Periodontal Charting – Initial Visit


MAXILLA DATE: 12/08/19

Buccal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
2 2 2 2 2 6 3 1 3 3 1 3 2 1 3 5 3 4 4 2 3

BOP/SUP
B B B B B B

Recession
2 2 2 1 2 1 1 2 1 0 1 0 0 0 0 0 0 0 0 3 2

CAL
4 4 4 3 4 7 4 3 4 3 2 3 2 1 3 5 3 4 4 5 5

Furcation

Buccal

Distal

Mobility
I I II

Palatal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
2 2 4 3 2 6 6 2 3 3 2 3 3 2 3 4 2 3 3 3 3

BOP/SUP
B B B B B B

Recession
1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2

CAL
3 3 4 3 2 6 6 2 3 3 2 3 3 2 3 4 2 3 3 4 5

Furcation

Mesial

MANDIBLE DATE: 12/08/19

Lingual

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
3 3 3 2 2 4 3 2 3 3 3 2

BOP/SUP
B

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
3 3 3 2 2 4 3 2 3 3 3 2

Furcation

Buccal

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
2 2 3 3 3 4 3 2 2 2 2 2

BOP/SUP
B

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
2 2 3 3 3 4 3 2 2 2 2 2

Furcation

Mobility
I I


Periodontal Charting – Re-evaluation Visit


MAXILLA DATE: 21/10/19

Buccal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
3 2 3 3 2 4 4 2 3 3 2 2 2 2 3 5 2 3 3 3 3

BOP/SUP
B

Recession
2 3 2 2 2 1 1 2 1 0 1 0 0 0 0 0 0 0 0 3 3

CAL
5 5 5 5 4 5 5 4 4 3 3 2 2 2 3 5 2 3 3 6 6

Furcation

Buccal

Distal

Mobility
I I II

Palatal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
2 2 4 3 2 4 4 2 3 3 2 3 3 2 3 5 2 3 3 3 3

BOP/SUP

Recession
2 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2

CAL
4 4 5 3 2 4 4 2 3 3 2 3 3 2 3 5 2 3 3 3 5

Furcation

Mesial

MANDIBLE DATE: 21/10/19

Lingual

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
3 3 3 3 2 3 3 3 3 3 2 2

BOP/SUP

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
3 3 3 3 2 3 3 3 3 3 2 2

Furcation

Buccal

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
3 2 2 2 3 3 2 2 3 3 3 3

BOP/SUP

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
3 2 2 2 3 3 2 2 3 3 3 3

Furcation

Mobility
I I


Medical History


History of Chief Complaint:

Pt feels tooth on ULHS is a bit loose. It has gotten looser over the past year. The pain is non-lingering, but is sometimes sharp and sometimes dull. Nil radiating pain and is only uncomfortable when the tooth moves. Pain severity 3/10. Sensibility testing in comparison to tooth 12: tooth 22 WNL to palpation, percussion, triplex cold air, PPD, but it is ++ to CO2 and is grade II mobile.


Family History:

Pt is separated from husband. 3 children (1 son and 2 daughters). Lives at home with her 2 daughters and 6 grandchildren. Both parents were diagnosed with type II diabetes, hypertension, and periodontal disease. Both parents had all their teeth eventually extracted and dentition was restored with F/F dentures.


General Medical History:

Nil medical alerts or allergies


Type 2 Diabetes:

Diaformin 2x/day and Qtern 1x/day (hypoglycemics)

Diagnosed in 1995.

HbA1c 8.6% (December 2018), but reduced to 7.3% (September 2019) – needs improvement


Hypertension:

Exforg 1x/day (antihypertensive)

Last BP reading was 110/70 (September 2019) – well controlled


Cholesterolemia:

Zimstat 1x/day (hypolipidemic)

Last cholesterol reading was 3.3mmol/L (September 2019) – well controlled


Bleeding Risk:

Aspirin 1x/day taken preventatively as pt has no cardiovascular issues


Asthma

: Ventolin (bronchodilator) PRN and Flutiform (preventative) PRN – well controlled

No medical alerts or allergies

No smoking, alcohol, or recreational drug use


Special Dental History:

Tendency to plaque formation
Gingival bleeding X
Frequent inflammation marginal gingiva generalised X localised
Increased tooth mobility X
Tooth loss due to increased tooth mobility X
Tooth movement X
Suppuration out of periodontal pockets
Periodontal abscesses
Parafunctional activity (clenching & grinding) X 22 opposing 33
Previous orthodontic treatment
Age of existing prosth. restorations

Age of existing implants

Previous dental treatment

P/P CoCr 14-15 years ago, but P/- is missing

Nil

Restorative, extractions, and dentures.

Smoker YES               NO X
Number of cigarettes/day _____________


Radiographs


Type of radiograph

Tick

Date

OPG
X 09/04/2019


BW


PA
X 12/08/2019


Other:


Radiographs


Radiographic Examination


General Radiographic Findings (oral):


OPG

TMJ and sinuses are clear.

No pathology associated with the maxilla or mandible.

Inferior alveolar nerve canal and mental foramen are identifiable.

Residual dentition is free of restorations, but root caries is noted.

Previously issued P/P CoCR dentures, but patient notes that the P/- is now missing.

Missing teeth include 18-16, 23-28, 37-35, 32-47.

Root caries present: 15D, 21D, 38M, 34D, 33M.

Bone loss present: generalized mild and localized moderate horizontal bone loss.


PA22

Teeth present: 11, 21, 22

Bone loss present: mild bone horizontal bone loss associated with 11, 21, 22

Pathology present: slight PDL widening and lamina dura disruption associated with 22


Special Radiographic Findings (periodontal):


I. Quadrant




Bone Loss distally



Bone loss mesially




Susp.


Furc.


Inv.



Wid.


Lig.-

Space


1.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

1.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

1.Q




18


18

18


17


17

17


16


16

16

15
h X
15
h X
15

14
h X
14
h X
14

13
h X
13
h X
13

12
h X
12
h X
12

11
h X
11
h X
11



II. Quadrant









Bone loss mesially



Bone Loss distally




Susp.


