Clinical Cases in Periodontics

Nadeem Karimbux

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN:
  9780813807942
• eBook ISBN:
  9780470962954
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

Wiley-Blackwell's "Clinical Cases" series is designed to recognize the centrality of clinical cases to the profession by providing actual cases with an academic backbone. Clinical Cases in Periodontics describes the core principles of periodontics and demonstrates their practical, every-day application through a range of representative cases building from the simple to the complex and from the common to the rare. This unique approach supports the new trend in case-based and problem-based learning, thoroughly covering topics ranging from infant oral health to complex pulp therapy. Highly illustrated in full color, Clinical Cases in Periodontics utilizes a format that fosters independent learning and prepares the reader for case-based examinations.

The book presents actual clinical cases, accompanied by academic commentary, that question and educate the reader about essential topics in periodontics. The book begins with a set of cases illustrating the most common diagnoses and the key decisions and evaluations leading up to them. Subsequent chapters continue in this style, presenting exemplary cases as the basis of discussing various treatment options including surgical and non-surgical treatment, regenerative therapy, mucogingival therapy, and interdisciplinary treatments. Concluding chapters cover implant site development and general prevention of such periodontal diseases.

Clinical Cases in Periodontics's case-based format is particularly useful for pre-doctoral dental students, post-graduate residents and practitioners, both as a textbook from which to learn about the challenging and absorbing nature of periodontology, and also as a reference tool to help with treatment planning when complex cases present in the dental office.

1

Examination and Diagnosis

Case 1: Examination and Documentation

Walter S. Krawczyk, DDS, and Anisha K. Thondukolam, DDS

Case 2: Plaque-Induced Gingivitis

Nadeem Karimbux, DMD, MMSc, and Satheesh Elangovan, BDS, DSc, DMSc

Case 3: Non–Plaque-Induced Gingivitis

N. Joseph Laborde III, DDS, and Mark A. Lerman, DMD

Case 4: Gingival Enlargement

T. Howard Howell, DDS, and Maria Dona, DDS, MSD

Case 5: Aggressive Periodontitis

Nadeem Karimbux, DMD, MMSc, Satheesh Elangovan, BDS, DSc, DMSc, and Martin Ming-Jen Fu, BDS, MS

Case 6: Chronic Periodontitis

Ricardo Teles, DDS, DMSc

Case 7: Local Anatomic Factors Contributing to Periodontal Disease

Daniel Kuan-te Ho, DMD, MSc, and David M. Kim, DDS, DMSc

Case 1
Examination and Documentation

CASE STORY

A 40-year-old African-American male (LD) in no apparent distress presented with a chief complaint of: “My dentist told me I have gum disease and I should see a periodontist.” Figures 1–5 are the patient’s intraoral photographs.

Figure 1: Frontal view.

Figure 2: Maxillary view.

Figure 3: Mandibular view.

Figure 4: Right occlusal view.

Figure 5: Left occlusal view.

LEARNING GOALS AND OBJECTIVES

• The patient’s chief complaint
• Medical and dental history
• Soft tissue and gingival examination
• Periodontal charting
• Radiographic interpretation and diagnosis of periodontal condition

Past Dental History

This patient denied having bleeding gums during brushing or flossing, he had no loose teeth, and he was not in pain. The patient claimed to brush twice a day and flossed sporadically. His last dental visit was a year ago for a cleaning.

This particular patient presented with a blood pressure of 140/90, a pulse of 70 beats per minute, and a respiration rate of 14 breaths per minute. The patient denied having any significant health problems, had no known allergies, and denied taking any medications.

Soft Tissue and Gingival Examination

The patient had no pathologic masses or lesions upon extraoral and intraoral examination (Figures 1–5). He presented with generalized coral pink gingiva with normal pigmentation, scalloped gingival contour with knife-edged margins, pyramidal papillae with localized areas of blunted papilla, stippling, localized areas of recession, and firm consistency with localized edematous areas. There was mild plaque, with no significant supra/subgingival calculus. There was some normal pigmentation associated with the attached gingiva (Figures 1, 4, and 5).

