Senior Perio Project

Kelli Redmond and Andrea Cates

West Los Angeles College
May 19, 2010
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I. Personal History

 42 year old male

 Hispanic descent
 Date of Birth: 3/29/1968
 Currently unemployed
 Married with 1 college-age son

II. Medical History Review

a. Past History:
i. Patient only visits the doctor when ill. Last visit was 4 years ago.
b. Present History:
i. Sleep Apnea, Hypertension, Dental anxiety
c. No medications
d. Baseline vitals:
1. March 4, 2010 BP: 132/90, P:80, R:14
2. March 11, 2010 (AM) BP: 122/98, P:64, R:12
(PM) BP: 130/88, P:70, R:12
3. April 8, 2010 (AM) BP: 138/90, P: 68, R:16
(PM) BP: 138/92, P:74, R: 16
4. May 6, 2010 BP: 120/90, P: 72, R:14
e. Modifying Factors:
i. Sleep apnea
ii. Ill-fitting maxillary bridges

III. Dental History Review

a. Past History:
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i. Patient had orthodontic treatment as a teenager in Mexico to

correct malaligned dentition.
ii. Last dentist visit was 2 years ago in Guadalajara, Mexico.
iii. Patient received a dental cleaning and had teeth extracted due to
decay.
iv. The patient had two ill-fitting bridges placed bilaterally in the
maxillary premolar area.
b. Present status:
i. Currently began treatment for scaling and root planning.
ii. He has existing caries that will be address during this SRP
treatment and after the SRP treatment has been completed.
c. Chief complaint:
i. Patient stated he wanted to have teeth whitened and have loose
maxillary anterior composite fillings replaced.
d. Caries Asssessment:
i. Pt reports using fluoridated toothpaste
ii. Adequate salivary flow
iii. Moderate visible plaque
iv. High carbohydrate intake
v. High acidic beverage intake
vi. 5 active caries.
1. Class II: #30
2. Class III: #7, #8, #9
3. Class V: #21

IV. Clinical Examination

a. Extra oral exam:

i. Within normal limits
b. TMD Exam:
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i. Crepitus in TMJ on left upon opening

ii. Wear facets on the mandibular cuspids due to ill-fitting
maxillary bridges.
iii. Bruxism has caused abfraction on #21 and attrition of anterior
teeth.
c. Intra Oral Evaluation:
i. Slight ankyloglossia
ii. Fissured tongue
d. Oral Hygiene evaluation:
i. Skill level:
1. Poor oral hygiene
ii. Present plaque control techniques:
1. Pt uses horizontal brushing.
2. Pt does not use interproximal aids.
3. Patient states he brushes twice a day.
iii. Patient is unaware of periodontal disease.
iv. Indices and Rational:
1. Gingival Index-
a. Rational is to assess gingival inflammation. The
baseline data allowed us to compare the tissue
changes after treatment was completed.
2. Plaque Index:
a. Rational is to assess the plaque removal. The
baseline data allowed us to educate and implement
and home care regimen. It was used post-treatment
to evaluate the effectiveness or lack of home care.
3. Marginal Bleeding Index:
a. Rational is to assess presence or absence of
gingival bleeding when periodontal pocket is
disrupted.
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4. DMFT Index-
a. Rational is to evaluate the patients dental health
status.

V. Periodontal Evaluation

a. Calculus-
i. Medium Heavy calculus.
b. Plaque:
i. Baseline Data: Moderate plaque. Plaque index: 48%
c. Restorations:
i. Quality of restorations on #7, 8 and 9 are poor. They were loose
and causing recurrent decay. Both maxillary bridges are ill-
fitting. The patient cannot clean under the pontics due lack of
space. The bridges impinge upon the gingiva.
ii. Maxillary: #1 Occ amal., #2 PFM abutment, #6 PFM abutment, #7
M comp., #8 M comp., #9 M comp., #11 PFM abutment, #14 PFM
abutment, #15 Occ amal., #16 Occ amal.
iii. Mandibular: #18 PFM abutment, #20 PFM abutment, #30 O
amal., #31 O amal.
d. Caries:
i. #30, #7, #8, #9, #21
e. Pocket depths:
i. Baseline:
1. Generalized 4-6mm pockets with 9mm pockets on
#15 B L
ii. Mobility:
1. +: # 7,8,9,10, 15, 22, 26
2. +1 : #15, 23, 24, 25
iii. Furcations:
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1. Class I: #18 lingual, #30 buccal

