Final Year DDS Perio Case

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33332

Changes in clinical attachment levels after Non-Surgical Therapy in a female patient with Moderate to Severe Generalized Chronic Periodontitis A Case of Restoration of Function and Patient Comfort: Examining the role of stress in Periodontal Disease

The purpose of this report is to highlight the factors involved in the management of Moderate to Severe Generalized Chronic Periodontitis. The patient, AJ presented to The UWI Dental School complaining of mobile teeth. Her condition was investigated and was found to be plaque induced Periodontitis modified by a stressful lifestyle. Outcome measures used included plaque and bleeding scores, BPE scores and full periodontal assessment including full mouth radiographs. Her main mode of treatment included non-surgical scaling and root planing the success of which was monitored using the same measures. Treatment saw a reduction in the general inflammatory state of the periodontium including a reduction in probing pocket depths with some areas proving to be a challenge. Overall this case emphasizes the point that in patients exhibiting a generalized advanced breakdown of the periodontal tissues, but with an intact number of teeth, considerable efforts should be made to address all contributing factors with the concept of “individualized dentistry in mind”.

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The Point of It All • • •

A healthy or a stable

periodontium is an

important prerequisite

both for the

maintenance of a

functional dentition

and to ensure a long-

term, successful

outcome of restorative

dental treatment.

Changes in clinical attachment levels after Non-Surgical Therapy in a female patient with Moderate to Severe Generalized Chronic Periodontitis A Case of Restoration of Function and Patient Comfort: Examining the role of stress in Periodontal Disease

SECTION 1: PRE TREATMENT ASSESSMENT PATIENT DETAILS

Initials: AJ

Sex: Female

Date of birth: 18/05/57 (55 years)

Occupation: Dress maker

REFERRAL

The patient was referred by Dr. Wiseman (General Dentist) and Dr.

Harper (Orthodontist) both advising that there were severe

periodontal disease that necessitated close attention. Dr. Wiseman’s

initial referral was to Dr. Brown (Periodontologist) but financial

constrains were problematic.

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Table of Contents SECTION 1: PRE TREATMENT ASSESSMENT................................................................................................. 2

PATIENT DETAILS ........................................................................................................................................ 2

REFERRAL ................................................................................................................................................... 2

PATIENT COMPLAINTS ..................................................................................................................................4

PATIENT EXPECTATIONS ...............................................................................................................................4

RELEVANT MEDICAL HISTORY ......................................................................................................................4

DENTAL HISTORY ........................................................................................................................................4

SOCIAL HISTORY/FAMILY HISTORY ............................................................................................................... 5

PRESENTING ORAL HYGIENE ........................................................................................................................ 5

CLINICAL EXAMINATION: EXTRA ORAL .......................................................................................................... 5

CLINICAL EXAMINATION: INTRA ORAL ........................................................................................................... 5

PERIODONTAL DIAGNOSIS (OVERALL): ....................................................................................................... 17

PRE TREATMENT ASSESSMENT: GENERAL RADIOGRAPHIC EXAMINATION ........................................................ 17

AIMS AND OBJECTIVES OF TREATMENT ....................................................................................................... 23

TREATMENT PLAN 30/04/12 ........................................................................................................................ 23

SECTION 2: TREATMENT ............................................................................................................................ 28

ORAL HYGIENE INSTRUCTION AND MOTIVATION ......................................................................................... 28

PLAQUE SCORE MONITORING ..................................................................................................................... 30

1ST RE-ASSESSMENT .................................................................................................................................. 40

2ND RE-ASSESSMENT .................................................................................................................................. 47

SECTION 3: CASE DISCUSSION ............................................................................................................................... 48

PERIODONTAL DISEASE ............................................................................................................................................ 48

SUMMARY OF AJ’S MANAGEMENT ............................................................................................................................. 51

TREATMENT PLANNING ............................................................................................................................................ 53

DIAGNOSIS ............................................................................................................................................................... 53

PREDISPOSING, INITIATING AND AGGRAVATING FACTORS ..................................................................................... 54

TREATMENT .............................................................................................................................................................. 58

CRITICAL APPRAISAL ................................................................................................................................................ 64

OPPORTUNITIES FOR LEARNING .............................................................................................................................. 65

CONCLUSION ............................................................................................................................................................ 65

References ................................................................................................................................................................... 68

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PATIENT COMPLAINTS

AJ complained of buildup around her teeth and that they were drifting (progressing mobility) and taking

up strange angulations. A tooth in the upper right anterior sextant was described as having “dropped”.

Dr. Harper advised her that there was bone loss. The general dentist suggested antiseptic mouthwash

and had general debridement done to alleviate the complaint but commented that buildup would come

back quickly. She began noticing symptoms in 2008. There was associated bleeding (occasionally

spontaneous upon waking up), halitosis but no pain or soreness.

PATIENT EXPECTATIONS

1. To restore cavities

2. Have teeth cleaned

3. Address spontaneous bleeding and bone loss

4. Address tooth malposition, possibly with orthodontic treatment and tooth adjustment

RELEVANT MEDICAL HISTORY

1. Gastro-duodenal ulcers

2. Fibroids

3. Periodically swollen ankles

4. Removed cyst from right breast in ’83 with no complications

5. Blood smear showed oddly shaped cells (not specified), findings of little significance according

to the physician

DENTAL HISTORY

AJ was not a regular dental attender. As mentioned previously, she has undergone “cleanings” and has

had extractions of carious teeth (2010, patient bled a lot). A history of blunt force trauma to the upper

front teeth was reported.

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SOCIAL HISTORY/FAMILY HISTORY To the knowledge of the patient she has no family history of periodontal disease. She is a non-drinker

and non-smoker, single mother of two (one being murdered in 2002). She was previously in a marriage

that caused her extreme stress due to abuse and financial strain and which she says led to her son’s

death. AJ admitted to binge eating especially of sweet snacks when under stress often before bedtime

without toothbrushing.

