WEST LOS ANGELES COLLEGE
DEPARTMENT OF DENTAL HYGIENE
WRITTEN CASE PERIO PRESENTATION
I.
A.
B.
C.
D.
E.
F.
II.
Personal History
Name: Pedro Zamora
Age and date of birth: 6/30/1980 30 yrs old
Sex: Male
Race: Hispanic
Occupation: Unemployed
Marital status: NA
Medical History Review
Past history:
- Previous illnesses, hospitalizations, surgeries: Patient states having
previous malnutrition due to lack of shelter and food. Patient reported
prior physical trauma of mouth and head that resulted in the fracture of
tooth #8, #9, #10.
B. Present history:
- Systems review: Uncontrolled Hypertension; history of controlled
substance use and has smoked tobacco for the past 10 years.
- Present illnesses: Patient states that he currently has an eating disorder
where he over eats and has become obese.
- Current medications: None
- Baseline vitals: 134/94 1st reading
128/90 2nd reading
C. Identify modifying factors: Patient is obese and has been smoking for the past
10 years, poor oral hygiene and plaque.
A.
III.
A.
B.
C.
D.
Dental History Review
Past history:
- Last dental visit: 1997
- Previous restorative: #8, #9, #10 PFM crowns due to fight which
resulted in #8,#9, #10 being broken.
- Oral surgery: None
- Periodontal: None
- Dental hygiene services: None
- Endodontic and orthodontic treatment: None
Present status: New patient for dental hygiene services
Chief complaint: Would like #10 re-cemented, crown fell out.
Caries assessment:
- Patient has several clinically visible carious lesions, however the
radiographs were undiagnosable due to lack of resources and expired
developing/fixing solutions.
- Per dentist on site, patient needs a RCT on #10. Due the deep recurrent
decay crown cannot be re-cemented. A new crown must be made.
However, patient cannot afford it.
- CAMBRA evaluation: Patient is at HIGH RISK for caries.
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1. Patient frequently snacks and drinks acidic beverages throughout
the day.
2. Visible plaque and carious lesions.
3. Patient has a history of prior restorations within the past three
years.
IV.
A.
B.
C.
D.
E.
Clinical Examination
Extra oral evaluation: WNL
TMD Evauation: Patient has slight asymptomatic clicking on right TMJ and his
mandibular jaw slightly deviates to the right upon opening. Pt is not in need of
occlusal splint.
Intra oral evaluation: Patient is missing #10 PFM crown. He has slight cervical
abrasion of teeth #6, #11, #12, #21, #22, #27, #29. Slight attrition on lower
anteriors. There were no soft-tissue pathology noted.
Oral hygiene evaluation
1.
Patient’s skill level was poor and he presented with generalized
heavy plaque.
2.
Patient stated that he only brushes 1x per day, usually in the
mornings and also admits that he never flosses.
3.
Patient is completely unaware of his periodontal condition and the
modifying effects of smoking on his alveolar bone level.
4.
In addition to Plaque Index (Pl1) and Marginal Bleeding Index
(MBI), periodontal index and oral hygiene index was used to
measure our patient’s oral condition. We chose to use oral hygiene
index Simplified (OHI-S) because although he had moderate bone
loss, he had generalized gingival inflammation mostly from plaque
and poor oral hygiene. OHI-S measures the patient’s ability to
maintain oral hygiene. Periodontal index (PI) is an effective
method to measure the extent and severity of bone loss.
Periodontal evaluation
1.
Calculus: Generalized medium-heavy tenacious calculus
2.
Plaque: PI was 81% at the first visit and 18% at the re-evaluation
visit
3.
Restorations:#8, #9, #10 PFM crowns with ill fitting margins.
Amalgam restorations on: #3 O, #14 O, #18 O, #19
BO, #30, #31 O
4.
Caries: #10 severe marginal and root decay.
5.
Pocket depths: generalized 3-4 mm pocket depths, with localized
5-6 mm depths in the posteriors and the mesial #8 and distal of #9
buccal surfaces, most likely due to ill-fitting margins.
6.
Mobility: + on teeth #7-11 and #23-#27.
7.
Furcations: Class I on #2, #3, #14, #15, #31, #30 buccal; Class II
on #19 buccal.
8.
Describe the marginal and attached gingival
(1)
Color: Coral/Red
(2)
Contour: Generalized edematous and erythematic marginal
gingival.
2
(3)
E.
V.