Furc.


Inv.



Wid.


Lig.-

Space


2.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

2.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

2.Q



21
h X
21
h X
21

22
h X
22
h X
22
X

23

23

23

24

24

24

25

25

25

26

26

26

27

27

27

28

28

28


III. Quadrant








Bone Loss distally



Bone loss mesially




Susp.


Furc.


Inv.



Wid.


Lig.-

Space


3.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

3.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

3.Q



38
Nil
38
h X
38

37

37

37

36

36

36

35

35

35

34
h X
34
h X
34

33
h X
33
h X
33

32

32

32

31

31

31


IV. Quadrant










Bone loss mesially



Bone Loss distally




Susp.


Furc.


Inv.

.



Wid.


Lig.-

Space


4.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

4.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

4.Q



41

41

41

42

42

42

43

43

43

44

44

44

45

45

45

46

46

46

47

47

47

48
h X
48
Nil
48


DIAGNOSIS


General Periodontal Diagnosis:

Localized stage IV grade C chronic periodontitis


Single Tooth Periodontal Diagnosis:









(attachment/bone loss based on radiographic findings)

Tooth 18 17
16
15 14 13 12 11 21 22 23 24 25 26 27 28
superficial X X X X X X X
medium (moderate)
profound (advanced)

and complex
Tooth 48
47

46

45

44

43

42

41

31

32
33 34
35

36

37
38
superficial X X X
medium (moderate) X
profound (advanced)

and complex


PROGNOSIS


First


prognostic evaluation

(after initial periodontal assessment)


General Periodontal Prognosis:

Overal prognosis is questionable to good given EF’s OH, caries risk, and medical history.


Single Tooth Prognosis (Perio, Endo, Prosth.)



Tooth
18
17
16
15 14 13 12 11 21 22 23 24
25

26

27

28
Spec. Period. Prognosis + + + + + + 0
Endodont. Prognosis
Prosth.Prognosis + 0

Final prognostic value
+ + + + + + 0

good:

+

questionable:

0

hopeless:









Tooth 48 47 46 45 44 43 42 41
31

32
33 34 35
36

37
38
Spec. Period. Prognosis + 0 + +
Endodont. Prognosis
Prosth.Prognosis + + + +

Final prognostic value
+ 0 + +


2nd prognostic evaluation

(after re-evaluation)



General Periodontal Prognosis:

Overall prognosis is good provided oral and general health can be maintained to a high standard and no further progression in secondary occlusal trauma to 22.


Single Tooth Prognosis (Perio, Endo, Prosth.)






Tooth 18 17
16
15 14 13 12 11 21 22
23
24 25 26 27
28
Spec. Period. Prognosis + + + + + + 0
Endodont. Prognosis
Prosth.Prognosis + + 0

Final prognostic value
+ + + + + + 0

good:

+

questionable:

0

hopeless:






Tooth 48 47
46

45
44
43
42
41
31
32
33 34
35

36
37 38
Spec. Period. Prognosis + 0 + +
Endodont. Prognosis
Prosth.Prognosis + + + +

Final prognostic value
+ 0 + +


TREATMENT PLAN

Date 12/08/2019 Planned by (student) Henry Ma
Approved by (tutor) Wesley Wong


Professional Prophylaxis:

supragingival debridement & establishment good oral hygiene

(mandatory)



Initial Visit

At the initial visit, EF presented with SBI of 0%, API of 75%, and PSR of 3/3/-/3/-/2 EF was given oral hygiene instructions specifically to switch to an Oral B electric toothbrush from her firm manual toothbrush and the use of green and black Pixster interdental brushes for her maxillary and mandibular teeth, respectively. EF was taught toothbrush technique using an electric toothbrush and how to clean interproximally. EF presented with 5 root carious lesions that require restorations. Whole mouth supragingival plaque and calculus removal was completed.


Problem List

Mobile teeth with recession

Root carious teeth


Treatment Plan

Restorative: 15D, 21D, 38M, 34D, 33M

Prosthodontic: P/- acrylic or CoCr denture

Initial Therapy I: SBI/API, oral health education, oral hygiene instructions, demonstration of plaque control, education on interdental cleaning and use of an electric toothbrush, whole mouth supragingival debridement

Periodontal Assessment: SBI/API, assessment after 4 weeks to assess healing, 6 point chart, review oral hygiene

Initial Therapy II: SBI/API, quadrant-based subgingival debridement under LA, review oral hygiene

Re-evaluation: SBI/API, 6 point chart after 10-12 weeks to assess healing, review oral hygiene

Initial Therapy II: SBI/API, quadrant-based subgingival re-debridement under LA, review oral hygiene

Re-evaluation: SBI/API, 6 point chart after 10-12 weeks to assess healing, review oral hygiene

Supportive Periodontal Therapy: SBI/API, recall 3/12 to re-evaluate and re-debride as required, review oral hygiene


Subgingival Debridement:

I. Quadrant II. Quadrant III. Quadrant IV. Quadrant
Teeth 14, 13 21, 22 33 Nil


Extraction:

Nil, but monitor 22 for increasing mobility.

Root canal treatment:

Nil

Restorative treatment:

Restorations: 15, 21, 38, 34, 33 in GIC and CR depending on access and moisture control.
Prospective Prosth. Restoration: Fixed Removable X Implant-based

Details:

Pt is currently missing her P/- CoCr denture. In order to prevent further secondary occlusal trauma to 22, a new P/- in acrylic or CoCr with meshwork near 22 should be constructed. The rationale for a P/- acrylic or CoCr with meshwork near 22 is in case 22 needs to be extracted in the future due to increasing mobility. The abutment teeth for the P/- denture include 15 and possibly on 22. Alternatively, a full palatal acrylic or CoCr casting can be used for further retention of the P/- denture should 22 not be used as an abutment due to esthetic concerns.


