By Shirley Neuebaumer

PERIODONTAL COMPETENCY

53 years old African American malePlays in a band

Works as a billboard installerSingle, no children

Has medical but no dental insurance

PATIENT INFORMATION

General health is goodNon-smoker

Diagnosed with benign prostate hyperplasia in 2012

Takes Terazosin every dayNo hospitalization history within the last 5 years

and no major surgeriesLast medical exam was January 2014 for regular

check-up. No significant findings.Vitals: Pulse: 90 Resp: 18 BP: 132/79 Pre-hypertensive

MEDICAL HISTORY

Goes to the dentist irregularly.Had a “deep cleaning” before.

Had an extensive amalgam fillings.FMX taken on 3/2013

Learning ladder: Unaware- did not know that plaque causes cavities.

DENTAL HISTORY

Brushes 1x per day using Colgate Total using a manual toothbrush

Does not floss because said he’s lazy. Uses Listerine mouthwash 1x per day.

ORAL HYGIENE PRACTICES

INITIAL ASSESSMENTSFor MM

• Physiologic pigmentation of the gingiva• Bilateral linea alba adjacent to the molars only• Geographic tongue • Possible sleep apnea due to enlarged tongue,

very difficult to see oropharynx

E/I EXAM

Color—pigmented Consistency—boggy Contour– rounded margins on lower anteriors Texture– smooth and stippled Papilla— flat between 3 and 6, blunted between

#23-27, bulbous on buccal and lingual of mandibular anteriors.

Heavy plaque on IP of posteriors Moderate inflammation Calculus class 5 and AAP 2

GINGIVAL DESCRIPTION

• Plaque index: 1.67 (Fair)• DMFT: 22 (D=3, M=0, F=19)• High caries risk due to current decay • BANA test: positive• Saliva pH: 7• Low salivary flow at 5ml

OTHER TESTS

• Severe open bite resulting in difficulty in chewing. Patient stated he has to cut most foods and push it inside his mouth or he has to bite large chunks of food in order to be able to chew it.

• Only 3rd and 2nd molars occlude (1 and 32, 2 and 31, 15 and 18 and 16 and 17).

• Heavy mouth breather = fogged mirror• 6mm anterior open bite• 4mm posterior open bite

OCCLUSION

RADIOGRAPHS

Suspicious caries found on: 1-O 8-M 9-M 13-D

Slight horizontal bone loss Calculus present: 20D, 19D, 18M, 24M, 28D,

32M Tooth #4 has retained root tip

CARIES EXAM & RADIOGRAPHIC

INTERPRETATION

PERIODONTAL EXAM

Assessment Findings Goals(Pt./client centered)

Expected outcomes(evaluation methods, time frame)

Periodontal risk: high PD range 2-6 mm Moderate

inflammation on lower anteriors

Moderate supra calculus on lingual of lower anteriors

Heavy subgingival calculus

moderate plaque on posterior teeth

BOP Recession

1. Pt. will learn Bass TB technique.

2. Pt. will learn C-shape flossing.3. Patient will understand the

link btw plaque and periodontal disease.

4. Pt. will understand the benefits of antimicrobial rinses.

5. Patient will learn how to use gum stimulator.

 

1. Pt. demonstrates Bass TB technique

2. Pt. demonstrates C-shape flossing.

3. Pt. explains the link btw plaque and periodontal disease.

4. Pt. reports using antimicrobial rinses daily

5. Patient reports using gum stimulator at least 1x per day.

 Caries risk: high Suspicious caries

#1-O, 8M, 9M, 13D

1. Pt. will understand the link btw plaque and caries formation.

2. Pt. will understand the benefits of topical fluoride

1. Pt. explains the link btw plaque and caries formation.

2. Pt. explains the benefits of topical fluoride

TREATMENT PLAN

Appt. #

Plan for education, OHI, counseling

Area Plan for treatment & services

1 OHI: Bass techniqueEducate on plaque biofilm and periodontal disease

FM Complete Assessments, disclose, OHI

2 Review Bass technique FM Check-in assessments, photos, complete perio competency assessments, OHI

3   18-24 Update assessments, Topical, Administered Lidocaine 2% with epinephrine, Chlorhexidine pre-procedural rise, scaled 18-24 for Mock Board using hand instruments and USS.  

4 OHI: C-shape flossing 25-31 Update assessments, OHI, Topical, Administered Lidocaine 2% with epinephrine, Chlorhexidine pre-procedural rise, scaled 25-31 for Test Case using hand instruments and USS.  

5 Review C-shape flossingEducate on benefits of frequent topical fluoride application

32, 31, 27, 26, 22, 20, 18, 1-5

Update assessments, OHI, chlorhexidine pre-procedural rinse, Topical, Lidocaine 2% with epinephrine, scaled residual calculus from Test case and Mock Board, scaled 32 and 1-5 using hand instruments and USS.

