Colette Fontaine DH57C Spring 2017

Transcription

1 Colette Fontaine DH57C Spring 2017

2 CLIENT INFORMATION 82 year old African Male Born and raised in Senegal West Africa, moved to the US in 2014 Client worked as a civil servant, diplomat and later an ambassador of foreign affairs for Senegal under the prime ministers cabinet and president s office. Later he served as an ambassador to some Arabic and European countries. Retired in 1995 Visits home 2-3 times a year Married, 3 children, 1 granddaughter

3 CLIENT INFORMATION He was referred to FHDHC from Apple Tree Dental, Sonritas Center in Half Moon Bay Patient was told that periodontal work needed to be performed prior to any restorative treatment Limited dental insurance Chief Concern: Y.B. was most concerned about losing more teeth. He wished to restore better mastication Life stage: mature adult Learning Ladder: action Maslow s: self-actualization Motivation: good Dexterity: fair eyesight was poor

4 CASE PRESENTATION NOVEMBER 22 ND 2016 Five appointments

5 MEDICAL HISTORY Client states he s generally healthy: ASA II Vitals: Pulse : 64 (mean) Respiration :14 (mean) BP : 121/ 69 (mean) Pre-Hypertensive Height: 5 ft. 6 in Weight: 135 BMI: (Normal) High Cholesterol Drug : Atorvastatin calcium tabs Dosage :10mg 1x day DC: may cause muscle and jaw weakening with chewing Hard of hearing in left ear Glaucoma

6 EXTRA ORAL / INTRA ORAL EXAM Findings: atypical Other Lymph nodes: WNL Below clients chin, adjacent to tooth #25-28, there Edentulous ridge: Generalized keratination, 1x1- was a 9x9mm prominent fixed nodule. 2x2mm regular bordered white papules Possible enlarged submental lymph node Buccal Mucosa: Generalized leukoedema No pain upon palpation Tongue: Slightly coated Duration: Exostosis: #6-11 Client recalls it occurring when he was years TMJ: WNL of age Took two Occlusal X rays ( ) Took X rays from two planes (inferiorly below chin and superiorly at bridge of nose) I wanted to rule out cysts, solid growths (tumors), or abscesses Sent copy to patients DDS on file w/ referral letter immediately

7 GINGIVAL DESCRIPTION Consistency: Fibrotic Inflammation: Boggy Plaque: heavy Margins: Generalized recession Red Papilla: Missing #23-26, #7-11 Exudate: Blood and suppuration

8 DENTAL HISTORY & HABITS Hygiene: Last Dental Visit: Client had tooth #11 extracted Last DH Visit: Client reports 2 years ago Last Dental X-Rays: FMX Oral Surgery: 10 years ago Patient had 3 teeth extracted. Last year (2016) client reported removing his own tooth Preventative care: none as a youth or young adult poor Brushing: 1x day Toothpaste: fluoridated Colgate Flossing: never Mouthwash: never Mouth breather: night time No sensitivity

9 RADIOGRAPHS

10 No radiolucent or radiopaque structures evident on films RADIOGRAPHS

11 RADIOGRAPH INTERPRETATION Type of film series: FMX ( ) Bone loss: Severe generalized horizontal and vertical #4D,#6D,#9M,#10D,#11D,# 24-29M Radiographic caries: None Calculus present: #20D,21D,#22D/M,#24D,#25M/D,#26M/ D,#27M Furcation: None Overhangs: None Radiopacities/radiolucencies: #4 sheered off enamel appears less dense and radiolucent Same for wear facets on #6 MO surfaces Radiolucent areas above and around apices of #9,#11,#21,#24,#25,28. Pneumatization of Maxillary sinuses, exhibiting both radiopacities and radiolucency. Crown to root ratio: 1:1-3:1 3:1 in areas of sever bone loss and necrosis.