Oral Hygiene Indices (API/SBI)


Changes in Plaque Control



Oral Hygiene Indices

Initial visit

Integrated clinic treatment plan visit

Periodontal assessment visit

Subgingival debridement visit #1

Periodontal reassessment visit

Date
12/05/19 05/08/19 12/08/19 19/08/19 21/10/19

API (%)
75 83 67 50 25

SBI (%)
0 0 0 0 0


Non-surgical


Treatment Outcome (PPD/BOP)



Changes in Clinical Parameters (%)


Clinical parameters (PPD/BOP)

PPD ≤ 3mm

PPD 4-5mm

PPD ≥ 6mm

BOP

Initial exam (12/08/19)
86.3% 10.1% 3.6% 8.3%

Re-evaluation (08/10/19)
91.7% 8.3% 0.0% 0.6%


Clinical Photographs – Initial Visit


Image 1 Anterior view of Maxilla and Mandible with teeth in contact


Image 2 Occlusal view of Maxilla


Image 3 Occlusal view of Mandible



Clinical Photographs – Initial Visit


Maxilla and Mandible with teeth in contact (occlusion)


Image 4 Lateral right view


Image 5 Lateral left view



Clinical Photographs – Re-evaluation Visit


Image 1 Anterior view of Maxilla and Mandible with teeth in contact


Image 2 Occlusal view of Maxilla


Image 3 Occlusal view of Mandible



Clinical Photographs – Re-evaluation Visit


Maxilla and Mandible with teeth in contact (occlusion)


Image 4 Lateral right view


Image 5 Lateral left view


Periodontal Risk Assessment


Supportive Periodontal Treatment (SPT) visit

for the patient booked for: 3 months

Date:
TBD


Discussion


Diagnosis

According to the 2017 AAP and EFP classification, EF is diagnosed as localized stage IV grade C chronic periodontitis(1). This diagnosis can be attributed to tooth 14 with 6mm PPD, 7mm CAL, ~40-45% bone loss associated with tooth 33, and at least 5 teeth were lost due to periodontal disease. EF displays secondary occlusal trauma associated with tooth 22, only 11 teeth remaining, and only 1 remaining opposing pair of teeth (22 occluding with 33). EF does not have % bone loss/age indicator greater than 1.0, but she demonstrates HbA1c more than 7.0%.


Prognosis

The primary risk factors for EF include poor oral hygiene and plaque control, a high sugar diet, lack of exercise, and obesity resulting in a high caries risk, and a medical history highlighted by poorly controlled type 2 diabetes. At her initial appointment, EF noted that she only brushed her teeth in the morning and sometimes at night with a firm manual toothbrush and Colgate toothpaste, and never flossed. Although her lunch and dinner are healthier, her breakfast consists of 4 pieces of toast in the morning with butter and jam, and she consumes 2 cups of tea and 1 cup of coffee all with 1 teaspoon of sugar daily. Exercise mainly consists of doing housework and looking after the grandchildren. At present EF weighs 93kg and is 174cm in height. EF previously weighed as much as 112kg in March 2015. In completing an odontogram for EF, she presented with several ICDAS 5 (frank cavitation) lesions found on the root surface that were also visible on the OPG. As previously mentioned, EF has a medical history consisting of poorly controlled type 2 diabetes. In September 2019 her HbA1c reading was 7.3%, which represents an improvement compared to December 2018 where it was 8.6%. However, EF’s reading still represents a value greater than 7.0% which is a recommended general target for patients requiring insulin medication(2). EF reports a family history of diabetes and periodontal disease whereby both parents required F/F dentures following the extraction of all their teeth. On the basis of this information, the prognosis for the remainder of EF’s dentition was questionable to good at best.


Customized Treatment Plan

In order to improve the prognosis of EF’s dentition, a treatment plan was devised consisting of periodontal screening with PSR and patient education. This was followed by initial therapy I with prophylaxis and oral hygiene instruction. Following this, periodontal assessment, initial therapy II with subgingival root debridement, and reevaluation were commenced. The primary goal of the treatment plan for EF was to educate her on the holistic role of each risk factor and their contribution to her periodontal disease.  This included the roles of excellent oral hygiene, improved diet, increasing exercise, in combination with periodontal treatment in order to successfully treat her periodontal disease. EF initially presented with poor oral hygiene as outlined by her high % API scores. The presence of approximal plaque and residual food debris was shown to EF. It was explained to EF that her periodontal disease in particular could be attributed to her lack of oral hygiene and high caries risk, but also her family history of periodontal disease and type 2 diabetes, and most importantly, the bidirectional relationship between type 2 diabetes and periodontal disease, which she displayed (3). EF was asked to demonstrate her normal brushing, which required improvement. A customized plan was devised for EF whereby she was recommended to switch to an Oral B electric toothbrush, a 5000ppm fluoride Colgate toothpaste, and use of green and black Pixster interdental brushes for her maxillary and mandibular teeth, respecitively. To address EF’s diet, she was encouraged to decrease the amount of sugar in her breakfast, and also, the amount of sugar in her tea and coffee. EF was also encouraged to exercise at least 30 minutes per day by taking her grandchildren to the park and engaging with them to elevate her heart rate and promote progressive weight loss.


Diabetes and Periodontal Disease

EF was diagnosed with type 2 diabetes in 1995. In March 2015, EF’s HbA1c was as high as 10.5%, but this has gradually decreased to 7.3% in May 2019 and remains the same in September 2019 at 7.3%. EF has been informed about the association between type 2 diabetes and periodontal disease, especially that periodontitis is significantly associated with poor glycemic control as measured by HbA1c (4). She has also been informed that those with periodontitis are at a greater risk of developing prediabetes and diabetes, and furthermore, the risk of developing diabetic complications such as retinopathy, neuropathy, and adverse cardiovascular effects(5). There are several potential mechanisms associated with the relationship between type 2 diabetes and periodontal disease, and they include an altered periodontal microbiome and elevated levels of proinflammatory mediators within gingival tissues of diabetics(5). To date, there is no evidence to suggest the positive impact of long-term periodontal treatment in type 2 diabetes, but short-term human intervention studies have demonstrated that periodontal treatment alone is effective in improving glycemic control in type 2 diabetes with a statistically significant reduction in HbA1c that is comparable to the addition of a second diabetic medication (5).


