1. Periodontal competency
By Shirley Neuebaumer

2. 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

3. 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

4. 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.

5. 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.

6. Initial assessments
For MM

7. 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

8. 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

9. 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

10. 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

11. Radiographs

12. 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

13. Periodontal exam

14. 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

15. 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 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 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.

16. Nutritional analysis

17. MM’s food Diary

18. Re-evaluation

19. 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.

20. Periodontal exam

21. Comparison

22. Photos
Pre-treatment
Post-treatment

23. Photos
Pre-treatment
Post-treatment

24. Photos
Pre-treatment
Post-treatment

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

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

32. 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] Apr [cited 2015 May 1]; 147(5). Available from: 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] Oct[cited 2015 May 1]; 35(5), Available from: e-17f2-43b3-be25-cdb08bcbf493%40sessionmgr111&vid=32&hid=119