Case 2
Reassessment and Maintenance
Dental History
After years of undergoing periodontal treatment, the patient states that she does not want to return to a specialist, does not want periodontal surgery and is “just looking to maintain” her periodontal condition. The patient has a history of both surgical and nonsurgical periodontal treatments, with the most recent scaling and root planing completed in 2012 on the upper right (UR) and upper left (UL) quadrants. She complains of bleeding and food trapping between implant tooth #12 and a mesial‐occlusal (MO) restoration on #13.
Medical History
The patient is being treated for type I diabetes and hypothyroidism. Both conditions are controlled. She sees her physician regularly and takes her medications as prescribed. No known allergies reported.
- Medications
- Novolog 100 units/mL,
- Januvia 100 mg, and
- levothyroxine (Synthroid)100mcg
- Vital Signs:
- Blood pressure: 135/80 mmHg
- Pulse: 70 beats/min
- Respiration: 14 breaths/min
- A1C (glycosylated hemoglobin test): 7
Social History
The patient reports a history of smoking as a teenager. She states currently no tobacco or alcohol use. The patient works full time and prefers her appointments to be scheduled early in the morning after finishing work.
Dental Examination
Extraoral examination and intraoral soft tissue examination are within normal limits. The gingival examination reveals moderate facial inflammation, an implant crown replacing tooth #7 and crown on #8. The remaining gingiva on the maxillary arch is light pink, stippled with 4–5 mm gingival recession on both facial and lingual aspects. Bleeding on probing occurs on all surfaces of tooth #8 and tooth #13. The patient presents with light generalized interproximal plaque accumulation. Moderate localized subgingival calculus is present on #8 distal lingual and distal facial surfaces. The deepest probing depth on this tooth is an 8 mm pocket on the distal surface measured from both the facial and lingual. Threads of the adjacent implant replacing tooth #7 are detectable from the mesial surface with a plastic probe. A large open contact exists between implant replacing tooth #12 and #13 MO restoration. Tooth #15 presents with Class III mobility. The patient currently uses a power toothbrush twice daily and interdental brushes three to four times per week.
Radiographic Examination
Generalized moderate to severe horizontal bone loss is present on the maxillary arch (see Figure 4.2.1). A severe vertical bony defect is present on #8 distal and #7 mesial. Implants replace teeth #5 and #7 (see Figure 4.2.2) and #12.
Figure 4.2.1: Radiograph showing severe bone loss between #7 and 8.
Figure 4.2.2: Implant supported bridge for teeth #5 to #7. Note the vertical bone loss occurring on the mesial of implant #7.
Dental Hygiene Diagnosis
| Problems | Related Etiology |
| Increased periodontal disease | Systemic relationship with type I diabetes; irregular recare and dental maintenance |
| Root caries and sensitivity | Loss of clinical attachment due to surgical and nonsurgical periodontal procedures |
| Xerostomia | Medication use and type I Diabetes |
| Bleeding upon probing | Generalized biofilm accumulation, localized subgingival calculus, open contact between restorations |
Planned Dental Hygiene Interventions:
| Clinical | Education | Oral Hygiene Instruction |
| Review most recent HBAC1 (glycated hemoglobin) level at each visit; review medical history; ensure patient ate prior to the appointment Selective scaling and root planing implant #7 and tooth #8 with ultrasonic, hand instrumentation, and plastic implant scalers and plastic tipped ultrasonic insert Subgingival placement of minocycline HCl, 1 mg (Arestin) tooth #8 Periodontal maintenance of remaining dentition Four to eight week re‐evaluation #7 and #8 5% fluoride varnish on exposed root surfaces Three‐month periodontal maintenance |
Systemic relationship between diabetes and periodontal disease (wound healing) Stress the importance of regular medical evaluations for control of systemic diseases Educate on healthy lifestyle, diet, and exercise Increased susceptibility for caries and root sensitivity due to exposed root surfaces Educate on proper biofilm control for natural and implant supported teeth Educate on the benefits of periodontal nonsurgical therapy Educate on importance and necessity of frequent dental recall visits for periodontal maintenance Explain benefits of varnish |
Modified Stillman’s technique at least twice daily with manual or powered tooth brush Interdental brushes and waxed or unwaxed floss with floss threaders for removal of debris under the bridge. Use of saliva substitute oral rinse twice daily and additional saliva substitute products as needed for xerostomia Use of fluoridated toothpaste or a desensitizing toothpaste Provide instruction post fluoride varnish application Use of oral irrigator for removal of food particles from interproximal areas. |
Progress Notes
The patient presents with advanced periodontal disease and a history of surgical and nonsurgical periodontal therapies. There is severe vertical bone loss and active localized periodontal disease on tooth #8. The patient prefers to forego further surgical procedures and commits to periodontal maintenance. She currently brushes two to three times per day, alternating between electric and manual toothbrushes. She uses interproximal brushes for interdental cleaning and rinses occasionally with an antimicrobial rinse. Upon initial oral hygiene instructions, the use of oral irrigation in addition to use of interproximal brushes and floss threaders is recommended for daily use for cleaning under her bridge and implant bridge areas. The patient is informed on the systemic relationship between periodontal disease and diabetes, as it relates to creating a viable dental hygiene maintenance program.