Secondary Occlusal Trauma and Periodontal Disease

In total, EF has lost 19 teeth associated with various causes. She reports that some teeth were loose and sore, whereas others were carious. At present, EF is missing her P/- CoCr denture, but still retains her -/P CoCr denture that fits well. However, EF has only 1 opposing pair of teeth remaining (22 occludes with 33), which has resulted in secondary occlusal trauma to 22. It is imperative to prevent further occlusal trauma as it has previously been shown that its progression in severity is positively correlated with the severity of attachment loss(7). In consulting with a prosthodontist, it has been suggested that 22 should not be splinted as it could potentially increase mobility in adjacent abutment teeth. It has been recommended to EF that 22 should be extracted and that an immediate P/- acrylic denture be constructed to allow EF to use both dentures during the day and at night to prevent further secondary occlusal trauma. In contrast to this, in consultation with a periodontist, it has been suggested that 22 should be retained and that a P/- acrylic or CoCr denture be constructed either with or without a retainer on 22 (due to esthetic concerns) to allow EF to use both dentures only during the day to prevent further secondary occlusal trauma, but also allowing her to maintain excellent denture hygiene. EF has decided to pursue the more conservative approach and allow for continual monitoring of 22.


Re-evaluation

In order to improve short- and long-term outcomes of periodontal disease, it is imperative that the patient is motivated and continuously maintains adequate oral hygiene. At every appointment, customized oral hygiene instructions were provided to EF with regards to technique associated with use of an electric toothbrush and interdental brushes in order to properly clean all surfaces of the teeth. EF has consistently maintained excellent SBI scores, and she has gradually improved her API scores. This demonstrates her motivation to improve the outcome of her periodontal disease, and she has mentioned that her grandchildren have also become more motivated to brush their teeth in the morning and in the evening as they have witnessed her doing it on a regular basis. In addition to the patient’s role in maintaining their oral hygiene, the role of non-surgical periodontal therapy in the treatment of periodontal disease cannot be overstated, and together, it is responsible for the reduction in PPD and gain in CAL (8). Following initial therapy II and the first round of non-surgical periodontal therapy, EF displayed reduced gingival erythema and reduced bleeding on probing during the periodontal reassessment. Furthermore, EF displayed elimination of all pockets with PPD greater than or equal to 6mm, a reduction in pockets with PPD between 4-5mm, and an improvement in pockets with PPD less than or equal to 3mm. Because EF does not require surgical periodontal therapy, it is critical to continue non-surgical periodontal therapy for EF in order to reassess for further improvement in PPD reduction and CAL gain given her motivation to improve her oral health and her overall health. Despite the initial questionable prognosis given EF’s specific risk factors, her overall prognosis is actually good provided she can maintain the customized treatment plan that has been devised for her.


Supportive Periodontal Therapy

Successful long-term control of EF’s periodontal disease is not only dependent on supportive periodontal therapy, maintenance of excellent oral hygiene, but also continued improvement in her overall health as managed by her GP. It has been previously shown that supportive periodontal therapy is critical in long-term sucscess as demonstrated by stable clinical attachment levels in comparison to patients who are not maintained in a supervised program who demonstrate a return to active periodontal disease (9). According to the 2003 Lang and Tonetti periodontal risk assessment, EF is still considered high risk for periodontal disease due to her extensive tooth loss and her systemic diagnosis of type 2 diabetes (10). This risk outcome requires a 3 month interval recall and it is critical that she is continued to be seen following her second round of non-surgical therapy and reassessment.


References

  1. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, Flemmig TF, Garcia R, Giannobile WV,  Graziani F, Greenwell H, Herrera D, Kao RT, Kebschull M, Kinane DF, Kirkwood KL, Kocher T, Kornman KS, Kumar PS, Loos BG, Machtei E, Meng HX, Mombelli A, Needleman I, Offenbacher S, Seymour GJ, Teles R, Tonetti MS. Periodontitis: Consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. Journal of Periodontology. 2018;89(Suppl 1):S173-S182.
  2. American Diabetes Association. Standards of medical care in diabetes – 2014. American Diabetes Association. 2014;37(Suppl 1):S14-S80.
  3. Mealey BL. Periodontal disease and diabetes: A two-way street. The Journal of the American Dental Association. 2006;137(Suppl 10):26S-31S.
  4. Graziani P, Gennal S, Solini A, Petrini M. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontal disease on diabetes: An update on the review of the EFP-AAP workshop. Journal of Clinical Periodontology. 2018;45:167-187.
  5. Polak D, Shapira L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. Journal of Clinical Periodontology. 2018;45:150-166.
  6. Madiano PN, Koromantzos PA. An update of the evidence on the potential impact of periodontal therapy on diabetes outcomes. Journal of Clinical Periodontology. 2018;45:188-195.
  7. Braschofsky M, Beikler T, Schafer R, Flemmig TF, Lang H. Secondary trauma from occlusion and periodontitis. Quintessence International. 2011;42:515-522.
  8. Heitz-Mayfield LJA, Trombelli L, Heitz F, Needleman I, Moles D. A systematic review of the effect of surgical debridement vs. Non-surgical debridement for the treatment of chronic periodontitis. Journal of Clinical Periodontology. 2002;29(Suppl 3):92-102.
  9. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults: Results after 30 years of maintenance. Journal of Clinical Periodontology. 2004;31:749-757.
  10. Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health and Preventative Dentistry. 2003;1:7-16.


