Periodontal competency By Shirley Neuebaumer

Patient information 53 years old African American male Plays in a band Works as a billboard installer Single, no children Has medical but no dental insurance

Diagnosed with benign prostate hyperplasia in 2012 Medical history General health is good Non-smoker Diagnosed with benign prostate hyperplasia in 2012 Takes Terazosin every day No hospitalization history within the last 5 years and no major surgeries Last medical exam was January 2014 for regular check-up. No significant findings. Vitals: Pulse: 90 Resp: 18 BP: 132/79 Pre-hypertensive

Dental history Goes to the dentist irregularly. Had a “deep cleaning” before. Had an extensive amalgam fillings. FMX taken on 3/2013 Learning ladder: Unaware- did not know that plaque causes cavities.

Oral hygiene practices Brushes 1x per day using Colgate Total using a manual toothbrush Does not floss because said he’s lazy. Uses Listerine mouthwash 1x per day.

Initial assessments For MM

Physiologic pigmentation of the gingiva E/I exam Physiologic pigmentation of the gingiva Bilateral linea alba adjacent to the molars only Geographic tongue Possible sleep apnea due to enlarged tongue, very difficult to see oropharynx

Contour– rounded margins on lower anteriors Gingival description Color—pigmented Consistency—boggy Contour– rounded margins on lower anteriors Texture– smooth and stippled Papilla— flat between 3 and 6, blunted between #23-27, bulbous on buccal and lingual of mandibular anteriors. Heavy plaque on IP of posteriors Moderate inflammation Calculus class 5 and AAP 2

High caries risk due to current decay BANA test: positive Saliva pH: 7 Other tests Plaque index: 1.67 (Fair) DMFT: 22 (D=3, M=0, F=19) High caries risk due to current decay BANA test: positive Saliva pH: 7 Low salivary flow at 5ml

Heavy mouth breather = fogged mirror 6mm anterior open bite Occlusion Severe open bite resulting in difficulty in chewing. Patient stated he has to cut most foods and push it inside his mouth or he has to bite large chunks of food in order to be able to chew it. Only 3rd and 2nd molars occlude (1 and 32, 2 and 31, 15 and 18 and 16 and 17). Heavy mouth breather = fogged mirror 6mm anterior open bite 4mm posterior open bite

Radiographs

Caries Exam & Radiographic interpretation Suspicious caries found on: 1-O 8-M 9-M 13-D Slight horizontal bone loss Calculus present: 20D, 19D, 18M, 24M, 28D, 32M Tooth #4 has retained root tip

Periodontal exam

Treatment Plan Periodontal risk: high PD range 2-6 mm Assessment Findings Goals (Pt./client centered) Expected outcomes (evaluation methods, time frame) Periodontal risk: high PD range 2-6 mm Moderate inflammation on lower anteriors Moderate supra calculus on lingual of lower anteriors Heavy subgingival calculus moderate plaque on posterior teeth BOP Recession Pt. will learn Bass TB technique. Pt. will learn C-shape flossing. Patient will understand the link btw plaque and periodontal disease. Pt. will understand the benefits of antimicrobial rinses. Patient will learn how to use gum stimulator.   Pt. demonstrates Bass TB technique Pt. demonstrates C-shape flossing. Pt. explains the link btw plaque and periodontal disease. Pt. reports using antimicrobial rinses daily Patient reports using gum stimulator at least 1x per day. Caries risk: high Suspicious caries #1-O, 8M, 9M, 13D Pt. will understand the link btw plaque and caries formation. Pt. will understand the benefits of topical fluoride Pt. explains the link btw plaque and caries formation. Pt. explains the benefits of topical fluoride

Treatment plan by appointments Appt. # Plan for education, OHI, counseling Area Plan for treatment & services 1 OHI: Bass technique Educate on plaque biofilm and periodontal disease FM Complete Assessments, disclose, OHI 2 Review Bass technique Check-in assessments, photos, complete perio competency assessments, OHI 3   18-24 Update assessments, Topical, Administered Lidocaine 2% with epinephrine, Chlorhexidine pre-procedural rise, scaled 18-24 for Mock Board using hand instruments and USS. 4 OHI: C-shape flossing 25-31 Update assessments, OHI, Topical, Administered Lidocaine 2% with epinephrine, Chlorhexidine pre-procedural rise, scaled 25-31 for Test Case using hand instruments and USS. 5 Review C-shape flossing Educate on benefits of frequent topical fluoride application 32, 31, 27, 26, 22, 20, 18, 1-5 Update assessments, OHI, chlorhexidine pre-procedural rinse, Topical, Lidocaine 2% with epinephrine, scaled residual calculus from Test case and Mock Board, scaled 32 and 1-5 using hand instruments and USS. 6 OHI: Gum stimulator 6-16 Update assessments, OHI, chlorhexidine pre-procedural rinse, Topical, Lidocaine 2% with epinephrine, scale using hand instruments and USS.