PRESENTING ORAL HYGIENE

AJ’s methods of personal oral care included a toothbrush of medium texture. She used Aquafresh®

toothpaste to brush manually twice daily for approximately 2 minutes. Flossing was not part of her

cleansing routine, while CARE ® mouthwash (prescribed by the GD) along with Listerine® were used

occasionally for symptomatic bleeding.

CLINICAL EXAMINATION: EXTRA ORAL

General Appraisal: AJ appeared healthy, alert and demonstrated a very good awareness of her

personal hygiene and dress.

Specialized: Examination also revealed deviation to the left on closing and forced lip competency.

CLINICAL EXAMINATION: INTRA ORAL

Soft tissues: Within normal limits

Gingival health: The gingiva appeared pink with some patches of brown racial pigmentation. Areas of

attached gingiva were paler in comparison to the free gingiva. A firm consistency and a particularly

round form were noted. There was some stippling still evident. There was also extensive recession on

the upper palatal incisor region (Miller’s classification III).

Oral hygiene: Plaque deposits were found to be distributed in all interproximal areas and generally on

the palatal and lingual aspects of the teeth.

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PRE TREATMENT ASSESSMENT: DENTAL

CHARTING

• Findings: • #13 – Supra-erupted • #12 - shallow palatal groove in enamel (corono-radicular) • #17 – occlusal caries • #21 - grey discoloration • #27 – buccal root caries • #47 - occlusal caries

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PRE TREATMENT ASSESSMENT: VITALITY TESTING

Tooth Endo Ice Electric pulp tester

#11 No response No response #21 No response No response #27 No response No response

Plaque Score: 72%

BPE scores: 4* 3 4*

4* 2 3*

Occlusion: Anterior open bite with proclined upper incisors and associated increased overjet. The

upper central incisors were also supra-erupted. An occlusal analysis post extraction was conducted and

is to be reported

BOP: Probing resulted in a generalized distribution of immediate bleeding.

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PRE TREATMENT ASSESSMENT: PRE TREATMENT PHOTOGRAPHS

Labial and buccal segments

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PRE TREATMENT ASSESSMENT: PRE TREATMENT PHOTOGRAPHS

Upper and Lower Arches

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PRE TREATMENT ASSESSMENT: STUDY MODELS

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PRE TREATMENT ASSESSMENT: STUDY

MODELS

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PRE TREATMENT ASSESSMENT: FULL PERIODONTAL ASSESSMENT 02/03/12

Periodontal chart: Buccal Tooth Pocket depth Furcation Recession Tooth

involvement mobility

D MID M D M D MID M

MAXILLA

18

17 8 5 8 5 5 2 3

16 6 1 5

15 3 2 5

14

13 1 2 6

12 5 1 5 1

11 6 2 6 3

M MID D M MID D

21 3 2 3 3

22 5 2 5

23 1 1 4

24 2 1 7

25 4 6 7

26

27 7 8 5 3

28

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MANDIBLE

38

37 5 5 4

36

35 3 3 2

34 4 2 2

33 3 2 2

32 2 2 3 1

31 2 1 2 1

M MID D M MID D

41 2 1 2 1

42 5 3 2 1

43 1 1 3

44 5 1 5

45 5 1 6 0 4 0

46

47 7 6 7 3

48

Tooth Pocket depth Furcation Recession Tooth


D MID M D M D MID M

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Periodontal chart : Palatal/lingual Tooth Pocket depth Furcation Recession Tooth


D MID M D M D MID M

MAXILLA

18

17 7 10 8 III 2 1 0 3

16 5 1 7

15 3 1 5

14

13 4 4 6 2 3 2

12 7 5 7 1 3 1 1

11 6 6 8 2 4 2

M MID D M MID D

21 5 3 5 0 6 0 3

22 5 2 4 2 3 2

23 2 1 5

24 1 1 6 0 2 3

25 3 4 6 3 5 3

26

27 12 7 7 III 3 5 2 3

28

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MANDIBLE

38

37 5 1 6

36

35 2 1 1 0 4 0

34 1 1 1

33 2 1 2

32 2 1 3 1

31 1 1 1 1

M MID D M MID D

41 2 1 2 1

42 1 1 3 1

43 3 1 3

44 5 1 5

45 3 1 6

46

47 7 5 5 III 3

48



D MID M D M D MID M

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PRE TREATMENT ASSESSMENT: FULL PERIODONTAL ASSESSMENT

Summary of periodontal assessment:

Full Mouth Plaque Score - 72%

Full Mouth Bleeding Score – 53%

Deepest pockets –10mm (mid-palatal of #17), 12mm (mesio-palatal of

#27)

Diseased sites- 40%

Upper right

quadrant 16% Upper left quadrant 11%

Lower right

quadrant 10% Lower left quadrant 3%

Pockets ≥ 6mm - 25% of all sites

Recession ranging from 0 mm to 6 mm with the greatest recession seen

on #21

Degree 1 mobility was associated with: #12, , #31, #32, #41, #42,

Degree 3 mobility was associated with: #17, #27, #47

Grade 1 Furcation Involvement was associated with: #47

Grade 3 Furcation Involvement was associated with: #17, #27

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PERIODONTAL DIAGNOSIS (OVERALL):

Moderate to Severe Generalized Chronic Periodontitis with a primary etiology of plaque retention and extreme stress and calculus as a secondary etiologic factors.

PRE TREATMENT ASSESSMENT: GENERAL RADIOGRAPHIC EXAMINATION

Key

Horiz

Horizontal bone loss

PL

Periodontitis levis

PG

Periodontitis gravis

PG et co

Periodontitis gravis et complicata

S Secure Q Questionable

H Hopeless

*Percentages suggest the percentage bone loss on the Mesial (M) or Distal (D)

Bitewings Taken on 14/02/12

Right Bitewing

Distal caries into dentine

Left Bitewing

Mesial caries into dentine

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Periapicals Taken on 02/03/12

Upper right posterior sextant

#17 100%

Horiz H PG et co

#16 50%(D)

30%(M)

Horiz Q PG

#15 30%(D)

60%(M)

Horiz Q PG

Calculus deposits on root surfaces of

#17, distal of #16, mesial of #15, #14

is a root stump

Upper anterior sextant (right half)

#13 10%(D)

50% (M)

Horiz Q PL

#12 60%(D)

70%(M)

Horiz Q PG

#11 100%

Horiz H PG

Calculus deposits on the mesial root

surface of #13, mesial of #12, distal of

#11. Periapical radiolucency #11

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Upper anterior sextant

(left half)

Calculus deposits on the root surfaces of #21, #22, mesial of #23

#21 100% Horiz H PG

#22 60%(M)

70%(D)

Horiz Q PG

#23 25%(M)

30%(D)

Horiz S PL

Upper left posterior sextant

Calculus deposits on the distal root surface of #24, on the root surface of #25. #26 is a root stump with apical radiolucencies. A large radiolucency is present mesial to the root of #27. Mesial interproximal caries is evident once more.

