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Case

Study
Created and Presented by
Beth Powlison DH2

Rationale
 During

her initial assessments Teresa
presented as a Periodontal Case Type IV,
Generalized Severe Periodontitis
patient. In addition to attachment loss,
Teresa also exhibited generalized heavy
root surface calculus and was
characterized as a 4 sub. Teresa has 21
teeth with extensive bridge and crown
work.
 NSPT was completed on 3/2/2015

Appointment #1: 1/30/2015

Pretreatment Assessments
 History

of cold sores, arthritis in hands, thyroid
radiation in 1999, quit tobacco 35 years ago.
 Medications: levothyroxine, multi-vitamin,
calcium, oregano & magnesium.
 Allergic to latex & injectable iodine
 Blood pressure readings ranged between 90/57136/80 over the period of 4 months.
 Heart rate was typically in the mid-60’s.
 Intra-Extra Oral findings were within normal
limits.
 Microscope Risk Factor C with high quantities of
highly motile spinning rods, gliding rods and
spirochetes.

Appointment #1: 1/30/2015

Full Mouth Series

Appointment #1: 1/30/2015

Periodontal Chart

Appointment #1: 1/30/2015

Dental Chart
As the dental chart
demonstrates,
Teresa will require
a full metal crown
on #19 and a
prefabricated resin
crown on #25 in
the future. #19 is
a current crown
that needs
replaced and #25
is a previous root
canal that is
discolored.

Appointment #1: 1/30/2015

Pre-Treatment Model

Appointment #1: 1/30/2015

Pre-Treatment Photographs:
Maxilla

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Appointment #1: 1/30/2015

Pre-Treatment Photographs: Mandible

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Appointment #1: 1/30/2015

Dental Hygiene Diagnosis

Case Type IV, Generalized Severe Periodontitis

Generalized severe horizontal bone loss with
localized severe vertical bone loss on #19 & #30

Deposit Evaluation 2.5/4

Tissue Color: generalized slight hyperemic

Tissue Contour: generalized slight enlarged;
generalized moderate recession

Tissue Consistency: generalized slight fibrotic

Appointment #1: 1/30/2015

Risk Assessment
 Periodontal

Risk Factors included irregular dental care,
root exposure, dental biofilm, and calculus.

 Caries

Risk Factors included root exposure, dental biofilm,
calculus, and crowns and a bridge.

 The

patient’s goal was to get her teeth cleaned and get
back into a routine of going to the dentist.

 The

interventions included NSPT, OHI involving sulcular
brushing, c-shaped flossing, xylitol gum, superfloss and an
interdental brush.

 Expected

outcomes included reduced bleeding pointing
during probing, reduced plaque biofilm, reduced calculus,
and reduced pocket depths.

Appointment #1: 1/30/2015

Treatment Plan
Appointment #1: Comprehensive Oral
Evaluation, Full Mouth Series, OHI, and Intraoral
Photos
 Appointment #2: OHI, Perio Scaling UR
 Appointment #3: OHI, Perio Scaling LL & UL
 Appointment #4: OHI, Perio Scaling LR, Topical
Application of Fluoride Varnish

This treatment plan was based off of the
patient’s need for NSPT because of her level of
CAL, root surface calculus and inflammation.
After presenting this treatment plan to the
patient she felt comfortable with the plan to
carry out her treatment.

Appointment #2: 2/2015

Treatment Progress Notes
 SERVICES

PROVIDED/COMPLETED: OHI, Perio Scaling UR, Arrestin
placement on #5ML & #6ML
 DENTAL CONCERNS: All teeth are a bit sore
 IMPLEMENTATION OF CARE
     Techniques Used: Ultra-Sonic, Hand-Scaled
     Local Anesthesia:
         I: #3 Local Infiltration, R. MSA, R. AMSA, L. MSA, L. AMSA
        T: Articaine 4% 1:100,000 Epi; Benzocaine 20% Topical
        A: 2 1/2 cartridges altogether
        C: Patient tolerated anesthesia very well, profound
anesthesia was established
 HARD/SOFT DEPOSITS: Generalized heavy calculus on all root
surfaces
 BLEEDING: Generalized moderate bleeding upon scaling
 MEDICAMENTS: Arrestin placement on #5ML, #6 ML
COMMENTS: Discussed using a warm salt water rinse with patient
along with gentle brushing, optional use of tylenol or ibuprofen,
and abstaining from spicy and crunchy foods
PARQ

Appointment #3: 2/17/2015

Treatment Progress Notes Cont.
SERVICES PROVIDED/COMPLETED: OHI, NSPT #13-#15, LL Quad NSPT, Gingival
Curettage on #13-#15, #18, #19, #21, intraoral photos.
 EVALUATION OF PREVIOUSLY DEBRIDED AREAS: UR Quad + #11-#12
Client compliance with OHI: Sulcular brushing twice a day; gums used to bleed
when brushing, now they don`t; flosses once a day; uses interdental brush twice
a day and loves it.
Bleeding: gen slight
Location and extent of plaque: gen slight interproximal
Inflammation: gen slight marginal/papillary
Remaining Deposits: None
Home Care Modifications: Use interdental brush from the lingual also, tell-showdo
 IMPLEMENTATION OF CARE
     Techniques Used: Ultra-sonic, hand scale, gingival curettage on #13-#15 and
#18, #19 & #21
     Local Anesthesia:
        I: L. PSA, L. MSA, L. GP, L. IA,  L. LB
        T: Lidocaine 2% 1:100,000 Epi; Articaine 4% 1:100,000 Epi; Benzocaine
20% Topical
        A: Lidocaine- 1 cartridge, Articaine- 1 cartridge
        C: None
     HARD/SOFT DEPOSITS: Generalized heavy calculus
     BLEEDING: Generalized severe bleeding
     MEDICAMENTS: None