Nutritional analysis

MM’s food Diary

Re-evaluation

Periodontal Assessment High periodontal risk: PD range 2-6 mm Moderate inflammation on lower anteriors Moderate supra on lingual of lower anteriors light subgingival calculus Light to moderate plaque on posterior teeth BOP NOTE: Patient stated that he was brushing and flossing more when I was seeing him consistently almost every Tuesday.

Periodontal exam

Comparison

Photos Pre-treatment Post-treatment

Photos Pre-treatment Post-treatment

Photos Pre-treatment Post-treatment

The success of any dental treatments depend heavily on home care. Reflection The success of any dental treatments depend heavily on home care. Changing behavior is hard but having continued discussion with patients do make an impact. Time management- always be prepared. In clinic, setting the right expectations is critical.

MALOCCUSION AND PERIODONTAL DISEASE Research MALOCCUSION AND PERIODONTAL DISEASE Malocclusion is any deviation from the normal relationship of the maxillary arch to the mandibular arch. Anterior open bite is a type of malocclusion characterized by a deviation in vertical relationship between maxillary and mandibular dental arches resulting in the absence of contact between the incisal edges of both dental arches.

Anterior open bite may be caused by: Prolonged thumb sucking Etiology Anterior open bite may be caused by: Prolonged thumb sucking Tongue thrusting Poor teeth position Skeletal deformities Classification of anterior open bite: dental or skeletal Correct diagnosis is critical since each classifications have different treatment modalities ranging from orthodontics alone or in combination with orthognathic surgery.

Dental Malocclusion Classified similar to Angle’s method of malocclusion classification. This is malocclusion involving poor teeth position. POSSIBLE CAUSES: Posterior teeth erupt too far or if anterior teeth erupt too little Prolonged thumb sucking Tongue thrusting This type of malocclusion are generally fixed by orthodontics.

Skeletal Malocclusion This exists when the problem is caused by the position of the jaws relative to one another. Multifactorial etiology Classifications: horizontal, transverse and vertical planes. Horizontal malocclusions are classified as Class II or Class III malocclusions similar to Angle’s classification. Vertical malocclusions include open bites and severe overbites Transverse malocclusions include crossbites. Treatment includes both orthodontics or orthognathic surgery.

Effects of malocclusion to quality of life A study done in Wonkwang University dental hospital and six private clinics in Korea aimed to evaluate the effect of malocclusion on oral health quality of life in adults. 860 participants were divided into four groups: normal occlusion, malocclusion, fixed treatment and retention. Normal occlusion and malocclusion classification were decided clinically for adults visiting the hospital and clinics who had not received previous orthodontic treatment. The classification was based on the alignment of the anterior teeth and the degree of lip protrusion. The participants were asked to complete a questionnaire assessing how frequently they experience functional limitation, physical pain, psychological and social disability and handicap.

Results The malocclusion group perceived the strongest psychosocial impact related to esthetics.

Darby M, Walsh M. Dental hygiene theory and practice References Darby M, Walsh M. Dental hygiene theory and practice Choi, S., Kim, B., Cha, J., & Hwang, C. Impact of malocclusion and common oral diseases on oral health–related quality of life in young adults. Am Journal Of Orthodontics & Dentofacial Orthopedics [Internet]. 2014 Apr [cited 2015 May 1]; 147(5). Available from: http://library.foothill.edu:2206/ehost/pdfviewer/pdfviewer?sid=a2ef8c3 e-17f2-43b3-be25-cdb08bcbf493%40sessionmgr111&vid=32&hid=119 Geron, S., Wasserstein, A., & Geron, Z. Stability of anterior open bite correction of adults treated with lingual appliances. European Journal Of Orthodontics [Internet]. 2013 Oct[cited 2015 May 1]; 35(5), 599-603. Available from: http://library.foothill.edu:2206/ehost/pdfviewer/pdfviewer?sid=a2ef8c3 e-17f2-43b3-be25-cdb08bcbf493%40sessionmgr111&vid=32&hid=119