#24 50%(D)

25%(M)

Horiz Q PG

#25 60%(M) lamina dura

unremarkable(D)

Horiz Q PG

#27 100% distal

aspect is

unremarkable

Horiz H PG

et

co

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Lower left posterior sextant

Calculus deposits on the root

surface of #37 just below the

cervical regions.

#34

15%

Horiz S PL

#35

15% Horiz S PL

#37

35%

(D) The distal

root apex is

not seen

here

55%(M)

Horiz Q PG

Page21

Lower anterior sextant

Calculus deposits on the root surface of #43, #42.

#43

35%(D)

30%(M)

Horiz

S

PG

#42

60%

Horiz

Q

PG

#41

20%

(D)

30%(M)

Horiz

S

PL

Calculus deposits on the mesial surface of #31

#33

40%

Horiz

S

PG

#32

10%(D)

15%(M)

Horiz

S

PL

#31

15%

(D)

10%

(M)

Horiz

S

PL

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Lower right posterior sextant Calculus deposits on the distal root surface of #46; #46 is a root stump with apical radiolucencies. Calculus deposits on the distal root surface of #45. Periapical of the same premolar region on 25/10/12 (7 months later)

#45

60%(D)

30%(M)

Horiz

Q

PG

#44

60%(D)

30%(M)

Horiz

Q

PG

#47 50%(D)

55(M)

Horiz

S

PG

et co

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AIMS AND OBJECTIVES OF TREATMENT

1. < 10 %, of sites BOP

2. No sites with PPD > 5 mm, but preferably < 4 mm

3. No furcation involvement of degree II or III.

4. Satisfy the patient's demands regarding esthetics and masticatory function.

TREATMENT PLAN 30/04/12

I. Initial phase therapy

1. Motivation and OHI

2. Extraction of hopeless teeth and root stumps

3. Restore #16M and #47O

4. Scaling and root planing

5. Reassess 6-8 weeks

II. Corrective phase

1. Adjunctive antibiotic treatment if necessary in local areas

2. Transitional denture in lower arch for posterior support with

concurrent adjustment of the supra-erupted #13 effort to address

occlusal discrepancy (modified 01/02/12)

3. Transitional denture for upper arch (decision to replace teeth on the

free end saddle is tentative) to be modified and include #11 and #21

post extraction

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III. Final Reconstructive phase

1. Orthodontic treatment if feasible

2. Final removable/fixed prosthodontic therapy

3. Supportive periodontal care during reconstructive/orthodontic phase

4. Referral for psychological counseling

Final 3 month evaluation

IV. Supportive periodontal therapy or maintenance

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CONSULTATIONS

• Periodontology

o Extraction of hopeless #11 and #21 along with other hopeless

teeth considering aesthetic value?

Result: Extraction of the same teeth should be done at a time that

an immediate interim denture can be provided. Thus scaling and

root planing will be attempted on the both teeth.

• Orthodontics

o Fixed appliances to close spaces and correct angulation

especially proclination of lower incisors.

Result: Patient seems to be having a “mid –life crisis” and

concerns may be over emphasized by emotional state. Attempt to

convince patient that esthetics of lower may improve with

prosthetic replacement of upper central incisor. However patient

will still be assessed for treatment.

• Prosthodontics

o Fixed prosthodontic option (bridge) preferred by patient for

replacement of upper central incisors.

Result: Due to the patients high smile line (excess of 2mm gingival display) and expected retraction of gingiva post scaling

a removable prosthesis with a flange to overcome these issues

are best option to avoid teeth appearing to be “floating in air”.

Patient reactions

• Agreed to see wax up and approved of attempt to camouflage

lower incisor proclination. However she still would like to have the

teeth “braced to prevent further movement”

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• Agreed to accept removable prosthesis instead of bridge

o Occlusal analysis post extractions of posterior teeth:

Upper arch: Kennedy Class 1 Mod 1 (bilateral free end saddle)

Lower arch: Kennedy Class 3 Mod 1

The cusp of #13 is proving to be working side interference.

Occlusal contact is solely occurring between #13 and #44 and

#15 and #45. This is the only support and means of mastication

with group function in lateral excursion to that side.

Result: In order to address the discomfort experienced by the

contact of the supraerupted #13 with the lower arch, occlusal

adjustment will have to be carefully carried out while making

occlusal (wax rim) adjustments in the jaw registration phase of

the transitional denture. This should be done first on a working

cast to gauge the amount of tooth structure adjustment required

without causing the tooth to become symptomatic. A transitional

denture for the upper arch can only be fabricated after this

adjustment is made as the denture teeth will not come into

contact with the lower arch. After this phase the patient should be

more acclimatized to the removable prosthesis and consequently

more accepting of the proposed extractions and denture

replacement planned for #11 and #21.

Patient reactions

• Agreed to use the first transitional denture as a “training

mechanism” before extracting the central incisors and was very

willing to accept it also as treatment for the troublesome #13.

Page27

DIAGNOSTIC WAX UP

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SECTION 2: TREATMENT ORAL HYGIENE INSTRUCTION AND MOTIVATION

• Generally the modified bass technique and flossing methods were

demonstrated on the models.

• Patient was asked to mimic methods with mirror held in front of her.

Plaque disclosing agent was applied prior to her attempt.

• Different aids were issued due to different needs of individual and groups

of teeth.

