Periodontally Involved Patient Competency (MT) By Jillian Scialanga Spring 2017

Patient Background Age: 52 Race/Ethnicity: Chinese (born in Hong Kong) Location: Los Gatos, CA Maslow’s Hierarchy of Needs: Self Actualization Learning Ladder Continuum: Awareness Chief Compliant: MT states that she is worried about bone loss and losing her teeth.

Case Presentation Initial assessment

Medical history Major Medical Concerns: None Allergies: None Medications: None Last medical Exam: October 2016, NSF Vital Signs: Pulse: 73 BP: 119/82 WNL Resp: 16 ASA: I BMI: 21 Normal weight

Dental history Last Dental Visit: 3 years ago Last Dental Hygiene Visit: 3 years ago Last Dental X-Rays: 3 years ago Orthodontic Treatment: Traditional braces as a child, for 3 years. MT does not remember if she had a retainer. E/I Exam: On the hard palate, adjacent to #3 there were 6, 1x1mm regular bordered red ulcerations. Duration unknown.

Oral hygiene Practices Toothbrushing: MTB 2x/day Flossing: 1x/day Mouthwash: Not often Sweets: Dark Chocolate and ice cream. Usually as a snack almost everyday.

Gingival description Consistency: Firm/fibrotic Inflammation: Light Plaque: Generalized light subgingival Hygiene: Fair Margins: Receded Attached Gingiva: Pink, firm and glossy. Papilla: Blunted, pink and boggy. Suppuration: Bleeding AAP: III

Periodontal examination Probing Depths: 2-7mm Recession: Generalized Furcation: None Mobility: + on #7, 8,10, 23 and 24. MGJ: None Bleeding: Localized Plaque: Generalized light subgingival Calculus Class: Heavy AAP Type: III

Pre-Treatment intraoral photos Anterior- Normal Bite Anterior- Edge to Edge

Pre-treatment intraoral photos Right Buccal Left Buccal

Pre-treatment Intraoral photos Maxillary Occlusal Mandibular Occlusal

Pre-Treatment Intraoral Photograph Mandibular Anterior Lingual

Dental Charting Missing: #1, 2, 16, 20, 26, 30 and 32. Amalgams: #3, 12 and 17. Composites: #4, 5, 6, 12, 15, 29 Other Restorations: #29-31 PFM bridge PFM: #13, 14, RCT: #13, 14 Defective Restorations: #3, 12, 13, 14, 15, 29, 31. Abfraction: #7 & 9

Caries Examination & Occlusion Suspicious Caries: #8-M, 9- M, 18-D, 19-D, 31-DL. Occlusion: Class III Overbite: 2mm Overjet: 2mm Midline: Even

Caries Risk assessment High Caries Risk Suspicious caries Plaque - Light Sweet Score – 60 mins Snacking Exposed roots DMFT – 0.54 Good pH – Normal Salivary flow - >1ml/min Only drinks bottled water, no fluoride.

Periodontal risk Assessment High Perio Risk Plaque Index: 0.6 Good BANA Test: Negative Probing Depths: 2-7mm Generalized recession Severe localized vertical bone loss. Infrequent DH care Furcations: None Mobility: Slight MGJ: None BOP: Localized

Radiographs December 6, 2016 taken at FHDHC.

Radiographic Interpretation FMX Bone Loss: Moderate horizontal bone loss on anteriors. Vertical bone loss #6-D, 7-D, 18-M, 19-M, 17-M, 29-D, and 31-M. Calculus Present: #3-D, 6-D, 7-MD, 14-D, 15-MD, 19-M, 28-D, 23-M, 24-M, 25-M and 29-D Radiographic caries: #18-D & 19-D Overhangs: #29-D & 31-M&D Crown to Root Ratio: 1:1

Nutritional Assessment BMI: 21 Grains Target 5 oz Actual 4.5 oz Vegetables Target 2 cups Actual 2 cups Fruits Target 1.5 cups Actual 0.75 cup Dairy Target 3 cups Actual 1 cup Protein Actual 6 oz

Treatment goals: Caries Risk Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Caries Risk: High Suspicious caries Generalized light plaque Inadequate OH Recession   Pt understands plaque biofilm and its contribution to caries Pt learn to use the C-shape floss technique Pt understands the benefits of topical fluoride in the reduction of dental caries Refer pt to DDS for restorative treatment Pt will be able to explain plaque biofilm and its contribution to caries by NV Pt will demonstrate proper C-shape floss technique by 3rd visit Pt will report using prescription fluoride toothpaste once a day by 3rd visit (after a week of chlorhexidine) Pt will make appointment with DDS by last visit

