Colette Fontaine Dr. Horowitz DH62 C

Spring2017 Periodontal Competency: Y.B.

Introduction

Y.B. is an 82-year-old, African-born adult male. He was born and raised in Senegal, West Africa and moved to the U.S. in 2004. Y.B now resides in Half Moon Bay which is in San Mateo County which is supplied by the Crystals Springs reservoir that provides fluoridated tap water. Prior to moving to the U.S., Y.B. lived in many countries worldwide. He mentioned that due to the nature of his work as a master of public law, he resided in Australia, England and Italy. Y.B. shared, that prior to retirement in 1995, he was a civil servant who worked first as a diplomat, and then successively in the Ministry of Foreign Affairs of Senegal, in the Prime Minister's Cabinet and in the President's Office, after that he was an ambassador to some Arabic and European countries. After retirement, he decided to volunteer as a leader in some national human rights organizations until 2004 when he left Senegal to join his family, a wife and three children, in New Jersey. In 2014 Y.B. relocated to California where he lives to this day. Y.B. has many interests and stays well connected to his family, colleagues and friends. He travels home one to three times a year and enjoys staying connected to his family roots. Y.B. stated that currently he has no real hobbies. He used to play chess and enjoys classical music, but he stated that he likes to meet people and discuss current events and almost every other subject. He mentioned that when he first moved to Half Moon Bay, he would walk a lot along the beach, about 5 - 8 miles a day, but finally stopped when he discovered he was losing weight. Now he walks about 30-40 minutes a day. Y.B. has both visual and verbal learning styles, and because he is hard of hearing in his left ear, he reacted positively to diagrams and visual aids. Y.B. doesn’t have a special diet, but tries to stay away from high fat and cholesterol foods; also, due to his lack of posterior bite, his food choices are limited. Y.B. noted that he rarely snacks and likes to stay disciplined about food consumption. On the learning ladder, Y.B. is currently in the action stage. However, he has not been aware of his oral health needs nor the importance of regular maintenance for much of his 82 years. Unfortunately, while growing up in Senegal during the thirties and forties, he was not provided access to

preventative care. As an adult, due to his traveling abroad, he admitted to never establishing regular oral health care and only saw a dentist for toothaches and extractions. Y.B. recently received dental insurance and has decided to address his dire dental condition. He hoped to prevent further tooth loss and this was why he was sent to our clinic. The dentist he recently began seeing recommended he have his teeth deep cleaned prior to determining the survivability of his remaining teeth.

Case Study Presentation

Medical and Dental History

Y.B. is in good, overall health. He has a team of doctors, from a dermatologist to primary care physician he sees on a yearly basis. His last medical exam was in August 2016, and his last dental visit was on December 20, 2016 when he had tooth #11 extracted. Y.B. reported no known allergies. He is currently taking 10mg of Atorvastatin w/ calcium tabs daily for high cholesterol. I advised him that when I looked into the dental considerations associated with Atorvastatin, I read that it may cause muscle and jaw weakening with chewing. He hadn’t experienced this side effect; however due to his missing posterior teeth, chewing was minimal at best. His mean blood pressure over the nine visits was 121/69 which was slightly above normal limits for an eighty-two-year-old male which put him in the pre hypertensive class. He is an ASA class II. Y.B. currently weighs 135 lbs. and stands 5’ 6” tall. His body mass index (BMI) was 21.8 which according to the CDC was considered normal.

Extra Oral and Intraoral Examination

Y.B.’s extra oral and intraoral examination was slightly abnormal with one notable, significant finding. Below his chin, adjacent to tooth #25-28, there was a 9x9mm prominent fixed nodule. It appeared to possibly be an enlarged submental lymph node. There was no reported pain upon palpation. Y.B. recalled it appearing when he was 18-20 years of age. I looked for facial symmetry and couldn’t find a nodule on the contralateral side. I decided that taking an occlusal X-ray would be prudent. I wanted to rule out the possibility of cysts, solid growths (tumors), or abscesses. I took two X rays from two planes (inferiorly below chin and superiorly at bridge of nose) My X-ray instructor evaluated the film and didn’t see any anatomical variations from normal. I immediately sent a copy to his DDS on file with a referral letter. The other two findings included a generally keratinized edentulous ridge, that presented with

diffuse clusters of 1x1-2x2mm regular bordered white papules. Lastly he had what appeared to be generalized leukoedema on both his left and right buccal mucosa.