 

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Periodontal Charting – Initial Visit


MAXILLA DATE: 12/08/19

Buccal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
2 2 2 2 2 6 3 1 3 3 1 3 2 1 3 5 3 4 4 2 3

BOP/SUP
B B B B B B

Recession
2 2 2 1 2 1 1 2 1 0 1 0 0 0 0 0 0 0 0 3 2

CAL
4 4 4 3 4 7 4 3 4 3 2 3 2 1 3 5 3 4 4 5 5

Furcation

Buccal

Distal

Mobility
I I II

Palatal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
2 2 4 3 2 6 6 2 3 3 2 3 3 2 3 4 2 3 3 3 3

BOP/SUP
B B B B B B

Recession
1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2

CAL
3 3 4 3 2 6 6 2 3 3 2 3 3 2 3 4 2 3 3 4 5

Furcation

Mesial

MANDIBLE DATE: 12/08/19

Lingual

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
3 3 3 2 2 4 3 2 3 3 3 2

BOP/SUP
B

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
3 3 3 2 2 4 3 2 3 3 3 2

Furcation

Buccal

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
2 2 3 3 3 4 3 2 2 2 2 2

BOP/SUP
B

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
2 2 3 3 3 4 3 2 2 2 2 2

Furcation

Mobility
I I


Periodontal Charting – Re-evaluation Visit


MAXILLA DATE: 21/10/19

Buccal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
3 2 3 3 2 4 4 2 3 3 2 2 2 2 3 5 2 3 3 3 3

BOP/SUP
B

Recession
2 3 2 2 2 1 1 2 1 0 1 0 0 0 0 0 0 0 0 3 3

CAL
5 5 5 5 4 5 5 4 4 3 3 2 2 2 3 5 2 3 3 6 6

Furcation

Buccal

Distal

Mobility
I I II

Palatal

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

Pocket Depth
2 2 4 3 2 4 4 2 3 3 2 3 3 2 3 5 2 3 3 3 3

BOP/SUP

Recession
2 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2

CAL
4 4 5 3 2 4 4 2 3 3 2 3 3 2 3 5 2 3 3 3 5

Furcation

Mesial

MANDIBLE DATE: 21/10/19

Lingual

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
3 3 3 3 2 3 3 3 3 3 2 2

BOP/SUP

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
3 3 3 3 2 3 3 3 3 3 2 2

Furcation

Buccal

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Pocket Depth
3 2 2 2 3 3 2 2 3 3 3 3

BOP/SUP

Recession
0 0 0 0 0 0 0 0 0 0 0 0

CAL
3 2 2 2 3 3 2 2 3 3 3 3

Furcation

Mobility
I I


Medical History


History of Chief Complaint:

Pt feels tooth on ULHS is a bit loose. It has gotten looser over the past year. The pain is non-lingering, but is sometimes sharp and sometimes dull. Nil radiating pain and is only uncomfortable when the tooth moves. Pain severity 3/10. Sensibility testing in comparison to tooth 12: tooth 22 WNL to palpation, percussion, triplex cold air, PPD, but it is ++ to CO2 and is grade II mobile.


Family History:

Pt is separated from husband. 3 children (1 son and 2 daughters). Lives at home with her 2 daughters and 6 grandchildren. Both parents were diagnosed with type II diabetes, hypertension, and periodontal disease. Both parents had all their teeth eventually extracted and dentition was restored with F/F dentures.


General Medical History:

Nil medical alerts or allergies


Type 2 Diabetes:

Diaformin 2x/day and Qtern 1x/day (hypoglycemics)

Diagnosed in 1995.

HbA1c 8.6% (December 2018), but reduced to 7.3% (September 2019) – needs improvement


Hypertension:

Exforg 1x/day (antihypertensive)

Last BP reading was 110/70 (September 2019) – well controlled


Cholesterolemia:

Zimstat 1x/day (hypolipidemic)

Last cholesterol reading was 3.3mmol/L (September 2019) – well controlled


Bleeding Risk:

Aspirin 1x/day taken preventatively as pt has no cardiovascular issues


Asthma

: Ventolin (bronchodilator) PRN and Flutiform (preventative) PRN – well controlled

No medical alerts or allergies

No smoking, alcohol, or recreational drug use


Special Dental History:

Tendency to plaque formation
Gingival bleeding X
Frequent inflammation marginal gingiva generalised X localised
Increased tooth mobility X
Tooth loss due to increased tooth mobility X
Tooth movement X
Suppuration out of periodontal pockets
Periodontal abscesses
Parafunctional activity (clenching & grinding) X 22 opposing 33
Previous orthodontic treatment
Age of existing prosth. restorations

Age of existing implants

Previous dental treatment

P/P CoCr 14-15 years ago, but P/- is missing

Nil

Restorative, extractions, and dentures.

Smoker YES               NO X
Number of cigarettes/day _____________


Radiographs


Type of radiograph

Tick

Date

OPG
X 09/04/2019


BW


PA
X 12/08/2019


Other:


Radiographs


Radiographic Examination


General Radiographic Findings (oral):


OPG

TMJ and sinuses are clear.

No pathology associated with the maxilla or mandible.

Inferior alveolar nerve canal and mental foramen are identifiable.

Residual dentition is free of restorations, but root caries is noted.

Previously issued P/P CoCR dentures, but patient notes that the P/- is now missing.

Missing teeth include 18-16, 23-28, 37-35, 32-47.

Root caries present: 15D, 21D, 38M, 34D, 33M.

Bone loss present: generalized mild and localized moderate horizontal bone loss.


PA22

Teeth present: 11, 21, 22

Bone loss present: mild bone horizontal bone loss associated with 11, 21, 22

Pathology present: slight PDL widening and lamina dura disruption associated with 22


Special Radiographic Findings (periodontal):


I. Quadrant




Bone Loss distally



Bone loss mesially




Susp.


Furc.


Inv.



Wid.


Lig.-

Space


1.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

1.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

1.Q




18


18

18


17


17

17


16


16

16

15
h X
15
h X
15

14
h X
14
h X
14

13
h X
13
h X
13

12
h X
12
h X
12

11
h X
11
h X
11



II. Quadrant









Bone loss mesially



Bone Loss distally




Susp.