iv. Marginal Gingiva:
1. Maxillary: Edematous, blunted, hemorrhagic, localized
rolled borders on #1,2 14,15, 16.
2. Mandibular: Edematous, blunted, hemorrhagic, glossy,
localized rolled borders on buccals of #18, 30, 31.
Erythemateous on linguals of anterior sextant.
v. Attached Gingiva:
1. Maxillary: Pink, firm, glossy, localized areas of bulbous
hemorrhagic tissue on #14, 15, 16
2. Mandibular: Pigmented, firm, glossy localized edematous
on lingual #18, linguals # 30, 31
vi. Alveolar Mucosa:
1. Smooth and shiny
vii. Perpetuating Factors:
1. Open contacts
2. Dental caries
3. Faulty restorations
4. Plaque
5. Calculus
viii. Etiology
1. Plaque
ix. Diagnosis
1. AAP: Generalized Severe Chronic Periodontitis modified
by sleep apnea and perpetuated by local factors such as
plaque and calculus
x.Prognosis
1. ULQ: Poor
2. LLQ: Fair
3. URQ: Poor
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4. LRQ: Fair
xi: Occlusal and TMD evaluation
1. Right: C: Class I, M: Class I
2. Left: C: Class I, M: Class I with crossbite
3. Facial Profile: Mesognathic
4. Overbite: 1mm
5. Overjet: 3 mm
6. TMD evaluation: Crepitus in TMJ on left upon opening.
Wear facets on the mandibular cuspids possible due to ill-
fitting maxillary bridge. Bruxism has caused abfraction on
#21 and attrition of anterior teeth.
7. Maximum opening: 44mm

VI. Radiographic Examination

a. The quality of the radiographs is poor. Six radiographs stuck together
during processing which caused water marks. Poor film placement
resulting in horizontal overlapping and missing apices. Cone cut
appeared on one film.
b. Normal trabeculation, no radiolucencies, no opacities
c. Alveolar bone:
i. Generalized horizontal bone loss.
ii. Localized vertical bone loss interproximal of #15 and #16. No
radiographic furcations.
iii. Generalized fuzziness of the crestal bone indicates active
periodontal disease.
d. No periapical radiolucencies
e. Generalized widening of the PDL. Lamina dura has generalized
fuzziness due to active periodontal disease
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f. Teeth:
i. ULQ: 2:1 crown-root ratio on molars. Possible radiographic
calculus on the base of #16 mesial. Hyperocclusion of #16.
1:2 crown-root ratio on cuspid.
ii. LLQ: 1:1 crown-root ratio on molar, 1:2 crown-root ratio on
cuspid and bicuspids. 2:1 crown-root ratio on #24.
iii. URQ: 1:1 crown-root ratio on molars, 1:2 crown-root ratio on
canine. Root lengths are slightly longer than average
iv. LRQ: 1:1 crown-root ratio on molars. 1:2 crown-root ratio on
cuspid and bicuspids. 2:1 crown-root ratio on #25.
v. Radiographic caries: #30 distal, #21 mesial
VII. Oral Hygiene Evaluation

a. Plaque Free Index: Baseline 52%

Re-evaluation: 55%
3% improvement
b. MBI: Baseline 0%
Re-evaluation: 0%
c. The patient’s skill level is poor. The patient used horizontal brushing
method with poor plaque removal. The patient has no knowledge of
periodontal disease.
d. Objectives for oral hygiene
i. Educate the patient on the effects of plaque in the periodontium
ii. Use interproximal aids once a day
iii. Use modified bass technique twice daily
e. Oral aids that were introduced throughout the treatment were end tuft
brush, floss handle, go-between flossers, and interproximal brush with
moderate size bristles.
f. Barriers to treatment:
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g. The patient has a faulty bridge between #2-6 and #11-14. It is impossible
to use oral aids to clean under the bridge. He does not have the financial
means to replace them.
h. The patient is currently unemployed. Not having financial stability may
make it difficult to maintain the periodontal recalls we have recommended.
It also affects his access to a periodontist and oral surgeon.