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B.
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VI.
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B.
C.
D.
Consistency: Surprisingly his tissue was not fibrotic, but
rather soft and friable.
(4)
Texture: Marginal gingival was shiny and attached gingival
was stippled.
9.
Alveolar Mucosa: Generalized pigmented and smooth
10.
Perpetuating factors: heavy plaque and heavy smoker.
11.
Etiology: Smoking, neglect of dental hygiene care, and poor
patient compliance.
12.
Diagnosis: Generalized Moderate Chronic Periodontitis modified
by smoking and perpetuated by plaque.
13.
Prognosis: Based on clinical evaluation of the patient’s oral
condition, the prognosis is good. However, due to the lack of
patient compliance and social-economical constraints, the patient’s
overall prognosis is fair to poor. Therefore, it is necessary to put
the patient on a 3-month recare basis. If the patient complies with
oral hygiene at home and becomes more motivated to quit
smoking, the overall prognosis is good.
Occlusal and TMD evaluation:
The occlusal relationship is Class I molar and canine relationship. Pt has a
2mm overbite and 1 mm overjet. Patient has slight asymptomatic clicking
on right TMJ and his mandibular jaw slightly deviates to the right upon
opening.
Radiographic examination
Quality of radiographs: The radiographs were completely undiagnosable due to
expired solutions. After careful discussion with our clinical instructor, we
agreed that we would not re-expose the patient to additional radiographic
radiation.
Basal bone, trebeculation, atypical radiolucencies and opacities were all within
normal limits
Alveolar bone: Generalized horizontal bone loss
There was no periapical pathology
The crown to root ratio was 2:1 generalized. There is also generalized
radiographic calculus evident. Tooth #32 is impacted and partially erupted. The
pulp chambers are all within normal limits and no root canals present. There
were no root resorption, fractures, and hypercementosis present.
Oral Hygiene Evaluation
Plaque Index was 81% at the first visit and 18% at the re-evaluation visit.
Marginal Bleeding Index was 29% at the first visit and 9% at the re-evaluation
visit
The patient’s skill level is poor
The patient has no knowledge about periodontal disease. We educated the
patient on the importance of regular hygiene visits, proper tooth brushing, and
flossing to prevent further periodontal destruction. We also discussed with the
patient about the effects smoking has on his periodontal health in addition to his
systemic health, by correlating our information with his periodontal
assessments, such as probing depths and radiographic bone level as best as we
could. We provided the patient with several resources to assist in smoking
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E.
F.
G.
VII.
A.
B.
C.
cessation. We discussed alternative options that were available, such as the
nicotine patch and nicotine gum.
The main objective is to educate the patient on the importance of stabilizing the
present periodontal condition. We would also like for the patient begin to
flossing regularly in addition to brushing two times a day.
We demonstrated the modified bass with a manual toothbrush to show the
patient how to brush properly. We also gave the patient an electronic toothbrush
to motivate him to brush his teeth more often. We also demonstrated proper
flossing techniques. We found that the patient still had difficulty flossing
properly, so we provided him with a floss handle. At the end of the treatment,
the patient still admits to rarely flossing. We also provided the patient with
Pro-Health antimicrobial rinse to use daily.
One of the barriers to treatment was the patient’s poor dexterity and motivation
to take care of his oral health. The patient also has unstable shelter and
transportation to and from the dental clinic.
Indices
We used oral hygiene index which is reversible and periodontal index, which is
irreversible.
There was also a significant improvement in the patient’s plaque index from
81% pre-treatment to 18% post-treatment and the patient’s marginal bleeding
index from 29% pre-treatment to 9% post-treatment. The patient’s oral hygiene
index indicated that his oral home care has been inadequate. OHI-S score
ranges from 0 to 6, good to poor. The patient’s OHI-S score was 4.7, which
was considered fairly high. Prior to treatment, the patient’s periodontal index
scored at 3.7, which indicated the occurrence of an established destructive
periodontal disease. Since the periodontal index also measures gingival
inflammation, the patient’s score decreased slightly post therapy.
The patient’s pockets depths consisted of localized areas of 6 mm pocket depths
in the posteriors, as well as on tooth #8 and #9 mm. Even though the
radiographs were not clear to provide complete oral diagnoses, there is
evidence of moderate horizontal bone loss. The periodontal index correlates
with our AAP classification of Generalized Moderate Chronic Periodontitis, as
well as the generalized appearance of gingival inflammation. The patient also
demonstrated an improvement in oral home care, as evident by significant PlI
and MBI improvement score.
