Periodontal Project

Dental Hygiene Practice IIBy: Brittanymarie Horrigan

Medical History• Date of Last Physical Exam 3/2013• Currently under the care of a Physician for

- Endometriosis -Chronic Migraines -ADD

*All conditions are well controlled with Medication

• Has been hospitalized for-Endometriosis: Surgery- Feb. 2011, Jul. 2013

- Concussion: Car accident- Oct. 2013

-Migraines: Jan. 2009

• Occasional Drinker & Smoker• Father has a history of type II Diabetes

Medical History ContinuedCurrent MedicationsName/ Dose

Gabapentin 600 mg

Aygestin 5mg

Miratazapine 7.5 mg

Femara 2.5 mg

Topamax 50 mg

Ibuprophen 600 mg

Adderall RX 25 mg

Mirena 20 mg

Multi Vit. 1 Tab

Purpose

Migraine Prevention

Endometriosis

Sleep

Endometriosis

Migraine Prevention

Pain Management

ADD/ADHD

Hormone Therapy

Increase Vit. Intake

Time to be taken

Night

Night

Night

Night

Night

As needed

Morning

Morning

Drug Class

Anticonvulsant

Progestin Contraceptive

Antidepressant, tetracyclic

Anti-estrogen

Anticonvulsant

Non-steroidal anti-inflammatory

Amphetamine

Progestin Contraceptive

Vit. And Mineral Combo

Adverse Effects

Fatigue, Rhinitis, Xeristomia, Hypersensitivity, Dizziness

Headache, Dizziness, Nausea, Insomnia

Xeristomia, Dizziness, Drowsiness, Flu like symptoms

Hot flashes, joint pains, fatigue, insomnia, dizziness, hair loss

Fatigue, Loss of coordination, Altered taste

Dizziness, Vomit, Nausea, Rash

Xeristomia, insomnia, Fever, Anxiety, Loss of Appetite

Pain, Migraine, Hypersensitivity, Anxiety, Depression

Dizziness, Upset Stomach, Headache, Allergic Reaction

Medical His. Continued

Allergies

• Bactrim• Erythromycin eye ointment

Vitals• Blood Pressure:

110/60 RAS• Pulse: 64• Respiration: 17

ASA II

Dental History

• Last Dental Appt. 8-30-2013 • Last Hygiene Appt. 8-30-2013***Completed in clinic 03/2014

• Last X-Ray. 8-30-2013-Panoramic -Bite Wings

• History of Ortho treatment-Palate expander: 2003 -Ortho: 2003-2007

• Currently uses a Maintenance Retainer- Wears while sleeping

***Invisalign

• All 4 wisdom teeth Extracted in 2004

Dental History Continued

• Currently has Sensitivity-Hot -Cold -Sweet

***Mandibular Anteriors

• Gums Bleed when flossing-4x weekly

***Improper flossing technique

• Generalized Food entrapment-Posteriors

*** Slightly open contacts

• Clenches -Induced by stress

• Grinds -Nocturnal

***Generalized slight attrition on posteriors

• TB -2x daily -Manual -

Soft -Angled Bristles

*** Patient would like to discuss the usage of an electric TB

Patients right side

Occlusion:• Molar Right- Class

I

• Canine Right- Class I

• Molar Left- Class I

• Canine Left- Class I

Patients Left side

Facial ViewFrenum:- Slight involvement

Facial ViewMalocclusion:- Open bite

Maxillary ViewPalate:- Median

palatine tori

Mucosa:- Bilateral

linea alba- Keratinized

tissue from cheek biting habit

Tongue:- scalloped, slightly coated

Mandibular View

Floor of the mouth:- Tight frenum- Slight

mandibular tori

Tongue:- moderate-severe vascularity

Gingival Description

Color: Gen. pale pink with loc. sl. marginal and papillary redness on ant.Contour: Gen. rolled margins on post. with rounded margins on anteriors and localized sl. bulbous papillae on mand. ant.Consistency: Gen. sl. spongySize: Gen. sl. enlarged Texture: Gen. sl. stippled Exudate: Gen. BOP on the facials of # 2, 14, 18, 19, 20, 21, 22 and linguals of #15, 13, 8, 9, 18, 19Tissue Type: Gen. sl. edematous

GINGIVAL DESCRIPTION: Generalized, pink, rolled, stippled, spongy, enlarged edematous tissue with bleeding upon probing and localized slight marginal redness with bulbous papillae on the mandibular anteriors.

Dental Chart• Defective Sealants:#3, 15,18,19

• Sealants:#14, 30

• Caries:Buccal of #19,30

• Amalgam:#2-OL

• Composite:#31- O#18-O

Perio ChartAverage PD:3mm

Average GM:1mm coronal to CEJ

Periodontal Chart

Bleeding on Probing

Facials: # 2, 14, 18, 19, 20, 21, 22

Linguals: #8, 9, 13, 15, 18, 19

AAP Class type II

Generalized Slight Active Chronic Periodontal Disease

Periodontal Diagnosis

Hard and Soft Deposit > Generalized small spicules of subgingival and supragingival calculus.