Furc.


Inv.



Wid.


Lig.-

Space


2.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

2.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

2.Q



21
h X
21
h X
21

22
h X
22
h X
22
X

23

23

23

24

24

24

25

25

25

26

26

26

27

27

27

28

28

28


III. Quadrant








Bone Loss distally



Bone loss mesially




Susp.


Furc.


Inv.



Wid.


Lig.-

Space


3.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

3.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

3.Q



38
Nil
38
h X
38

37

37

37

36

36

36

35

35

35

34
h X
34
h X
34

33
h X
33
h X
33

32

32

32

31

31

31


IV. Quadrant










Bone loss mesially



Bone Loss distally




Susp.


Furc.


Inv.

.



Wid.


Lig.-

Space


4.Q


h/v



c





1/3



m





1/3



a





1/3


2/3-wall

4.Q




h/v



c





1/3



m





1/3



a





1/3


2/3-wall

4.Q



41

41

41

42

42

42

43

43

43

44

44

44

45

45

45

46

46

46

47

47

47

48
h X
48
Nil
48


DIAGNOSIS


General Periodontal Diagnosis:

Localized stage IV grade C chronic periodontitis


Single Tooth Periodontal Diagnosis:









(attachment/bone loss based on radiographic findings)

Tooth 18 17
16
15 14 13 12 11 21 22 23 24 25 26 27 28
superficial X X X X X X X
medium (moderate)
profound (advanced)

and complex
Tooth 48
47

46

45

44

43

42

41

31

32
33 34
35

36

37
38
superficial X X X
medium (moderate) X
profound (advanced)

and complex


PROGNOSIS


First


prognostic evaluation

(after initial periodontal assessment)


General Periodontal Prognosis:

Overal prognosis is questionable to good given EF’s OH, caries risk, and medical history.


Single Tooth Prognosis (Perio, Endo, Prosth.)



Tooth
18
17
16
15 14 13 12 11 21 22 23 24
25

26

27

28
Spec. Period. Prognosis + + + + + + 0
Endodont. Prognosis
Prosth.Prognosis + 0

Final prognostic value
+ + + + + + 0

good:

+

questionable:

0

hopeless:









Tooth 48 47 46 45 44 43 42 41
31

32
33 34 35
36

37
38
Spec. Period. Prognosis + 0 + +
Endodont. Prognosis
Prosth.Prognosis + + + +

Final prognostic value
+ 0 + +


2nd prognostic evaluation

(after re-evaluation)



General Periodontal Prognosis:

Overall prognosis is good provided oral and general health can be maintained to a high standard and no further progression in secondary occlusal trauma to 22.


Single Tooth Prognosis (Perio, Endo, Prosth.)






Tooth 18 17
16
15 14 13 12 11 21 22
23
24 25 26 27
28
Spec. Period. Prognosis + + + + + + 0
Endodont. Prognosis
Prosth.Prognosis + + 0

Final prognostic value
+ + + + + + 0

good:

+

questionable:

0

hopeless:






Tooth 48 47
46

45
44
43
42
41
31
32
33 34
35

36
37 38
Spec. Period. Prognosis + 0 + +
Endodont. Prognosis
Prosth.Prognosis + + + +

Final prognostic value
+ 0 + +


TREATMENT PLAN

Date 12/08/2019 Planned by (student) Henry Ma
Approved by (tutor) Wesley Wong


Professional Prophylaxis:

supragingival debridement & establishment good oral hygiene

(mandatory)



Initial Visit

At the initial visit, EF presented with SBI of 0%, API of 75%, and PSR of 3/3/-/3/-/2 EF was given oral hygiene instructions specifically to switch to an Oral B electric toothbrush from her firm manual toothbrush and the use of green and black Pixster interdental brushes for her maxillary and mandibular teeth, respectively. EF was taught toothbrush technique using an electric toothbrush and how to clean interproximally. EF presented with 5 root carious lesions that require restorations. Whole mouth supragingival plaque and calculus removal was completed.


Problem List

Mobile teeth with recession

Root carious teeth


Treatment Plan

Restorative: 15D, 21D, 38M, 34D, 33M

Prosthodontic: P/- acrylic or CoCr denture

Initial Therapy I: SBI/API, oral health education, oral hygiene instructions, demonstration of plaque control, education on interdental cleaning and use of an electric toothbrush, whole mouth supragingival debridement

Periodontal Assessment: SBI/API, assessment after 4 weeks to assess healing, 6 point chart, review oral hygiene

Initial Therapy II: SBI/API, quadrant-based subgingival debridement under LA, review oral hygiene

Re-evaluation: SBI/API, 6 point chart after 10-12 weeks to assess healing, review oral hygiene

Initial Therapy II: SBI/API, quadrant-based subgingival re-debridement under LA, review oral hygiene

Re-evaluation: SBI/API, 6 point chart after 10-12 weeks to assess healing, review oral hygiene

Supportive Periodontal Therapy: SBI/API, recall 3/12 to re-evaluate and re-debride as required, review oral hygiene


Subgingival Debridement:

I. Quadrant II. Quadrant III. Quadrant IV. Quadrant
Teeth 14, 13 21, 22 33 Nil


Extraction:

Nil, but monitor 22 for increasing mobility.

Root canal treatment:

Nil

Restorative treatment:

Restorations: 15, 21, 38, 34, 33 in GIC and CR depending on access and moisture control.
Prospective Prosth. Restoration: Fixed Removable X Implant-based

Details:

Pt is currently missing her P/- CoCr denture. In order to prevent further secondary occlusal trauma to 22, a new P/- in acrylic or CoCr with meshwork near 22 should be constructed. The rationale for a P/- acrylic or CoCr with meshwork near 22 is in case 22 needs to be extracted in the future due to increasing mobility. The abutment teeth for the P/- denture include 15 and possibly on 22. Alternatively, a full palatal acrylic or CoCr casting can be used for further retention of the P/- denture should 22 not be used as an abutment due to esthetic concerns.