• Aids and advice given

1. Brushes:

i. Soft toothbrush

ii. Interproximal brush (purchased personal set as well)

iii. Round headed brush for lone standing molars

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iv. Angled single tufted

brush for palatal aspect of upper

incisors

2. Floss:

• To be used where contacts existed

3. Mouthwash

• AJ was told to discontinue Listerine® and was instructed to use CARE®

mouthwash at least a half hour after brushing as well as occasionally.

4. Plaque disclosing tablets

• This was issued to AJ in order for her to grow accustomed to the difficult

areas as well as the new technique that was learnt.

5. Toothpaste

• Colgate TOTAL® was given to AJ

Page30

PLAQUE SCORE MONITORING

Graph showing plaque deposit levels over the course of 9 months after oral

hygiene advice was given. Along the way the technique had to be personalized.

The first greatest reduction was seen after all hopeless posterior teeth and root

stumps had been extracted (8%). The trouble areas responsible for the

increases seen subsequently included the lone standing lower molars (#37 and

#47) and the palatal aspect of the upper incisors (see mapping below) due to

the very deep pockets and associated recession. As a result brushes with

features that could overcome the shortcomings of the regular tooth brush

0%10%20%30%40%50%

Date

Date

AJ thought that proxa- brushes

were for one time use and discarded

them

Inconsistency with cleaning palatal of upper

incisors47%

8%

11%25%

All extractions of hopeless posterior teeth

and root stumps complete

Neglect of lone standing molars were noted; round

head brush given

Plaque Score

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OTHER TREATMENT COMPLETED TO DATE

• Extraction of all root stumps and hopeless teeth.

• Scaling and root planing of all four quadrants.

• Restorations (amalgam) of #16M and #47O.

• Periodontal reassessment.

• Fabrication of temporary denture to replace #11 and #21 (not in use)

• Re-scaling of upper anterior sextant

• Periodontal re-assessment

KEY STAGES IN TREATMENT

DATE STAGE 1. 14.02.12 First visit 2. 28.05.12 Extraction of #27 3. 12.06.12 Extraction of #18, # 17, #14 and #46 4. 26.06.12 Extraction of #26 5.

18.09.12

Scaling and root planing of the upper

right quadrant 6.

04.10.12

Scaling and root planing of the upper

left quadrant 7.

11.10.12

Restoration of #16 (Class II amalgam) 8. 18.10.12 Scaling and root planing of the lower

left quadrant

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9. 25.10.12 Scaling and root planing of the lower

right quadrant and consultation with

conservative department concerning

prosthetic replacement of #11 and #21 10. 29.11.12 1st Periodontal Re-assessment

11. 12. 13.

22/11/12 07/01/13 31/01/13

Restoration of #4.7(Class I amalgam

and class V composite).

Re- scaling of the upper anterior

sextant

2nd Periodontal Re- assessment

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POST TREATMENT PHOTOGRAPHS

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Page35

Periodontal chart :

Buccal



D MID M D M D MID M

MAXILLA

18

17

16 2 1 1

15 2 1 1

14

13 2 2 5

12 2 1 2 1

11 2 2 4 2

M MID D M MID D

21 6 2 4 3

22 5 2 4

23 2 1 3

24 2 2 1

25 2 3 4 0 1 2

26

27

28

1ST PERIODONTAL REASSESSMENT 29/11/12

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MANDIBLE

38

37 5 5 4

36

35 3 3 2

34 4 2 2

33 3 2 2

32 2 2 3 1

31 2 1 2 1

M MID D M MID D

41 2 1 2 1

42 5 3 2 1

43 1 1 3

44 5 1 5

45 5 1 6 0 4 0

46

47 7 6 7 3

48



D MID M D M D MID M MANDIBLE

38

37 4 2 5

36

35 2 1 2

34 2 1 2

33 3 1 2

32 1 1 2 1

31 2 1 1

M MID D M MID D

41 2 1 2

42 2 2 4

43 2 1 2

44 5 1 5 1

45 2 2 3 0 0 2 1

46

47 3 3 5 I 3

48



D MID M D M D MID M

Page37

Periodontal chart :

Palatal/lingual Tooth Pocket depth Furcation Recession Tooth


D MID M D M D MID M

MAXILLA

18

17 7 10 8 III 2 1 0 3

16 5 1 7

15 3 1 5

14

13 4 4 6 2 3 2

12 7 5 7 1 3 1 1

11 6 6 8 2 4 2

M MID D M MID D

21 5 3 5 0 6 0 3

22 5 2 4 2 3 2

23 2 1 5

24 1 1 6 0 2 3

25 3 4 6 3 5 3

26

27 12 7 7 III 3 5 2 3

28

Periodontal chart :

Palatal/lingual Tooth Pocket depth Furcation Recession Tooth


D MID M D M D MID M

MAXILLA

18

17

16 3 2 3 1 1 1

15 3 2 5

14

13 3 3 4

12 4 5 6 4 4 3 1

11 6 6 6 3 4 3

M MID D M MID D

21 3 4 3 5 6 6 3

22 2 2 2 3 3 3

23 2 2 4

24 2 3 4 2 3 4

25 3 3 3 3 5 6

26

27

28

2 2

Page38

MANDIBLE

38

37 5 1 6

36

35 2 1 1 0 4 0

34 1 1 1

33 2 1 2

32 2 1 3 1

31 1 1 1 1

M MID D M MID D

41 2 1 2 1

42 1 1 3 1

43 3 1 3

44 5 1 5

45 3 1 6

46

47 7 5 5 III 3

48



D MID M D M D MID M

MANDIBLE

38

37 4 4 4

36

35 2 2 1 0 4 0

34 4 4 3

33 1 1 2

32 3 3 5

31 3 1 1

M MID D M MID D

41 2 1 2

42 6 4 3

43 3 1 3

44 6 2 5 1

45 1 4 4 1

46

47 3 3 5 I

48



D MID M D M D MID M

1

1

Page39

SUMMARY OF 1ST PERIODONTAL RE-ASSESSMENT

Full Mouth Plaque Score - 9% Full Mouth Bleeding Score – 32%

Deepest pockets –6mm (palatal of #11, mesio-palatal of #21, mesio-

buccal of #21 and mesio-lingual of #44 ),

Diseased sites- 14%

Upper right

quadrant 5% Upper left

quadrant 2%

Lower right

quadrant 5% Lower left

quadrant

2%

Pockets ≥ 6mm – 5% of all sites with #11 and #21 still to be extracted

(carrying a hopeless prognosis)

Recession ranging from 0 mm to 6 mm with the greatest recession

still seen on #21.

