Dr. Alfred Khallouf revisits the world of comprehensive care and how to develop an effective treatment plan. Please visit AlfredKhallouf.com to learn more.

1. Welcome to our world, enter
the AEGD-2

2. Comprehensive Care II
Treatment Plan Presented by
Captain Alfred G. Khallouf
AEGD-2 Resident
Class of 2005

3. Introducing Our Patient
37 years old
Male
African-American
Attitude-Positive
Patient type-
Indifferent

4. Historical Notes
Joined the USAF in
Feb 1986, currently a
MSgt
Not married and has
no children
States that he is in
good health and
physically active
Born and raised in Tx.

5. Subjective Findings
Chief Complaint: “My upper left tooth is
sensitive to cold since I received a filling.”
Denies any history of smoking, occasional
social drinker
Majority of his treatment was completed prior
to PCSing here to Lackland in April of 2002. .
Previously, he had been seen as a periodontal
maintenance pt

6. Medical Hx. AF form 696

7. Medical / Systemic
Reports a history of High Blood Pressure,
which is controlled by diet
Currently under the care of a physician at
WHMC for the high blood pressure.
B.P. is high normal for him.
B.P. average: 131 / 89
Previous history of Acid reflux (no meds)
Reports no known drug allergies

8. Med use, regimen, effects
and concerns
HYDROCHLOROTHIAZIDE: - 25 mg once daily
- Thiazide Diuretic
- Management of mild to moderate hypertension.
- Dental Tx. Concerns: No effects or Contraindications reported
LISINOPRIL: -10 mg/day
- ACE Inhibitor (Angiotensin-Converting Enzyme)
- Tx. of hypertension, either alone or in combination with other
hypertensive agents.
-Dental Tx. Concerns: No effects or Contraindications reported

9. Oral Pathology

10. Oral Pathology
Pt. states that these lesions have been
present for an unknown duration of time.
They have been there as long as he can remember.
Pt states that occasionally his mouth becomes
painful to very hot and spicy foods, which is
only temporary, otherwise, it normally remains
asymptomatic. These lesions were originally
documented in July 1991, with no biopsy or
follow up performed.

11. Oral Pathology
Multiple asymptomatic, generalized erythematous
yellowish-white patches bilaterally on buccal mucosa
and tongue and inner aspect of lower lip.

13. Oral Pathology
Also a large asymptomatic pink smooth-surfaced
papule about 7mm in diameter which was firm and non-
fluctuant on inner aspect of lower lip. Lip lesion had
been present for several years with no apparent
change in size.

15. Oral Pathology
Deep-fissured grooves on dorsal surface of tongue
consistent with fissured tongue.

16. Oral Pathology
PRE-OPERATIVE
DIAGNOSIS:
A) Lip Lesion
● Irritation Fibroma
● Neuroma
● Papilloma
B) BUCCAL MUCOSA LESION
● Erythema Migrans
● Benign migratory stomatitis.
● Erosive lichen planus.
● Pemphigus
● Verruca Vulgaris
FINAL DIAGNOSIS:
A) LEFT LABIAL MUCOSA:
IRRITATION FIBROMA
B) LEFT BUCCAL MUCOSA:
PSORIASIFORM MUCOSITIS
(SEE COMMENT)
Comment: The histological findings,
together with the submitted digital
clinical images are consistent with
ERYTHEMA MIGRANS

17. Restorative Findings
Caries risk: low
Carious teeth: none
Defective / Incomplete restorations:
• #2 and 4- partially prepared, into enamel for
Resin-Bonded FPD
• #14 has a large amalgam overhang, which
is sensitive to cold (skin refrigerant causes
lingering pain which reproduces pts C.C.)

18. Anterior Dentition View

19. Maxilla

20. Max Right Sextant
1- Occlusal Amalgam
2- Occlusal Amalgam, with
partial prep for RR-FPD

21. Max Right Sextant
3- Missing
4- Occlusal Amalgam, with
partial prep for RR-FPD
5- Sealant

22. Max Anterior Sextant
6- no treatment
7- no treatment
8- no treatment
9- no treatment
10- no treatment
11- no treatment

23. Max Left Sextant
12- DO Amalgam
13- MOD Amalgam

24. Max Left Sextant
14- Defective MODFL Amalgam Restoration
Symptomatic, skin refrigerant cause lingering pain
which reproduces pts. C.C.