VIII. Treatment plan
A. Patient status
1.
Patient is a new patient for dental hygiene services
2.
Patient was treatment planned for 4 appointments of scaling and
rot planning with local anesthesia and one re-evaluation
appointment to assess the completed treatment
B.
Dental hygiene treatment plan
1.
Due to the severity of the periodontal destruction including the
calculus level and probing depths, the treatment plan was for 4
appointments. Each appointment will consist of scaling and root
planning using 2% Lidocaine 1:100,000 epinepherine. Our goals
were to educate our patient the importance of proper brushing and
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flossing. We would also give him the proper guidance and tools for
smoking cessation. Our goals were to improve the overall gingival
tissue and decrease the pocket depths.
2.
The major focus of our treatment was to remove the calculus and
stabilize the periodontium and emphasis smoking cessation to the
patient.
3.
There was a total of 4 appointments
4.
Treatment completed at each visit:
-Appointment #1 (12/03/09): Initial exam, FMX, intraoral
photographs, full mouth probing, indices were taken, #10 PFM
recemented by supervising dentist.
-Appointment #2 (12/10/09) The patient was scheduled both
morning and afternoon. Initiated smoking cessation, re-assessed
OH-brushing and flossing, LLQ and ULQ SRP with 2% Lidocaine
with 1:100,000 epinepherine.
-Appointment #3 (1/21/10). The patient was scheduled both
morning and afternoon. ULQ and LLQ SRP with 2% Lidocaine
with 1:100,000 epinepherine. Re-enforce OH and smoking
cessation. 2% NaF carnish was applied, CAMBRA assessment,
nutritional counseling.
-Appointment #4 (2/18/10) Re-evaluation, full mouth probing,
intraoral photographs, case study models, and indices were taken.
Fine scaling to remove residual calculus.
5.
Oral hygiene instructions were given to him such as, modified bass
for toothbrushing instructions, and the “C” shape flossing method.
We also demonstrated how to use a floss holder due to his poor
dexterity and motivation.
6.
There was no oral surgery treatment completed that was noted in
the chart
7.
Supportive periodontal therapy (maintenance): Due to the patients
poor motivation to properly care for is oral health at home we
recommend that he remain on a 3-month recare interval to
maintain his periodontal condition and prevent the inflammation
from continuing.
VII. Post treatment status
A. Indices: Plaque index pre-treatment was 81% and post treatment was 18%
Marginal bleeding index pretreatment was 29% and post treatment was
9 %.
B. Probings
1.
Pre-scale pocket depths: generalized 3-4 mm pocket depths, with
localized 5-6 mm depths in the posteriors and the mesial #8 and
distal of #9 buccal surfaces, most likely due to ill-fitting margins.
2.
Post scale probing depths generalized 3-4 mm w/localized 5 mm
on #8MB, #31DB, #17MD. There was a 1 mm decrease in probing
depths in the posterior teeth. #8MB reading did not improve due to
ill fitting PFM crown.
3.
Post surgery: There was no surgery noted in the chart.
4.
SPT / Maintenance appointments: The patient was placed on a 3
month recare.
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C.
Tissue changes, comment on changes as they occurred in each phase of
treatment.
1.
Pre-scale: Gingival description
Marginal: Generalized smooth, Edematous and erythematic, rolled
borders, and glossy
Attached: Generalized Pigmented, fibrotic and stippled
2.
D.
E.
Post scale: Gingival description:
Marginal: Generalized pink, smooth, firm, rolled
borders
Attached: Generalized pigmented, fibrotic and
stippled
3.
There was an exceptional amount of tissue resolution from pre to
post treatment especially with decrease in tissue inflammations.
4.
SPT / Maintenance appointments: 3- month recare
Patient consideration
- Pt had a good understanding of the treatment that was
completed and was excited to participate. However, pt’s
circumstances made it difficult to maintain compliance.
-Complications during treatment: Patient did not have cell phone
or number for direct contact. He was dependant on friends driving
him to and from appt. No Show on 2 appts.
Operator considerations
- We did our best to reschedule broken appts
- Provided pt with Sonicare TB as well as ACT daily fluoride
rinse, and other OH aids so patient would not have to buy on their
own.
- It was difficult to attain the ideal resolution because pt was not
compliant with smoking cessation & medical consults/check-ups.