Degree 1 mobility was associated with: #12, #41, #42 #44, and #45.

Degree 2 mobility was associated with: #11

Degree 3 mobility was associated with: ##21.


Page40

PERIODONTAL ASSESSMENT COMPARISON

Initial Periodontal Assessment

Periodontal Reassessment

Full Mouth Plaque Score

72% 9%

Full Mouth Bleeding Score

53% 32%

Deepest Pocket 6mm 6mm

Diseased Sites 46% 27%

Pockets ≥ 6mm 25% 5%

Recession 23% of sites 20% of sites

Mobility Degree 1

Associated with 5 teeth Associated with 3 teeth

Mobility Degree 2

Associated with 0 teeth Detected in 1 tooth

Mobility Degree 3

Associated with 3 teeth Associated with 1 tooth

Furcation involvement


Page41

IMMEDIATE DENTURE THAT WAS PREMATURELY FABRICATED

Page42

Periodontal chart :

Buccal



D MID M D M D MID M

MAXILLA

18

17

16 2 1 1

15 2 1 1

14

13 2 2 5

12 2 1 2 1

11 2 2 4 2

M MID D M MID D

21 6 2 4 3

22 5 2 4

23 2 1 3

24 2 2 1

25 2 3 4 0 1 2

26

27

28

2ND PERIODONTAL REASSESSMENT 31//01/13



D MID M D M D MID M

MAXILLA

18

17

16 2 1 1

15 2 1 2

14

13 2 1 5

12 2 1 2 1

11 3 1 1 2

M MID D M MID D

21 6 2 4 3

22 3 2 4

23 2 1 3

24 2 1 1

25 1 1 4 1 2 3

26

27

28

Page43



D MID M D M D MID M

MANDIBLE

38

37 5 5 4

36

35 3 3 2

34 4 2 2

33 3 2 2

32 2 2 3 1

31 2 1 2 1

M MID D M MID D

41 2 1 2 1

42 5 3 2 1

43 1 1 3

44 5 1 5

45 5 1 6 0 4 0

46

47 7 6 7 3

48

38

37 3 2 3

36

35 2 1 2 2 0 0

34 2 1 2

33 2 1 2

32 2 2 2

31 2 1 2

M MID D M MID D

41 2 1 2 1

42 2 1 4 1

43 2 1 2

44 7 2 5

45 3 2 3 0 0 2

46

47 3 2 5 I

48



D MID M D M D MID M

I

Page44



D MID M D M D MID M

MAXILLA

18

17

16 2 1 7

15 3 1 3

14

13 3 4 5 3 3 3

12 3 4 4 3 3 3 1

11 5 4 4 3 3 3 2

M MID D M MID D

21 2 3 2 8 8 8 3

22 2 2 2 3 3 3

23 2 1 4

24 1 2 3 1 2 3

25 2 3 3 2 5 5

26

27

28

Page45

MANDIBLE

38

37 4 4 4

36

35 2 2 1 0 4 0

34 4 4 3

33 1 1 2

32 3 3 5

31 3 1 1

M MID D M MID D

41 2 1 2

42 6 4 3

43 3 1 3

44 6 2 5 1

45 1 4 4 1

46

47 3 3 5 I

48



D MID M D M D MID M

38

37 5 3 7

36

35 4 2 3 2 0 0

34 6 3 2

33 2 1 2

32 2 1 4

31 3 1 2

M MID D M MID D

41 2 2 1 1

42 5 2 2 1

43 1 2 2

44 6 2 5

45 3 3 4 2 3 4

46

47 3 4 2 I

48



D MID M D M D MID M

Page46

SUMMARY OF 2ND PERIODONTAL RE-ASSESSMENT

Full Mouth Plaque Score - 9% Full Mouth Bleeding Score – 15%

Deepest pockets –7mm (Disto-palatal of #37, mesio-buccal of #44

and mesio-palatal o #16)

Diseased sites- 11%

Upper right

quadrant 3% Upper left

quadrant 1%

Lower right

quadrant 5% Lower left

quadrant

2%

Pockets ≥ 6mm – 5% of all sites

Recession ranging from 0 mm to 8 mm with the greatest recession

still seen on #21.

Degree 1 mobility was associated with: #12, #41, and #42.

Degree 2 mobility was associated with: #11

Degree 3 mobility was associated with: ##21.


Page47

2NDPERIODONTAL ASSESSMENT COMPARISON




9% 9%


32% 15%





Mobility Degree 1


Mobility Degree 2

Associated with 1 tooth Detected in 1 tooth

Mobility Degree 3

Associated with 1 tooth Associated with 1 tooth



Page48

SECTION 3: CASE DISCUSSION

PERIODONTAL DISEASE

Gingivitis is a mild, reversible form of periodontal disease characterized by

gingival inflammation without attachment loss and is detected by bleeding on

probing. Untreated gingivitis may (but not necessarily) develop into periodontitis,

a chronic inflammatory state which leads to periodontal attachment loss.

However, the initiation of periodontitis is still unclear. Clinical indicators of

periodontitis include probing depth, recession, measure of attachment loss and

radiographic level of alveolar bone.

The inflammatory state seen in periodontitis is triggered by a persistent

microbial challenge (microorganisms vary but some are pathognomonic) at or

below the gingival margin. These microbes are present in a ubiquitous biofilm

(dental plaque) that adheres tenaciously to the non-shedding surface of the

tooth. Dental plaque that gains the opportunity to calcify (calculus), also serves

as a continued source of viable bacteria. With regard to pathogenesis, microbes

do get the opportunity to colonize, evade the host’s responses and cause tissue

damage.

