1 Case of Periodontal Disease

This article is made in courtesy of University of Sydney Dental School.

Patient Case 1

OPG taken on 12/10/2020

Discuss

1. Calculate full mouth clinical attachment loss. 

2. Explain your periodontal diagnosis (extent, severity/ complexity) 

• Generalised Stage III Grade C periodontitis

• Severity:

  • greatest CAL is greater or equal to 5mm on 6 teeth (47,41,31, 36, 37, 38)

  • greatest CAL between 2 - 4mm on 12 teeth (17, 16, 15, 14, 25, 26, 27, 28, 35, 42,43, 46)

  • greatest CAL between 1- 2 mm on 6 teeth (23, 24, 34, 33, 32, 44, 45)

  • Only no CAL on 5 teeth (13, 12, 11, 21, 22)

  • Generalised horizontal bone loss and some vertical bone loss, 12 teeth with bone loss >33%

  • Number of teeth lost due to periodontitis: 0 (no tooth loss due to periodontitis)

• Complexity

  • Maximum probing depths greater than or equal to 6mm on 14 teeth

  • Vertical bone loss noted

• %bone loss/ age > 1.0. Patient is also a smoker and has diabetes

3. Identify and discuss risk factors. 

1. insufficient oral hygiene with API 89% (>35%)  and SBI 89% (>25%). May be the result of incorrect brushing technique (horizontal strokes) and lack of interdental cleaning disease (only waterjet). Lower lingual surfaces of anteriors appear to be missed. Aggressive horizontal brushing exacerbates gum recession with age. Localised risk factors include presence of wisdom teeth which complicate the process of cleaning effectively, increasing the risk of food impaction.

2. Periodontal risk factors high. 5 cigarettes a day but 14 x 5/12 = 5.83 pack years. Smoking causes delayed healing via decreased vasculature to the area.

3. Diabetes. Diabetes increases AGE products. The heightened immune response involving cytokines causes more inflammation in the area.

4. Mild neutropenia. Mild neutropenia renders the patient less equipped to deal with anaerobic microorganisms of periodontal disease. e.g. Tannerella forsythia, Treponema denticola and porphyroseudomonas gingivalis.

   
   

4. Explain association between the patient's systemic conditions and periodontitis. 

• Chronic hyperglycaemia in diabetes mellitus increases the levels of pro-inflammatory cytokines such as TNF-alpha, IL-1B and IL-6. These cytokines lead to greater inflammation (swelling, redness, pain) and destruction to the periodontium. 

• There is slight neutropenia, so the decreased neutrophil response means weakened fighting of infections in the gums.  

• Microvascular damage caused by diabetes is worsened by smoking. The hampered circulation to the gums reduces oxygen supply in the area and accelerates tissue breakdown and delayed healing. 

• AGEs (advanced glycation end products) accumulate as a result of chronically elevated hyperglycaemia, contributing to oxidative stress and further damage of collagen. 

• Dysbiosis is caused by the hypoxic, high glucose environment created by diabetes. This environment favours the survival of anaerobic and typically pathogenic microorganisms associated with periodontal disease. 

5. Discuss your patient treatment plan and expected outcome (control of biofilm, inflammation, reduction of PPD, etc) 

Education/ Information & Initial Therapy I

• Oral hygiene instructions: teach patient to use interdental brushes with the correct sizing. Teach patient to focus on one tooth at a time for 3 -5 s holding the electric brush perpendicular to the teeth and gently touching the gumlines. Check using mirror. Particularly focus on the lower anterior lingual and also lower back teeth. Consider the switch of brush heads to one with softer bristles.

• Discuss the effects of smoking, diabetes, and neutropenia and link with periodontistis.

• Offer smoking cessation advice

• Demonstrate problem zones with disclosing solution

• Initial Therapy I: Supragingival removal of plaque and stains, oral prophylaxis, fluoride application.

• Recommend 5000ppm Neutra Flor toothpaste once a day before bedtime. Decrease intake of acidic and sugary foods. 

Periodontal assessment (6 point periodontal chart if API <40 and SBI <30)

• Extractions/ Endodontic therapy:  extract teeth with hopeless prognosis

  • consider extraction of 38 as patient complained of food trap in lower back teeth, and recurrent pericoronitis

  • 47 (non-vital) extraction due to severe bone loss/ mobility, possible endo-perio involvement

• Initial Therapy II: subgingival scaling under anaesthesia . Visit 1: Q1 and Q4, visit 2: Q2 and Q3

• Reevaluation and extractions if 38 and 47 are not extracted earlier

• If results of non-surgical treatment not satisfactory (PPD>4mm and BOP+), consider reinstrumentation or perio surgery

• Supportive periodontal therapy: continue to monitor SBI/ API at every appointment, see patient for checkups every 3 months for cleans until SBI/ API indicates good oral hygiene was achieved.  

  • Control grade modifiers: To ensure good management of diabetes, consider regular BGL testing with HbA1c testing within 7%. Continue good control using diet but consider mediations if needed. Reduce smoking, if possible, educate patient on smoking and decreased vascularisation, healing and staining. 

6. Provide LA plan for subgingival debridement (type of LA and technique for each quadrant that needs subgingival debridement)

   
   

   Lidocaine (2% Lignospan with 1:80000 adrenaline) as patient does not have any contraindications for its use. Buccal infiltration and palatal infiltration can be used for debridement of upper teeth.

   IAN block for subgingival debridement of lower teeth as molars were affected on both sides.

   Regarding palatal LA, usually shallow pockets on palatal can be debrided without palatal LA. If deep pockets are usually present on lingual surfaces of lower teeth, additional lingual nerve block would be beneficial.