Caries Risk Assessment My caries risk assessment and PreViser results found Y.B. to be at high risk. His disease indicators included visible and suspicious caries on the lingual surface of tooth #7. His risk factors for developing carious lesions included extensive root exposure and heavy visible plaque. I observed signs of bruxism evidenced by attrition on the incisal and occlusal surfaces of all upper and lower remaining anterior teeth as well as a deep Palatal-lingual groove on tooth #7. On the brighter side, as mentioned earlier, Y.B. lives in a fluoridated community; however, he noted he doesn't drink tap water. There were a few important protective factors Y.B. had and they included his use of over the counter fluoride toothpaste one time a day and his saliva production flow rate was 8ml per min which is considered good and allows for proper digestion, enamel lubrication and the washing away of food debris and bacteria that remain in his mouth. The PH level of Y.B’s saliva was neutral (7). I conducted a plaque index on Y.B., and his score was 2.1 which is considered poor. Y.B.’s DMFT was 20: two teeth with suspicious caries, seventeen missing and one restored tooth. I shared all the caries risk assessment findings with him and advised him that meticulous plaque control and alleviating the pressure of his deep anterior, only unbalanced bite will help him decrease his caries risk potential. She also had a couple of abfraction lesions and mild xerostomia related to her mouth breathing at rest. I observed signs of bruxism, evidenced by attrition on the incisal edges of all upper and lower anterior teeth.

Periodontal Risk Assessment Y.B’s gingival description was red, boggy, inflamed with blunted and fibrotic papillae. Plaque and inflammation were generally heavy with exudate present. His full mouth periodontal probe exam revealed 3-9 mm pocket depths. He also had generalized rolling of his gingival margins and multiple areas of recession ranging from 1-4 mm indicating attachment loss. His AAP type was class IV due to the extreme amount of bone loss. Y.B.’s calculus class was moderate. His mobility was recorded having a (+) on tooth #10, a one on teeth #7,8, and #26 a two on teeth # 4,6,9 and 22 and a three on #25, all of which was expected due to the signs of attrition from his poorly functioning bite. Tooth #4, 9 and 25 were of most concern due to the advanced stage of clinical attachment loss which ranged from 5-9mm of total loss. My periodontal risk assessment and PreViser results found Y.B. to have a high risk score for the development of periodontal disease which was obviously apparent. Y.B.’s occlusion

was a Class 1 based on his right cuspid relationship. Y.B.’s overjet was 4 mm and overbite was 5 mm resulting in tissue injury of the lingual gingiva and gingival margins of teeth #’s 6-9. His midline was shifted 3 mm to his left, presumably due to the tooth migration resulting from his missing tooth #23.

Radiograph Interpretation

Y.B. had a FMX taken in September of 2016 at his DDS on file. The series revealed severe generalized horizontal and vertical bone loss. Vertical bone loss was evident on

FMX Taken by DDS on file

6/2016

FMX Taken by DDS on file

9/12/2016

No radiolucent or radiopaque structures evident on occlusal films, ruling out the possibility of cysts, solid growths (tumors), or abscesses associated with the nodule found during his E/I exam.

teeth numbers 4D,#6D,#9M,#10D,#11D,#24-29M. This bone loss is consistent with the advanced levels of mobility I recorded. Y.B. had a crown to root ratio of 1:1 on his lower posterior premolars and anteriorly a 2:1 and 3:1 ratio. Calculus was also easily visible on this FMX. The series also revealed a large number of radiolucent areas. Tooth #4 had sheared off enamel on the lingual surface so it appears less dense and more radiolucent. The same applies to the wear facets on #6 MO surfaces. Most concerning were the radiolucent areas above and around apices of #9, #11, #21, #24, #25, #28 possibly indicating apical abscesses and infection. Lastly, I interpreted bilateral pneumatization of his maxillary sinuses, which is often a result of having maxillary premolars and molars missing for some time. Having these X-rays to refer to in combination with his periodontal probe readings during my scaling was essential to help me stay adapted to his roots in their deep and narrow pockets.