Page49

Plaque and calculus are accepted to be etiologic factors. However individual

factors including co-morbidity (systemic disease), genetics, smoking, oral

hygiene and age do affect the severity of periodontitis. The role of psychological

factors is no exception and has been shown to influence other parameters of

health and disease. (Irwin M, 1990). A strong link between stress, depression

and periodontal disease has been indicated with a biologic and behavioral

mechanism being proposed and supported by recent studies. (Higert, Hugo,

Bandeira, & Bozzetti, 2006) (Ng & Keung Leung, 2006) (Peruzzo, et al., 2007)

(Rosania, Low, Mc Cormick, & Rosania, 2009).

The importance of this finding is to increase awareness of psychological factors

as etiologic or contributing factors in an effort to individualize dental protocol.

Diagram showing mechanisms of proposed relationship between stress,

depression and periodontal disease of mechanisms:

Page50

BIOLOGICAL

Hypopituitary-adrenal

axis:production of cortisol

Inhibition of IgA and IgG and

PMN

Increased biofilm

colonization and reduced ability

to prevent conective tissue

invasion

Long term loss of ability to

inhibit inflammatory responses by

chronic cortisol elevation

BEHAVIOURAL Stress and depression

Increased poor health behaviors

Increased oral biofilm burden and

decreased resistance of the periodontium to inflaammatory

destruction

Page51

SUMMARY OF AJ’S MANAGEMENT

AJ presented to the UWI Dental School Polyclinic with complaints of “buildup”

around teeth, bleeding gums tooth malposition and progressing mobility.

Medical history did not reveal active disease. However a history of gastro-

duodenal ulcers, fibroids, cyst removal from right breast and periodically swollen

ankles was elicited. A stressful lifestyle stood out in AJ’s medical history,

highlighted by the loss of her son in 2002 to murder and a marital relationship

that was abusive and led to the death of her son. Clinical examination revealed

deviation to the left on closing and a forced lip competency owing to her anterior

open bite. A discolored central incisor, recession in the palatal anterior aspect

and increased overjet featured the intra-oral examination with attached gingiva

that was notably round in form. Periodontal screening revealed an initial plaque

score of 72% with a generalized distribution on all interproximal surfaces and

significant amounts on the palatal and lingual surfaces. BPE scores of asterix (*)

was present in all posterior sextants indicated furcation involvement and a need

for further investigation. Detailed full periodontal assessment inclusive of six

point charting and a full mouth radiographic series was then completed indicated

by this code.

Periodontal assessment showed generalized attachment loss with pockets as

deep as 12mm and recession as extensive as 6mm. A full mouth bleeding score

of 53% was recorded with the bleeding being spontaneous in nature. The sites

affected amounted to 40% with furcation involvement detected in three molars

and up to degree 3 mobility present in five teeth.

Page52

Radiographic assessment revealed generalized horizontal bone loss, including

bone loss to the apex and allowed the examination of several root stumps some

of which had periapical radiolucencies.

Page53

TREATMENT PLANNING

Fundamental dentistry is underscored by disease elimination and prevention as

well as the restoration of foundations. A treatment plan places structure to

therapeutic protocol and dictates the call to attention to various components that

may cause or contribute to loss of aesthetics, form and function. In addition,

instituting the periodontal treatment plan may well serve as the foundation for

further restorative work (be it basic or advanced).

In order to arrive at this treatment plan a diagnosis was made, predisposing,

initiating and aggravating factors unearthed and an appreciation for AJ’s

attitudes habits and health was gained.

DIAGNOSIS

AJ’s condition was labeled with a diagnosis of Severe Generalized Chronic

Periodontitis with primary plaque etiology and secondary factors being calculus

and stress. The following observations were made concerning the chronicity of

the condition:

1. AJ is an adult (although the disease can present at any age).

2. The amount of destruction documented was consistent with a high

plaque score of 72%.

3. Subgingival calculus was substantial.

4. May have been modified by stress (also may have worsened acutely

when her son was murdered).

A generalized distribution was given due to the involvement of 40% of the sites

(greater than 30% in the chronic form) and a severity assigned due to greater

than 6mm pocket depth and greater than one third alveolar bone loss when

seen radiographically in the worse affected sites.

Page54

PREDISPOSING, INITIATING AND AGGRAVATING FACTORS

Deposits of plaque and calculus were a significant finding. Also of note was AJ’s

repeated mention of the loss of her son and the relationship that she was

previously in. During two of the appointments she broke down in tears when

asked how he son died and about whether counseling was received. It was at

this time that she revealed that the person she entered a relationship with

caused her son to be murdered and referred to him as a “pest”. Interestingly she

asked if she” could cry” in the dental chair. AJ also admitted to binge eating

sugary foods such as cakes to feel better about her situation and did not brush

before bedtime.

There was complete bone loss recorded radiographically on #11and #21 with

the latter showing a grey discoloration. AJ reported that she suffered trauma to

this region after falling and hitting edge of a concrete staircase. This event may

have certainly exacerbated her developing periodontal condition.

Individual tooth diagnosis

Diagnoses of each tooth were made in order to treatment plan accordingly. In

addition AJ was able to be advised on how supported each tooth was (excluding

the root stumps). This diagnosis was made according the following criteria

(Nyman and Lindhe 89):

• Periodontitis levis (overt periodontitis): Horizontal bone loss less than

one third the root length, bleeding on probing

• Periodontitis gravis (advanced periodontitis): horizontal bone loss greater

than one third the root length, bleeding on probing

• Periodontitis gravis et complicata

o Angular bony defect (infrabony pocket, interdental osseous crater)

present adjacent to the tooth

o Furcation involvement of grade II and III have been identified in a

multirooted tooth.

