Periodontal Case Study

BY: HELENA YOSHIMURA

Section 1: Patient Information

 Profile: Patient is 30 years old and works long hours as a truck driver. He has
never been to the dentist before
 Chief concern: Worried that he should get teeth checked since it’s been so
long
 Client factors: Lack of motivation with oral health
 Medical or dental indications: none
 Dental history: No previous dental history
 Health history overview:
• General health is good
• Smokes cigarettes 10/day for a few years (ASA II)
Nutritional and Diet Analysis:

 Was unable to get diet analysis.

 In the Risk assessment it was noted that he
frequently drinks carbonated sugary
beverages throughout the day
 Diet low in fruits and vegetables
Intraoral Before Pictures:
 Section 2: Clinical Assessment

 Current oral care routine:

Brushes 1/day with manual toothbrush or uses mouth rinse.
Flosses only when he remembers (rarely)
 EO:
Good skin color
Few scattered brown macules throughout face
TMJ popping on L-side
Slight deviation to right on opening and closing
 IO:
Possible angular chelitus on outer lips
Small bilateral tori
Retromolar operculum on L/R (#18 slightly covered)
Gingival Description

Gen mod/severe, edemic, smooth tissues with slightly enlarged blunted

papilla and thickened margins.
Loc. Severe redness linguals of #32/31, 13/14, 17, facial #16 and max
posterior lingual; more severe rolling #22-27 and sloughing on facials #17/18
and #29/31 (will monitor for changes)
Hard Tissues

 No existing restorations
 Has attrition on anteriors from edge-to-edge
margins
 Active rampant caries
 Occlusion class:
R: missing molar on R, canine II
L: molar I tt III, canine II tt III
 Cross bite: #27/6, 8/9 to 24/25
 Open contacts: #13/14 and 30 from missing
teeth due to severe decay
Radiographs

 Mod/severe horizontal bone loss

with loc vertical bone loss where
#30 and #12/13 used to be
Radiographs
Restorative

 No pathological findings but lots of

restorative work needed from
rampant decay
 Referral for EXT of root tips
Periodontal Exam
Periodontal status

 Probing depths: Gen 3-4 mm with loc 5/6 mm pockets

 Furcations: class 1 buccal #14/15, class I/II on all mand posteriors buccal
and lingual
 Recession gen: mand anteriors, posteriors max/mand
 MAG/ NAG: L/R posteriors of mand
 Mobility: loc 8,9, 23-26
 Bleeding index: moderate over 30%
 Case type: Stage III/ Grade B
 Calculus classification: Heavy III/IV
Plaque map:

 76%
 Gen moderate/heavy plaque and staining
 Mainly in interproximal, posteriors, and
anteriors (especially mand anteriors)
Risk Assessment

 High periodontal risk  High caries risk

Poor oral hygiene (brush 1/day, rarely Frequent exposure to sugary foods/drinks
flosses)
3 or more carious lesions
Smoker (cigarettes 10/day)
Visible plaque
Generalized BOP
No dental home
Heavy calculus
Exposed root surfaces

 Moderate oral cancer risk

Present smoker
Diet low in fruits and vegetables
Assessment

 Psychosocial Observations:
▪ Oral health status motivation is low
▪ Dental education is low

 Referrals:
• Remove root tips of #12/13
• May need one if sloughing lesion by #17/18 and #29/31 has not gone
away or changed in appearance
Section 3: Treatment Planning

 Why did I choose this patient?

• He has a lot of factors influencing his oral health. Challenging
and wanted to see if I could make a difference in his health.

 What are the treatment goals?

• Improve oral health
• Better OHI (less calculus and plaque build up)
• Prevent further destruction from rampant decay
• Tobacco cessation (best for overall health)
Section 3: Treatment Planning

 Initial therapeutic strategy:

Patient’s chief complaint was he was embarrassed
to come since he has never been and knows he is
missing teeth.
Assured patient that glad he is here now and it’s a
good first step to getting him back to good oral
health

 His treatment needs:

• Nonsurgical periodontal therapy SRP 4341
• Prescription fluoride toothpaste or mouthwash
• Local anesthetic to make SRP more comfortable
• OHI
Prevention and Education Strategy

 1st Appointment: Modified bass brushing (high

percentage of plaque)
 2nd Appointment: C-wrap flossing (since rarely flosses
and had interproximal plaque)
 3rd Appointment: Rubber tip stimulator (alternative if
doesn’t have toothbrush or floss)
 4th Appointment: Recommend electric toothbrush to
better remove plaque (easier for patient and less
work)
 5th Appointment: Water flosser (if patient still hasn’t
picked up flossing habit)
Instrumentation Strategy