Appointment #4: 3/2/2015

Treatment Progress Notes Cont.
SERVICES PROVIDED/COMPLETED: OHI, NSPT LR
DENTAL CONCERNS: #25 is sensitive when brushing due to the "movement of the
tooth" 
RADIOGRAPHS: 2 indirect BWS to evaluate root deposits; no charge to the patient
EVALUATION OF PREVIOUSLY DEBRIDED AREAS:
    Client compliance with OHI: Brushing twice a day, uses interdental brush
twice a day from outside-in and inside-out, flossing once daily. 
    Bleeding: None
    Location and extent of plaque: Generalized slight interproximal
    Inflammation: Generalized slight marginal/papillary
    Remaining Deposits: None
    Home Care Modifications: Use the smaller interdental brush in the smaller
embrasures from the lingual, mainly between #14 & #15; dip brush in hydrogen
peroxide and baking soda before use; rinse with diluted hydrogen peroxide; maybe
try a waterpik with diluted hydrogen peroxide
 IMPLEMENTATION OF CARE
     Techniques Used: Ultra sonic, hand scaling, polish 
     Local Anesthesia:
         I: R. IA & R. LB
        T: Lidocaine 2% 1:100,000 Epi; Benzocaine 20% Topical
       A: 1 cartridge
        C: None       
     HARD/SOFT DEPOSITS: Generalize heavy root calculus
     BLEEDING: Generalized moderate bleeding upon scaling
     MEDICAMENTS: Fluoride Varnish 5%

Before & After
Pre-NSPT

Pre-NSPT

Post-NSPT

Post-NSPT

Notice the difference in
the root surfaces
between the pre-NSPT
and post-NSPT
bitewings. As made
evident by these
radiographs, the root
surface is much
smoother after NSPT
allowing the junctional
epithelium to better
attach to the root
surface.

DATE

Post Treatment Photographs:
Maxilla

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Appointment #4: 3/2/2015

Post Treatment Photographs: Mandible

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Oral Hygiene Instruction
 Initial

Recommendations: Sulcular Brushing, cshaped flossing, interdental brush, xylitol gum, &
superfloss.
 Patient Compliance: Patient did well with sulcular
brushing, but wasn’t consistent with interdental
cleaning.
 Modifications to OHI: I asked the patient to focus
on using just the interdental brush once daily
instead of floss due to her crowns, bridge, and
large gingival embrasures.
 Patient Compliance to modifications: Patient
performs sulcular brushing twice daily, flosses
once daily and uses the interdental brush twice
daily.

Motivation Strategies
 Extrinsic:

Teresa was motivated to perform
OHI because she had experienced pain,
discomfort and bleeding. She was motivated
to improve her OHI in order to prevent these
unpleasant symptoms in the future along
with saving money on future restorations.
 Intrinsic: Teresa did not demonstrate a lot of
intrinsic motivators.
 OHI: Motivating Teresa to begin performing
adequate OHI was easy because of the
external motivators of pain, bleeding and
money.

Appointment #5: 5/26/2015

Continuing Care Appointment
Case Type IV, Generalized Severe Periodontitis
 Deposit Evaluation: 1.5/2
 MICROSCOPE:  Risk factor C
 OHI: Patient was compliant with sulcular brushing twice daily and using
the interdental brush twice daily.
 OHI Modifications: Use the interdental brush with water, peroxide, baking
soda mixture once daily, use super floss under the bridge once daily,
recommended purchase of waterpik with use of diluted peroxide 
 Tissue Color: generalized slight hyperemic
 Tissue Contour: generalized slight enlarged
 Tissue Consistency: generalized slight edematous

Treatment Plan: OHI, Limited Exam, Perio Maintenance, Arestin #29 ML,
#15 DL, Fluoride Varnish 5%

Patient Motivation: Teresa’s motivation remained the same except with
the added addition of wanting to improve pocket depths even further to
prevent having to see a periodontist.

No additional dental chart entries were made.

  

Continuing Care Appointment:
5/26/2015

Periodontal Chart

Continuing Care: 5/26/2015

Continuing Care Photographs: Maxilla

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Appointment #5: 5/26/2015

Continuing Care Photographs: Mandible

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Appointment #5: 5/26/2015

Continuing Care Outcomes
 Overall,

the expectations from the initial
treatment plan were met including
reducing bleeding points during probing,
reducing pocket depths, reducing dental
plaque biofilm, and reducing root
surface calculus. Unfortunately, even
though progress was made we still
made a referral for Teresa to visit a
periodontitis due to the remaining
attachment loss and recession.

Comparison
NSPT
Appointments
Case Type IV
 Deposit: 2.5/4
 Bleeding Sites: 21
 Probing Depths
above 3mm: 50

OHI Recommendation:
sulcular brushing twice
daily, c-shaped
flossing once daily,
interdental brush once
daily, superfloss for
bridge.

Continuing Care
Case

Type IV
Deposit: 1.5/1.5
Bleeding Sites: 12
Probing Depths above
3mm: 36
OHI

Results: Inflammation was
reduced from severe to slight,
however, there was still a high
amount of bacteria shown on the
microscope slide. I further
recommended using a water,
peroxide, baking soda paste with
the interdental brush once daily
and using a waterpik once daily
with a diluted hydrogen peroxide
solution to decrease the level of
bacteria in the deep pockets.