Page55

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Gingivitis Periodontitis

levis


-et complicata

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Gingivitis Periodontitis

levis


-et complicata

Page56

It was then prudent to perform a tooth by tooth risk assessment or prognosis in

order to fully present the case to AJ. The root stumps present were assigned a

prognosis for the sake of intention to extract. This was based on clinical criteria

surrounding periodontal endodontic and dental factors. These are as follows:

Hopeless prognosis

o Periodontal

Recurrent periodontal abscesses

Periodontic-endodontic lesions

Attachment loss to the apex

o Endodontic

Root perforation in the apical half of the root

Periapical pathology in the presence of obturating post

and core

o Dental

Long fracture of the root

Oblique fracture in the middle third of the root

Caries lesions that extend into the root canal

o Functional

Third molars without antagonists and with

periodontitis/caries

Page57

Questionable prognosis

o Periodontal


Angular bone defects

Horizontal bone loss involving > two-thirds of the root

o Endodontic

Incomplete root canal therapy

Periapical pathology

Presence of voluminous posts/screws

o Dental

Extensive root caries

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Good prognosis/

secure


Hopeless prognosis

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Good prognosis/

secure


Hopeless prognosis

Page58

TREATMENT

Treatment was initiated and diagnosis of moderate to severe generalized

chronic periodontal disease warranted a treatment plan that included:

I. Initial phase therapy

1. Motivation and OHI

2. Extraction of hopeless teeth and root stumps

3. Restore #16M and #47O

4. Scaling and root planing

5. Minor occlusal therapy

6. Reassess 6-8 weeks

Initial phase therapy is aimed at eliminating infection and gaining control of

plaque levels. The stage must be set for the start of healing. AJ’s motivation and

oral hygiene instruction was a challenge. Several different aids were

administered including four different types of brushes that were suited for the

wide interproximal areas, lone standing teeth, the extensively receded palatal

regions and for general cleaning. This occurred after it was noticed that the

plaque distribution but persisted in certain areas, namely palatal (particularly just

below the subgingival margin) of the upper incisors. Although the upper central

incisors were deemed hopeless they were not initially extracted for esthetic

purposes as well as to re-evaluate after scaling. It proved quite difficult for AJ to

keep these clean even after issuing an angled single tufted brush. The brush

itself cleaned well but AJ’s motivation for this area waxed and waned thus re-

establishing the prognosis of these teeth. #37 and #47 were retained in the

mouth. Their mesial interproximal surfaces were almost always covered with

plaque until a smaller round headed brush was administered for these teeth.

Ideally a single tufted brush would have been preferred. The mobility and

recession of the gingiva that occurred as a result of active disease resulted in

Page59

wide embrasure space especially anteriorly where there was loss of contact.

Various interproximal brushes became necessary. AJ even discarded her first

set thinking that they were disposable. This saw a spike in plaque score from 18

to 47%. Her lowest plaques score to date has been 9%.

At the late stage of treatment AJ was quizzed on her condition. She was asked

to tell everything she understood about her disease. This served to refresh her

knowledge mid treatment and to ensure that the goal of disease management

with regard to primary plaque etiology, remained of importance and to highlight

the susceptibility of sites to deteriorate.

Extraction of the hopeless teeth including root stumps was traumatic for AJ.

While the provision of local anesthesia was adequate she would always cry out.

AJ had to be counseled on managing her anxiety during dental extractions and

came to control it very well. Some of the root stumps, particularly #47, were

heavily invested by dense granulation tissue. This led to prolonged healing of

the extraction sites and difficulty of cleaning the teeth adjacent to them.

The two restorations outlined in the treatment plan were uneventful with the

exception of a pin point pulp exposure on #47. This was addressed with a direct

pulp cap and AJ was advised but possible sequelae. The tooth will be monitored

for symptoms of pulpitis but is expected to repair itself after the capping

procedure was done.

Scaling and root planing including deep scaling was performed. There was

difficulty in removing calculus in some areas as the deposits were highly

aggregated and surrounded by purulent granulation tissue. Marked bleeding

accompanied the procedure prompting a need on occasion to re-visit scaled

sites. This was aided by post- scaling gingival recession. A second round of

scaling was then carried out after the first re-evaluationn but this was only in the

upper anterior sextant.

Page60

Minor occlusal therapy on #13 was thought to have been necessary. However

an occlusal analysis was not carried out until the 28/01/13. In addition AJ would

always comment that the tooth “dropped” and was not always in that position.

Findings of the analysis included:

The cusp of #13 is proving to be working side interference. Occlusal contact is

solely occurring between #13 and #44 and #15 and #45. This is the only support

and means of mastication with group function in lateral excursion to that side.

The initial phase therapy terminated with two re-evaluations of all parameters

of a full periodontal assessment. A summary of the findings is as follows:

First:




72% 9%


53% 32%





Mobility Degree 1


Mobility Degree 2

Associated with 0 teeth Detected in 1 tooth

Mobility Degree 3




Page61

Second:




9% 9%


32% 15%





Mobility Degree 1


Mobility Degree 2

Associated with 1 tooth Detected in 1 tooth

Mobility Degree 3




Aims of treatment were:

1. < 10 %, of sites BOP

2. No sites with PPD > 5 mm, but preferably < 4 mm

3. No furcation involvement of degree II or III.

4. Satisfy the patient's demands regarding esthetics and masticatory

function.

The level of bleeding in the mouth reduced but is still significantly high. This

becomes important for stability as there is a 30% probability for attachment loss

for sites with repeated bleeding. While there was a general reduction in probing

depths (#11 and #21 had minor reduction but were largely unresponsive after

Page62

first re-assessment), probing depths of 5mm appeared sporadically with one site

recording 6mm in the first re-assessment and three sites recording 7mm in the

second re-assessment. Elimination of advanced furcation involvement was

achieved however furcation plasty can be considered for #47 which retained a

grade I furcation involvement.

II. Corrective phase

1. Adjunctive antibiotic treatment if necessary in local areas

2. Transitional denture in lower arch for posterior support with

concurrent adjustment of the supra-erupted #13 effort to address

occlusal discrepancy (modified 01/02/12)

3. Transitional denture for upper arch (decision to replace teeth on the

free end saddle is tentative) to be modified and include #11 and #21

post extraction

The adjunctive antibiotic treatment was not explored to date. After much deferral,

extraction of #11 and #21 were finally decided on only to have AJ refuse on the

day of the appointment. The immediate denture was fabricated for this

appointment. However the occlusal analysis conducted after this roadblock

resulted in the realization that more effective treatment planning for the

temporary prosthesis at this stage had to be done and that replacement of the

central incisors were only for esthetics while her masticatory function was

lacking. As a result the immediate denture may not be used as AJ is currently in

the treatment phase for fabrication of a lower transitional denture instead to first

address the occlusal discrepancies including the supra-erupted #13. Extraction

of the central incisors will eventually be carried out.