Treatment Goals: Periodontal risk Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Perio Risk: High Probing depths: 2-7mm Moderate generalized calculus BOP Infrequent DH Care Recession Mobility Generalized moderate horizontal and vertical bone loss Pt understands plaque biofilm and its contribution to periodontal disease Pt understands the link between periodontal disease and systemic health Pt learns modified Bass toothbrushing technique Pt understands the correlation between BOP and periodontal disease Pt understands the importance of frequent recalls Pt learns how to use interproximal brushes Pt understands the role of Arestin in reduction of pocket depths. Refer pt to Periodontist Pt will be able to explain plaque biofilm and its contribution to periodontal disease by NV Pt will be able to explain the link between periodontal disease and systemic health by NV Pt can demonstrate modified Bass toothbrushing technique by NV Pt will be able to explain the correlation between BOP and periodontal disease Pt will schedule dental hygiene appointments on 3-4 month intervals Pt will report using interproximal brushes by 3rd visit Pt can explain how Arestin works to reduce pocket depths. Pt will make appointment with Periodontist by NV

Treatment Goals: Oral cancer risk Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Oral Cancer Risk: Low No risk factors for oral cancer   Pt understands the importance of the E/I exam to check for oral cancer Pt can explain why the E/I exam is important to check for oral cancer by NV

Treatment Plan schedule Appt. # Plan for education, OHI, counseling Area Plan for treatment & services 1 Teach proper brushing using the modified Bass technique & Educate pt on link between periodontal disease and systemic health FM Complete medical/dental history, complete E/I exam, complete assessments, OHI, intraoral photos. 2 Teach proper C-shape flossing technique & educate UR LR Update medical/dental history, update E/I exam, update assessments, complete dental charting, BANA, perio risk assessment, caries risk assessment, plaque indices, DMFT, OHI, scale UR and LR with USS and hand instruments and LA, place Arestin. 3 Teach interproximal brushes educate pt on nutritional habits and link to oral health (OHI evaluation) UL LL Update medical/dental history, update E/I exam, update assessments, OHI evaluation, nutritional assessment, scale UL and LL with USS and hand instruments and LA, place Arestin, selective coronal polish, Fluoride Varnish, Referrals. 4 Review modified bass technique and c-shaped flossing. Review link between periodontal health and systemic health, and nutritional habits and oral health. 6 week follow up Update medical/dental history, update E/I exam, update assessments, OHI, scale FM with USS and hand instruments, selective polish, Referrals.

Case Presentation Re-Evaluation Assessments

Medical history Major Medical Concerns: None (no change) Allergies: None (no change) Medications: None (no change) Last Medical Exam: October 2016 (no change) Vital Signs: Pulse: 72 BP: 138/88 PRHTN Resp: 14

Oral practices Toothbrushing: 2x/day (no change) Flossing:1x/day (no change) Mouthwash: Not often (no change) Sweets: Dark chocolate and ice cream daily as a snack (no change)

Gingival Descriptions Consistency: Firm Inflammation: Light Plaque: Light Hygiene: Fair Margins: Receded Attached Gingiva: Pink, firm and glossy. Papilla: Blunted Suppuration: Localized BOP

Periodontal Examination Probing Depths: 2-5mm Recession: Generalized Furcations: None Mobility: None MGJ: None BOP: Light localized Plaque: Light Calculus Class: Light AAP Class: III

PD Comparison

CAL Comparison

Post-treatment intraoral Photos Pre-Treatment Post-Treatment

Post-treatment intraoral photographs Pre-Treatment - Right Buccal Post-Treatment - Right Buccal Pre-Treatment Left Buccal Post-Treatment – Left Buccal

Post-Treatment intraoral photos Pre-Treatment Post-Treatment

Post-treatment Intraoral photographs Pre-Treatment Post-Treatment

Treatment Goals: caries Risk Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Caries Risk: High Suspicious caries Generalized light plaque Inadequate OH Recession   Pt understands plaque biofilm and its contribution to caries Refer pt to DDS for restorative treatment Pt will be able to explain plaque biofilm and its contribution to caries by NV Pt will make appointment with DDS by last visit

