Christina Tulloch NC Case PERI 329

Patient Case, Nancy Carp Worksheet

Part 1
Name: Christina Tulloch

Task 1 – Provide Medical Contraindications and/or Precautions to Dental

Treatment

Systemic diseases/conditions: Diabetes (strong link to oral health), HTN (monitor at

appts, use local w/epi and cord w/epi with caution)
Medications: Daily aspirin, monitor bleeding during tx
Antibiotic prophylaxis: Not indicated for joint replacement (Jan 2015 ADA clinical
practice guideline) but need to ascertain if there’s a history of joint infection.
Stress/anxiety management: “Afraid of dentist”, Hx of trauma and tooth loss at early
age, has not been to dentist in 20 years. Strong need for dental anxiety management.
Vital signs: WNL
Chemistry: HbA1c is WNL for diabetic, non-fasting BG is WNL for diabetic
Other: Possibly postmenopausal (has bearing on alveolar bone levels), her race is a
factor in increasing likelihood of certain oral conditions, moderate caries risk (ADA CRA
form), Allergic to PCN (hives), medications may be causing xerostomia, or orthostatic
hypotension.

Task 2 – Provide Gingival Description

Sextant Gingival Description

Gen physiological pigmentation, gen rolled marginal tissue, gen bulbous
1
papillae, gen mod edematous, loc slight erythematous
Gen physiological pigmentation, prominent stippling (lost on marginal
2 tissue), gen rolled marginal tissue, gen blunted papillae, gen mod
edematous
Gen physiological pigmentation, gen rolled marginal tissue, gen bulbous
3
papillae, gen mod edematous, loc slight erythematous
Gen physiological pigmentation, gen rolled marginal tissue, gen blunted
4
papillae, gen mod edematous
Gen physiological pigmentation, prominent stippling (lost on marginal
5 tissue), gen rolled marginal tissue, gen blunted papillae, gen mod
edematous
Gen physiological pigmentation, gen rolled marginal tissue, gen blunted
6
papillae, gen mod edematous
Christina Tulloch NC Case PERI 329

Task 3 – Provide Radiographic Interpretation

Sextant Radiographic Interpretation

#4M caries, gen mod HBL, loc VBL #3M, #4M, #5M, gen widened PDLs,
1
gen 1:1.5 CR ratio, gen calc.
Gen mod HBL, loc ridge collapse, gen widened PDLs, gen 1:1 CR ratio,
2
gen calc.
Gen mod HBL, loc VBL #13M, #13D, gen widened PDLs, gen 1:1.5 CR
3
ratio, gen calc.
Gen mod HBL, loc VBL #18D, #19D, gen widened PDLs, gen 1:1.5 CR
4
ratio, gen calc.
Gen mod HBL, gen widened PDLs, gen 1:1 CR ratio for centrals, 1:15 CR
5
ratio for laterals and canines, gen calc.
Gen mod HBL, loc VBL #29M, gen widened PDLs, gen 1:1.5 CR ratio, gen
6
calc.

Task 4 – Provide Diagnoses

Sextant Diagnoses
Decay #4M, gen moderate loc severe chronic periodontitis (gen stage III
1
grade B periodontitis)
Gen moderate chronic periodontitis (gen stage II, loc stage III grade B
2
periodontitis)
3 Gen moderate chronic periodontitis (gen stage III grade B periodontitis)
Decay #21B, gen moderate loc severe chronic periodontitis (gen stage III
4
grade B periodontitis)
5 Gen slight chronic periodontitis (gen stage I grade B periodontitis)
6 Gen severe chronic periodontitis (gen stage III grade B periodontitis)

Task 5 – Provide Etiologies and Risks for Oral Diseases

Sextant Etiologies and Risks for Oral Diseases

Gen Plaque, gen calculus, loc angular bone loss and excessive occl forces
1
(see Task 3)
Gen Plaque, gen calculus, loc ridge collapse and excessive occl forces
2
(see Task 3)
Gen Plaque, gen calculus, #13 D amalgam overhang, loc angular bone
3
loss and excessive occl forces (see Task 3)
Gen Plaque, gen calculus, loc angular bone loss, loc gingival hyperplasia
4
#18 DL, and excessive occl forces (see Task 3)
5 Gen Plaque, gen calculus, and excessive occl forces (see Task 3)
Gen Plaque, gen calculus, loc angular bone loss and excessive occl forces
6
(see Task 3)

What if… (Scenario 1)

NC had a heart valve replacement (3 years ago)
 Does she need premedication?
Yes, prosthetic valves have been indicated as an evidence-based qualifier for
antibiotic prophylaxis prior to dental treatment.
Christina Tulloch NC Case PERI 329

 What are the indications for prophylaxis?