12 DENTAL CHART

13 DENTAL CHARTING Occlusion: Class 1 ( right cuspid) Overbite: 5 mm Overjet: 4 mm Midline: Left to 3 mm due to missing incisor #23 Cervical abfraction lesions: #4,#28,#29 Missing teeth: Max #1-3,5,11-16 Mand #32-30,23,19-17 Excessive incisal/occlusal wear facets: Loss of posterior bite, no centric occlusion #4 lingual sheered smooth #6 incisal cupping #24-28 dentin visible Tissue healing/shrinkage: #11 extraction sight

14 INITIAL PERIODONTAL PROBING CHART

15 INITIAL PERIODONTAL RISK ASSESSMENT Risk High AAP: IV DMFT: 20 47% tooth loss 15 remaining teeth (7 maxillary, 8 mandibular) BANA: Negative Furcation: None Bleeding: 9 teeth 23 sites Suppuration: 5 teeth 5 sites Plaque index score: 2.1 (poor) Mobility: Cass teeth (retained by embedded calculus)

16 INITIAL CARIES RISK ASSESSMENT Risk High Disease indicators: Visible/suspicious caries: #7 L Risk factors: Exposed roots Heavy visible plaque Deep pits/fissures wear on incisal and occlusal surfaces Palatal-lingual groove #7 Lives in a fluoridated community, but doesn't t drink tap water Protective factors: OTC fluoride toothpaste used one time a day Saliva flow rate: 8ml per min (good)

17 NUTRITIONAL ANALYSIS Sugar intake: 16 min per day 4 liquid exposures Lemonade & Espresso PH level: 7 (neutral) Vitamin and mineral deficiency: Increase H2O intake Increase calcium consumption and vitamin supplementation Yogurt (A) Egg yolks (A) Carrots (A) Sunlight (D) Fortified Milk (D) Green veggies (E)

18 NUTRITIONAL ANALYSIS

19 NUTRITIONAL ANALYSIS

20 INITIAL TREATMENT GOALS

21 INITIAL TREATMENT GOALS

22 ORIGINAL TREATMENT PLAN

23 CASE PRESENTATION RE EVALUATION MARCH 15 TH 2017 Three appointments 3/15/17-4/10/17

24 Risk High RE-EVAL PERIODONTAL ASSESSMENT (SIX WEEKS LATER) Plaque index: (good) 15 teeth (more teeth mobile after calculus removal) DMFT: Furcation: 22 (up by 2) None Y.B. had #11 extracted Bleeding: 14 remaining teeth (6 maxillary, 8 mandibular) 9 teeth new suspicious caries visible #10 D 25 sites CAL: Suppuration: Increased 3 teeth Pocket depth: 10 sites Some increased and some decreased New OH Practices: Inflammation: Now using CHX 2x day for 1 week per month. Reduced Tissue shrinkage Mobility: Now using the rubber tip stimulator

25 RE-EVAL PROBING CHART

26 1-2 mm reduction of certain pocket depths Due to the formation of a long junctional epithelium 1-2 mm increase of certain pocket depths Due to the removal of the calculus PERIODONTAL COMPARISON CHART

27 CLINICAL ATTACHMENT LEVEL COMPARISON CHART Loss increased due to inflammation resolution and more recession 11/22/16 3/15/17

28 GINGIVAL MARGIN COMPARISON GRAPH Tissue shrinkage= more recession 11/22/16 3/15/17

29 RE-EVAL CARIES RISK ASSESSMENT (SIX WEEKS LATER) Risk High Disease indicators: Visible/suspicious caries: #7 L,#10 D Risk factors: Exposed roots Moderate visible plaque Deep pits/fissures wear on incisal and occlusal surfaces Palatal-lingual groove #7 Protective factors: Prescription fluoride toothpaste (Prevident 5000ppm) Now drinks fluoridated tap water Saliva flow rate: 8ml per min (good)