Oral Hygiene Indices (API/SBI)


Changes in Plaque Control



Oral Hygiene Indices

Initial visit

Integrated clinic treatment plan visit

Periodontal assessment visit

Subgingival debridement visit #1

Periodontal reassessment visit

Date
12/05/19 05/08/19 12/08/19 19/08/19 21/10/19

API (%)
75 83 67 50 25

SBI (%)
0 0 0 0 0


Non-surgical


Treatment Outcome (PPD/BOP)



Changes in Clinical Parameters (%)


Clinical parameters (PPD/BOP)

PPD ≤ 3mm

PPD 4-5mm

PPD ≥ 6mm

BOP

Initial exam (12/08/19)
86.3% 10.1% 3.6% 8.3%

Re-evaluation (08/10/19)
91.7% 8.3% 0.0% 0.6%


Clinical Photographs – Initial Visit


Image 1 Anterior view of Maxilla and Mandible with teeth in contact


Image 2 Occlusal view of Maxilla


Image 3 Occlusal view of Mandible



Clinical Photographs – Initial Visit


Maxilla and Mandible with teeth in contact (occlusion)


Image 4 Lateral right view


Image 5 Lateral left view



Clinical Photographs – Re-evaluation Visit


Image 1 Anterior view of Maxilla and Mandible with teeth in contact


Image 2 Occlusal view of Maxilla


Image 3 Occlusal view of Mandible



Clinical Photographs – Re-evaluation Visit


Maxilla and Mandible with teeth in contact (occlusion)


Image 4 Lateral right view


Image 5 Lateral left view


Periodontal Risk Assessment


Supportive Periodontal Treatment (SPT) visit

for the patient booked for: 3 months

Date:
TBD


Discussion


Diagnosis

According to the 2017 AAP and EFP classification, EF is diagnosed as localized stage IV grade C chronic periodontitis(1). This diagnosis can be attributed to tooth 14 with 6mm PPD, 7mm CAL, ~40-45% bone loss associated with tooth 33, and at least 5 teeth were lost due to periodontal disease. EF displays secondary occlusal trauma associated with tooth 22, only 11 teeth remaining, and only 1 remaining opposing pair of teeth (22 occluding with 33). EF does not have % bone loss/age indicator greater than 1.0, but she demonstrates HbA1c more than 7.0%.


Prognosis

The primary risk factors for EF include poor oral hygiene and plaque control, a high sugar diet, lack of exercise, and obesity resulting in a high caries risk, and a medical history highlighted by poorly controlled type 2 diabetes. At her initial appointment, EF noted that she only brushed her teeth in the morning and sometimes at night with a firm manual toothbrush and Colgate toothpaste, and never flossed. Although her lunch and dinner are healthier, her breakfast consists of 4 pieces of toast in the morning with butter and jam, and she consumes 2 cups of tea and 1 cup of coffee all with 1 teaspoon of sugar daily. Exercise mainly consists of doing housework and looking after the grandchildren. At present EF weighs 93kg and is 174cm in height. EF previously weighed as much as 112kg in March 2015. In completing an odontogram for EF, she presented with several ICDAS 5 (frank cavitation) lesions found on the root surface that were also visible on the OPG. As previously mentioned, EF has a medical history consisting of poorly controlled type 2 diabetes. In September 2019 her HbA1c reading was 7.3%, which represents an improvement compared to December 2018 where it was 8.6%. However, EF’s reading still represents a value greater than 7.0% which is a recommended general target for patients requiring insulin medication(2). EF reports a family history of diabetes and periodontal disease whereby both parents required F/F dentures following the extraction of all their teeth. On the basis of this information, the prognosis for the remainder of EF’s dentition was questionable to good at best.


Customized Treatment Plan

In order to improve the prognosis of EF’s dentition, a treatment plan was devised consisting of periodontal screening with PSR and patient education. This was followed by initial therapy I with prophylaxis and oral hygiene instruction. Following this, periodontal assessment, initial therapy II with subgingival root debridement, and reevaluation were commenced. The primary goal of the treatment plan for EF was to educate her on the holistic role of each risk factor and their contribution to her periodontal disease.  This included the roles of excellent oral hygiene, improved diet, increasing exercise, in combination with periodontal treatment in order to successfully treat her periodontal disease. EF initially presented with poor oral hygiene as outlined by her high % API scores. The presence of approximal plaque and residual food debris was shown to EF. It was explained to EF that her periodontal disease in particular could be attributed to her lack of oral hygiene and high caries risk, but also her family history of periodontal disease and type 2 diabetes, and most importantly, the bidirectional relationship between type 2 diabetes and periodontal disease, which she displayed (3). EF was asked to demonstrate her normal brushing, which required improvement. A customized plan was devised for EF whereby she was recommended to switch to an Oral B electric toothbrush, a 5000ppm fluoride Colgate toothpaste, and use of green and black Pixster interdental brushes for her maxillary and mandibular teeth, respecitively. To address EF’s diet, she was encouraged to decrease the amount of sugar in her breakfast, and also, the amount of sugar in her tea and coffee. EF was also encouraged to exercise at least 30 minutes per day by taking her grandchildren to the park and engaging with them to elevate her heart rate and promote progressive weight loss.


Diabetes and Periodontal Disease

EF was diagnosed with type 2 diabetes in 1995. In March 2015, EF’s HbA1c was as high as 10.5%, but this has gradually decreased to 7.3% in May 2019 and remains the same in September 2019 at 7.3%. EF has been informed about the association between type 2 diabetes and periodontal disease, especially that periodontitis is significantly associated with poor glycemic control as measured by HbA1c (4). She has also been informed that those with periodontitis are at a greater risk of developing prediabetes and diabetes, and furthermore, the risk of developing diabetic complications such as retinopathy, neuropathy, and adverse cardiovascular effects(5). There are several potential mechanisms associated with the relationship between type 2 diabetes and periodontal disease, and they include an altered periodontal microbiome and elevated levels of proinflammatory mediators within gingival tissues of diabetics(5). To date, there is no evidence to suggest the positive impact of long-term periodontal treatment in type 2 diabetes, but short-term human intervention studies have demonstrated that periodontal treatment alone is effective in improving glycemic control in type 2 diabetes with a statistically significant reduction in HbA1c that is comparable to the addition of a second diabetic medication (5).