Artificial heart valve patients have an elevated risk of IE. Antibiotic prophylaxis is
indicated prior to dental treatment, as its benefits outweigh side effects in these
patients.

 If you were going to prescribe pre-medication, what would you prescribe? Give
medication, dosage and regimen.
Due to PCN allergy (hives), Rx: Clindamycin 600 mg taken 1 hr prior to dental
treatment.

What if… (Scenario 2)

NC took Plavix or Coumadin
 How do these drugs work?
These drugs are antiplatelet and anticoagulant respectively. They decrease the
clotting ability of the blood, and reduce the likelihood of clotting-associated emergencies,
such as stroke or MI.
 Would the use of these drugs impact patient management? If so, how?
These drugs can increase the likelihood of intraoperative and post-operative
bleeding complications. Patients would need to work with their prescribing physician to
determine if dental treatment is contraindicated. Often, these medications are briefly
discontinued preoperatively, peroperatively, and briefly postoperatively. INR values are
verified by a lab one to two days maximum before the dental appt. NSAIDs and Aspirin
would be contraindicated for these patients unless prescribed by a physician.

What if… (Scenario 3)

NC had the following blood chemistry
 Plasma glucose concentration (non-fasting) - 180 mg/dl
Non-fasting levels of 180mg/dl are indicative of hyperglycemia and poor glycemic
control. One would anticipate progression of her diabetes and systemic effects on
organs. In the oral cavity, her periodontal disease would likely worsen at a faster rate
than her normoglycemic counterparts.
 HbA1c – 9.8%
An HbA1c over 7% is indicative hyperglycemia and poor glycemic control. One would
anticipate progression of her diabetes and systemic effects on organs. In the oral cavity,
her periodontal disease would likely worsen at a faster rate than her normoglycemic
counterparts. One may also reason, from scientific evidence, her existing periodontal
infection is contributing to her poor glycemic control.
 Would this impact patient management? If so, how?
Diabetic patients with periodontal concerns should be managed on a more frequent
recall schedule. It is important to work with the patient and her endocrinologist to meet
HbA1c goals. Diabetics are best seen in the morning, and stress reduction is very
important for these patients. It is important that the patient receives nutritional counseling
as well as OHI, and for the dental provider to ascertain the patient’s level of control over
their disease (do they know what their BG normally is, do they test BG regularly at
home, have they had any recent crises, etc.)

What if... (Scenario 4)

NC’s blood pressure was 160/90
 What is the current classification for a blood pressure of 160/90?
Stage II HTN
Christina Tulloch NC Case PERI 329

 Would this blood pressure impact patient management? If so, how?

According to VCU SoD’s Clinic Manual, this reading would not preclude a patient
from receiving treatment. Benefits and risks would be weighed, and it would be
the decision of the provider on whether to postpone treatment or to proceed. If
proceeding with treatment, blood pressure should be measured intraoperatively,
stressors kept to a minimum, and patients with uncontrolled HTN should not be
exposed to gingival cord or local anesthesia that contains epinephrine.

What if… (Scenario 5)

The gingiva had these appearances.
 How would you describe the gingiva in terms of color, contour, and consistency
for clinical photographs (A-D)?

Gingival Description
A Gen bluish-red, gen rolled marginal tissue with gen spongy papillary tissue
Gen erythematous, gen edematous, gen rolled marginal tissue and
B
bulbous papillary tissue.
C Gen pink with loc erythematous, firm, knife-edge papillary tissue.
D Gen erythematous, gen edematous, gen papillary gingival hyperplasia.

What if... (Scenario 6)

Osseous defects had these appearances.
 How would you describe the osseous defect (A-C)?

Osseous Defects
A Gen mod HBL with loc severe VBL #5 distal (3 wall defect)
B Gen mod HBL with loc severe VBL #21 D (2 wall defect)
C Loc severe VBL #11D and #12 M (interproximal osseous crater)

What if... (Scenario 7)

A 30 year old patient had this clinical presentation.
 What type of periodontal disease does this patient have?
Molar/incisor (localized) stage III Grade C periodontitis aka localized juvenile
(aggressive) periodontitis

What if… (Scenario 8)

Mucogingival defects had these appearances.
 How would you describe the mucogingival defects (A-D)?

