I.

Assessment

 Age: 45, Sex: Male, Height: 5’8”, Weight: 210lbs, BMI: 31.9

 Career: IT technician full-time that requires traveling 12-14 days a month

 Family history of Type II diabetes in both mother and father with multiple systemic concerns

 Chief complaint: maxillary right gingiva near molars is swollen, sore, and bleed

 Medical history: history of tonsillectomy, appendectomy, and kidney stone removal with

laser. No known allergies

 Medications: Hydrochlorothiazide- 25 mg twice a day, Lisinopril- 10 mg daily, Pravastatin- 40

mg daily, Metformin- 500 mg daily, Alogliptin and Pioglitazone- 25 mg and 15 mg daily

respectively, and Aspirin- 325 daily.

 Last medical checkup found BP 140/90, A1C 9.3, Fasting blood glucose 222 mg/dL, next

appointment is set to adjust medications

 Dental history: Last seen at a dentist 4-5 years ago where radiographs were taken, a

cleaning was done, and restorative fillings were completed. The patient was told then that

he had periodontal disease and was recommended to have a deep cleaning. Braces from

age 14-17.

 Home care: The patient brushes once a day and gets food impacted so he uses round

toothpicks to remove it

 EO: Enlarged and palpable right submandibular lymph node palpated. Everything else WNL

 IO: spongy, swollen, and painful facial soft tissues around the maxillary right molars.

Everything else WNL

 Radiographs: large calculus deposits, radiolucency mesial to tooth #4

 Bleeding and exudate upon probing interproximal of #2 and #3

 Bleeding index 78%, Plaque score 70%

red gingiva, LOC cleft gingiva tooth #26

 Treatment modification:

 The patient does not have a controlled BP or A1C which would indicate we should

postpone treatment until it is well controlled with his physician. If anesthesia is

needed, we would calculate using minimal amount necessary. Medications can

effect orthostatic hypotension, dry mouth, cough, steven-Johnson syndrome,

muscle weakness, taste disorder, bleeding

 Sit patient up slowly, minimize aerosols, consider auxiliary aids for muscle

weakness during home care, consider fluoride varnish as dry mouth makes

the risk of caries higher

 Diabetes increases the risk for periodontal disease which would indicate shorter

recall. The deep probing depths would also indicate 3 month recall.

 Diabetes patients should still take their medication and eat as normal on

appointment days.

 Oral changes associated with special needs: diabetes and periodontal disease are

interrelated and can exacerbate one another, the red irritated gums can be explained by the

heavy calculus and high blood pressure that is destructive to the tissue, the bulbous clefted

tissue can be seen with poor tissue healing from diabetes,

II. DH Diagnosis

 ASA III

 Periodontal Disease Stage: IV Grade: C

with the progression from his last appointment from “some” periodontal disease

to generalized periodontal disease with deep pockets at this appointment

III. Plan

 Consult periodontologist, physician for lymph node, diabetes, and hypertension, and oral

diagnosis to check on the painful lesion found during the intraoral examination

 Goals:

 Stop the progression of periodontal disease. Remove calculus deposits. Provide

OHI to improve homecare and reduce bleeding index and plaque score

 Phases of Treatment

 Preliminary

 Summary: Periodontal disease, heavy plaque and calculus, high bleeding

index, uncontrolled hypertension and diabetes

 Diagnostic statements: Gingival bleeding related to accumulation of calculus

and biofilm causing inflammation. Build up of plaque and calculus from

inadequate home care. Intraoral lesions from slow wound healing as an

effect from uncontrolled diabetes. Periodontal disease resulting from

inadequate home care, missing dental cleanings, and uncontrolled diabetes

and hypertension.

 Health goals: stop the progression of periodontal disease with SRP to

remove calculus deposits, reduce gingival bleeding and inflammation with

ongoing homecare, and maintain health with shorter recall appointments

 Emergency care: biopsy intraoral lesion and reevaluate lymph node at next

appointment with further investigation if still present

 Control biofilm with toothbrush, prophy cup, and ultrasonic debridement.

Advise fluoride toothpaste for root exposure at recession. Remove calculus

with ultrasonic followed by fine hand scaling. Remove food traps with

restorative work where possible.

 Phase I Outcomes evaluation

 Evaluate using periodontal probe charting to record if periodontal disease is

stable or progressing. Evaluate future bleeding index and plaque score to

ensure homecare has improved and OHI was effective.

 Evaluation of overall outcomes

 Evaluate how the treatment for the intraoral lesion progresses.

 Phase IV maintenance

 Recall appointments every 3 months emphasizing good home care between

sessions

IV. Implementation

 Consult physician to stabilize diabetes to get their A1c level and BP to a healthy range

and to evaluate the enlarged lymph node if persistent. Consult the periodontologist to

evaluate disease progression and maintenance. Consult oral pathology to diagnose and

treat intraoral lesion.

 Ultrasonic scaling before hand scaling will help remove calculus and plaque once

clearance is given by the physician to begin treatment with stabilized conditions.

Aerosols produced with the ultrasonic need to be considered as one of his medications

can cause a cough that may make tolerating the procedure difficult. With such deep

pockets anesthetic can be used as long as his new medications are not contraindicators.
 Lidocaine with epinephrine would help control bleeding while providing profound

anesthesia. Anesthetic should not be placed in the area of lesions on the tissue as

infection can lessen the effectiveness. Polishing with fine paste can aid in plaque

removal as well as preventing plaque from accumulating in the future by smoothing the

tooth surface. Flossing between each tooth while giving the patient a mirror to watch

will aid in homecare knowledge. The patient should be shown how to brush as well and

asked to preform the task to ensure he is able to do so since a side effect of one of his

medications can cause muscle weakness that may inhibit his abilities. Fluoride varnish

can be applied to protect exposed roots from the generalized recession present. Recall

will be every 3 months for periodontal maintenance. It is important that the patient get

his oral bacteria under control to help keep his diabetes under control. It is also

important to keep the oral bacteria low as to prevent any complications to his

cardiovascular system with his history of high blood pressure.

V. Evaluation

 Probing depths should be used to ensure the efficacy of the treatment as well as

bleeding index, plaque score, and radiographs

 Follow up charting will need to include probing depths, radiographic bone loss, whether

it is horizontal or vertical, if teeth are being extracted or loss due to the progression of

the disease, and updates on the patient’s systemic factors as they change

 The patient should be monitored for motivation and ability to control his periodontal

disease. We need to evaluate if either or both is a concern

 CMS should be completed every 3 years with an OP200 every ten. Bitewings should be

taken in a vertical orientation to accurately document CAL over time.

Wolters Kluwer.

Wynn, R. L., Meiller,. T. F., & Crossley, H. L. (2021). Drug information handbook for dentistry:

Including oral medicine for medically compromised patients & specific oral conditions.

Lexicomp/Wolters Kluwer.