Periodontal+Case++4+Necrotizing+Ulcerative+Periodontitis

= Periodontal Case #4 Necrotizing Ulcerative Periodontitis =



Carranza and Newman (2006) states that Necrotizing Ulcerative Periodontitis also known as NUP, is characterized by soft tissue necrosis, rapid periodontal destruction, and interproximal bone loss. This is a fast growing form of periodontitis and is often seen in patient's that are HIV positive (Carranza & Newman 2006). Necrotizing ulcerative periodontitis may be seen as a progression of necrotizing ulcerative gingivitis (Carranza & Newman 2006). Patient's will present will attachment loss and bone loss. Treatment for NUP includes, debridement, scaling and root planing, oral irrigation as well as meticulous oral hygiene including at home antimicrobial rinses (Carranza & Newman 2006). In severe case of NUP antibiotics are necessary but should be used with care in HIV infected patients in order to avoid opportunistic infections (Carranza & Newman 2006).
 * Overview:**

Patrick Jane. 40yrs old. new patient and last time seen was two years ago. Emergency contact: Liz Jane. Relationship: Mother. Tel # 951-555-0001 Physician Name: VA hospital Tel #: 951-555-0002
 * Patient Profile:**

" I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat"
 * Chief Complaint**:

Bleeding gums when you brush: generalized bleeding Sensitivity to pressure: It hurts to eat and brush all over my mouth Clicking: bilaterally open opening Difficulty opening or closing: Opening slight pain Canker sores: Yes last one was 9/2010 Cold sores: Yes last one 10/2010 Last dental exam: 01/07. Last dental radiographs: 01/07 (10PAs & 2BWX). Swelling in mouth: "My gums are swollen and it hurts to touch them." Loose teeth: When I bite into things I feel my front lower teeth move. Previous Dentist: Dr. Tooth Last teeth cleaning: 01/2007
 * Dental History**:

Cardiovascular: None
 * Medical History**:

Respiratory Breathing problems: Shortness of breath upon physical exertion

Head & Neck Visual impairment: Glasses since 1981 Difficulty Swallowing: First noticed 10/10 Recurrent neck ache/pain: Under my chin 10/10

Social life Do you drink alcoholic beverages? 2-3 drink occasionally Past or current history of drug use: Heroin through IV from 1980-2005

Neuromuscular System Muscle weakness/multiple sclerosis: Yes Recent or recurrent headaches: Yes

Gastrointestinal/Genito-Urinary Persistent diarrhea: Yes Colitis or ulcers: Yes " I have ulcers in my mouth" Frequent canker sore: Yes last one 9/2010 Frequent cold sore: Yes last one 10/2010

Hemo/ Endo Immune Disorders: Bruise easily: Yes Anemia:Yes Pt states diagnosed ten years ago 2000 AIDS: diagnosed 2008

Mental Disorders: Depression diagnosed in 2008 by Dr Ramisini, taking medication daily

Family History Heart Disease: Dad stroke in 08 DOD Diabetes: Mom DM 2 controlled with meds, exercise and diet

Additional medical history: Contracted HIV due to sharing needles.

VITALS: Taken at each appointment. The measurements ranged from the following: Patient states CD4 count was 210 P:80-90 R: 18-23 B/P: 122-129/72-78 ASA: III

Zidovudine: Dose: 300mg 2 tab PO, period taken from 2008-present, last taken daily, taken for HIV Dental implications: Taste perversion, oral mucosa pigmentation, dysphagia, and mouth ulcers. Dental contraindications: None
 * Patient Medication**:

Efavirenz: Dose: 600mg 1 tab PO, period taken from 2008-present, last taken daily, taken for HIV Dental implications: Xeriostomia, abnormal taste. Dental contraindications: None

Saquinavir 500 mg Invirase 2 X tab PO, period taken from 2008-present, last taken daily, taken for HIV Dental implications: Buccal mucosa ulceration and taste alterations. Dental contraindications: None noted.

Ritonavirz: 100 mg 2 X tab PO, period taken from 2008-present, last taken daily, taken for HIV Dental implications: Xeriostomia, and taste ulcerations. Dental Contraindications: None noted.