25. Max Left Sextant
15 OL Amalgam Restoration
16- missing

26. Mandible

27. Mand Left Sextant
17 – missing
18 – DO Amalgam
19 – OF Amalgam

28. Mand Left Sextant
20 – Occlusal Pit Amalgam & Sealant
21 – Sealant

29. Mand Anterior Sextant
22 – no treatment
23 – no treatment
24 – no treatment
25 – no treatment
26 – no treatment

30. Mand Anterior Sextant
27- 6mm gingival recession on facial
● CT graft was first attempted in Oct 1999
● CT graft failed for unknown reasons

31. Mand Right Sextant
28 – No treatment
29 – Occlusal Amalgam & Sealant

32. Mand Right Sextant
30 – OF Amalgam
31 – MO Amalgam
32 – Missing

33. OK now, where are those
residents?

34. Endodontic Findings
14- defective restoration
● Large Amalgam overhang
● Symptomatic: skin refrigerant causes lingering pain, which
reproduces pts. C.C.
● No positive findings to apical palpation, percussion and biting
and no periapical pathology
● Periradicular Dx: Normal
● Pulpal Dx: Irreversible Pulpitis

35. AF form 935
Periodontal
Charting

36. AF form 935, Maxilla

37. AF form 935, Mandible

38. Periodontics
Initial Modified O’Leary score was 76% plaque free surfaces
PD: 1-5 mm
BOP: 15 of 25 teeth
Mobility: physiologic
Diagnosis:
● Localized chronic severe periodontitis involving tooth #27.
● Localized chronic moderate periodontitis involving #s 1, 13-15, 18,
19
● Generalized Gingivitis and moderate plaque present
Etiology: 1) Plaque 2) Calculus
CT graft was first attempted in Oct 1999 for #27. CT graft failed
for unknown reasons.

39. Periodontics: Prognosis
Short term:
● Overall: Good
● Individual: Fair #27
Long term:
● Overall: Good
● Individual: Guarded/Fair # 27
Perio Maintenance: Every 3-4 months

40. Orthodontics
No Maxillary Anterior crowding apparent
Midline discrepancy: mand 1mm to the left
Mesial / Facial rotation of #22
Slight Mandibular Anterior crowding
Pt. states he is not interested in Orthodontic Tx.
Dental Class I Malocclusion

41. Occlusion
Angle class I molar on left side
Class I premolar on right side
● #3 extracted several years ago
#1 Non-opposing
No need to alter plane of occlusion

42. Oral Surgery

43. Oral Surgery
Extraction of #1 - malposed and not in function or occlusion
Biopsy intra-oral lesions under local anesthesia

44. Prosthodontic

45. Prosthodontics
Missing teeth: # 3, 16, 17, 32
Single crown: # 14
3-unit Fixed Partial Denture: #’s 2 – 4
● #2 – 7/8th crown
● #3 - pontic
● #4 – 3/4th crown

48. Treatment Plan by Phase
I. Emergency Care
● RCT #14, address pts. chief complaint
II. Medical / Systemic
● HBP controlled by diet and Medication

49. Treatment Plan by Phase
III. Diagnostic / Initial Therapy
● Medical Model and Caries Control
● Pt has no caries or restorative procedures planned
● OHI- Brushing & Flossing
● Extract #1 (Disease control)
● Biopsy Intra-oral lesions

50. Treatment Plan by Phase
IV. Re-Evaluation
● Check O.H. and Pt. Compliance
● Re-chart 935
● Assess Key Teeth # 2, 14 & 27
V. Corrective Surgical
● Orthodontics:
● Discussed with pt.
● Pt. does not desire any Tx.

51. Treatment Plan by Phase
V. Corrective Surgical
● Periodontics
● #14 - crown lengthening
● #15 - Distal Wedge
● #27 – CT graft with lateral pedicle graft

52. Treatment Plan by Phase
V. Corrective Surgical
● Single Crown
● #14 - Full Gold Crown
● 3-unit Fixed Partial Denture
● #2 – 4
● #2 – 7/8th crown
● #3 – pontic
● #4 – 3/4th crown

53. Treatment Plan by Phase
Nightguard / Occlusal Guard
VI. Maintenance
● Re-evaluation
● Perio Recall every 3-4 months

54. Tooth by Tooth Treatment
Plan
1: Extraction
2: Abutment for a 3-unit FPD
3: Pontic (Hygenic or Bullet shaped)
4: Abutment for a 3-unit FPD
5: No Treatment
6: No Treatment
7: No Treatment
8: No Treatment
9: No Treatment
10: No Treatment

55. Tooth by Tooth Treatment
Plan
11: No Treatment
12: No Treatment
13: No Treatment
14: RCT, Amalgam build up, Crown Lengthening
and Gold crown
15: Distal Wedge
16: Missing

56. Tooth by Tooth Treatment
Plan
17: Missing
18: No Treatment
19: No Treatment
20: No Treatment
21: No Treatment
22: No Treatment
23: No Treatment
24: No Treatment
25: No Treatment

57. Tooth by Tooth Treatment
Plan
26: No Treatment
27: CT graft with possible lateral pedicle graft
28: No Treatment
29: No Treatment
30: No Treatment
31: No Treatment
32: Missing

58. Alternative TX. Plan
Maxilla
● Implant to replace #3
● Single unit crowns #2 and 4 versus
● Posterior composites #2 and 4
Mandible
● If pt chooses not to undergo a 2nd CT graft
surgery to correct recession, monitor #27
for continued recession

59. Everybody, out of the Residency