Aggressive Periodontics

Case 5Aggressive Periodontics

CASE STORY

A 53‐year‐old Caucasian female presents for treatment. Her chief complaint is “sensitive teeth.” She has experienced bleeding and sore gums. She has not been to the dentist in the last two years. She is currently a homemaker, works part time and has three adult children.

LEARNING GOALS AND OBJECTIVES

• Differentiate between a dental hygiene diagnosis and a dental diagnosis for periodontal diseases
• Identify signs/symptoms and causes of aggressive periodontal disease
• Identify health promotion strategies or interventions for periodontal diseases

Medical History

The patient’s medical history states she is in good health. She reported a hospital visit for a broken rib in 2014. She currently takes multivitamins and is not under the care of a physician. The patient does not smoke and her vital signs were within normal limits.

Dental History

The patient has not had a dental visit in the past two years. She has single surface amalgam restorations and a broken tooth #3. Missing teeth are #1, #7, #10, #16, #17, and #32. The patient brushes using toothpaste for sensitive teeth or multiple benefit toothpaste twice a day and flosses once a day. She is concerned about yellowing, crowding, and spacing.

Social History

She has been a full‐time mother and housekeeper. She has recently entered the work force part time as an aide at an elementary school. She is very active in her local church and volunteers.

Assessments

Extraoral/intraoral examination – large, firm thyroid gland, popping and clicking on the left TMJ, lower labial mucosa magenta and reddened, tonsils have been removed, reddened area bilateral anterior tonsillar pillars.

Periodontal Assessment

• Gingival Statement: Generalized moderate marginal and papillary redness with rolled margins and edematous papilla; localized area lingual teeth #12–#14 deeper blue color with frayed margins (see Figure 2.5.1)
• Generalized 4–9 mm pocket depths, recession present, furcation on #30 and mobility (see Figure 2.5.2)
• SBI 44%
• PCR 14%
• Calculus classification: moderate to heavy supragingival and subgingival deposits

Figure 2.5.1: During the visual examination of the gingiva the dental hygienist would interpret the gingival changes and further conduct a thorough periodontal examination.

Source: Photo courtesy of Rio Salado College.

Figure 2.5.2: Periodontal charting for patient with aggressive periodontitis. Note the deep pockets and multiple bleeding sites.

Dental Charting Assessment

• Occlusion: Class I right and left
• Amalgam restorations
• Broken tooth: #3
• Missing teeth: #1, #7, #10, #16, #17, #32

Radiographic Findings

• Severe bone loss both vertical and horizontal (see Figure 2.5.3)

Figure 2.5.3: Periapical image of the maxillary left premolars. Note both vertical and horizontal bone loss.

Risk Assessments

• Caries: low risk
• Periodontal: high risk
• Cancer: low risk

Problem List

• Gingival inflammation and bleeding
• Probing depths of 4–12 mm
• Severe bone loss both vertical and horizontal (see Figure 2.5.3)
• Missing teeth
• Broken tooth #3
• Mobility
• Furcation

Dental Hygiene Diagnosis

Unmet human need	Evidenced (caused) by	Signs/Symptoms
Conceptualization and problem solving	Lack of exposure to information	Patient has lack of knowledge about advanced periodontal diseases
Integrity of the skin and mucous membrane	Microbial infection and host response	Bleeding/severe bone loss
Biologically sound and functional dentition	Inadequate dental care	Missing teeth and broken tooth

Planned Interventions

Interventions	Goals	Evaluation
Oral Health Education	Patient will understand the disease process	Patient will schedule appointments for care and follow up with periodontist
Removal of calculus deposits and biofilm accumulation	Patient will understand the disease process and the importance of dental visits	Patient will be as plaque and calculus free as possible
Periodontal referral	Patient will make an appointment with the periodontist for evaluation and consultation	Patient will schedule appointment for treatment and follow up with a periodontist
Dental treatment	Patient will make an appointment with the dentist for consultation on missing teeth (permanent replacements) and broken tooth	After dental hygiene care and periodontal referral