Page63

Final Reconstructive phase

1. Orthodontic treatment if feasible

2. Final removable/fixed prosthodontic therapy

3. Supportive periodontal care during reconstructive/orthodontic phase

4. Referral for psychological counseling

To date this phase has not been entered. Active treatment including a third

round of scaling and root planing in persistent sites will be done before re-

evaluation for suitability for fixed reconstruction. However, referral for

psychological counseling will be embarked upon even now as this may affect

the desired outcome.

Final 3 month evaluation

V. Supportive periodontal therapy or maintenance

This phase requires stability and will be entered once there is the satisfaction of

control over the inflammatory degeneration. As mentioned previously a high

bleeding score indicates active inflammation and this along with residual sites

greater than 5mm are persisting are preventing AJ from currently entering this

phase.

Page64

CRITICAL APPRAISAL

Scaling and root planing therapy commenced in 18/09/12 and was completed on

25/10/12. This gives a time span of seven weeks. This time span was too

lengthy compared to the preferred period of two weeks. Reassessment is

recommended to be done within a 6-8 weeks following therapy. However this

was done 5 weeks after last scaling and approximately 10 weeks after scaling of

first quadrant. This lapse in time may have affected the success of the therapy.

Performing an occlusal analysis was planned to be part of the pre-treatment

analysis. However it was overlooked prior to the fabrication of the transitional

denture to replace the central incisors. This led to the neglect of the lack of

posterior support that AJ was now experiencing due to the extraction of several

hopeless teeth. The need to fabricate a new denture to accommodate the new

masticatory relationships arose when the occlusal analysis and relevant

consultations were done. The fortunate outcome is that it can be used as a

transitional denture to acclimatize her to the experience of wearing a more

permanent prosthesis. In addition AJ developed indecisiveness towards

extraction of the upper central incisors. This may have been due to lack of a

clear indication to her as to the severity of the loss of periodontal support

affecting these teeth. The transitional denture may prove to get her closer to the

point of extraction of the upper central incisors.

Skills in handling “tough” calculus could have been improved upon. This would

reduce the number of re-visits necessary to remove residual deposits

Page65

OPPORTUNITIES FOR LEARNING

Early recognition of the toll that the loss of a child had on AJ followed by quick

referral had the potential to set in motion the process of creating a

stress/depression free background to periodontal therapy. It was indeed

overlooked as she commented that she was better now until she broke down

into to tears in the dental chair on two occasions. This has certainly broadened

my scope with regard to modifying factors in periodontal disease as well as the

minor role I may play as a clinician in improving the overall health of my patients.

CONCLUSION

While the treatment of chronic periodontitis revolves around the cause related

therapy of plaque control and calculus removal, modifying factors must be

appreciated, end- treatment goals may be far off if this is not considered.

Intense life stresses and psychological factors may certainly contribute to the

falling short of these goals and thus must not be overlooked or postponed if

identified.

Page66

Referral Letter

University of the West Indies Dental School,

Eric Williams Medical Science Complex,

Uriah Butler Highway,

Trinidad

February 7th, 2013

Dr. X

Consultant Periodontologist,

Eric Williams Medical Sciences Complex,

Uriah Butler Highway,

Trinidad

Re: Periodontal Management of AJ

Dear Dr. X,

AJ is a fifty-five year old female who presented to our polyclinic on 14/02/2012

with complaints of the presence of buildup around teeth, bleeding gums and

tooth malposition.

AJ’s medical history has not revealed any particular condition of major concern.

Her lifestyle however was previously marked by extreme stress.

Clinical and radiographic examinations revealed generalised supragingival and

subgingival plaque and calculus deposits along with generalised attachment

loss. Basic periodontal examination gave (*) scores for all posterior sextants. A

diagnosis of Moderate to Severe Generalized Chronic Periodontitis was

established.

Page67

Initial phase therapy has been performed in all quadrants however most pockets

show improvements while others have worsened.

Your detailed assessment of the patient and any recommendations for further

management would be greatly appreciated.

Yours truly,

..................................

Tamika Peters

Dental Student

Page68

References Glassman, A., & Miller, G. (2007, April). Where there is depression, there is

inflammation....sometimes! Biol Psychiatry, pp. 280-281.

Heasman, P. (2003). Master Dentistry, Restorative Dentistry, Paediatric Dentistry and Orthodontics. Churchill Livingstone.

Higert, J., Hugo, F., Bandeira, D., & Bozzetti, M. (2006, April). Stress, cortisol, and periodontits in a poulation aged 50 years and over. Journal of Dental Research, pp. 324-328.

Iacopino, A. (2009). Relationship between stress and periodontal disease. Journal of the Canadian Dental Association, 329-330.

Irwin M, P. T. (1990, February). Reduction of immune function in life stress and depression. Biol Psychiatry, pp. 22-30.

Lindhe, J. (2003). Clinical Periodontology and Implant Dentistry. Oxford: Blackwell Munksgaard.

Ng, S., & Keung Leung, W. (2006, April). A community study on the relationship between stress, coping, affective dispositions and periodontal attachment loss. Community Dental and Oral Epidemiology, pp. 252-266.

Peruzzo, D., Benatti, B., Ambrosano, G., Nogueira-Filho, G., Sallum, E., & Casati, M. (2007, August). A systematic review of stress and psychological factors as possible risk factors for periodontal disease. Journal of Periodontology, pp. 1491-504.

Rosania, A., Low, K., Mc Cormick, C., & Rosania, D. (2009, February). Stress, depression, cortisol and periodontal disease. Journal of Periodontology, pp. 260-266.

Ramlogan, S; Raman V. Lecture notes in Periodontology. UWI School of Dentistry

Final Year DDS Perio Case

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