Pre-treatment Intraoral photos

Dietary Evaluation and Nutritional Counseling

Y.B.’s diet was quite poor and his caloric needs are not being satisfied. Although he regularly eats two meals a day, they are light and lack many of the essential food groups. Y.B. also fails to snack throughout the day. He mentioned taking in minimal amounts of lemonade and a small cup or two of espresso throughout the day. Y.B. eats meals primarily prepared by his wife. He stays away from fatty meats and prefers mainly chicken. He rarely eats at restaurants and never consumes fast food. Based on his height, weight and activity level, he should be consuming 2000 calories a day, and on average, he’s only consuming 959 calories. Although his BMI was within normal limits, he needs to increase his nutrient intake by nearly double for strength and immune health. Unfortunately, he was lacking nutrients in four of the five food groups. The only group he was meeting his target was protein. His five-day food diary revealed that he should consume more dairy, fruits and whole grains. Y.B. consumes absolutely no dairy. When I interviewed him and discussed my findings, he was under the impression that all dairy was bad due to his tendency to high cholesterol. I explained that although dairy can have high fat content, many varieties of milk, yogurt and cheeses can be bought in low fat concentrations. The scoring of Y.B.’s sweets intake resulted in sixteen minutes per day of acid production. According to my calculations, the exposure to bacteria producing acid occurred mostly from the liquid form and minimally from the solid forms of sugar consumed daily. As I mentioned earlier, Y.B. consumes lemonade and espresso a few times a day, exposing his oral environment to a significant amount of sugar, thereby increasing his exposure to acid throughout the day. Due to Y.B.’s religious practices, he rinses his mouth out with plain water five times daily during prayer. I thought that this was an inadvertent protective factor against acid attack and may be why he has minimal caries on his remaining dentition. Y.B’s diet was also low in a few essential vitamins including A, D, & E and the mineral calcium. I discussed Y.B.’s diet with him, and I commended his efforts regarding the lean home cooked eating. However, I advised him of the areas where he critically needs to make some improvements offering specific recommendations that I felt he could implement without too much change to his regular schedule.

5-day Food Diary

Nutritional Recommendations: Whole grains: YB is consuming well under the amount of grains that are recommended for his weekly intake by over half. This must be worked on, grains contain a bunch of nutrients that help to keep your digestive tract regular and working correctly. Try to make at least half of his daily intake of this group whole grains, such as whole wheat bread and whole wheat pasta. Whole grains, versus refined grains, try using whole wheat pasta for your pasta and wheat tortillas for your burritos. Vegetables: YB's vegetable intake is under the recommended intake by a 1.75 cups. If you include a side vegetables with lunch and dinner try to make them fresh or frozen vegetables. Cooked soft carrots & brocolli , eggplant and fresh green beans in addition to a regular small salad is essential to maintain overall wellness, immunity and organ function. Fruit: YB''s fruit intake is under for his weekly diet. Try selecting fresh fruit juices not from concentrate. Also try to incorporate berries and melons as they are loaded with vitamins and antioxidants and are soft enough to not easily chew and digest. Dairy: YB's Dairy intake is significantly below his weekly recommended intake of dairy. In fact, he wasn’t consuming any dairy at all. This is a very important food group because it promotes strong bones by providing calcium, vitamin A and vitamin D. When choosing dairy products try to choose the ones that are low-fat or fat-free, versus whole milk products which have more fat. Consuming yogurt, smoothies w/ yogurt and