6 OHI: Gum stimulator 6-16 Update assessments, OHI, chlorhexidine pre-procedural rinse, Topical, Lidocaine 2% with epinephrine, scale using hand instruments and USS.

TREATMENT PLAN BY APPOINTMENTS

NUTRITIONAL ANALYSIS

MM’S FOOD DIARY

Grains (oz)

Vegetables (cups)

Fruits (cups)

Dairy (cups)

Protein (oz)

0 1 2 3 4 5 6 7 8 9 10

Avg eaten

Target

RE-EVALUATION

High periodontal risk:

PD range 2-6 mm

Moderate inflammation on lower anteriors

Moderate supra on lingual of lower anteriors light subgingival calculus

Light to moderate plaque on posterior teeth

BOP

NOTE: Patient stated that he was brushing and flossing more when I was seeing him consistently almost every Tuesday.

PERIODONTAL ASSESSMENT

PERIODONTAL EXAM

COMPARISON

Pre-treatment Post-treatment

PHOTOS

Pre-treatment Post-treatment

PHOTOS

Pre-treatment Post-treatment

PHOTOS

• The success of any dental treatments depend heavily on home care.

• Changing behavior is hard but having continued discussion with patients do make an impact.

• Time management- always be prepared.• In clinic, setting the right expectations is

critical.

REFLECTION

MALOCCUSION AND PERIODONTAL DISEASE

• Malocclusion is any deviation from the normal relationship of the maxillary arch to the mandibular arch.

• Anterior open bite is a type of malocclusion characterized by a deviation in vertical relationship between maxillary and mandibular dental arches resulting in the absence of contact between the incisal edges of both dental arches.

RESEARCH

Anterior open bite may be caused by:

1. Prolonged thumb sucking

2. Tongue thrusting

3. Poor teeth position

4. Skeletal deformities

Classification of anterior open bite: dental or skeletal• Correct diagnosis is critical since each classifications

have different treatment modalities ranging from orthodontics alone or in combination with orthognathic surgery.

ETIOLOGY

Classified similar to Angle’s method of malocclusion classification.

This is malocclusion involving poor teeth position.

POSSIBLE CAUSES:

Posterior teeth erupt too far or if anterior teeth erupt too little

Prolonged thumb sucking

Tongue thrusting

This type of malocclusion are generally fixed by orthodontics.

DENTAL MALOCCLUSION

This exists when the problem is caused by the position of the jaws relative to one another.

Multifactorial etiology

Classifications: horizontal, transverse and vertical planes.

Horizontal malocclusions are classified as Class II or Class III malocclusions similar to Angle’s classification.

Vertical malocclusions include open bites and severe overbites

Transverse malocclusions include crossbites.

Treatment includes both orthodontics or orthognathic surgery.

SKELETAL MALOCCLUSION

• A study done in Wonkwang University dental hospital and six private clinics in Korea aimed to evaluate the effect of malocclusion on oral health quality of life in adults.

• 860 participants were divided into four groups: normal occlusion, malocclusion, fixed treatment and retention.

• Normal occlusion and malocclusion classification were decided clinically for adults visiting the hospital and clinics who had not received previous orthodontic treatment. The classification was based on the alignment of the anterior teeth and the degree of lip protrusion.

• The participants were asked to complete a questionnaire assessing how frequently they experience functional limitation, physical pain, psychological and social disability and handicap.

EFFECTS OF MALOCCLUSION TO QUALITY OF LIFE

• The malocclusion group perceived the strongest psychosocial impact related to esthetics.

RESULTS

1. Darby M, Walsh M. Dental hygiene theory and practice

2. Choi, S., Kim, B., Cha, J., & Hwang, C. Impact of malocclusion and common oral diseases on oral health–related quality of life in young adults. Am Journal Of Orthodontics & Dentofacial Orthopedics [Internet]. 2014 Apr [cited 2015 May 1]; 147(5). Available from: http://library.foothill.edu:2206/ehost/pdfviewer/pdfviewer?sid=a2ef8c3e-17f2-43b3-be25-cdb08bcbf493%40sessionmgr111&vid=32&hid=119

3. Geron, S., Wasserstein, A., & Geron, Z. Stability of anterior open bite correction of adults treated with lingual appliances. European Journal Of Orthodontics [Internet]. 2013 Oct[cited 2015 May 1]; 35(5), 599-603. Available from: http://library.foothill.edu:2206/ehost/pdfviewer/pdfviewer?sid=a2ef8c3e-17f2-43b3-be25-cdb08bcbf493%40sessionmgr111&vid=32&hid=119

REFERENCES