of enamel

• Patient Complain of Sensitivity due loss of enamel

• high risk of caries

• Dark brown bands on gingival part of crown• Tooth Size normal• Tooth Shape normal

• No Such thing can be noticed• No complain of sensitivity• Low risk of caries

Comparison B/w Amelogenesis Imperfecta and Fluorosis (clinical)

• Normal enamel thickness• Normal Size pulp

Chambers• No Tauro-donts are seen• Root size normal

• Enamel and dentine thickness is similar or decrease enamel thickness

• Enlarge pulp Chambers • Taurodonts are also

there• Roots size short

Evidences for ruling out Amelogenesis Imperfecta and Enamel hypoplasia and making a Diagnosis that this condition is Fluorosis

Fluorosis

• What is Fluorosis???• Is It dangerous???• What is threshold

dose???• What are the

causes????

Classifying Fluorosis A/c to index

• Chronological Fluorosis Assessment Index

Ref:School of Dental Science, University of Melbourne, Victoria, Australia. Journal of Dental Research 2003

•Cervical and little bit middle area is involved•So cervical is given score: 2•Middle: 1

Dean’s flurosis

• In my case according to dean’s fluorosis index the score is 3(moderate) because generalize discolouration is there

• No pitting is there • sign of attrition are there on posterior teeth

TREATMENT PLAN (initial)• Oral hygiene instructions• Diet modification • Scaling was done• Restoration of Class 1 cavities which is done with

amalgam

Final treatment plan was done according to Score

Conservative measures: • microabrasion • vital bleaching, Destructive measures:• porcelain veneers

Severity Conservative Measures Destructive Measures

Mild FluorosisScore : 1,2

Vital bleaching+ Microabrasion

Separate areas can be treated by localized composite restorations

Moderate FluorosisScore: 3

Microabrasion Composite veneer

Severe FluorosisScore: 4

Composite veneers only for adult but not in paeds why????Fix prosthesis is also considered when there is severe enamel loss

• In my case score is 3 that is moderate fluorosis is present so we have both approaches ie Micro-abrasion and Porcelain veneers

• Vital bleaching

THANK YOU