milkshakes are easy and tasty ways to enjoy dairy with minimal chewing. Healthy teeth and supporting bone depends on it. Protein: YB's protein intake was exactly on point. Protein is an essential part of our diet and should be included daily. Remember protein consist of meats such as fish, chicken or turkey, as well as beans, eggs, and nuts. When choosing your protein try and choose lean meats, and substitute lean low-fat turkey for ground beef. Too much red meat can lead to higher cholesterol and an increased risk of heart problems. Y.B was quite interested in the discussion about his diet, he had his food log created for me by his second assessment appointment. I created a PowerPoint presentation that I printed out for him to take home with his for future reference. I mainly focused on his calcium and vitamin A, D & E deficiencies. I explained to him that increasing foods like yogurt, fortified milk, egg yolks, fresh green vegetables, carrots as well as adequate amounts of sunlight especially during the colder and darker months of the year would be highly beneficial. I explained that in his stage of life, his bone health is extremely important because bone density can decrease rapidly and increase his risk of bone fractures. I also explained that cellular function and muscle organ systems are affected by calcium inadequacies and demand adequate levels of this element to work properly. He seemed fascinated by the information I provided and my knowledge of systemic links and risk factors. He seemed to grasp the concept of oral health and nutrition. Although he was open to my suggestions and was grateful that I took the time to research this information specifically for him, he explained to me that due to his Muslim religious beliefs and the way he grew up, he has trained himself to never overindulge in food and has learned to embrace an empty stomach. He explained that during Ramadan, fasting is seen as a way to purify spiritually as well as physically. It’s a time to detach from material pleasures and be closer to God. The act of fasting is also believed to increase Muslim's' piety, reminding them that others are less fortunate than themselves.

Treatment Goals

Y.B.’s chief complaint, was that he wished to keep his remaining teeth as long as possible and that he hoped to regain some of his masticatory function. There were no major modifications in his care. However, because Y.B. was hard of hearing in his left ear, tried to direct my voice into his right ear and when communicating about my findings I made sure to temporarily remove my mask so that he could read my lips. The clinic gets very loud with an array of high to low pitch tones from the suction, Cavitron and slow speed hand pieces; thus, I knew this was an important modification to make. Y.B. had a fairly low dental IQ, and had never been under close and regular care of dentist. I decided to create a basic treatment plan for Y.B. based on his chief concern about preserving his remaining teeth. I explained right after I completed his initial assessments that I could make no promises that the interventions and treatments I performed would improve his chances of saving his teeth. I didn’t want him to think I had a magic wand that could restore such a severe condition back to health. Because of his apparent lack of dental knowledge, I wanted to educate him on the importance

of periodontal debridement and removal of calculus, a local contributing factor of periodontitis, the benefit of chlorohexidine (Chx) and fluoride, and the the effects of his severe deep overbite and malocclusion on his periodontium. This was time well spent and most beneficial to Y.B’s particular set dental circumstances. My primary treatment goals were based on arresting the localized pocket infections associated with his infrabony defects and removing pathogen harboring, root embedded calculus in order to restore a smooth surface for which his gingival could pseudo reattach, thus possibly regaining a long junctional epithelium (LJE) to seal out plaque and debris from accumulating. For Y.B.’s visits, my goals included making sure he understood the link between the development of plaque biofilm and the risk for both caries and gum disease. I expected him to be able to explain this link and be able to understand conditions like recession, attachment loss, mobility, attrition, and abfraction involvement as it related to his bone loss and high rate of missing teeth, and then demonstrate the rubber tip and Waterpik technique I taught him. The second goal was to make certain that Y.B. understood that, should he be able to save some of his remaining teeth, he should be seen by a hygienist three times a year for maintenance visits. I further explained the difference between a periodontal maintenance (4910) visit and a regular prophylaxis (1110) visit. Lastly, I expected Y.B. to be able to explain the importance of chlorhexidine rinsing and pocket irrigation and fluoride treatments in response to his CAL, exposure, and caries risk. Y.B’s first five visits consisted of my completing his assessments in two visits, and on his third visit, I started his scaling and root debridement procedures. During three of these appointments, I carefully cleaned every millimeter of the large surface area of each tooth’s calculus embedded cementum. I had to manage to work around and on top of extremely mobile and infected dentition. I administered local anesthetic at each scaling visit to keep him comfortable, and to my credit, Y.B. fell asleep for the majority of all his visits indicating he felt safe and free of pain in my care. I believe I spent the majority of my time scaling his lower left quadrant, the deposits where circumferential and very tenacious. One particular pocket I scaled reached 9mm in depth. This was where adaptation techniques really came into play, and only my tactile sense was used because visually I was unable to see that deep. I used a combination of Chx irrigation which I delivered through the use of a monojet syringe after each scaling session; and also used ARESTIN (minocycline HCl) Microspheres in selected pockets, to target the source bacteria causing his localized infections.

