Periodontal+Case+5+Aggressive+Periodontitis

Periodontal Case #5 - Aggressive Periodontitis

There is no picture for this case. Please go to page 508 (Figure 33-1) in Carranza to see the picture for this case*



Patient Profile **: Mr. Pitt is a 25 year old, single, Caucasian, male. **

Chief Complaint : “I brush and floss daily in order to keep my teeth because my father lost his in his thirties.”

**Dental History **: Bleeding gums when you brush: localized in the molars Last dental exam: 01/2010 Last dental radiographs: 01/2010 Pano Previous Dentist: Dr. Scaler Last teeth cleaning: 1/2010

Medical History : __Cardiovascular__: None

__Respiratory__: None

__Head & Neck__: Patient wears contacts to correct a visual impairment.

__Social life__: Do you drink alcoholic beverages? 3-4 drinks socially on the weekends. Tobacco use: Recently started smoking three cigarettes a day due to stress at work. <span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">Past or current history of drug use: None

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">__Neuromuscular System__: None

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">__Gastrointestinal/Genito-Urinary__: None

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">__Hemo/ Endo Immune Disorders__: None

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">__Mental Disorders__: None

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">__Family History__: None

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">__VITALS__: During the patients treatment his vitals were taken at each appointment and ranged from <span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">P: 79-83, R: 18-20, B/P: 118-121/76-79, ASA: II- due to smoking.

Patient Medication <span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%; margin: 0in 0in 10pt;">**<span style="font-family: 'Arial','sans-serif';">: ****<span style="font-family: 'Arial','sans-serif'; font-weight: normal;">Amoxicillin ** Dose: 250mg Period of time taken: two weeks ago Last taken: 6/2010 Taken for: Aggresive periodonitis Dental implications: Prolonged use may lead to oral candidiasis Dental contraindications: Hypersensitivity to amoxicillin, penicillin, or any component of the formulation.

Clinical Findings **<span style="font-family: 'Arial','sans-serif';"> (as presented during second check in): **<span style="font-family: 'Arial','sans-serif';">The following assessments where noted at the first appointment

Extra-oral findings: none TMD: none Maximum opening: 50mm Intra-oral findings: none Gingival Description: as per page 508 (Figure 33-1) in Carranza Free gingiva is generalized erythematous, slightly edematous, scalloped filling the embrasures with localized bulbous on 24 & 25, and smooth. Attached gingiva is generalized erythematous, slighty edematous, and smooth with some loss of stippling. MBI: 8% Probing Depths: Generalized 2-4mm with localized 5-7mm on the mandibular molars. ** I would recommend you reassess your probing chart. It appears that there are 5 mm probing depths on tooth #29 which is not a molar. **

BOP: 39%

Recession: none Mobility: (+) 23-26, (+2) 19 & 30. Fremitus: + 8-9 Furcations: Class IV 19 & 30 Mucogingival Defect: None noted. Angles Classification: Class I bilateral Facial Profile: mesognathic Salivary flow: adequate. PI- 5% ADA: Generalized ADA II with Localized ADA IV AAP: Generalized Slight Chronic Periodonititis due to plaque and calculus with Localized Severe Aggressive Periodontitis MVC calculus code: Light

Radiographs and DDS exam:



Radiographic Interpretation **<span style="font-family: 'Arial','sans-serif';">: **<span style="font-family: 'Arial','sans-serif';">The following was discussed at the DDS exam

<span style="font-family: 'Times New Roman',serif; font-size: 12pt; line-height: 115%;">Trabecular pattern: – generalized consistent with localized radiolucencies on the 1st mandibular molars and #3. <span style="font-family: 'Times New Roman',serif; font-size: 12pt; line-height: 115%;">Lamina dura: – generalized present with localized loss on the 1st mandibular molars and #3. <span style="font-family: 'Times New Roman',serif; font-size: 12pt; line-height: 115%;">Alveolar crest: – generalized 1 to 2 mm from CEJ with localized areas of 7-9 mm on the 1st mandibular molars and #3. Correlates with the probing depths. <span style="font-family: 'Times New Roman',serif; font-size: 16px; line-height: 18px;">Periodontal interpretation: Localized loss of PDL on the mesial and distal of 3, mesial and distal of 19, mesial and distal of 30. <span style="font-family: 'Times New Roman',serif; font-size: 16px; line-height: 18px;">Interradicular radiolucency – furcation noted on on the 1st mandibular molars. <span style="font-family: 'Times New Roman',serif; font-size: 12pt; line-height: 115%;">Calculus noted: none was noted.

Referral **:** Based of the radiographic and clinical findings the Dentist referred the patient for the following



Critical Thinking **<span style="font-family: 'Arial','sans-serif';">: **<span style="font-family: 'Arial','sans-serif';">Based on the above assessments, we treatment planned Mr. Pitt for the following treatment.

Treatment Plan **<span style="font-family: 'Arial','sans-serif';">: **

== Mr. Pitt was treatment planned for only two visits because his calculus code was light and he had very good oral hygiene habits. He recently started smoking, so we would like to include smoking cessation into our OHI, if the patient is willing.


 * I would say that at the time of writing up a treatment plan, you should know if you will be including smoking cessation. At what point in the appoint do you address this with the patient? Isn't it at the medical history intake? DL **

SOAP Notes **<span style="font-family: 'Arial','sans-serif';">: **<span style="font-family: 'Arial','sans-serif';">The following took place at each appointment with Mr. Pitt.