Appointment Schedule

• First appointment
• Assessments
• OHI
• Full mouth debridement (D4355) / oral prophylaxis
• Chemotherapeutic
• Second appointment
• OHI
• Nonsurgical periodontal therapy (D4341) URQ
• Local anesthetic or pain control
• Chemotherapeutic as needed
• Third appointment
• OHI
• Nonsurgical periodontal therapy (D4341) LRQ
• Local anesthetic or pain control
• Chemotherapeutic as needed
• Fourth appointment
• OHI
• Nonsurgical periodontal therapy (D4341) ULQ
• Local anesthetic or pain control
• Chemotherapeutic as needed
• Fifth appointment
• OHI
• Nonsurgical periodontal therapy (D4341) LLQ
• Local anesthetic or pain control
• Chemotherapeutic as needed
• Sixth appointment
• OHI
• Four to six week re‐evaluation – referral to periodontist
• Chemotherapeutic as needed

Discussion

According to the American Academy of Periodontology (2000), aggressive periodontitis encompasses distinct types of periodontitis that affect people who, in most cases, otherwise appear healthy. This patient has no systemic considerations for the advanced state of bone loss in areas. Aggressive periodontitis tends to have a rapid rate of disease progression and can occur in generalized or localized forms. It typically is seen in patients aged under 30, but can occur in older adults. Clinical features may include the same as chronic periodontitis such as edema, redness, bleeding, and suppuration (American Academy of Periodontology 2000).

It is important for the patient to understand the aggressive form of this type of periodontal disease. Conceptualization and problem solving as a dental hygiene diagnosis will allow the dental hygienist to prioritize the patient’s education. Educating the patient on the progression and prognosis of the disease can initiate them to act. Discussing the bacteria associated with the disease and the host immune response may increase the patient’s willingness to help control the disease. The long‐term outcome may depend on the patient’s compliance and the host response (American Academy of Periodontology 2000).

To determine a dental hygiene diagnosis, the clinician must be able to critically analyze and interpret the assessment data. For example, during the assessment phase noted on the extra‐ and intraoral examination were popping and clicking TMJ and enlarged thyroid. The dental hygienist needs to interpret this data to determine if a problem exists that a dental hygienist is licensed to treat, formulate a dental hygiene diagnosis, and determine interventions for care. A thorough review of all the assessment data such as the gingiva, periodontal charting, and radiographs will help the dental hygienist to determine a dental hygiene diagnosis and direct patient care. During the patient’s gingival assessment (Figure 2.5.1) the arrows point to friable gingival margins and a diffuse magenta color during the observation, the dental hygienist would need to further assess the periodontal findings. The periodontal charting (Figure 2.5.2) indicates deep periodontal pocketing and further review of the radiograph on the upper left (Figure 2.5.3) shows both vertical and horizontal bone loss with calculus deposits on the root surfaces. Putting all the assessment data together (Figure 2.5.4) the dental hygienist is able to synthesize and interpret the information to produce a diagnosis.

Figure 2.5.4: Amalgamated assessment data allow the dental hygienist to analyze and interpret the information to provide a diagnosis.

Using the dental hygiene diagnosis of human need for integrity of the skin and mucous with the sign and symptom of pocket depths and bone loss as shown in Figure 2.5.2 and Figure 2.5.3 the dental hygienist will be able to provide services they are licensed to treat. Basic initial interventions include nonsurgical periodontal therapy, chemotherapeutics, pain control as needed, desensitization as needed, and most importantly oral hygiene education. In addition to these, more forms of chemotherapeutics such as antibiotic therapy, genetic testing, and microbiological identification may be needed. Initial therapy may prove to be ineffective with aggressive periodontitis (American Academy of Periodontology, 2000). Establishing an oral environment as free from periodontal pathogens as possible to provide an environment for healing is a first step. With aggressive forms of periodontitis, referral to a periodontitis should always be a planned intervention.

Including biologically sound and functioning dentition will address the patient’s broken and missing teeth and potential tooth loss due to the aggressive nature of the disease. Dental and periodontal referrals need to be included in the care plan and overall treatment plan for the patient with aggressive periodontitis. The human need for functioning dentition is a part of creating a healthy oral environment.

Take‐Home Hints

1. Consideration of advanced disease state.
2. Education of the patient.
3. Relate the dental hygiene care to the dental hygiene diagnosis.
4. Include dental referrals from the problem list.