Mucogingival Defects
A Miller Class I #27 F #25 F
B Miller Class I #24 F, #25 F, #26 F, Miller Class II #22 F, #23 F, #27 F
C Miller Class III #24 F, #25 F
D Miller Class II #6 F
Christina Tulloch NC Case PERI 329

Part 2
Task 6 – Provide Prognoses

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Restorability - - - Y - - - - - - - - - - -

Periodontal P P P P P P F F F P P P P P P

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Restorability - - - - - - - - - - - Y - - - -

Periodontal P P P F F F F F F F F F P P P P

Task 7 – Provide Treatment Plan

1. D4341 UR AND LR W/ D2392 #4-MO COMPOSITE

2. D4341 UL AND LL W/ D2330 #21-B COMPOSITE (W/ OCCL ADJ D9951 #12?)
3. EIT, IMPRESS FOR D9944 IF SHOWING IMPROVEMENT IN INFLAMMATION
AND PD
4. DELIVER OCCL GUARD IF FABRICATED
5. TO ACHIEVE PERIO STABILITY, MAY REFER TO PERIODONTIST FOR EVAL,
POSSIBLE OSSEOUS SURGERY
6. POSSIBLE PROST OR OMFS REFERAL FOR #9 IMPLANT AND EXT 3RD
MOLARS

Task 8 – Provide Gingival Description

Sextant Gingival Description

Gen physiological pigmentation, gen firm tissue, loc erythematous, loc
1
slight edematous, loc blunted papillae
Gen physiological pigmentation, prominent gen stippling, gen firm tissue,
2
loc erythematous, gen blunted papillae
Gen physiological pigmentation, gen firm tissue, loc erythematous, loc
3
slight edematous, gen blunted papillae
Gen physiological pigmentation, gen firm tissue, loc erythematous, loc
4
slight edematous, gen blunted papillae
5 Gen physiological pigmentation, gen firm tissue, gen blunted papillae
Gen physiological pigmentation, gen firm tissue, loc erythematous, loc
6
slight edematous, loc blunted papillae
Christina Tulloch NC Case PERI 329

Task 9 – Provide Diagnoses

Sextant Diagnoses
1 Gen moderate loc severe periodontitis (gen grade III stage B periodontitis)
Gen moderate periodontitis (gen stage II, loc stage III grade B
2
periodontitis)
3 Gen moderate periodontitis (gen stage III grade B periodontitis)
Gen moderate periodontitis (gen stage II, loc stage III grade B
4
periodontitis)
5 Gen slight periodontitis (gen stage I grade B periodontitis)
6 Gen severe periodontitis (gen stage III grade B periodontitis)

Task 10 – Provide Etiologies and Risks for Oral Diseases

Sextant Etiologies and Risks for Oral Diseases

1 Loc plaque, loc calc, loc angular bone loss and excessive occl forces
2 Loc plaque, loc calc, loc ridge collapse and excessive occl forces
Loc plaque, loc calc, #13-D amalgam overhang, loc angular bone loss and
3
excessive occl forces
Plaque not completely charted, loc calc, loc angular bone loss and
4
excessive occl forces
5 Plaque not completely charted, excessive occl forces
Plaque not completely charted, loc calc, loc angular bone loss and
6
excessive occl forces

Task 11 – Provide Prognoses

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Restorability - - - - - - - - - - - - - - -

Periodontal P P P P P F F F F F P P P P P

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Restorability - - - - - - - - - - - - - - - -

Periodontal P P P F F F F F F F F P P P P
P
Christina Tulloch NC Case PERI 329

Task 12 –Treatment Plan

1. REFER TO PERIODONTIST FOR OSSEOUS SURGERY (D4260 UR, UL, LR,
LL) W/ RP (D4240 UR, UL, LR, LL) AND REFER FOR D7210 (3RD MOLARS) IF
NOT ALREADY COMPLETED
2. POST-OP EVAL WITH PERIODONTIST AFTER 1-2 WEEKS
3. 1-2 MONTH POST-OP EVAL WITH PERIODONTIST
4. ALTERNATE 3MRC WITH PERIODONTIST