VIII. Indices
a. Reversible indices used were plaque free index, gingival index and
marginal bleeding index.
b. Irreversible indices used was DMFT
c. Indices pre-therapy and post-therapy
Reversible Indices Pre-Therapy Post-Therapy

Marginal Bleeding Index 0% 0%

Plaque Free Index 52% 55%

Gingival Index Moderate Mild Inflammation

Inflammation (.125)
(1.8)
DMFT 26 26

IX. Treatment Plan

a. Patient Status: The patient is a new patient of the clinic. There are
active caries that will be filled. He will be on a 3 month periodontal
maintenance.
i. Consultations:
1. We have recommended that he visit a periodontist. He has
localized areas > 5mm pockets
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2. Oral surgeon for possible extraction of #15 and #16.

b. Dental Hygiene Treatment Plan:
i. We determined the patient needed quadrant scaling and root
planning
ii. Rationale: Medium heavy calculus and pocket depths of 4mm to
9mm on the posteriors teeth.
iii. Goals:
1. Remove plaque and calculus in hope of reducing the
disease causing microorganisms.
2. Increase patient’s oral hygiene awareness so that he may
improve his home care.
3. Objectives:
a. Reinforce oral hygiene at each appointment
b. Remove plaque and calculus at each
c. at each appointment
iv. Total of 5 appointments
1. and knowledge level of Appointment #1- March 3, 2010
a. Get baseline status which includes E/I, MBI, plaque
index, DMFT, gingival index, probings, furcations,
mobility
b. Assessed patient’s skill periodontal disease.
c. Take photographs.
d. Oral hygiene instructions, which include modified
bass brushing, flossing instructions, and Go-
Between flossers for class II embrasures.
e. Address chief complaint of wanting to have whiter
teeth. We agreed to wait until the completion of the
SRP treatments to provide Crest Whitestrips.
2. Appointment #2- March 11, 2010 AM
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a. Scaling and root planing of URQ with local

anesthesia. Used the cavitron.
b. CAMBRA assessment and nutritional counseling
c. Recommended chewing xylitol after meals to
decrease caries risk
3. Appointment #3- March 11, 2010 PM
a. Scaling and root planing of LRQ with local
anesthesia. Used the cavitron.
b. Study models
c. TMD evaluation
d. Instructed patient on using floss threaders and
superfloss
4. Appointment #4- April 8, 2010 AM
a. Scaling and root planing ULQ with anesthesia. Used
cavitron.
b. Applied Arrestin on #15 distal
c. Oral hygiene instructions: Recommended
Sensodyne Pro Enamel for sensitivity
5. Appointment #5- April 8, 2010 PM
a. Re-take 4 periapical films
b. Scaling and root planing of LLQ with anesthesia.
Used cavitron.
c. Applied 5% fluoride varnish to all teeth
d. Oral hygiene instructions including End tuft brush
for and floss handle for posterior teeth. Re-evaluate
flossing and modified bass brushing
6. Appointment #6- May 6, 2010
a. Periodontal re-evaluation
b. Indices, MBI, Probings
c. Scale residual calculus
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d. Subgingival irrigation with iodine on #15 and #16

e. Intraoral photographs
f. Applied 5% fluoride varnish to all teeth
g. Instructed patient how to use the Crest Whitening
Strips that we provided
h. Oral Hygiene instructions included using a
interproximal brush with medium size bristles
v. Supportive Periodontal Therapy
1. Put the patient on a 3-month periodontal maintenance
recall.
2. Fluoride treatment should be done at every recall
appointment.
3. CAMBRA assessment done at recall appointment.

X. Post Treatment Status

a. Indices:
Reversible Indices Pre-Therapy Post-Therapy

Marginal Bleeding Index 0% 0%

Plaque Free Index 52% 55%

Gingival Index Moderate Mild Inflammation

Inflammation (.125)
(1.8)
DMFT 26 26

b. Probings:
i. Pre scale: Generalized 4-6 mm with localized 9mm on #15.
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ii. Post scale: Generalized 3-4 mm with localized 5-6mm and 9mm
on #15 D and 7mm on #16 MB
c. Tissue Changes:
i. Pre scale: Generalized areas of edemateous and hemorrhagic
gingiva
ii. Post scale: Localized areas of edemateous and hemorrhagic
tissue. The biggest change in tissue is seen on mandibular
sextant. The tissue is pink, firm, and stippled post-treatment.
d. Patient Consideration:
i. The patient needs to address the ill fitting bridges but the clinic
does not offer that service. He does not have the financial
resources to pay another dentist.
ii. The waitlist in the clinic is very long and it may be difficult to
maintain the 3 month recall.
iii. The patient was very motivated and compliant and we believe
his oral habits will improve indefinitely.
e. Operator considerations:
i. The original prognosis was poor in all four quadrants. After
evaluating the improvement in oral care, we believe some areas
have a fair prognosis.
f. Conclusion:
i. According to the plaque index a 3% improvement in oral
hygiene was noted for our patient. Most periodontal pockets
were decreased and there were less BOPs during the re-
evaluation appointment. The gingival index shows improvement
as well with mild inflammation opposed to the baseline result of
moderate inflammation. The fact that tissue inflammation
improved indicates that the periodontal therapy performed was
successful.
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Although our patient’s oral hygiene has improved he did