Treatment goals: perio Risk Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Perio Risk: High Probing depths: 2-5mm Light generalized calculus BOP Infrequent DH Care Recession Mobility Generalized moderate horizontal and vertical bone loss Pt understands plaque biofilm and its contribution to periodontal disease Pt understands the link between periodontal disease and systemic health Pt understands the correlation between BOP and periodontal disease Pt understands the importance of frequent recalls Refer pt to Periodontist Pt will be able to explain plaque biofilm and its contribution to periodontal disease by end of visit. Pt will be able to explain the link between periodontal disease and systemic health by end of visit. Pt will be able to explain the correlation between BOP and periodontal disease Pt will schedule dental hygiene appointments on 3-4 month intervals Pt will make appointment with Periodontist by NV

Treatment Goals: oral cancer Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Oral Cancer Risk: No risk factors for oral cancer   Pt understands the importance of the E/I exam to check for oral cancer Pt can explain why the E/I exam is important to check for oral cancer by NV

Treatment Schedule Appt. # Plan for education, OHI, counseling Area Plan for treatment & services * 1 Review modified bass technique and c-shaped flossing. Review link between periodontal health and systemic health, and nutritional habits and oral health. nutritional habits and link to oral health (OHI evaluation). FM 6 week follow up Update medical/dental history, update E/I exam, update assessments, OHI, scale FM with USS and hand instruments with LA, selective polish.  

What treatment goals were met? Pt was able to explain plaque biofilm and it’s contribution to caries and periodontal disease. In addition, she was able to understand BOP and it’s contribution to periodontal disease. Pt was able to explain the correlation between dental health and systemic health. Pt demonstrated Modified Bass TB and c-shaped flossing. Pt was able to explain why E/I exam was important to check for oral cancer. Pt was also educated on how to check for white or red lesions at home and advised to call if lesions did not resolve within 2 weeks.

What treatment goals were Not met? Pt did not schedule appointment with DDS to evaluate defective restorations and suspicious caries. Cost is a concern for this patient. A list of community resources (dental schools and dental hygiene schools) was distributed to the patient. Pt did not report using interproximal brushes at follow-up appointment.

Research Local Contributing factors of periodontal disease

Research: Local contributing factors to periodontal disease Mechanisms for increased disease risk: Local factor can increase plaque biofilm retention. Local factor can increase biofilm pathogenicity. A local factor can cause direct damage to the periodontium. Dental calculus* Faulty restorations* Developmental defects in teeth Dental decay* Certain patient habits* Trauma from occlusion

Research: Local contributing factors to periodontal disease Dental Calculus Living bacterial plaque always covers a calculus deposit. As plaque matures it become more pathogenic. Subgingival (black/brown) or supragingival (white/yellow) Brushite* < 6 months old - octacalcium phosphate > 6 months old – hydroxyapatite*

Research: Local contributing factors to periodontal disease Defective restorations – bulky or faulty margins of restorations can create areas where plaque is easily retained and allowed to mature. Can cause destruction of the periodontium. Difficulty in accessing tooth structure protected by an overhang can make it impossible for the pt to remove plaque biofilm effectively.

Research: Local contributing factors to periodontal disease Dental decay Untreated decay can increase biofilm retention when cavitated. Cavitated areas harbor and protect bacteria .

Research: Local contributing factors to periodontal disease Patient habits Infrequent professional DH care Inadequate home care, MT did not report using interproximal brushes.

Research: Local contributing factors to periodontal disease CEJ Variety of surface irregularities One of the most common areas to find post- scaling and root-planning residual biofilm and calculus. Microscopic structural features that appear to facilitate the attachment of pllque biofilms. Instrumentation in this area is challenging. Close to margins or restorations Pt may be uncomfortable/sensitive Aggressive instrumentation over time may lead to fracturing of enamel and irregular contours of the CEJ.

What DID I Learn? Don’t give up with the ultrasonic Continue to use this instrument to make microfractures in larger deposits. Placement of Arestin can sometimes wait until 2nd or follow up appointment. Take an x-ray to determine if deposits have been completely removed.

References Darby, Walsh. Dental Hygiene Theory and Practice. 4th edition. St. Louis Missouri: Elsevier Saunders. 2015. 1176. Gehrig JS, Willmann DE. Foundations of Periodontics for the Dental Hygienist. 4th edition. Philadelphia: Wolters Kluwer. 2016. 698. Satheesh K, MacNeill SR, Rapley JW, Cobb CM. The CEJ: biofilm and calculus trap. Compendium. 2001 March: 32 (2): 30-40. Google images