Discussion
Initial assessment includes medical history, dental history, social history radiographic interpretation and clinical findings (See Figure 4.2.3). Considering all of these factors allows the clinician to create a viable care plan and maintenance plan for continuing care and optimal oral health (Costa et al. 2015, p. 2). Factors contributing to maintenance planning include risk for periodontal disease activity, risk for caries, risk for oral cancers, predisposing conditions such as HIV/AIDS, history of dental treatments, ability for biofilm control, and compliance (Wilkins 2009, pp. 755–757). Current guidelines for maintenance of implants and implant restorations are not clearly defined or based on recommendations for patients with natural dentitions rather than what is best for implant maintenance and supporting tissues (Bidra et al. 2015, p. 61). Often patient compliance becomes a key obstacle in both appointment scheduling and biofilm control (Costa et al. 2015; Wilkins 2009). Neglect of regular recare appointments is associated with a higher risk of recurrence and progression of periodontitis (Costa et al. 2015, p. 2). Studies observing the progression of periodontal disease note the cumulative nature of the disease over time (Bidra et al. 2015, p. 61).
Figure 4.2.3: Reassessment and maintenance for dental hygiene process of care.
“Numerous numbers of pathogens may be left in the oral environment after instrumentation. Repopulation of these may occur within 60 days after periodontal debridement. Periodontal pathogens also populate the oral environment in areas such as the tongue, tonsils, saliva and buccal mucosa, and other non‐periodontal sites. The overall treatment must consider the possibility that these sites may be responsible for reinfection. There have been some chemical agents shown to be effective in suppressing dental plaque when used with periodontal debridement and surgery. It is known today that periodontal diseases are infectious diseases and treatment is focused on the reduction and the removal of specific bacteria. Antimicrobial products may be utilized as additional agents but not replacement of non‐surgical or surgical procedures. It is not the therapist’s goal to eliminate all oral bacteria, as many bacteria living in the oral environment are beneficial.” (Weinberg et al. 2015, p. 334)
The primary risk factor for failure of an implant is attributed to certain bacteria. The loss of an implant may occur from a bacterial infection caused by the repopulation of bacteria around the implant after being successfully placed (Weinberg et al. 2015, p. 131). The term used to describe soft‐tissue inflammation around an implant is known as peri‐implant mucositis. The term used to describe the inflammation of soft and hard tissue around an implant leading to bone loss is called peri‐implantitis. The treatment for this disease may include periodontal instrumentation, individualized instruction for oral hygiene, rinses, systemic antibiotics, peri‐implant surgery, or implant removal as a last resort (Weinberg et al. 2015, p. 131). Patients with complex tooth‐ and implant‐borne restorations, as the patient above in this case study (2), require long term professional individualized care and recall regimens for long‐term success (Bidra et al. 2015, p. 61).
For scaling and plaque removal around dental implant surfaces the clinician chooses from plastic or Teflon‐coated manual instruments and/or plastic tipped power instruments approved for implant use (Darby and Walsh 2003, p. 1038). Metal instruments, metal power instruments, or abrasive air polishers may scratch or form irregularities on the implant surface and should not be used on dental implants (Darby and Walsh 2003, p. 1038). Titanium scalers can be used. Periodontal probes may be used for assessment around the dental implant but should be used with caution so as to not disrupt the biologic seal (Darby and Walsh 2003, p. 1038).
Take‐Home Hints
- A patient’s ongoing compliance is required for successful maintenance.
- Metal instruments are not recommended for dental implants because they may damage the surface of the implant.
- Control of systemic diseases is necessary for optimal oral health.
- Gingival assessment, periodontal probing, and plaque indices allow the clinician to evaluate patient progress at maintenance appointments.
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