accumulate a fair amount of calculus on the lingual surfaces of his
mandibular anterior teeth a month after SRP. We believe that his
sleep apnea may have contributed to this rapid accumulation.
Studies indicate that patients with sleep apnea tend to be mouth
breathers, which causes a dry mouth. Studies also show that the
prevalence of periodontitis in patients with sleep apnea is
greater than the national average (Ganaratnam et al., 2009, p.26)
The final prognosis is fair considering that the patient’s
motivation with home care continues. We have determined poor
prognosis for the upper left quadrant and #24 and #25 due to the
substantial bone loss and pocket depth.
Our goals and objectives were met. Periodontal therapy
was successful in reducing tissue inflammation. Our patient’s
oral hygiene has improved through oral hygiene instruction.
The patient was able to understand the progression of
periodontal disease thus motivating him to improve his oral
habits. He also appeared to be motivated to keep his 3 month
recare visit.

g. Summary:

Our patient presented with medium-heavy calculus, moderate plaque

and generalized tissue inflammation. He was not aware of periodontal disease
and how this can cause tooth loss. We decided that the most important step
was to educate the patient on the benefits of proper oral care and periodic
maintenance to increase the prognosis of his dentition. We educated the
patient with oral hygiene instruction. We demonstrated the modified bass
technique and how to floss correctly. We introduced a interproximal brush
for the patient’s embrasures and Superfloss for his maxillary bridges.
Unfortunately the patient was unable to use the Superfloss under his maxillary
 [Perio Project 14]

bridges due to lack of space. The ill fitting bridges are impinging on the
gingival tissue making it impossible to floss beneath them. We suggested that
an oral water irrigator may be helpful in removing debris under these
bridges. During nutritional counseling, we felt that it was important to educate
him on the correlation of his diet considering his current decay. This included
decreasing his carbohydrate intake. We also suggested two tabs of xylitol
gum or candies four times daily. We also discussed with our patient the
importance of seeking medical attention for his high blood pressure. He
listened to our suggestion and did seek a medical consultation in which the
doctor advised him to make dietary changes and increase exercise to lower
his blood pressure.

We were fortunate enough to have our patient stay all day in order to
finish his SRP treatments in the least amount of time. After scaling and root
planning was completed we determined that teeth #14, #15, &#16 had the
least improvement. The 7mm-9mm pockets showed no improvement and
maintained BOPs. We believe that periodontal surgery is the most effective
way to eliminate the calculus deposits and decrease pocket depths for teeth
#14 and #15. Oral surgery should be considered for tooth #16. The most
successful outcome was changing the patient’s oral habits and the awareness
of his periodontal condition. He maintained a positive and motivated attitude
towards making lifestyle changes to improve his oral health. The patient
walked away with a clear understanding of periodontal disease and the effects
on the periodontium.
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Obstructive Sleep Apnea

Andrea Cates

And

Kelli Redmond

DH 88

Mrs. Dones

May 19, 2010

Obstructive sleep apnea is a risk factor for hypertension, and is involved in

the development of transient ischaemic attacks and stroke. There has also been
recent research that suggests a link between obstructive sleep apnea and
periodontitis (Gunaratnam et al., 2009). Considering that 10% of the population
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suffers from this disease and goes undiagnosed in many individuals it is important
for the dental health professional to be aware of the signs and systemic risks of sleep
apnea in their patients.

Obstructive sleep apnea is a disorder where there is recurrent collapse of the

upper airway while one sleeps causing them to completely stop breathing or to have
partial obstruction of breathing (Gunaratnam et al., 2009, p. 233). Increased age and
obesity in individuals appear to be significant risk factors for OSA (Culpepper &
Roth, 2009, p. 331). OSA symptoms include daytime sleepiness, poor sleep quality,
depression, and anxiety. According to Macey et al. (2010) these mood disturbances
could arise from neural injury “since animal evidence shows that repeated hypoxic
episodes lead to cellular injury and death.” Patients with OSA commonly complain
of more than normal daytime sleepiness, loud snoring, and gasping or choking at
night. Not all patients do experience these symptoms and that is why this disease so
often goes undiagnosed (Chotinaiwattarakul et al. 2009, p.222).

