Case 2
Non‐Plaque‐Induced Gingivitis
Medical History
The patient’s medical history revealed she is 14 weeks pregnant and is taking prenatal vitamins. She is under the care of an obstetrician‐gynecologist (OB‐GYN) for prenatal visits. Her obstetrician recommended a dental check‐up. The patient does not smoke and her vital signs were within normal limits.
Dental History
Patient has had routine dental exams and prophylaxis every six months since she can remember. She has had a few occlusal restorations when she was younger. The patient brushes twice a day in the morning and the evening with a fluoridated toothpaste. She flosses about three to four times per week. She has questions about her gums bleeding and her baby’s teeth development.
Social History
The patient works full time as an administrative assistant. She is recently married. She is very excited about her pregnancy and has been reading pregnancy and parenting books. She likes to cook and frequently has dinner parties with friends.
Assessments
Extraoral/Intraoral Examination
- Nonremarkable
Periodontal Assessment
- Gingival Statement: Generalized moderate marginal and papillary redness with edematous papilla; localized severe edematous papilla between tooth #29 and #30 (see Figure 2.2.1)
- Generalized 4 mm pocket depths with localized 5 mm between #’s 29 and 30, no recession present, no furcations or mobility
- SBI 75% (see Figures 2.2.2A and B)
- PCR 15% (see Figure 2.2.3)
- Calculus classification: light supragingival and no subgingival deposits
Figure 2.2.1: Note the edematous papilla between teeth #29 and #30 indicative of a pyogenic granuloma.
Source: Photo courtesy of Rio Salado College.
Figure 2.2.2: (A) Periodontal charting for non‐plaque‐induced gingivitis. (B) Periodontal charting summary for a patient with non‐plaque‐induced gingivitis – note the total sites and the bleeding sites compare with the plaque control record in Figure 2.2.3.
Figure 2.2.3: Plaque control record for a patient with non‐plaque‐induced gingivitis – note the low plaque score and compare with the bleeding points in Figures 2.2.2A and B.
Dental Charting Assessment
- Occlusion: Class I right/left
- Composite restorations on #3, #14, #19, and #30
- Missing teeth: #1, #5, #12, #16, #17, #21, #28, and #32
Radiographic Findings
- No radiographic loss of crestal bone
Risk Assessments
- Caries: low risk
- Periodontal: low risk
- Cancer: low risk
Problem List
- Bleeding
- Edematous papilla
Dental Hygiene Diagnosis
| Unmet human need | Evidenced (caused) by | Signs/Symptoms |
| Protection from health risks | Inadequate control of a systemic condition – pregnancy | Evidence on the medical history and patient interview |
| Integrity of the skin and mucous membrane | Inadequate control of a systemic condition – pregnancy | Bleeding on probing |
| Conceptualization and problem solving | Knowledge deficit | Patient asking questions regarding bleeding gums and baby’s development |
Planned Interventions
| Interventions | Goals | Evaluation |
| Address safety factors with patient | Referral to medical doctor | Patient consult with primary care provider |
| OHI tooth brushing instruction | Patient will demonstrate the proper brushing method | Immediate |
| Teach patient about systemic conditions and oral health | Patient will understand the relationship between pregnancy and gingival conditions | End of appointment |
| Biofilm reduction and calculus removal with ultrasonic | Patient will leave office plaque free | End of appointment |
Appointment Schedule
- First appointment
- Assessments with dental examination and radiographs as needed
- OHI – includes education on the relationship between oral health and pregnancy
- Prophylaxis
- Second appointment if necessary
- Re‐evaluation – determination of increasing the frequency for recare appointments
Discussion
Assessments should include a medical and dental history, social and cultural factors, and activities of daily living, extraoral and intraoral examinations, gingival statement, periodontal assessment, plaque and bleeding indices, risk assessments, and radiographs. Through the interview process the clinician can discuss the patient’s pregnancy and relationship with gingival conditions. A discussion of the nutritional needs during pregnancy and reinforcing the obstetrician’s recommendations would benefit the patient. Educating the expectant mother on fetal oral health and when the development and calcification of teeth occurs is an important function of the dental visit (Darby and Walsh 2015).
A dental diagnosis of non‐plaque‐induced gingivitis is defined as inflammation of the gingiva caused by factors other than plaque. These may include allergic reactions, bacterial associated infections, viral associated infections, foreign body response, or physical trauma (perio.org 2016). Pregnancy and other conditions can also be associated with non‐plaque‐induced gingivitis. As in plaque‐induced gingivitis a dental diagnosis is based on clinical findings, which may include: redness, edema, bleeding, and changes in gingival contour and consistency. Treatment considerations with a dental diagnosis may include surgical interventions.
The unmet human need of protection from health risks addresses the potential intervention of a medical referral to the patient’s OB‐GYN if necessary. In the case of pregnancy‐associated gingivitis this may or may not be required, dependent on the patient’s individual health concerns. It is addressed here as other conditions that relate to non‐plaque‐induced gingivitis may require a medical consult.
A dental hygiene diagnosis addressing the bleeding gingiva and the patient’s questions regarding oral health and pregnancy will engage and involve her in dental hygiene care and the care of her developing fetus. An unmet human need chosen was skin and mucous membrane integrity of the head and neck. This is a common unmet human for a dental hygiene diagnosis related to gingival and periodontal problems. An intact and functioning oral mucous membranes and periodontium defends against harmful microbes. Bleeding and inflammation relate to problems associated with gingival and periodontal conditions (Darby and Walsh 2015). Figure 2.2.1 shows the associated enlarged papilla between teeth s #29 and #30. This area serves as a pathway for bacteria to enter the blood stream and body. Refer to the patient’s periodontal charting and bleeding points. The sulcular bleeding index is high and unrelated to the accumulation of plaque as in Case 1 in this chapter.
Conceptualization and problem solving was identified as evidenced by the patient’s knowledge deficit shown by her asking questions. The definition conceptualization and problem solving is the need to grasp ideas and abstractions to make sound decisions about one’s oral health (Darby and Walsh 2015). Teaching and education of the patient will address this unmet human need. Educational factors to consider are oral hygiene instructions, nutritional counseling, and education on fetal oral health. While the patient has a relatively low plaque control record and previously did not have bleeding issues, oral hygiene instructions are important to incorporate the importance of biofilm accumulation and the host response. Basic nutritional counseling to include both gingival health and fetal development may begin to address the patient’s questions and educate her regarding oral health and nutrition.
Including a combination of therapies such as oral prophylaxis and patient education may contribute to the expected outcomes. The need for a medical referral may be necessary to improve the final outcome of care. All three unmet human needs maybe met with the same interventions. Patient education and understanding is key. Monitoring the status of the patient may include increased frequency for dental hygiene care and consideration of the gestational period.
Take‐Home Hints
- Relate the dental hygiene care to the dental hygiene diagnosis.
- Interventions can include a variety of procedures, education, oral hygiene instructions, and will take into account medical conditions that may require a referral.
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