Periodontal Project Spring 2014

1. Periodontal ProjectSpring 2014 Brooke Keniston

2. Patient Profile & Medical History • 27 year old female • Congenital hypothyroidism, controlled with Levothyroxine since birth and currently takes 200 micrograms per day but patient feels that her dosage may need to be adjusted. • ASA II • Patient reports discomfort in third molar regions, bleeding with flossing, sensitivity to cold, food trap on lower right, clenches teeth but does not wear a guard. • Brushes once daily with an electric toothbrush and flosses “sometimes”. • Vitamin D as vitamin supplement, 2000 IU per day. • Patient has recently moved, has no vehicle, and walks to both of her jobs. • Last dental and hygiene visit was in May 2011 • Last primary care physician appointment was in 2011.

3. Extra Oral Findings • Stature, gait, speech, head and neck, lymph nodes, and lips are all within normal limits. • TMJ has slight subligation on left

4. Intra Oral Findings • Halitosis • Fordyce granules • Palate, floor of mouth, saliva glands are all within normal limits • Fauces are moderately enlarged and patient reports intermittent food pockets on tonsillar area • Coated tongue • Labial frenum tag on maxillary incisalfrenum • 2mm aphthousulcer lower right labial mucosa near #28 • Excess salivary production present in mouth • Enlarged red lingual incisive papilla between #8 and 9

5. Intra Oral Findings • Slight erosion on lingual anterior incisive edges • Slight attrition on #6 distal edge, #12 mesiobuccal cusp, #21 distobuccal cusp, #27 distal edge, and #30 mesial cusp • Moderate decalcification on #9 facial, #28 and #29 cervical, #30 direct facial cervical and distobuccal lingual. Slight decalcification on #15 cervical, #18 buccal groove, #19 direct facial and direct lingual. • Root tips present on #1, 3, 5, and 14. Patient reports crown disintegration on #1, 5, and 14. #3 was extracted and roots left. • Biofilm index 54% • 60% overbite, 4mm overjet, #22-27 and #10-11 are slight torsoversion • Class I occlusion on right canine and left canine • No occlusion classification on right molar and left molar

6. Dental Chart

7. Assessment Findings • #16, 17, and 32 unerupted • Decay on #1 occlusal, 3 occlusal, 4 mesial, 5 occlusal, 14 occlusal, and 18 distobuccal • Possible carries on #19 and 29 • Occlusal amalgam on #15, 18, 30. Occlusal distal amalgam on #13, 20. Mesial occlusal amalgam on #19. • #1 has cratered out crown • #2 has band and loop space maintainer left in place since early adolescence, open contact on mesial, recurring decay on surface restoration on distobuccal.

8. Assessment Findings • #31 operculum covering occlusal, distobuccal, and distolingual surfaces • All 25 teeth have spicules of moderate supragingival calculus • #22-#26 have ledges of severely burnished supragingivalcalculus • #6, 7, 11, 12, 13, 15, 20-31 have spicules of moderate subgingivalcalculus interproximally.

9. Risk Factors • Caries risk factors: calculus, faulty restorations, exposed root tips, operculum tissue, obesity • Oral habits: poor home care, infrequent dental visits

10. Direct Facial Closed Bite

11. Right Side

12. Left Side

13. Mandible

14. Maxilla

15. Lingual Incisive Papilla Between #8 and 9

16. Band and Loop Space Maintainer on #2

17. #3-6

18. #14

19. Periodontal Charting

20. Periodontal Diagnosis • No mucogingival involvement or mobility. • Periodontal risk factors include controlled hypothyroidism, moderate stress, nutritional deficiencies, obesity, and possibly genetics. • Contributing factors include calculus, faulty restorations, root morphology, root resorption, mouth breathing, food impaction, malocclusion, occlusal discrepancies, appliances, un-replaced teeth, and anatomic defects. • AAP II • Generalized slight active chronic periodontitis and localized moderate active chronic periodontitis on #4, 18, 19, 29,30, and 31 with localized gingivitis on #7-11

21. Gingival Description • Generalized pink margins and papillae with localized slight marginal and papillary redness on #22-27, and #14 lingual with generalized slightly enlarged, rounded, edematous, spongy tissue and localized moderate edematous on all maxillary molars and mandibular anterior facial, with localized firm, smooth, moderate edematous on maxillary anteriors, generalized slightly enlarged, pyramidal shape with slight festooning on #28 facial, localized stippled on maxillary anterior.

22. Previous Radiographs(provided by DMD office)

23. Current Radiographs(provided by DMD office)

24. Treatment Plan

25. Procedures • First Appt: Medical history, vitals, extra oral exam, intraoral exam, exam findings, began dental charting. Second Appt: Medical history review, vitals, cursory EOE and IOE, gingival margin assessment, probe depths on maxilla, patient consultation with overseeing dentist. Third Appt: Medical history review, vitals, cursory EOE and IOE, completed probe depths, gingival assessment, periodontal assessment, deposit assessment. Fourth Appt: Medical history review vitals, cursory EOE and IOE, intraoral photos taken, treatment planning, oral hygiene instruction and patient education, biofilm index (54%), debridement of mandibular anterior linguals/ sextant V using ultrasonic scaler, biofilm removal of mandibular anterior linguals.

26. Procedures Fifth Appt: Medical history review, vitals, cursory EOE and IOE, biofilm index (45%), acquired radiographs from last dental office, debridement of lower right sextant VI with ultra sonic. Sixth Appt: Medical history review, vitals, cursory EOE and IOE, biofilm index (51%), debridement: mandibular anterior/sextant V facial, lower left/sextant IV, upper left quadrant, facial of upper right quadrant except #15. Seventh Appt: Medical history review, vitals, cursory EOE and IOE, biofilm index (51%), debridement of #15 and lingual of upper left quadrant. Biofilm removal by polishing on anteriors, by tooth brushing and scaling on posteriors and lingual maxillary anteriors, and flossing all teeth with crowns. Fluoride trays with 1.23% non-acidulated gel. Recare in 6 months.

27. Summary • I initially thought that my patient would be a higher AAP classification as I was alarmed with other overwhelming conditions in the mouth. Through taking Periodontology class and working with my patient, I understand the process and calculation of AAP determination, as well as how the diagnosis can be different then the generalized periodontal condition. I have also learned that a patient can be periodontally involved on more than one or even two levels; my patient has slight and moderate periodontitis as well as gingivitis. Due to the varying level of tissue type, I struggled in organizing the gingival description to be as short and concise as possible without excluding detail. Although I did not clinically see improvements with her treatment I feel there is a need for re-evalution due to the patient’s risk factors and contributing factors. I feel that after the more extenuating conditions have been resolved, my patient should be able to improve. I feel like my patient’s prognosis is good but will depend greatly on her ability to follow through with professional care from a referred dentist. After implementing treatment planning, this patient was able to secure an appointment with a new primary care physician and begin updated treatment for her hypothyroidism. She was also able to see a new dentist within walking distance from her house. That office took a new full mouth survey for my patient but did not succeed in retaining her as a patient. I am still trying to find her a dental office which accepts her insurance and of which she will be satisfied with. • During the last appointments with my patient, she was recovering from a cold and I had to seat her more upright, sometimes requiring me to stand. This made the pace of work a lot easier, as she has a sensitive gag reflex. I wish I would have thought to change her positioning much sooner in the treatment process as I may have been able to complete treatment in a lesser amount of time. I am hoping that her positive experience with me in the clinic has helped to improve her outlook on dental care.