Patient Education Y.B’s current home care practices are as follows: he brushes with an electric toothbrush one times daily, morning, and rarely before bed, for one minute; he never flosses and alternates between Colgate and Crest fluoride toothpaste. He rinses his mouth out five times a day during a cleansing process before his prayer, as I mentioned before. After gathering all the assessment information about Y.B., I decided to focus in on two major topics I wanted to review with him. I wanted him to understand how biofilm colonies accumulate and how it’s an ongoing battle to disrupt the bacteria to keep the pathogen vs. host balance. I also felt that spending time explaining how the various body systems work, emphasizing the link between nutrition, systemic and immune health was valuable. I didn’t want to overwhelm him, but because he showed such involvement and interest in his dental health, I wanted to let him know the rationales behind my recommendations.

The first intervention I proposed to teach was the Stillman's tooth brushing technique which is advised for sulcular cleansing. I stressed that the standard practice includes brushing not once, but at least two times a day. I explained that although he rinses briefly for prayer, it's inadequate for the level of plaque removal necessary for his set

Image 2. Stillman’s Tooth

brushing Technique

Image 1. ARESTIN

(minocycline HCl) Microspheres

of teeth. I practiced the tell, show, do technique, and he responded well to my instruction and was able to identify a few localized areas of disclosed plaque. I explained that because he had multiple areas of recession, deep pocketing and abfraction lesions, he must learn this tooth brushing technique to clean the remaining gingival tissues, root and enamel surfaces. I showed him the appropriate amount of pressure to be used, which wasn’t much, and advised him to hold the electric toothbrush with a light grasp, and to make sure he uses one with extra soft end-rounded nylon bristles. He was able demonstrate with a fair amount of success this vertical sweeping, tooth brushing technique.

I also taught him that he would benefit from a prescription strength tooth gel, such as Prevident 5000 ppm, that could be easily incorporated into routine as an addition to his regular Colgate toothpaste evening hygiene routine.

The second intervention was introducing him was the Waterpik, I spent time discussing his tooth morphology with him and explaining that crowns and roots alike have many concavities and convexities, and that toothbrushes often fails to completely contour to the tooth/root surfaces. I chose the appropriate Waterpik tip, called the pik pocket tip,

Image 3. Prescription

strength leave on tooth gel

Image 4. Benefit of sulcular and Interproximal flushing with .12% Chx.

based on the size of his missing papillae and his boggy loose tissues. I taught him how to adjust the rubber tip to flush the trapped plaque biofilm. Waterpik claims that the lavage accesses up to 90% of the depth of a 6mm pocket. This intervention, I felt, would be the best fit for Y.B. because he could save a step and add Chx to the water reservoir and reach deep into periodontal pockets with the pik pocket tip to deliver the antibacterial rinse to sites of infection that need it the most. I made sure he clearly understood that this new intervention was not to replace flossing; rather it would be an additional tool to help disrupt pathogenic bacteria growth. Y.B. had fair dexterity yet poor eyesight. However, he did exhibit good motivation. He was receptive to the instruction and learning experience I shared with him. He explained that he wished he had met me and had this educational experience years ago when he had more teeth remaining. I didn’t want to overwhelm him with too many new practices, yet I felt it was important we incorporate a few new practices and do as much as possible to increase the chances of prolonging the longevity of maintaining his remaining teeth. I received 42/42 points on my OHI evaluation indicating that I delivered an appropriate level of patient education to Y.B. based on the feedback I received. My instructor mentioned that she really liked that I explained the different stages of periodontal disease and that I provided a customized handout with large font regarding his condition for him to take home and refer to at a later time. My instructor commented that my Waterpik demo was excellent and that she felt that Y.B. was engaged in the process. She really liked that I gave Y.B. resources of where to buy the Waterpik and the price range so that he didn’t have to do this research on his own. Y.B. respected the time I spent gathering habit and history information and analyzing his dietary intake, He had never had such comprehensive care in all his 82 years. Overall, I believe that this oral hygiene instruction was well received and successful.

