By: Heather Atchley-Grey

This patient qualified to be my case study because she was

a generalized periodontal case type III with a localized
periodontal case type IV; and her subgingival deposit level
was a 3. Additionally, I believed non-surgical periodontal
therapy could stabilize and improve, in some areas, her
periodontal condition.

A little background about my patient

She is 56 years of age
Last dental hygiene treatment was 4 years ago
She does not take any medications except for a daily multi-vitamin
She was diagnosed, 5 years ago, with Hepatitis C. She underwent
antiviral treatment for it. As of her last test results, she tested
negative for Hepatitis C.
Suffers from mild arthritis

Dental History
She has been treated for periodontal disease in the past
Brushes 2-3 times a day with fluoride toothpaste
Flosses infrequently
A mouth breather at night

 Vital signs: Within normal limits

Intra and extra oral examination: No significant findings
Microscope evaluation: Risk factor B- Gliding and
spinning rids with high motility, a couple spirochetes

Periodontal Assessments:
Color: Generalized slight hyperemic with localized moderate
Contour: Generalized moderate enlargement; generalized
slight and localized moderate recession
Consistency/Texture: Generalized moderate edematous
Bleeding on Probing: Generalized slight
Clinical Assessment Markers: Class I,II & III furcation's
(teeth #3,18,19 & 30) and class I & II mobility (teeth #9,12,19,
20, 24 & 25)
CAL: Generalized 3-4mm & Localized 5-7mm
Probing Depths: Generalized 3-5mm & Localized 8-9mm
found on teeth #3 distal, #15 distal & #30 distal and lingual

Radiographs sent from private office

The following are radiographic findings and restorative

recommendations from the dental exam:
Extraction or a root canal on #30 due to a periapical
lesion
Crown on #14 due to a large filling and fractured
mesiolingual cusp
Crown on #3 to replace the temporary crown
#2 is over erupted and periodontally compromised, may
need an extraction. (This tooth was extracted between
our NSPT and continuing care appointment. Patient
developed pain and swelling in the area.)

The study model was

utilized to demonstrate
oral hygiene instructions
to my patient, using the
tell-show-do method.

 Periodontal Case Type: Generalized periodontal case type III

with localized periodontal case type IV
Generalized moderate periodontitis with localized severe periodontitis

Calculus deposit: 2/3- Generalized light to moderate supra

gingival calculus and moderate subgingival calculus
Gingival description: Generalized moderate papillary and
marginal inflammation
The radiographs showed generalized moderate horizontal
bone loss and localized severe horizontal bone loss. This
supports my diagnosis of moderate periodontitis with localized
severe.

 Dental biofilm: Moderate risk; generalized light to

moderate cervical and interproximal plaque
Calculus: Moderate risk; light to moderate supra and
moderate subgingival calculus
Bleeding on probing: Low risk; generalized slight
bleeding while probing
Contributing factors: Low risk; crowns and bridge are
plaque retentive
Loss of attachment (CAL): Moderate to high risk;
generalized 3-4mm and localized 5-7mm

 Visible caries or white spot lesions: Low risk; white spots

lesions
Recently restored caries: N/A
Deep occlusal pits & fissures: Low risk
Root exposure: Moderate risk; generalized slight to moderate
recession
Visible dental biofilm: Low risk; generalized slight cervical
and interproximal plaque
Diet/Frequent sugar exposure: Moderate risk; frequent soda
intake
Xerostomia or salvia reducing factors: N/A
Appliances: Low risk; fixed anterior bridge

 My patient expressed wanting to get her oral health back

on schedule and back to a healthy state. She has not had
insurance, for dental hygiene services, for 3-4 years now.
Prior to that she had great dental insurance and had
routine maintenance therapy.