VIII. CONCLUSION:
An improvement in the patient’s tissue and oral condition was achieved after the
completion of non-surgical scaling and rootplaning treatment. In addition, there was an
improvement in the patient’s awareness and knowledge of periodontal disease, as well as
a slight improvement in oral home care. However, the patient’s tissue resolution was not
maximized as a result of noncompliance and the combined systemic effects of smoking,
uncontrolled hypertension, and obesity. All three conditions affect the patient’s
periodontal condition by exacerbating the imbalance in the interaction between bacterial
pathogens and host immunity by inducing the additional secretion of pro-inflammatory
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markers consisting of cytokines, proteins and hormones in response to systemic
inflammation (Torres de Heens et al., 2009).
The patient had been a heavy smoker for the past 10 years. He had attempted to
quit several times, with the prior attempt having lasted 5 months. However, due to the
stress of having lost his job and home, he resorted to revert to smoking as a coping
mechanism. During the treatment, the patient discussed his desire to quit smoking. He
was aware of the detrimental effects of smoking on his lungs and major organs, but was
unaware of the effect it has on the periodontium. “Cigarette smoking is considered to be
one of the most important environmental risk factors in periodontitis since more clinical
attachment loss and bone loss have been observed in smoking than in non-smoking
patients” (Torres de Heens et al. 2009). The health benefits of quitting were stressed and
resources for support were presented to the patient. By the end of treatment, the patient
reported having reduced the number of daily cigarettes. However, he found it difficult to
quit completely with the continual stress in his life, as well as the constant temptations of
socially smoking. As a result, although gingival inflammation was less evident during
the re-evaluation appointment, pocket depth resolution was not as significant.
The lower level of inflammation observed clinically may be due to a decrease in
gingival crevicular fluid with a decrease in cytokines, enzymes, and polymorphonuclear
leukocytes (Laxman & Annaji, 2008). Due to the diminished response of this patient’s
tissue, an anti-microbial rinse was recommended. Locally administered antimicrobial
therapy was not indicated for this patient as his pocket depth and attachment loss was not
significant enough for a significant improvement.
In addition to smoking, the patient reported that his economic condition and stress
has contributed to a significant and unhealthy amount of weight gain. In recent studies
completed by Khader et al. (2009), obesity was significantly associated with the
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increased prevalence and severity of periodontitis possibly as a result of adipokines,
which include pro-inflammatory cytokines such as tumor necrosis factor- alpha (TNF- α)
that induce C-reactive proteins, known to be associated with periodontal disease.
Adipokines are stored in adipose tissues and secreted by adipocytes. The patient stated
that his diet consist of mostly fast food and junk food that are readily available and
affordable. He also drinks mostly soda and beer on a daily basis. Without a consistent
home and kitchen, it is difficult for the patient to store, cook, and eat healthy food. Daily
exercise was discussed with patient to combat the weight gain. In addition to weight loss
and de-stressing, regular exercise has been shown to reduce the plasma levels of
inflammatory markers such interleukin-6 and C-reactive protein, thereby, reducing
periodontal destruction (Pischon et al., 2007).
Weight gain and smoking is consistently associated with increased blood pressure
(Pischon et al. 2007). The patient presented with uncontrolled high blood pressure. He
was aware of this and stated that it had been a lot higher the last time he had checked
himself at a nearby drugstore. Yet, he was not prompted to get a medical exam. During
his hygiene visits at the dental clinic, the patient was referred to the free medical clinic
for an exam. Even though the patient verbally agreed to go, he did not follow through.
At the completion of treatment, the patient continued to delay his physical exam. Pischon
et al. (2007) found that in rats that had a combination of obesity and hypertension, plaque
accumulation caused even more pronounced periodontal destruction than in obese
animals (Pischon et al. 2007).
When considering the effects of hypertension alone, studies have found that it
could aggravate the severity of periodontitis and vice versa (Turkoglu et al., 2008). High
blood pressure is related to an increase in serum oxidized low density lipoprotein (LDL)
level and anti-cardiolipin (CL), which, according to the study, stimulate the production of
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pro-inflammatory cytokines, leading to vascular inflammation and dysfunction. Thus, it
results in the progression of atherosclerosis. High levels of anti-CL were also found in
patients with chronic periodontitis. This suggests that “systemic inflammation caused by
chronic periodontitis might affect the serum anti-CL and oxLDL levels in individuals
with essential hypertension, and increased serum anti-CL and oxLDL levels in
hypertensive individuals with chronic periodontitis.” Furthermore, this suggests the
possible implications of chronic periodontitis on atherosclerosis.