Zyban: 100mg 1 tab daily, period taken from 2008-present, last taken- this morning, taken for depression Dental implications: Xerostomia Dental Contraindications: hypersensitivity to any component of the formulation, seizure disorder, use of MOAI's within 14 days




 * Radiographs for DDS exam:**

Patient is missing 1,2, 14, 15, 16, 30, 31, 32. Patient have a DO composite on #13, O amalgam on #18 and #19, and an MOD composite on #29. Patient has deep pits on #3 (poss decay). Patient has radioopaque area on the mandibular anterior, due to mandibular tori.
 * DDS PRESENTATION**

Gathering the assessments can be extremely difficult for patients with NUP due to the excruciating pain that the patient is in. Sometimes the patient will need full mouth anesthesia in order for the clinician to be able to gather assessments and for patient comfort.
 * Clinical Findings: (as presented during second check in)**

Extra-oral finding: Enlarged right and left submandibular lymph nodes. TMD: Bilateral crepitation when patient moves jaw laterally. Maximum opening: 45 mm. Salivary flow: Inadequate due to medications taken. Intra-oral findings: Angular cheilitis (dry and cracked in the corners of the lips), red ulcerated 2x2 lesion on the vestibule of the lower right lip, geographic tongue, hairy tongue, leukoplakia on the lateral borders of the tongue. Patient has erosion on the buccal of #7, and mesial facial of #11. Gingival description: The free gingiva is generalized erythematous, sloughing of the tissue and hemorrhagic, localized blunting on the mesials of #8 and #9 due to slight diastema, generalized punched out interdental papilla, generalized loss of structure and shiny. The attached gingiva is generalized erythematous, fluctuant, complete loss of stippling and glossy MBI: 75% Probing depths in chart. Generalized 5-6mm localized 7mm and 8mm pockets BOP: 79% Recession- 3 mm recession on #6, 2 mm on facial # 11, 2 mm facial #23 - #26 Mobility: class I mobility on #5 - #11, #12, #23 - #26, with class II on 3, 19 Fremitus: +7 & 9 Furcations- Class IV #3, 19 Attachment loss: localized 5 mm attachment loss on the buccal of #2, #11, #23 - #25, lingual of #23 and #25, and localized 6 mm attachment loss on the facial of #26 and lingual of #24 and #26. Mucogingival defect: None noted Angles classification: Class I bilaterally, bilateral crossbite. Facial profile: Mesognathic PI- 100% MVC Calculus code: four quads medium

Missing teeth: 1, 2, 14, 15, 16, 17, 30, 31, 32. The above radiograph is diagnostic with the exception of the upper left PA and the left BWX. The upper left PA and the left BWX need the positive angulation to be increased in order for it to be diagnostic. Trabecular pattern: Is consistent throughout, with localized radioopaque on the lower anteriors due to mandibular tori. Lamina dura: Generalized fuzzy. Alveolar crest: Is generalized 5-6mm below the CEJ, with localized 7 and 8mm below the CEJ. Patient has generalized horizontal bone loss with localized bone loss on Periodontal ligament: Is generalized widen throughout. ADA: ADA III with localized ADA IV. AAP: AAP severe chronic periodontitis due to plaque and calculus modified by systemic disease and medications.
 * Radiographic interpretation**:


 * Critical Thinking:**

Appointment 1 S: I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P: 88 R: 22 B/P: 122/72 A: ASA III P: Gathered assessments with anesthesia patient received 3.5 ml of lidocaine with epi. (12) film FMX. OHI. Patient tolerated procedure well and left in good condition. NV: DDS, 2nd check in nutritional counseling
 * Treatment Plan:**

Appointment 2 S: "I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P: 88. R 23. B/P 118/76 A: ASA III P: DDS, 2nd check in, PI, nutritional counseling NV: scale of LL quad w/anesthesia. Localized CHX in pockets 5mm or more. OHI

Appointment 3 S: I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P 82. R: 24 B/P 122/75 A: ASA III ADA III with localized ADA IV. AAP severe chronic periodontitis due to plaque and calculus modified by systemic disease and medications. P: Scale of LL quad w/anesthesia. Localized CHX in pockets 5mm or more. OHI Patient tolerated procedure well and left clinic in good condition. NV: Scale of UL quad w/anesthesia. Localized CHX in pockets 5mm or more. OHI

