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

2. 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.

3. Case Presentation
Initial assessment

4. 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

5. 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.

6. 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.

7. 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

8. 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

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

10. Pre-treatment intraoral photos
Right Buccal
Left Buccal

11. Pre-treatment Intraoral photos
Maxillary Occlusal
Mandibular Occlusal

12. Pre-Treatment Intraoral Photograph
Mandibular Anterior Lingual

13. 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

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

15. 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.

16. 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

17. Radiographs
December 6, 2016 taken at FHDHC.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. Case Presentation
Re-Evaluation Assessments

25. 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

26. 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)

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

28. 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

29. PD Comparison

30. CAL Comparison

31. Post-treatment intraoral Photos
Pre-Treatment
Post-Treatment

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

33. Post-Treatment intraoral photos
Pre-Treatment
Post-Treatment

34. Post-treatment Intraoral photographs
Pre-Treatment
Post-Treatment

35. 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

36. 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

37. 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

38. 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.

39. 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.

40. 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.

41. Research
Local Contributing factors of periodontal disease

42. 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

43. 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*

44. 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.

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

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

47. 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.

48. 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.

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