Although the prognosis of the patient’s periodontal condition is good, the impact
of his social condition and lifestyle may hinder his ability to highly prioritize his systemic
and oral health. The patient had been in and out of a home for the past five years due to
unemployment and social mishaps. This has prevented him from successfully quitting
smoking and seeking medical attention for his high blood pressure and malnourishment.
During his visits to the dental clinic, he was routinely advised to visit the free medical
clinic for a check-up, particularly concerning his high blood pressure. According to Daly
et al. (2010), it was found that in a study exploring homeless people’s use of dental care,
“there was a high prevalence of ineffective oral hygiene practices with 75% of people
experiencing BOP or calculus accumulation” because “while homeless people wanted to
access dental care the homeless lifestyle made acting on this intention difficult.” This
was quite evident during treatment when the patient did not appear for his scheduled
appointment and was unresponsive to phone call. After diligent and persistent attempts,
the patient was contacted and eventually receptive to treatments and demonstrated an
improvement in his oral hygiene practices. Furthermore, the patient demonstrated a
greater awareness of his periodontal condition and the negative effects of smoking, stress,
and poor systemic health on his oral condition. With additional positive reinforcement
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and routine dental care, there is hope that the patient will succeed in arresting his
periodontal disease and maintaining a healthy oral condition.
Overall, we believe our goal and objectives for improving our patient’s awareness
and self-efficacy in his oral health had been met. We provided our patient with Sonicare
electronic toothbrush, which appeared to have improved his oral hygiene. However, we
noticed that he was still lax on daily flossing. We would have liked to have been able to
have a greater influence in helping the patient seek medical care and fully quit smoking,
but we understand the patient’s circumstance and environmental limitations.
IX. SUMMARY:
The patient is a 30 year old male with generalized moderate chronic periodontitis
modified by smoking and uncontrolled hypertension, further exacerbated by stress from
being unemployed and homeless. The patient presented to us with generalized 3-4 mm
pocket depths and localized 5-6 mm pocket depths, severe dental decay, and medium
heavy calculus build-up. His tissue was edematous with generalized bleeding on probing.
Four appointment scaling and rootplaning was completed with attention placed on
smoking cessation and oral hygiene education.
At the completion of treatment, during the re-evaluation, the patient demonstrated
an improvement in oral home care, resulting in fewer surfaces of plaque retention.
Although gingival inflammation was no longer evident, periodontal depth did not
significantly improve and the patient continues to smoke. However, the patient walked
away with knowledge on the importance of oral health care and its significant
interrelation to the whole body, further stressing the impact of smoking. It will take
additional visits and persistence to instill a desire for the patient to change his behavior.
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Reference
Daly, B., Newton, T., Batchelor, P., Jones, K. (2010). Oral health care needs and oral healthrelated quality of life (OHIP-14) in homeless people. Community Dentistry and Oral
Epidemiology, 38, 136-144.
Khader Y.S., Bawadi, H.A., Haroun, T.F., Alomari, M., Tayyem, R.F. (2009). The association
between periodontal disease and obesity among adults in Jordan. Journal of Clinical
Periodontology, 36, 18-24.
Laxman, V., Annaji, S. (2008). Tobacco use and its effects on the periodontium and periodontal
therapy. The Journal of Contemporary Dental Practice, 9(7), 2-11.
Pischon, N., Heng, N., Bernimoulin, J.P., Kleber, B.M., Willich, S.N., Pischon, T. (2007).
Obesity, inflammation, and periodontal disease. Journal of Dental Research, 86(5), 400409.
Seckman, C.H. (2002). Dental Indices Health article. Retrieved from
http://www.healthline.com/galecontent/dental-indices.
Torres de Heens, G.L., Kikkert, R., Aarden, L.A., van der Velden, U., Loos, B.G. (2009). Effects
of smoking on the ex vivo cytokine production in periodontitis. Journal of Periodontal
Research, 44, 28-34.
Turkogu, O., Baris, N., Kutukculer, N., Senarslan, O., Guneri, S., Atilla, G. (2008). Evaluation of
serum anti-cardiolipin and oxidized low-density lipoprotein levels in chronic
periodontitis patients with essential hypertension. Journal of Periodontology, 79(2), 332340.
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