Re- Evaluation

Six weeks later, Y.B. returned for his reevaluation appointments. During his first of three re-evaluation appointments, I re-assessed his oral tissues and home care practices. Y.B. reported that he had bought the Waterpik and was using the Chx in the water well to irrigate his pockets. He was cleaning better as well. His plaque index score was now .54 which is considered good, down from a 2.1 score that is considered poor. I considered this a successful finding, indicating improvement. However, his calculus had returned and he was classified as a moderate case again. I noticed that the color of his gingival margins had improved and instead of being a red color, they appeared closer to a pink color. The other periodontal findings I observed was that his gingiva had shrunk, which I learned is a common sign of successful tissue debridement. This shrinkage indicated the resolution of his inflamed and edematous gingiva. Although this shrinkage is a good indication of healing, consequently, it resulted in more rough root surface exposed to his oral environment. His periodontal pocket readings more or less were the same and in a few sites had increased in depth. Unfortunately, the five

sites of suppuration increased to ten sites showing that the pocket infections were still active and despite the regular use of Chx and the application of ARESTIN, his condition was not improving. I had Y.B. back for two additional appointments for another series of full mouth periodontal scaling and root debridement/planing procedures. Each time using local anesthetic to keep him comfortable and using Chx irrigation. At the end of his treatment I applied 5% sodium fluoride varnish in hopes of sealing up the exposed dentinal tubules and to provide caries protection. At the end of his second round of treatment with me. I sat him up and had a heart to heart conversation about his current condition and periodontal prognosis. I explained that although I am not a dentist and cannot definitively diagnose or determine the viability of his remaining teeth, I could give him my professional opinion. I explained to him that although there were some localized areas of improvement, he would most likely be faced with additional loss of teeth. I explained that his infected pockets did not respond well to my interventions and to control them extraction may be his best option. Y.B. understood and was grateful for my honesty and the thorough care he received. We spoke about tooth replacement options, including implants and dentures. He explained that finances were a concern and that dentures may be the way he goes, if his DDS agrees that additional teeth must be lost. This appointment was a great opportunity for me to explain and make certain Y.B. understands the threat his oral condition puts on his overall health. Overall, the education I provided Y.B. helped him to have a better understanding of his health and options he has moving forward.

Post-treatment Intraoral photos

Were goals met?

Due to the severity of his periodontal condition, Y.B.’s outcome was exactly what I thought it would be. Unfortunately, his advanced stage of periodontal disease was not going to improve and there would be no dramatic improvements regardless of the

Findings Goals Outcomes MET Periodontal Risk High

• Probing depths: 2-9mm • Missing teeth: posteriors • Generalized Moderate calculus • BOP/Suppuration • Generalized moderate

horizontal bone loss • Recession: Generalized F/L • Mobility: I-III (#9,24-25 severe) • Generalized horizontal and

vertical bone loss (severe loss of supporting bone)

• 6 max teeth remain • 9 mandibular teeth remain

47% tooth loss

1. Pt will understand plaque biofilm and its contribution to periodontal disease

2. Pt will understand the link between periodontal disease and systemic health

3. Pt will learn Stillman tooth brushing technique

4. Pt will understand the correlation between BOP and periodontal disease

5. Pt will learn the positive effects of chlorhexidine for periodontal disease

6. Pt will understand the importance of frequent recalls

1. Pt will be able to explain plaque biofilm and its contribution to periodontal disease by NV

2. Pt will be able to explain the link between periodontal disease and systemic health by NV

3. Pt can demonstrate Stillman tooth brushing technique by NV

4. Pt will be able to explain the correlation between BOP and periodontal disease

5. Pt will report using chlorhexidine twice a day for a week by NV

6. Pt will schedule dental hygiene appointments on 3-4 month intervals

skillful and thorough hygiene treatment I provided. I feel that the goal of providing education to Y.B. and allowing him the right to autonomy and full disclosure of his oral health was met. In regards to the ability to try to prevent further tooth loss, the goals were not met.