Interventions Planned:
Non-surgical periodontal therapy with the ultrasonic and
local anesthesia
Oral hygiene instructions consisting of sulcular brushing,
perio-aid and proxy brushes
Expected Outcomes:
Reduce inflammation, plaque biofilm and calculus
Arrest periodontal disease process

I believe the patient has a greater periodontal risk factor

than caries, at this time. She has generalized slight to
moderate recession, 3-4mm and 5-7mm of clinical
attachment loss, mobility and furcations. Whereas for
caries she has slight to moderate plaque, no visible or
radiographic caries and no recently restored caries.

 Appointment 1
D0150- Comprehensive oral exam
D1330- Oral hygiene instructions
D0350- Intra oral photos

Appointment 2

D4341- Periodontal scaling UL

D4341- Periodontal scaling LL
D9215- Local anesthesia
D1330- Oral hygiene instructions

Appointment 3

D4341- Periodontal scaling UR

D4341- Periodontal scaling LR
D9215- Local anesthesia
D1330- Oral hygiene instructions
D1206- Topical application of fluoride varnish

Appointment 4
D4999- Reevaluation/Continuing care
D1330 Oral hygiene instructions
D1206 Topical application of fluoride varnish

 Based on our pretreatment assessments, I identified

generalized clinical attachment loss of 4-6mm and localized 89mm. A moderate supra and subgingival deposit level with
generalized slight bleeding
In addition, this patient had previous non-surgical periodontal
therapy but was unable to continue with her maintenance
therapy.
With my current findings and history of her previous dental
hygiene therapy, I diagnosed that she needed a retreatment of
non-surgical periodontal therapy
The use of local anesthesia was indicated based on her
moderate sensitivity during assessments

 This patient was a middle-aged Caucasian. After talking

with her, I concluded she has a more natural approach to
life and believes in taking treatment from a conservative
approach. Her health does mean a lot to her so after
discussing the benefits of retreatment and maintenance
thereafter, she was very accepting of the treatment plan.
The main behavior modification I discussed was making
sure to continue with periodontal maintenance after our
initial treatment, on a 3-4 month regimen. I believe she
would have done this the previous time but due to
resources she was unable to do so.

 January 19, 2016- Initial appointment

January 26, 2016- NSPT UL & LL, OHI
February 9, 2016- NSPT UR & LL, OHI, fluoride varnish
April 26, 2016- Reevaluation/continuing care, OHI,
fluoride varnish

 Sulcular brushing was demonstrated and recommended

twice daily
The perio-aid and proxy brush were demonstrated and
recommended once daily
Additionally, I demonstrated c shaped flossing for the
areas where the proxy brush could not fit and work
effectively.

 Each visit the patient reported using the home care aids I
recommended. She enjoyed the perio-aid best for the
posterior teeth where it is harder to reach. She felt she
could effectively remove the plaque with it. She was not
as compliant with the proxy brush and floss use.
Cervical plaque removal improved with each visit but she
still needed to focus on interproximal plaque removal
more and the lingual of the mandibular anterior.

 Since she was not as compliant with the interproximal

homecare aids as I hoped, I decided to recommend
something different.
I recommended a Waterpik to help flush out the bacteria
of the deeper pockets, as well as for interproximal plaque
removal. She seemed more interested in this option
versus the floss and proxy brush.

Evaluated at the reevaluation/continuing care appointment:

She was more compliant with interproximal plaque removal after
getting a Waterpik. This just worked better for her! She continued
working on sulcular brushing and perio-aid use, and her cervical
plaque removal continued to improve.
Being able to maintain her oral health and keep it in a healthy
place was the key motivation for her. Once she realized how
important homecare was in this process, she started to focus more
on it.

Intrinsic Motivation Strategies:

The overall health of her body. She knew she had not
focused on her mouth as much as the rest of her body
lately. She wanted to get her oral health back to a healthy
place.
Extrinsic Motivation Strategies:
My motivation to her was to continue with maintenance
appointments and recommended homecare aids to arrest
and stabilize the disease process, after non-surgical
periodontal treatment.

