1. Periodontal Project WLAC 2010 Betty Tran Ruzan Ayvazyan

2. Personal History Name: Pedro Zamora Age: 30 yrs old Sex: Male Race: Hispanic Occupation: Unemployed Marital Status: Single

3. Medical History Past History: - Pt states having previous malnutrition due to lack of shelter and food. - Prior physical trauma of head and mouth that resulted in the fracture of tooth #8, #9, #10 Present History: - Systemic: Uncontrolled hypertension, history of substance use, smokes tobacco for the past 10 years - Present illnesses: Pt states that he currently has an eating disorder where he over eats and has become obese.

4. Medical History Current Medication: None Baseline Vitals: 134/94 = 1 st reading 128/90= 2 nd reading **Refer to physician

5. Dental History Past History: Last dental visit: 1997 Previous restorations: #8,#9,#10 PFM Amalgam #3 O #14 O #18 O #19 BO #30 BO #31 O Present status: New pt for dental hygiene services CC: Would like crown re-cemented #10

6. Caries Assessment Pt has several clinical caries - #10 Tx planned for RCT due to recurrent decay. New crown must be made - Radiographs were undiagnosable CAMBRA evaluation: - Pt is at HIGH RISK for caries

7. Radiographs

8. Clinical Examination Extra oral: WNL Intra oral: Slight attrition on lower anteriors Abrasion on #6, #11, #12, #21, #22, #27, #29 TMD Evaluation: Asymptomatic clicking on right TMJ Mandibular jaw slightly deviates to the right upon opening.

9. Oral Hygiene Evaluation Skill level: Poor Only brushes 1x a day and never flosses Knowledge of periodontal disease: Unaware Objective: Educate pt about the importance of stabilizing the present periodontal condition. Provide proper OH aids to best suit his needs. Aids: Demonstrated modified bass w/manual TB, proper flossing techniques SonicCare toothbrush, floss holder, Antimicrobial rinse. Barriers: Poor dexterity and motivation, lack of shelter, transportation and employment.

10. Indices

11. Pre Treatment

13. Pre Treatment PI: 81% MBI: 29%

14. Occlusal Evaluation Bilateral Class I molar and canine relationship 2mm overbite 1mm overjet

15. Periodontal Evaluation Calculus: Generalized medium-heavy tenacious calculus Plaque: Heavy Restorations: #8,#9,#10 ill-fitting margins Pocket depths: Generalized 3-4 mm w/localized 5-6 mm on posteriors and #8MB and #9 DB Mobility: + on teeth #7-11 and #23-27 Furcations: Buccal Class I #2,#3,#14,#15,#31,#30 Buccal Class II: #19

16. Periodontal Evaluation Gingival Description Marginal: Generalized smooth, Edematous and erythematic, rolled borders, and glossy Attached: Generalized Pigmented, fibrotic and stippled

17. Periodontal Evaluation Diagnosis: Generalized Chronic Moderate Periodontitis modified by smoking and perpetuated by plaque Prognosis: clinically = GOOD, however… non-compliance + smoking + stress + poor oral hygiene POOR

18. Treatment Plan 4 quads SRP w/ local anesthesia Re-evaluation in 4 weeks to assess completed treatment. Assess OH Emphasis on Smoking Cessation

19. Treatment Appointment #1 (12/03/09) Initial exam, FMX, intraoral photographs, full mouth probing, indices were taken, OHI, #10 PFM re-cemented by supervising dentist. Appointment #2 ( 12/10/09 ) Morning: Initiated smoking cessation, re-assessed OH – brushing & flossing, LLQ SRP w/ local anesthesia. Afternoon: ULQ SRP w/ local anesthesia

20. Treatment Appointment #3 (1/21/10) Morning: ULQ SRP w/ local anesthesia, re-enforce OH and smoking cessation. Afternoon: LLQ SRP w/local anesthesia, 2% NaF varnish was applied, CAMBRA Assessment, nutritional counseling Appointment #4 (2/18/10) Re-evaluation, full mouth probing, intraoral photographs, case study models, and indices were taken. Fine scaling to remove residual calculus.

21. Post Treatment Probing: Generalized 3-4 mm w/localized 5 mm on #8MB, #31DB, #17MD Gingival description: Marginal: Generalized pink, smooth, firm, rolled borders Attached: Generalized pigmented, fibrotic and stippled

22. Post Treatment

24. Post Treatment PI:18% MBI:9%

25. Post Treatment Patient consideration - Pt had a good understanding of the tx that was completed and was excited to participate. However, pt’s circumstances made it difficult to maintain compliance. - Complications during treatment: * Pt did not have cell phone or number for direct contact * Pt was dependant on friends driving him to and from appt * No Show on 2 appts.

26. Post Treatment Operator Considerations: - We did our best to reschedule broken appts - Provided pt with Sonicare TB as well as ACT daily fluoride rinse, and other OH aids so pt would not have to buy on their own. - It was difficult to attain the ideal resolution because pt was not compliant with smoking cessation & medical consults/check-ups.

27. Research Disease perpetuated & modified by smoking. –Evidence based research has shown that the prevalence and severity of periodontal disease is increased in smokers compared to non-smokers. –In an ex vivo study comparing non-smokers and smokers, it was suggested that smoking may influence the balance between T-helper cells 1 (Th1)/T-helper 2 (Th2) balance towards Th2, which results in a continuous B cell activation and less protective antibody production, leading to the progression and relapse of periodontal disease during Supportive Periodontal Therapy. ( Torres de Heens et al., 2008).

28. Research (cont’d) Obesity may be linked to an increase risk of periodontal disease due to the adipose-tissue-derived cytokines (tumor necrosis factor alpha, lentin, and interleukin 6 ) and hormones that will increase the pro-inflammatory response. (Pischon et al., 2007) Chronic periodontitis may play a role in elevating the serum level of anti-cardiolipin antibodies in hypertensive patients, resulting in a increased risk for atherosclerosis. (Turkoglu et al. 2008). Furthermore, the study suggest that both hypertension and chronic periodontitis may be related to exacerbating the other’s condition.

29. References Khader Y.S., Bawadi, H.A., Haroun, T.F., Alomari, M., Tayyem, R.F. (2009). The association between periodontal disease and obesity among adults in Jordan. Journal of Clinical Periodontology, 36, 18-24. Laxman, V., Annaji, S. (2008). Tobacco use and its effects on the periodontium and periodontal therapy. The Journal of Contemporary Dental Practice, 9(7), 2-11. Pischon, N., Heng, N., Bernimoulin, J.P., Kleber, B.M., Willich, S.N., Pischon, T. (2007). Obesity, inflammation, and periodontal disease. Journal of Dental Research, 86(5), 400-409. Torres de Heens, G.L., Kikkert, R., Aarden, L.A., van der Velden, U., Loos, B.G. (2009). Effects of smoking on the ex vivo cytokine production in periodontitis. Journal of Periodontal Research, 44, 28-34. Turkogu, O., Baris, N., Kutukculer, N., Senarslan, O., Guneri, S., Atilla, G. (2008). Evaluation of serum anti-cardiolipin and oxidized low-density lipoprotein levels in chronic periodontitis patients with essential hypertension. Journal of Periodontology, 79(2), 332-340.