Obstructive sleep apnea causes increased cardiovascular morbidity and

mortality (Baguet et al., 2009, p.1063). There is evidence of systemic inflammation in
OSA patients. Aside from hypertension systemic inflammation caused from OSA
could be one of the major causes for the development of vascular morbidities.
Patients with OSA have increased plasma markers of systemic inflammation, such as
inflammatory cytokines. It is suggested that these inflammatory processes may be
directly responsible for the development of cardiovascular disease and is believed
to be due to hypoxia. Like OSA periodontal disease has been discovered to be
associated with systemic inflammation and cardiovascular morbidity. The possibility
that the two may be associated has been questioned (Gunaratnam et al., 2009,
p.234). In a study conducted by Gunaratnam, Taylor, Curtis and Cistulli (2009) it is
demonstrated that the prevalence of periodontitis in a group of patients with OSA is
greater than the national average. They state “that the increased prevalence of
periodontitis in our group in comparison to the national average could be due to
either the existence of a true association between periodontitis and OSA or due to
OSA and periodontitis sharing several overlapping aetiological factors” (p.237). It
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was also stated that the subjects with OSA in their study may also have a mouth
breathing tendency, so it was questioned if mouth breathing could explain the
higher prevalence of periodontitis in OSA patients. It is discussed that further studies
are needed as there is the possibility that periodontitis may be involved in the
relationships between OSA and cardiovascular disease and OSA and inflammation.
Also, due to the increases in systemic inflammation OSA may increase the presence
and severity of periodontitis (Gunaratnam et al., 2009, p. 238).

Patients who are suspected of having OSA should be referred to a specialist

for a consultation where severity and treatment can be determined. The most
effective treatment for moderate to severe OSA is known as continuous positive
airway pressure. CPAP stops sleep apneas, hypopneas, and snoring to lessen
oxygen desaturation in the sleeping individual to improve the quality of sleep. This
has been shown to improve the quality of life and lower blood pressure in
hypertensive patients with OSA. CPAP is pressurized air that is delivered through a
nasal mask that the patient wears while sleeping. This supports the airway and
prevents soft tissue from collapsing. Surgical intervention may also be done though
it is not proven to be as effective as CPAP. Surgical intervention includes removal of
large tonsils and resection of the uvula and soft palate in order to enlarge the
oropharynx. Other therapies include weight loss, avoiding alcohol and sedatives,
sleeping in a more upright position, and using nasal dilation clips (Culpepper &
Roth, 2009, p. 333-336).

It is predicted that patients with OSA will become more common as the
population ages and becomes more overweight. Health professionals must be
aware of OSA as it is only through diagnoses and treatment that the mortality and
morbidity associated with this sleep disorder can be lessened (Culpepper & Roth,
2009 p. 336).

References

Baguet, J., Nadra, M., Barone-Rochette, G., Ormezzano, O., Pierre, H., & Pepin, J. (2009). Early
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cardiovascular abnormalties in newly diagnosed obstructive sleep apnea. Vascular

Health and Risk Management, 5, 1063-1073.

Chotinaiwattarakul, W., O'Brien, L., Fan, L., & Chervin, R. (2009). Fatigue, tiredness, and lack

of energy improve with treatment for osa. Journal of Clinical Sleep Medicine, 5(3), 222-

227.

Culpepper, L., & Thomas, R. (2009). Recognizing and managing obstructive sleep apnea in

primary care. Prim Care Companion J Clin Psychiatry, 11(6), 330-338.

Gunaratnam, K., Taylor, B., Curtis, B., & Cistulli, P. (2009). Obstructive sleep apnoea and

periodontitis: a novel association?. Sleep Breath, 13(3), 233-239.

Macey, P., Woo, M., Kumar, R., & Harper, R. (2010). Relationship between obstructive sleep

apnea severity and sleep apnea severity and sleep, depression and anxiety symptoms in

newly-diagnosed patients. PLoS ONE, 5(4). Retrieved April 20, 2010, from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855711/?tool=pubmed

VIII. Photographs and Forms

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Radiographs
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Study Models
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Plaque Free Index

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Before 52%

After 55%

Before Photos
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Before Photos
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After Photos
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After Photos
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