<span style="font-family: Arial,sans-serif; line-height: normal;">**S**: Patient is here to get his teeth cleaned. <span style="font-family: Arial,sans-serif; line-height: normal;">**O**: RMH, BP:121/79, P:83, R:20 Extra-oral findings: none TMD: none Maximum opening: 50mm Intra-oral findings: none Gingival Description: as per page 508 (Figure 33-1) in Carranza Free gingiva is generalized erythematous, slightly edematous, scalloped filling the embrasures with localized bulbous on 24 & 25, and smooth. Attached gingiva is generalized erythematous, slighty edematous, and smooth with some loss of stippling. MBI: 8% Probing Depths: Generalized 2-4mm with localized 5-7mm on the mandibular molars. BOP: 39% Recession:none Mobility: (+) 23-26, (+2) 19 & 30. Fremitus: + 8-9 Furcations: Class IV 19 & 30 Mucogingival Defect: None noted. Angles Classification: Class I bilateral Facial Profile: mesognathic Salivary flow: adequate. PI- 5% <span style="font-family: Arial,sans-serif; line-height: normal;">**A**: ASA II, Generalized ADA II with Localized ADA IV, AAP Generalized Slight Chronic Periodonititis due to plaque and calculus with Localized Severe Aggressive Periodontitis, MVC calculus code: Light <span style="font-family: Arial,sans-serif; line-height: normal;">**P**: x-ray check, gather assessments, DDS Exam, Second Check-in, PI, OHI

<span style="font-family: Arial,sans-serif; line-height: normal;">**S**: Patient is here to get his teeth cleaned. <span style="font-family: Arial,sans-serif; line-height: normal;">**O**: RMH, BP:118/76, P:79 R:18, E&I- no pathological findings <span style="font-family: Arial,sans-serif; line-height: normal;">**A**: ASA II, Generalized ADA II with Localized ADA IV, AAP Generalized Slight Chronic Periodonititis due to plaque and calculus with Localized Severe Aggressive Periodontitis, MVC calculus code: Light <span style="font-family: Arial,sans-serif; line-height: normal;">**P**: Full mouth scale. Administered a total 1.2mL of Lidocaine 2% w/epi 1:100,000. Performed a supraperiosteal injection on teeth 19 and 30. Performed CHX and Sodium Fluoride Tx. Gave post-op instructions for fluoride: don't eat or drink for 30min. Patient tolerated procedure well and left clinic in good condition.

I ** would have to ask this questions: Have you ever been told that a supraperiosteal injection on a mandibular molar is effective? This comment demonstrates a huge lack of understanding of local anesthesia. And then my next question is why would you NOT anesthesize tooth #18? DL **

Prognosis and Rationale : Based off the assessments gathered, with strict adherence to oral hygiene instruction, antibiotic therapy and maintaining recare appointments, Mr. Pitt will be able to maintain his oral health. His generalized prognosis is good and localized prognosis is hopeless for #19 & 30 due to the class IV furcations.


 * I would have question the prognosis of "good" for teeth #29 and 18 based off the probing depths. DL **

Patient Education of Disease **<span style="font-family: 'Arial','sans-serif';">: ** Aggressive perio is different than chronic perio by the rate of progression, absence of large amounts of plaque and calculus that is inconsistent with the amount of destruction present (due to poor antibody response to pathogens), and possibility of a family history of the disease. Age of onset is usually early, between 10-30 years old and may otherwise be a healthy patient. Aggressive periodontitis may appear localized or generalized. There is rapid attachment loss and bone destruction.

__Localized__- involves first molar or incisor with interproximal attachment loss on at least two permanent teeth, one of which is a first molar. There is a lack of clinical inflammation despite presence of deep pockets and advanced bone loss. Rate of bone loss is 3 to 4 times greater than that of chronic perio. Plaque that is present is minimal and rarely mineralizes to form calculus. Clinical findings may include: distolabial migration of maxillary incisors, increased mobility of incisors and first molars, deep/dull pain during mastication. Periodontal abscesses may be present as well as lymph node enlargement. Radiographicaly, it will present with vertical bone loss around first molars and incisors. “Arc-shaped loss” of alveolar bone will be present from distal of second premolar to mesial of second molar. Some cases of localized aggressive perio may be self-limiting without the progression of bone loss. Prognosis is usually good with scaling and root planning, OHI, and systemic antibiotics.

__Generalized__- involves interproximal attachment loss affecting at least three teeth other than first molars and incisors. Severe bone loss may be present on minimal number of teeth with others having no bone loss, or severe destruction on the majority of the teeth. The destruction occurs episodically; with periods of rapid destruction followed by periods of less destruction (may be weeks, months, or years). During the rapid destruction period, the tissue will appear acutely inflamed, proliferating, ulcerated, and bright red. Bleeding may occur spontaneously and suppuration may be present. Radiographs will typically indicate bone loss since the last radiographic exam. During the less destructive stages, the tissue may appear pink, little to no inflammation, with possible stippling. However, deep pockets will still be present. The bone level will remain stationary. Patients with generalized aggressive periodontitis may present with weight loss, depression, and general malaise. The disease may be self-limiting or have a positive response to therapy. Prognosis varies from fair to questionable depending on secondary contributing factors such as tobacco use.

References **<span style="font-family: 'Arial','sans-serif';">: **

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: normal;">Carranza, K., & Newman, T. (2006). Carranza's clinical periodontology. In T.D. Rees (Ed.), //<span style="font-family: 'Arial','sans-serif';">Pathology and management of periodontal problems in patients with HIV infection // (pp. 513-538). St. Louis, Missouri: Saunders Elsevier