1. By: Ashly Adermann DH2

2.  62 year old female  No infectious diseases  No systemic diseases  No medications  Penicillin allergy  Smokes ½ pack of cigarettes per day  Brushes 2 times per day  Flosses on occasion  Last cleaning 4 years ago in Vietnam  Vital signs within normal limits

3. Generalized moderate horizontal bone loss, localized severe UR * No caries diagnosed

5.  IO/EO exam: NSF  Generalized mobility  Generalized 1-3mm recession  Furcations present  Class I occlusion (R/L), 2mm overjet, 2mm overbite  Abfractions: #10, 20, 22, 28, and 29  Statement of Inflammation: Generalized moderate marginal and papillary inflammation, localized severe UR lingual (molars)  Deposit Evaluation: 2.5/3.5  Case Type: Generalized III, Localized IV (UR)  Chose for case study because patient presented with the need and willingness for periodontal treatment.

7.  Comprehensive Oral Exam (D0150)  Full Mouth Series (D0210)  Impressions for study model  Non-Surgical Periodontal Therapy on all quadrants (D4341 UR, D4341 LR, D4341 UL, D4341 LL)  Local Anesthetic (D9210)  Oral Hygiene Instructions (D1330)  Fluoride Varnish (D1206)

8.  At her initial appointment Kim’s chief concern was sensitivity (UR, #2-3 area). Doctor recommended extractions or bone graft. After her initial appointment Kim went to Vietnam. While she was in Vietnam, before NSPT, she had #2 extracted due to severe bone loss and sensitivity. At her third NSPT appointment, after returning from Vietnam, she had #3 extracted in our office.

9.  Full Mouth Series  Comprehensive Oral Evaluation  Oral Hygiene Instructions  Intraoral/Extraoral Exam  Microscope: highly motile, spirochetes (TNC), risk factor C  Full mouth periodontal chart  Check-In with instructor  Did not start NSPT at this appointment  Patient Goals: To remove stain, whiten, and keep up with regular maintenance appts.

10.  Patient brushes 2x per day; discussed and demonstrated brushing at a 45 degree angle.  Explained to patient that this allows the bristles of her toothbrush to get into the periodontal pockets and disrupts biofilm.  Suggested brushing for 2 minutes.  Patient only flosses occasionally; discussed and demonstrated floss picks/soft picks.  Suggested using floss picks/soft picks 1x per day. Suggested keeping floss picks in her purse and/or flossing while watching TV.  Showed patient how to floss under bridge with using floss threader.

11.  Discussed the etiology of periodontal disease and how smoking relates. Explained to patient that if she quit smoking this could have a significant impact on her oral health. Patient said she has smoked half a pack of cigarettes for 35 years and was not interested in quitting. She stated smoking is what gets her though the day. Patient smoked during breaks at her appointments.

12.  Appointment One: D4341 (LR), comprehensive oral evaluation, OHI, impressions, and intraoral photos  Appointment Two: D4341 (UL/LL) and OHI  Appointment Three: D4341 (UR), PA #2-3, limited exam, OHI, extraction #3, and fluoride varnish  Appointment Four:  D4999 reevaluation, limited exam, PA #15, limited exam, OHI, fluoride varnish (NSPT completed in mid March)

13.  Techniques: Used cavitron and hand instruments to scale entire dentition.  Patient compliance with oral hygiene instructions: Patient was very good with brushing but had a hard time flossing regularly. Started patient out with floss picks/soft picks.  Patient’s main concern besides the need for extractions was whitening. Planned on bleach trays but patient decided to hold off do to finances.

14.  No changes in medications or health history  Generalized normal tissue, localized moderate inflammation #14-15 area  Localized slight bleeding  Microscope: decrease in amount of bacteria including spirochetes, less motile, risk factor B  Deposit Rating: 1.5/1.5  Chief Concern: Tooth #15 is causing sensitivity due to severe bone loss (increase in pocket depths since initial appointment) and an infection present at the apex.  Recommended extraction of #15

19.  Patient is brushing 2x per day but is still not flossing regularly.  Told patient to keep up the good work with brushing and reviewed why flossing is so important. Patient stated she likes the floss picks but just forgets to floss.  Suggested setting a pack of floss picks on her night stand that way she is reminded to floss before bed.  Reminded patient to use tongue scrubber due to coated tongue.  Reminded patient why flossing under her bridge is so important.

20. Kim was a great patient to have in the clinic. Although she had two teeth extracted and one still may need to be extracted; she is on her way to maintaining her periodontal condition. Kim had a decrease in inflammation and pocket depths following NSPT. I recommended that Kim have 3-4 month re-call appointments following her reevaluation. If Kim would have been open to quitting smoking, I feel she would have had even better results. One thing I would have changed about treatment would be recommending an electric toothbrush and a water pick. I believe this would have helped Kim with her home care.