Research

After performing all the assessment on Y.B., I found that he had many unmet needs according to the Human Needs Conceptual Model of Dental Hygiene1 which include the following: skin and mucous membrane integrity of the head and neck, biologically sound and functional dentition, wholesome facial image, responsibility for oral health, as well as protection from health risks. I felt that the most detrimental risks to Y.B.’s oral wellness revolved around his poor bite and malocclusion. Ultimately, his malocclusion has negatively contributed to his active periodontal disease which affects not only his oral health, but his systemic health as well. The lack of posterior biting force also affects his ability to consume certain types of food, and as I explained earlier, his dietary analysis revealed a significant deficiency in calorie intake as well as vitamin D and the mineral Calcium. I found interesting research on the effects of malocclusion and its role in periodontal disease. I first took a look into the cause and effects of his deep bite and the occlusal load placed on his anterior teeth due to his lack of posterior teeth. Over the years, very little attention has been given to the detrimental effects of malocclusion, despite the fact that research has shown that both the soft and hard tissues of the periodontium are negatively affected by this condition. I researched what is called secondary occlusal trauma. Secondary trauma from occlusion is an injury that occurs from normal occlusal forces placed on a weakened periodontium. 1 This trauma often results in rapid clinical attachment loss (apical migration of JE).1 Y.B. exhibited the obvious clinical signs of occlusal trauma including, but not limited to, tooth migration, wear facets, chipped enamel and tooth mobility.1,2,3. According to my research, there are two types of injury. There is injury to the JE attachment as a result of excessive occlusal force, as well as injury to gingival surfaces that are caused by the direct impingement of a tooth on the gingival margin and periodontal tissues of an opposing tooth. Thus, this widens the sulcus/pocket space allowing pathogens and food debris (plaque) burrow deep along tooth surface. There’s a good amount of evidence that occlusal trauma does not cause periodontitis. However, a deep traumatic overbite is considered a contributing risk factor, that in certain cases, causes significant localized periodontal breakdown.4 My research indicated that the most important aspect in controlling trauma resulting from

a deep bite is achieving a good level of oral hygiene to stabilize the periodontal condition. Performing standard non-surgical periodontal therapy which includes: root planing and antibacterial irrigation (Chx) of the deep pockets, and in some more severe cases, use of topical antimicrobials such as arestin to reach the depth of the periodontal pocket. Nasry et al stated that in some cases, periodontal splints can be fabricated to protect tissues from opposing tooth impingement. Furthermore, orthodontic treatment may often be prescribed to reduce the depth of the overbite, but usually is successful only if treated before one's’ periodontal condition is severely compromised. Unfortunately, this wouldn’t apply to Y.B.’s advanced conditions. However, partial dentures can be fabricated to open up the deep bite and restore the posterior occlusion for a more even distribution of mastication forces. I documented Y.B.’s occlusal class as a class I based only on his right cuspid to cuspid relationship. However, this occlusal classification may be a result of the tooth migration that has occurred because of the loss of bone support and lack of posterior occlusion. Therefore, it’s hard to know what position the teeth were in prior to his steady tooth loss which began roughly eight to ten years ago. Another area that I was interested in learning more about was the effect of low vitamin D, and calcium on his oral and overall skeletal health. At 82 years of age, bone health becomes a common concern as nine percent of adults aged 50 years and over have reported having osteoporosis, as defined by the World Health Organization in 2008.1 Supplementation through diet is the only way counteract these common deficiencies. Y.B’s average Calcium and Vitamin D intake is extremely low. For Vitamin A, he is averaging 509µg per five days while his weekly target is 900µg indicating he is well below meeting his daily-recommended intake. As for his calcium consumption, he is consuming 204 mg per five days while his recommended daily target is 1000 mg. A deficit or insufficiency of vitamin D is very common in a majority of the population.10 Anand, et al. discussed that there is significant associations between periodontal health and intake of Vitamin D allowing calcium to be optimally absorbed and later released upon demand.6 According to Walsh, approximately 98% of the calcium present in the human body is contained in bone and teeth.1 Proper blood serum levels of Vitamin D and calcium are vital to the proper functioning of multiple, different organ systems. Adequate Vitamin D intake also has been linked to an increase in bone density of the mandible and a reduced incidence of alveolar resorption6. Furthermore, research has identified Vitamin D to have an anti-inflammatory and antibiotic effect on the periodontium, thus reducing the periodontal destruction caused by certain periodontal pathogens and the cytokines that are chemically produced as a response to this bacterial invasion. 6 I explained to Y.B. that these two dietary deficiencies are directly related and that for the maintenance and preservation of his bone and oral

health, both Vitamin D and Calcium will need to be increased simultaneously. I also advised him to get outside and get adequate exposure to sunshine to aid in Vitamin D production, especially during the darker winter months, I explained that 5-10 min a day is adequate.