Appointment 4 S: "I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P 88 R. 24. B/P 120/78 A: ASA III ADA III with localized ADA IV. AAP severe chronic periodontitis due to plaque and calculus modified by systemic disease and medications. P: Scale of UL quad w/anesthesia. Localized CHX in pockets 5mm or more. OHI. Patient tolerated procedure well and left clinic in good condition. NV: Scale of LR quad w/anesthesia. Localized CHX in pockets 5mm or more

Appointment 5 S: "I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P:90 R: 25. B/P 120/82 A: ASA III ADA III with localized ADA IV. AAP severe chronic periodontitis due to plaque and calculus modified by systemic disease and medications. P:Scale of LR quad w/anesthesia. Localized CHX in pockets 5mm or more. Patient tolerated procedure well and left clinic in good condition. NV: Scale of UR quad w/anesthesia. Localized CHX in pockets 5mm or more.

Appointment 6 S: "I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P 88. R: 23. B/P 118/80 A: ASA III ADA III with localized ADA IV. AAP severe chronic periodontitis due to plaque and calculus modified by systemic disease and medications. P:Scale of UR quad w/anesthesia. Localized CHX in pockets 5mm or more. Patient tolerated procedure well and left clinic in good condition. Fluoride application. Patient was advised not to eat or drink any food or liquids for 30 minutes. NV: 4-6 week evaluation.

Appointment 7 S: "I have bleeding gums, bad breath, loose teeth and my gums are extremely painful I can't even eat" O: RMH. P 86. R: 23. B/P 120/80 A: ASA III ADA III with localized ADA IV. AAP severe chronic periodontitis due to plaque and calculus modified by systemic disease and medications. P: Gathered assessments. 2nd check in. Scaled residual calculus. NV: 3 month re-care.

Patient education is extremely important in order to help the patient understand the disease progression as well as the importance of maintaining more than adequate oral hygiene at home. As clinicians we would explain to the patient the assessments we have gathered in order for him to understand healthy versus unhealthy. Also we would explain that his body is already immunocompromised and the bacteria is able to cause more harm than in an average person. This is when we would incorporate our oral hygiene instructions in order for the patient to understand the importance of taking care of his oral cavity at home. We would explain the amount of bone loss and the effects that is has on the teeth that are present and that he can't reverse the bone loss however he can slow or stop the further destruction of the bone. It is also important to discuss the attachment loss that is due to the deep periodontal pockets due to the disease and then explain that it is important to work as team in order to get the condition under control. Also we would explain to the patient that other factors will contribute to a possible outbreak of the disease in order for the patient to try their best to control these factors such as: malnutrition, and type of infection or stress.
 * Patient education of disease:**

It is important that Mr Jane keep up with his oral hygiene. Since his immune system is at a critically diminished level it is important that we control the bacteria that is creating his condition. Bass technique, "C" shape floss technique and a non alcohol antimicrobial rinse done 3-4 times a day. It is important that he continues too come to the clinic for his scaling of deep pockets and plaque removal with irrigation of chlorhexide gluconate. It is important to note the pharmacologic induced xerostomia and recommend oral moisturizers or sugar free candy. If the condition starts to worsen and the notices white patches ( oral candidiasis ) it is important for them to call their Dr and schedule an appointment as soon as possible. It is important so that the Dr. can start an antifungal and antibiotic regiment to reduce the bacteria and fungi infection.
 * OHI:**

The prognosis for Mr. Jane is questionable due to the patient's advance bone loss. Mr. Jane also has furcations that are seen radiographically as well as clinically. The patient also has been diagnosed with HIV and at this time it is controlled. This prognosis is dependent on the patient also due to his interest in joining the team to control his NUP. We plan to find ways that will motivate Mr. Jane in order to help him increase his at home care in order to decrease the amount of bacterial flora and plaque present in the mouth allowing the disease to progress further.
 * Prognosis and why:**


 * REFERENCES:**

Carranza, K., & Newman, T. (2006). Carranza's clinical periodontology. In T.D. Rees (Ed.), //Pathology and management of periodontal problems in patients with HIV infection// (pp. 513-538). St. Louis, Missouri: Saunders Elsevier