Secondary Occlusal Trauma and Periodontal Disease

In total, EF has lost 19 teeth associated with various causes. She reports that some teeth were loose and sore, whereas others were carious. At present, EF is missing her P/- CoCr denture, but still retains her -/P CoCr denture that fits well. However, EF has only 1 opposing pair of teeth remaining (22 occludes with 33), which has resulted in secondary occlusal trauma to 22. It is imperative to prevent further occlusal trauma as it has previously been shown that its progression in severity is positively correlated with the severity of attachment loss(7). In consulting with a prosthodontist, it has been suggested that 22 should not be splinted as it could potentially increase mobility in adjacent abutment teeth. It has been recommended to EF that 22 should be extracted and that an immediate P/- acrylic denture be constructed to allow EF to use both dentures during the day and at night to prevent further secondary occlusal trauma. In contrast to this, in consultation with a periodontist, it has been suggested that 22 should be retained and that a P/- acrylic or CoCr denture be constructed either with or without a retainer on 22 (due to esthetic concerns) to allow EF to use both dentures only during the day to prevent further secondary occlusal trauma, but also allowing her to maintain excellent denture hygiene. EF has decided to pursue the more conservative approach and allow for continual monitoring of 22.


Re-evaluation

In order to improve short- and long-term outcomes of periodontal disease, it is imperative that the patient is motivated and continuously maintains adequate oral hygiene. At every appointment, customized oral hygiene instructions were provided to EF with regards to technique associated with use of an electric toothbrush and interdental brushes in order to properly clean all surfaces of the teeth. EF has consistently maintained excellent SBI scores, and she has gradually improved her API scores. This demonstrates her motivation to improve the outcome of her periodontal disease, and she has mentioned that her grandchildren have also become more motivated to brush their teeth in the morning and in the evening as they have witnessed her doing it on a regular basis. In addition to the patient’s role in maintaining their oral hygiene, the role of non-surgical periodontal therapy in the treatment of periodontal disease cannot be overstated, and together, it is responsible for the reduction in PPD and gain in CAL (8). Following initial therapy II and the first round of non-surgical periodontal therapy, EF displayed reduced gingival erythema and reduced bleeding on probing during the periodontal reassessment. Furthermore, EF displayed elimination of all pockets with PPD greater than or equal to 6mm, a reduction in pockets with PPD between 4-5mm, and an improvement in pockets with PPD less than or equal to 3mm. Because EF does not require surgical periodontal therapy, it is critical to continue non-surgical periodontal therapy for EF in order to reassess for further improvement in PPD reduction and CAL gain given her motivation to improve her oral health and her overall health. Despite the initial questionable prognosis given EF’s specific risk factors, her overall prognosis is actually good provided she can maintain the customized treatment plan that has been devised for her.


Supportive Periodontal Therapy

Successful long-term control of EF’s periodontal disease is not only dependent on supportive periodontal therapy, maintenance of excellent oral hygiene, but also continued improvement in her overall health as managed by her GP. It has been previously shown that supportive periodontal therapy is critical in long-term sucscess as demonstrated by stable clinical attachment levels in comparison to patients who are not maintained in a supervised program who demonstrate a return to active periodontal disease (9). According to the 2003 Lang and Tonetti periodontal risk assessment, EF is still considered high risk for periodontal disease due to her extensive tooth loss and her systemic diagnosis of type 2 diabetes (10). This risk outcome requires a 3 month interval recall and it is critical that she is continued to be seen following her second round of non-surgical therapy and reassessment.


References

  1. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, Flemmig TF, Garcia R, Giannobile WV,  Graziani F, Greenwell H, Herrera D, Kao RT, Kebschull M, Kinane DF, Kirkwood KL, Kocher T, Kornman KS, Kumar PS, Loos BG, Machtei E, Meng HX, Mombelli A, Needleman I, Offenbacher S, Seymour GJ, Teles R, Tonetti MS. Periodontitis: Consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. Journal of Periodontology. 2018;89(Suppl 1):S173-S182.
  2. American Diabetes Association. Standards of medical care in diabetes – 2014. American Diabetes Association. 2014;37(Suppl 1):S14-S80.
  3. Mealey BL. Periodontal disease and diabetes: A two-way street. The Journal of the American Dental Association. 2006;137(Suppl 10):26S-31S.
  4. Graziani P, Gennal S, Solini A, Petrini M. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontal disease on diabetes: An update on the review of the EFP-AAP workshop. Journal of Clinical Periodontology. 2018;45:167-187.
  5. Polak D, Shapira L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. Journal of Clinical Periodontology. 2018;45:150-166.
  6. Madiano PN, Koromantzos PA. An update of the evidence on the potential impact of periodontal therapy on diabetes outcomes. Journal of Clinical Periodontology. 2018;45:188-195.
  7. Braschofsky M, Beikler T, Schafer R, Flemmig TF, Lang H. Secondary trauma from occlusion and periodontitis. Quintessence International. 2011;42:515-522.
  8. Heitz-Mayfield LJA, Trombelli L, Heitz F, Needleman I, Moles D. A systematic review of the effect of surgical debridement vs. Non-surgical debridement for the treatment of chronic periodontitis. Journal of Clinical Periodontology. 2002;29(Suppl 3):92-102.
  9. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults: Results after 30 years of maintenance. Journal of Clinical Periodontology. 2004;31:749-757.
  10. Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health and Preventative Dentistry. 2003;1:7-16.


 

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