Periodontal Charting

A thorough periodontal examination was completed. The periodontal chart (Figures 6 and 7) shows that the patient had generalized bleeding on probing, minimal plaque, pocket depths ranging from 2 to 15 mm with the more severe probing depths in the posterior teeth, class 1–2 furcations, class 1–3 mobility, and localized recession.

Figure 6: Maxillary periodontal charting.

Figure 7: Mandibular periodontal charting.

Radiographic Examination

From this full mouth radiograph (Figure 8), generalized bone loss is evident with severe bone loss surrounding #4, #6, #7, and #30. Bone loss in the furcation area is evident for #17 and #30.

Figure 8: Full mouth series radiographs.

Diagnosis

According to the American Academy of Periodontology (AAP), patient LD would be diagnosed with generalized severe chronic periodontitis, which corresponds to an ADA diagnosis of Case Type IV.

Diagnosis (ADA)

Case Type I. Gingivitis

• No attachment loss
• Bleeding may or may not be present
• Pseudopockets may be present
• Only the gingival tissues have been affected by the inflammatory process
• No radiographic evidence of bone loss
• The crestal lamina dura is present
• The alveolar bone level is within 1–2 mm of the CEJ area

Case Type II. Early Periodontitis

• Bleeding on probing may be present in the active phase
• Pocket depths or attachment loss of 3–4 mm
• Localized areas of recession
• Possible class I furcation invasion areas
• Horizontal type of bone loss is most common
• Slight loss of the interdental septum
• Alveolar bone level is 3–4 mm from the CEJ area

Case Type III. Moderate Periodontitis

• Pocket depths or attachment loss of 4–6 mm
• Bleeding on probing
• Grade I and/or grade II furcation invasion areas
• Tooth mobility of class I
• Horizontal or vertical bone loss may be present
• Alveolar bone level is 4–6 mm from the CEJ area
• Radiographic furcations of grade I and/or grade II
• Crown to root ratio is 1 : 1 (loss of a third of supporting alveolar bone)

Case Type IV. Advanced Periodontitis

• Bleeding on probing
• Pocket depths or attachment loss >6 mm
• Grade II, grade III furcation invasion areas
• Mobility of class II or class III
• Horizontal and vertical bone loss
• Alveolar bone level is ≥6 mm from the CEJ area
• Radiographic furcations
• Crown to root ratio is ≥2 : 1 (loss of more than a third of the supporting alveolar bone)

Source: American Academy of Periodontology: Current Procedural Terminology for Periodontics and Insurance Reporting Manual, 7th ed.

Self-Study Questions

A. What dental history questions are important to consider for a periodontal patient?

B. What medical history questions are important to consider for a periodontal patient?

1. From a medical perspective for medical management of the patient

2. From a perspective of conditions that might affect the gingiva/periodontium

C. What constitutes a thorough periodontal examination?

D. How often and what type of radiographs should be exposed for a periodontal examination?

E. How does one come to a diagnosis for gingival and periodontal diseases?

Answers located at the end of the chapter.

References

1. Academy Reports position paper: Tobacco use and the periodontal patient. J Periodontol 1999;70:1419–1427.

2. Haber J, Wattles J, et al. Evidence of cigarette smoking as a major risk factor for Periodontitis. J Periodontol 1993;64:16–23.

3. Emrich LJ, Shlossman M, et al. Periodontal disease in non-insulin dependent diabetes mellitus. J Periodontol 1991;62:123–131.

4. Nelson RG, Shlossman M, et al. Periodontal disease and NIDDM in Pima Indians. Diabetes Care 1990;13:836–840.

5. Academy Reports informational paper: Drug associated gingival enlargement. J Periodontol 2004;75:1424–1431.

6. Rose L, Mealey B. Periodontics: Medicine, Surgery, and Implants. St. Louis, MO: Elsevier Mosby, 2004.

7. Association Report: The use of dental radiographs. Update and...

Table of contents

• Cover
• Title page
• Copyright page
• DEDICATION
• CONTRIBUTORS
• 1 Examination and Diagnosis
• 2 Nonsurgical Periodontal Therapy
• 3 Resective Periodontal Therapy
• 4 Regenerative Therapy
• 5 Mucogingival Therapy
• 6 Interdisciplinary Treatment
• 7 Implant Site Preparation
• 8 Dental Implants
• 9 Preventive Periodontal Therapy
• Index
• Eula