30 RE-EVAL TREATMENT GOALS

31 RE-EVAL TREATMENT GOALS

32 RE-EVAL TREATMENT PLAN

33 I NTR AOR AL P H OTOG R AP H S Pre Op Post Op

34 I NTR AOR AL P H OTOG R AP H S Pre Op Post Op

35 I NTR AOR AL P H OTOG R AP H S Pre Op Post Op

36 RESEARCH: MALOCCLUSION AND ITS ROLE IN PERIODONTAL DISEASE Secondary Occlusal Trauma Secondary trauma from occlusion is an injury that occurs from normal occlusal forces placed on a weakened periodontium. 1 Often rapid clinical attachment loss (apical migration of JE) 1 Clinical Signs of Occlusal Trauma 1,2,3 Tooth migration Wear facets exceeding expected levels for the client's Chipped enamel Tooth mobility Two types of injury 4 1. An injury to the JE attachment as a result of excessive occlusal force 2. Gingival surface injury is caused by the direct impingement of a tooth on the gingival margin and periodontal tissues of an opposing tooth. a. Thus widening the sulcus/pocket space allowing pathogens and food debris (plaque) burrow deep along tooth surface.

37 RESEARCH: MALOCCLUSION AND ITS ROLE IN PERIODONTAL DISEASE Deep traumatic overbite 4 There s a good amount of evidence that occlusal trauma does not cause periodontitis, however a deep traumatic overbite is considered a contributing risk factor that in certain cases causes significant localized periodontal breakdown. 1. MOST important in achieving a good level of oral hygiene and a stable periodontal condition. 2. Performing standard non-surgical periodontal therapy: including root planing and antibacterial irrigation (CHx) of the deep pockets and in some more severe cases, use of topical antimicrobials such as arestin to reach the depth of the periodontal pocket. 3. Splints can be fabricated to protect tissues from opposing tooth impingement. 4. Orthodontic treatment prescribed to reduce the depth of the overbite, usually successful if treated before their periodontal condition is severely compromised (supportive bone loss). 5. Partial dentures can be fabricated as well to open up the deep bite and restore the posterior occlusion for a more even distribution of mastication forces. 6. Y.B was documented as a class I based only on his right cuspid to cuspid relationship, however this occlusal classification may be a result of the tooth migration that has occurred because of loss of bone support and lack of posterior occlusion. Therefore, its hard to know what position the teeth were in prior to his steady tooth loss which began roughly eight to ten years ago.

38 WHAT DID I LEARN? Patient Management: Always address pts. chief concern 1 st Even if prognosis is poor Explain risks, benefits and alternative treatments if they apply. Be honest with findings Its an ethical responsibly as a human and a healthcare provider Encourage autonomy Clinically: How to use an alternative fulcrum Mobile teeth are challenging, especially when depressible How to check for suppuration Using pressure on attached gingiva apically toward gingival margin

39 WHAT DID I LEARN? Overall take home message: As a new hygienist, I must remember that periodontal conditions are always multifactorial. Sometimes I ll need to remember to look beyond plaque and calculus and recognize the many other contributing factors and conditions that may have a role in the continuum of periodontal disease2, both localized as well as systemically. I also learned that Some cases are not always successful, not because the interventions were not performed competently, but because the loss of bone and/or tooth structure was too severe

40 REFERENCES 1. Darby, Michele, Margaret Walsh. Dental Hygiene: Theory and Practice, 4th Edition. W.B. Saunders Company, VitalBook file. 2. Gehrig J., Willmann DE. Foundations of Periodontics for the Dental Hygienist. 4th ed. Philadelphia (PA): Wolters Kluwer; p. 3. Harrel, Stephen K., and Martha E. Nunn. "The Effect Of Occlusal Discrepancies On Periodontitis. II. Relationship Of Occlusal Treatment To The Progression Of Periodontal Disease". Journal of Periodontology 72.4 (2001): Web. 16 Apr Nasry, H A, and S C Barclay. "Periodontal Lesions Associated With Deep Traumatic Overbite". British Dental Journal (2006): Web. 4 May 2017.