 Cavitron (triple bend and universal) to

remove plaque and break up calculus
 Periofiles (tenacious pieces)
 Barnhart 5/6 (smaller broken up pieces)
 4R/4L (smaller broken up pieces)
 Gracey 13/14, 11/12, ½ (more tenacious
calculus pieces)
 Nevi (finishing tighter contact areas and
anteriors)
Discussion points with patient

 Regular perio maintenance cleanings every 3

months to see how his oral health is improving
 Start restorative work soon to remove decay
 Educated patient on smoking related to
periodontal disease and healing in the oral cavity
• Higher plaque amounts were found, GI was
examined to assess the severity of inflammation,
which presented clear severity in smoking groups.
The observation of PD revealed that the current
smokers had a higher mean probing depth than
non-smokers and former smokers
• Smoking has detrimental effects on oral tissues. In
terms of periodontal health, smoking clearly
increases the presence and severity of
periodontal disease (Becklen A, 2021)
Patient Discussion Continued

 Prescription for fluoride toothpaste to

improve teeth strength and decrease
risk of future caries
• Why then is fluoride effective in
preventing caries? Because it slows
down demineralization. As a result, the
critical pH for fluoride-containing
apatite is slightly lower than the original
mineral (Ten Cate, 2019)
Informed consent

 Restorative informed consent

 Dental Hygiene care plan
Section IV: Implementation

 Appt 1 (2/14/22)
New HH
RAD pano and FMX
-Double booked new patients

 Appt 2 (2/28/22)
EO, IO, GD, PC, DHCP/RA
-Lots of decay and Dr. Nguyen wanted to wait until
next visit for DDS exam
Section IV: Implementation

 Appt 3 (3/7/22)
RAD 3 supplemental BWX taken, DDS Exam, informed consent, plaque map, OHI
demonstrated modified bass brushing
SRP 4341 UR started (LA given)
Tenacious calculus removal

 Appt 4 (3/14/22)
SRP 4341 UR continued and completed (LA given)
OHI Demonstrated C-wrap flossing
Tenacious calculus removal
Section IV: Implementation

 Appt 5 (3/21/22)
SRP 4341 LR completed (LA given)
Dr. Nguyen extracted root tip #30
Arestin placed #32 mesial
Revision: did not have time for rubber tip stimulator with root extraction
Patient was excited to go to his next appointment, he said he could feel a
difference in the areas cleaned

 Appt 6 (3/31/22)
SRP 4341 LL completed by another student
LA given
Patient wanted to get in as soon as possible to finish cleaning, possibly
more motivated to have a clean/stain free mouth
Section IV: Implementation

 Appt 7 (4/11/22)
SRP 4341 UL completed by another student
Tenacious calculus removal
LA given

 Appt 8 (future 4-6 week re-eval)

Tobacco cessation
OHI review
Section V: Post-treatment 4-6 week Re-
evaluation

 Was unable to do the 4-6 week re-eval with

patient. Hope to see the following results:
 Post treatment photos: less staining, healthy-
looking tissues, minimal calculus present
 HH: smoking less and general good health
maintained.
 Tobacco cessation done at this visit
 EO/IO no changes and healing of sloughing
tissues
Periodontal Re-Evaluation

 Periodontal Exam: decreased pocket depths,

decreased bleeding, lower plaque score, less gum
inflammation
 New oral hygiene: Brushes 2/day (possibly uses
electric toothbrush), uses interdental cleaning aids,
regular cleaning schedule
 Patient more motivated to take care of oral health
 Based on results from exam discussion with patient if
disease is improving or if it’s progressed worse.
Responsibility to take care of teeth and remind they
will lose teeth, may be in pain, and cost a lot of
money to fix if not taking seriously
Periodontal Re-Evaluation

 Future care recommendations:

• Follow up on referrals for extractions
• Restorative needs
• Possible referral for abnormal
looking lesion on tissues
• 3 month recall perio maintenance
appointments
Section VI: Student Summative Evaluation
of Therapeutic and Preventive Outcomes

 I’ve learned as a clinician to adapt better to more challenging patients.

Through both treatment planning and instrumentation of more
periodontally involved patients.
 Modifying more time to review OHI and do the tobacco cessation sooner
in the appointment schedule
References

 Beklen, A., Yildirim, B. G., Mimaroglu, M., & Yavuz, M. B. (2021). The impact
of smoking on oral health and patient assessment of tobacco cessation
support from Turkish dentists. Tobacco induced diseases, 19, 49.
https://doi.org/10.18332/tid/136418
 Ten Cate, J. M., & Buzalaf, M. A. R. (2019). Fluoride Mode of Action: Once
There Was an Observant Dentist Journal of Dental Research, 98(7), 725–
730. https://doi.org/10.1177/0022034519831604