Task 13 – Provide Gingival Description

Sextant Gingival Description

Gen physiological pigmentation, gen firm tissue, gen blunted papillae, gen
1
erythematous (surgical healing areas)
Gen physiological pigmentation, prominent gen stippling, gen firm tissue,
2
gen blunted papillae
Gen physiological pigmentation, gen firm tissue, gen erythematous
3
(surgical healing areas), gen blunted papillae
Gen physiological pigmentation, gen firm tissue, gen erythematous
4
(surgical healing areas), gen blunted papillae
Gen physiological pigmentation, prominent gen stippling, gen firm tissue,
5
gen blunted papillae
Gen physiological pigmentation, gen firm tissue, gen erythematous
6
(surgical healing areas), loc slight edematous, gen blunted papillae

Task 14 – Provide Diagnoses

Sextant Diagnoses
1 Gen moderate loc severe periodontitis (gen grade III stage B periodontitis)
2 Gen moderate periodontitis (gen stage II grade B periodontitis)
3 Gen moderate periodontitis (gen stage III grade B periodontitis)
4 Gen moderate periodontitis (gen stage III grade B periodontitis)
5 Gen slight periodontitis (gen stage I grade B periodontitis)
6 Gen severe periodontitis (gen stage III grade B periodontitis)

Task 15 – Provide Etiologies and Risks for Oral Diseases

Sextant Etiologies and Risks for Oral Diseases

1 Loc plaque, loc calc, excessive occl forces
2 Loc plaque, loc calc, loc ridge collapse and excessive occl forces
3 Loc plaque, loc calc, #13-D amalgam overhang, excessive occl forces
4 Loc plaque, excessive occl forces
5 Loc plaque, loc calc, excessive occl forces
6 Loc plaque, excessive occl forces
Christina Tulloch NC Case PERI 329

Task 16 – Provide Prognoses

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Restorability - - - - - - - - - - - - -

Periodontal P F F F F F F F F F F F F

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Restorability - - - - - - - - - - - - - -

Periodontal F P P F F F F F F F F F F F

Task 17 –Treatment Plan

What if… (Scenario 9)

NC had the following intra-oral findings at EIT
 Intra-oral findings
– Marginal and papillary tissues - erythema and edema
– Supragingival and subgingival calculus detected
– Plaque index (% surfaces plaque free) - 10%
– PD ranged from 2-7 mm with 38% ≥ 4 mm
– CAL ranged from 1-5 mm with 10% ≥ 4 mm
– BOP - 80% of the sites
 Would these findings modify your management of the patient? If so, how?
Would heighten the urgency for referral to periodontist, may also indicate usage
for chemotherapeutics in conjunction with proceeding surgical periodontal
treatment. Would change prognosis for many teeth from F/P to H.

What if… (Scenario 10)

NC had the following intra-oral findings, quadrant 4, at EIT
 Intra-oral findings, quadrant 4
– Marginal and papillary tissues firm and pink with localized erythema and
edema at tooth #19 mesial
– Supragingival and subgingival calculus - none detected
– Plaque index (% surfaces plaque free) - 86%
– PD < 3 mm except tooth #19 mesial 6 mm
– CAL < 5 mm, tooth #19 mesial 5 mm
Christina Tulloch NC Case PERI 329

– BOP - tooth #19 mesial and lingual

 Would these findings modify your management of this quadrant? If so, how?
These findings may indicate the necessity for GTR (D4263, D4266, etc.) if a
qualifying vertical defect is found during surgical therapy. Or, if this is an
isolated site, a D4381 may be attempted in this site before surgical
measures are attempted, knowing only moderate outcome would be
expected.

 What is the evaluation interval?

For D4381, eval should occur after 1-2 months; GTR after 1-2 week, and
again at 1-2 months

 What is the recommended if these findings persist? See above

What if… (Scenario 11)

Procedure Description Site Surface Phase Sequence

Extraction x2 w/ #30, #32 Urgent 1
Restoration (to minimize anes & appts) #31 O
Extraction w/ #19 Urgent 2 (eval visit 1
Restoration (to minimize anes & appts) #18 O at this appt)
Nutritional Counseling, OHI, Prevident ODCT 1, 2, 3, 4, 5

SCRP LL & UL (would restore #18 at this LL, UL ODCT 3 (eval visit 2
appt if not done at earlier appts) at this appt)

SCRP UR & LR (would restore #31 at this LR, UR ODCT 4

Christina Tulloch NC Case PERI 329

time if not done at earlier appts)

EIT ODCT 5

ODCT Complete, Place on 3MRC Eval