> Generalized slight biofilm located around the cervical 1/3

> Localized slight tobacco stain on lingual surfaces of mandibular anteriors

Contributory Factors• Calculus – Generalized sub(spicules), Localized areas of

supra• Mouth breathing- Open bite, Nocturnal• Food impaction - Gen. Sl. Post, Lo. Mod. #3-4, 29-30• Position of teeth/malocclusion - Open bite 2mm• Appliances- retainer top & bottom, only worn at

night( invisalign)• Toothbrush Trauma- 1mm recession on #4-6, #11-13,

#20-22, #27-22• Parafunctional habits- Grinding• Orthodontics- 2003-2007

Bite Wings

Radiolucency around the amalgam on #2

Radiolucency under the contact point of #2 and 3

Slight vertical loss on the mesials of #3, 4 and 14

Overall there is a normal pattern of generalized slight horizontal bone loss

Full Mouth Series

Full Mouth Series (Patients Right side)

> Radiolucency on #4 apical to the CEJ, mesial aspect

> There is a combination of slight bone horizontal and vertical bone loss around the maxillary premolar

> There is noticeable widening of the PDL on the mandibular 1st premolar and canine

Full Mouth Series(anteriors)

> Slight horizontal bone loss present on the mandibular anteriors

> Vertical bone loss present between the maxillary central and lateral incisors

> Patient has close root proximity, which could be decreasing the available blood flow to tissues

> Widening of the PDL is visible on the right premolar and canine film

> Areas of radiolucency are present on the mesial aspects of the maxillary lateral incisors

Full Mouth Series(Patients Left side)

> First molar root morphology

> Vertical bone loss on the distal aspect of the mandibular second molar

> Radiolucent area apical to the contact point of tooth # 18 and 19

> Spicule of calculus on the distal aspect of #15, located at the CEJ

Treatment/ Care Plan

Dental Hygiene Diagnosis:High caries risk related to high sucrose diet, occasional tobacco usage, and medications used to control systemic disease

Clinic Procedure Notes

03/04/2014Medical History: Reviewed MHX, vitals, no contra. ASA IIPatient Assessment: Cursory EOE and IOEBiofilm Index: 43 %Debridement: MaxillaeNext Visit: Debride Mandible

02/06/2014MEDICAL HISTORY: Reviewed MHX, Vitals, No contra., ASA IIPATIENT ASSESSMENT: Cursory EOE & IOE, Perio, Hard and Soft deposit. DetectionRADIOGRAPHS: X-Ray auth. ProcuredNEXT VISIT: Biofilm index, Treatment plan

02/18/2014MEDICAL HISTORY: Reviewed MHX, Vitals, no contra. ASA II PATIENT ASSESSMENT: Cursory EOE, IOE, Hard and soft depositBIOFILM INDEX: 59%NEXT VISIT: TX plan, Debridement

02/04/2014MEDICAL HISTORY: Comp. MHX, No contra., ASA II, VitalsPATIENT ASSESSMENT: EOE, IOE, Occlusion, Dental charting

02/04/2014MEDICAL HISTORY: Reviewed MHX, Vitals, no contra.PATIENT ASSESSMENT: Cursory EOE, IOE, PerioNEXT VISIT: perio assess.

03/04/2014MEDICAL HISTORY: Reviewed MHX, vitals, no contraindications, ASA IIPATIENT ASSESSMENT: Cursory EOE and IOEBIOFILM REMOVAL: TB and FlossingDEBRIDEMENT: MandibleREFERRALS: General dentist for continuing comprehensive careRECARE: 6 months

Risk Factors• Smoking- occasional, social• Systemic disease- Endometriosis- hormone

imbalance• High biofilm index- 59%• Hormonal Involvement- Endometriosis, Mirena• Medication- Gabapentin, Femara, Topamax,

Miratazapine, Adderall RX• Alcohol use- occasional• Genetics- All systemic diseases are genetically

linked• Stress- Moderate, school related• Nutritional deficiencies- Balanced out by multi

vitamin, working on better nutritional habits

Summary

Initially: Upon completion of assessing this patient I had diagnosed them to be a AAP II directly based upon my clinical findings.

Following completion of the dental hygiene treatment the patient was then brought in for a full mouth series.Currently:After completing a full mouth series and a comprehensive interpretation of the series I have come to the conclusion that my original diagnosis is incorrect and is not supported by the radiographic images.

The alveolar bone height is generalized healthy with localized areas of slight horizontal or vertical bone loss- these localized areas are in relation to where the patient occludes(edge to edge on the premolars) because of their anterior open bite

Recommended Referalls:General dentist ***Continue comprehensive care*** Possible restorative needs

Orthodontist:*** Malocclusion- anterior open bite***Occlusal trauma due to edge to edge position of teeth. (premolar region)

TB

- Electric, oral B

*** one that monitors the patients pressure on teethNutritional

-Avoid sticky/ adherent substances- Variety = Daily recommended values for food groups

Tooth Paste-Flouridex, Sensodyne, Pronamel***Toothpaste focusing on sensitivity

Floss-Tufted*** Open contacts posteriors-Waxed***Tight contacts anteriors

Advice for Patient