April 26, 2016: 11 weeks after Non-Surgical Periodontal Therapy

Date: April 26, 2016

Calculus deposit: 1.5/1.5- Generalized light supra and subgingival
calculus
Periodontal case type: Generalized moderate with localized severe
periodontitis; Generalized periodontal case type III with localized
periodontal case type IV
OHI compliance from previous recommendations: Good- fair
OHI modifications and rationale for change: Continue with sulcular
brushing, perio-aid, and Waterpik. Intrinsic and extrinsic factors have
remained the same
Gingival description: Generalized slight- moderate papillary and
marginal inflammation

 Appointment 1
D4910 Periodontal maintenance
D1330 Oral hygiene instructions
D4381 Locally delivered antimicrobial #30 distal (7mm pocket after
NSPT)
D1206 Topical application of fluoride varnish

Appointment 2: (3-4 month recall)

D4910 Periodontal maintenance
D1330 Oral hygiene instructions
D1206 Fluoride varnish

 The expected outcomes from our initial appointment of

non-surgical periodontal therapy were to reduce plaque
biofilm and calculus, reduce inflammation, reduce
probing depths above 4mm and arrest periodontal
disease.
The expected outcomes were reached. Although she still
has some room for improvement, she decreased her
plaque biofilm and calculus. Gingival inflammation has
decreased in all areas except the maxillary anteriors. It
was suggested by my instructor this may be due to
mouth breathing at night. The probing depths of 4mm
and above decreased by 32 spots.

 The microscope at the initial appointment:

Risk factor B- gliding and spinning rods with high motility, and a
few spirochetes.

Continuing care appointment:

Risk factor B+ gliding and spinning rods with slight motility.

 The probing depths of 4mm and above decreased by 32

spots!!!
Initial appointment had 87 spots
Continuing care had 55 spots

Bleeding points on probing:

Initial appointment had 33 spots
Continuing care appointment had 5 spots

Tissue Statements:
Initial Appointment:
Color: Generalized slight hyperemic with localized moderate
Contour: Generalized moderate enlargement ; generalized slight
and localized moderate recession
Consistency/Texture: Generalized moderate edematous

Continuing Care Appointment:

Color: Generalized slight hyperemic with localized moderate
maxillary anteriors
Contour: Generalized slight enlargement with localized moderate
maxillary anteriors ;generalized slight and localized moderate
recession
Consistency/Texture: Generalized slight edematous

Calculus deposit:
Initial Appointment:
2/3

Continuing Care Appointment:

1.5/1.5

Periodontal case type:

Initial Appointment:
Generalized moderate with localized severe periodontitis;
Generalized periodontal case type III with localized periodontal case
type IV

Continuing Care Appointment:

Generalized moderate with localized severe periodontitis;
Generalized periodontal case type III with localized periodontal case
type IV

Oral hygiene instructions:

Before starting our initial treatment, the patient only used
floss for interproximal plaque removal. She brushed 2-3
times a day but did not emphasis on sulcular brushing.
Upon completion of treatment, we were able to find a
better interproximal aid for her, the Waterpik. With a tellshow-do method, I was able to teach her better cervical
plaque removal with the help of sulcular brushing and the
perio-aid.
My recommendations for her were to continue using the
Waterpik and perio-aid once daily. And to remember to
focus on sulcular brushing 2-3 times daily. Also, to pay a
little more attention to the mandibular lingual anteriors.

 Before

After

 Before

After

 Before

After

 Before

After (#2 was extracted)

Overall, I think the treatment went well for this patient. We were
able to get a good result for her. Although she has some areas to
work on, I think she now has the knowledge and motivation to do
so. I would do the same treatment plan for her and would not
change any treatment. I recommended 3-4 month maintenance
appointments. She has some deep pockets that would benefit
from this recall time frame. Additionally, until she can learn to
better manage her plaque removal a 3-4 month recall would be
best. She has a couple 9mm pockets that may benefit being
seen by a Periodontist, but one of those pockets was on the
distal of #3 and with #2 being recently extracted, she may be
able to better care for this area. For now, I think the treatment
can be adequately treated in the clinic or a general dentist office.