Reflection

I think I learned the most, both clinically and culturally during this periodontal competency experience. Y.B. and I created a very close and supportive relationship. This kind of trusting and caring relationship I hope to achieve with many future clients. Over the course of nine appointments, I felt very comfortable providing care and thorough explanations to Y.B that were appropriate and congruent to his interest and level of understanding. I was extremely nervous prior to starting treatment on Y.B., I had never seen a case like his before. Although I was prepared and focused, I still was unsettled with the fact his teeth were in the condition they were to begin with, and deep down inside I knew that many of his remaining teeth would have to be lost. As always, I made sure I obtained his consent and explained each step to Y.B. before proceeding. I made sure to speak and listen to Y.B. in a professional and subtly empathetic manner. As a new dental hygienist, I must remember that periodontal conditions are always multifactorial. Sometimes I’ll need to remember to look beyond plaque and calculus and recognize the many other contributing factors and conditions that may have a role in the continuum of periodontal disease, both localized as well as systemically. I also learned that some cases are not always successful, not because the interventions were not performed competently, but because the loss of bone and/or tooth structure was too severe. I was reminded during this experience to always address the patient's chief concern, regardless of any preconceived notion that the condition is hopeless. Through education, disclosure and documentation of the discussed risks, benefits, and alternative treatment options the ethical principle of autonomy is exercised and the patient will be able to make the appropriate treatment decision based on fact, rather than personal opinion. Unfortunately, I realize that many adult patients I will come into contact with over my career will not have been fortunate enough to receive comprehensive, detailed and individualized oral hygiene instruction due to circumstances, such as access to care, which is beyond the control of the patient. I’m constantly reminded of how thorough, intuitive, and present I must be to be able to identify the unmet oral health needs that are presented with each patient. In particular, the periodontal patient is especially vulnerable to miseducation, guilt and shame associated with the deterioration of their periodontium.

Since I completed my hygiene care on Y.B. I have kept in touch with him, and he has seen his DDS on file. Together they decided that the remaining maxillary teeth would need to be extracted and replaced by a full upper denture. Additionally, a few of his lower anterior teeth will also be lost, and a lower partial denture made. He was able to make this decision because I gave him the education he needed to make a sound, personal decision for his own heath, showing ownership and responsibility for his oral wellness and overall health.

Bibliography

1. Darby M.L., Walsh M.M. Dental hygiene theory and practice. 4th ed. Dolan, John J. St. Louis (MO): Saunders Elsevier; 2015. P. 614-623 P. 1054-10731

2. Gher, M.E. "Changing Concepts. The Effects of Occlusion On Periodontitis.". Dent Clin North America 42.2 (1998): 285-99. Print.

3. Gehrig J., Willmann DE. Foundations of Periodontics for the Dental Hygienist. 4th ed. Philadelphia (PA): Wolters Kluwer; 2016. 533-550p.

4. Harrel, Stephen K., and Martha E. Nunn. "The Effect Of Occlusal Discrepancies On Periodontitis. II. Relationship Of Occlusal Treatment To The Progression Of Periodontal Disease". Journal of Periodontology 72.4 (2001): 495-505. Web. 16 Apr. 2017.

5. Nasry, H A, and S C Barclay. "Periodontal Lesions Associated With Deep Traumatic Overbite". British Dental Journal 200.10 (2006): 557-561. Web. 4 May 2017.

6. Anand N, Chandrasekaran S, Rajput N. Vitamin D and periodontal health: Current concepts. Journal of Indian Society Periodontology. 2013 May-June;17(3):302-8.

7. Google images (1,2,3,4)