Case History taking in periodontology .pptx

case history, periodontics, diagnosis, treatment planning

1. CASE HISTORY

2. Contents Diagnosis: Types of diagnosis: A. Provisional diagnosis B. Differential diagnosis C. Probable etiologic factors - Local factors - Systemic factors D. Radiographic findings E. Special Investigations - Microbiological - Immunological F. Blood examinations G. Biopsy H. Study Casts I. Final diagnosis Prognosis: Overall prognosis Individual prognosis Types of prognosis

3. Diagnosis:  Diagnosis can be regarded as an attempt at classification of an individual's condition into separate and distinct categories that allow medical decisions about treatment and prognosis to be made. “Diagnosis is not the end But the beginning of practice”

4. Provisional Diagnosis: Also known as interim, working, presumptive diagnosis. It is the diagnosis that the clinician uses to initiate definitive treatment despite the inability to determine a Definitive diagnosis Considered as tentative and altered as soon as the diagnosis become more definite

5. Differential Diagnosis: When the diagnosis is uncertain the possibilities are listed  as the Differential Diagnoses 1. Illnesses that are possible causes of the presenting Symptom complex or Syndrome 2. A range of alternative diseases

6. Probable etiologic factors: Local factors : Plaque, calculus, etc. Trauma from occlusion : Faulty restoration, bruxism, clenching, etc. Systemic factors

7. Systemic disorders linked to periodontal health: Endocrine disorders Hematologic disorders Genetic disorders Nutritional disorders Medication related Stress and psychosomatic disorders Others

8. Endocrine disorders

9. 25-50% patients have associated periodontal disorders Depression of maternal T lymphocytes Females >45 years experience gingivostomatitis Defective insulin production causes rise in blood glucose levels Increased sex hormones cause enlarged edematous gingiva

10. Hematological disorders

11. Cyclic neutropenia Leukemias Defective neutrophil mobility Antibody deficiency disorders Different types of Anemias Platelet disorders: Purpuras

12. Genetic disorders

13. Papillon Lefevre syndrome Down Syndrome Chediak Higashi Syndrome Genetic Disorders

14. Nutritional Deficiencies

15. Nutritional deficiencies by themselves do not cause periodontal problems! Nutritional Deficiencies Deficiency of: Vitamin A - hyperkeratosis Vitamin D - disturbs the Ca-K metabolism of the body Vitamin E - Glossodynia , angular cheilitis B complex - variety of oral changes Vitamin C - Boggy gums

16. Medication related : Oral contraceptives Bisphosphonates- osteonecrosis (BRONJ) Corticosteroids- decreased immune response

17. Stress and psychosomatic conditions:

18. Radiographic findings : In periodontics, the main purpose of radiography is to detect the level of the alveolar bone including the pattern and extent of bone loss Measurements which are of linear form from the cemento enamel junction to the crest of alveolar bone and from the cement enamel junction to the osseous defect base are commonly used to measure crestal bone levels and osseous defects the periodontal ligament space, lamina dura and periapical region are evident and also useful in identifying risk factors, such as calculus and defective restorations

19. Adult Full mouth survey - 7 anterior, 8 posterior = 15 IOPA Child <5 - 4 film survey Child <10 – 12 film survey Child 10- 12 years - 12-16 film survey Bitewing films offer the best and most accurate levels of alveolar bone crest

20. Radiographic technique- Paralleling technique provides the most accurate positioning of the alveolar crest with least distortion Both bone margins are shifted toward the crown, the facial margin (smooth wire) more than the lingual margin (knotted wire), creating the illusion that the lingual bone margin has shifted apically. Long cone paralleling technique (A and B) Bisecting angle technique (C and D)

21. Normal Interdental bone: The bone which is present interdentally normally is seen as a radiopaque line beside the periodontal ligament (PDL) and at the bone margin, called as the lamina dura Crest of the interdental bone normally vary according to the convexity of the proximal tooth surfaces and the level of the cementoenamel junction (CEJ) of the approximating teeth

22. Bone destruction in periodontal disease -Early destructive changes of bone that do not remove sufficient mineralized tissue cannot be captured on radiographs. Bone loss -The radiographic image tends to underestimate the severity of bone loss. The difference between the alveolar crest height and the radiographic appearance ranges from 0 to 1.6 mm , mostly accounted for by X-ray angulation

23. Exposure parameters: Higher kvp , milliamperes , exposure time- higher kvp (>95) provides increased density of radiograph which allows detection of even subtle changes in the bone Short gray scale and high contrast required for ideal bone images Reference radiograph Less density Increased density

24. Other radiographic investigations: Orthopantomogram CBCT (Cone beam computed tomography) CT (Computed tomography) Ultrasonography - Assessment of periodontium - Detection of subgingival calculus - As diagnostic aid

25. Special Investigations: MICROBIOLOGICAL ANALYSIS: It involves the isolation and identification of bacteria from plaque samples. Some bacteria can be grown in culture. It gives us an indication regarding number of bacteria in plaque sample. This investigation is important for diagnosis of aggressive periodontitis cases and some special cases where repeated treatment is not able to control the disease progression (refractory periodontitis)

26. DNA ANALYSIS FOR PLAQUE MICRO-ORGANISMS: The DNA analysis is for those bacteria which cannot be grown in culture. Here the plaque sample is subjected to various DNA amplification methods. Specific DNA for a bacterial species is allowed to pair with the DNA available in sample. If that particular organism is present in the sample its DNA makes a double strand with the test DNA single strand which is then amplified for identification.

27. IMMUNOLOGICAL INVESTIGATIONS: Based on immunological tests These tests are used to confirm the abnormalities Eg . Patients with aggressive periodontitis have PMN cell function abnormalities which predispose the patient for rapid periodontal breakdown Direct and indirect immunofluorescence tests Flow cytometry Enzyme linked immunosorbent assay Latex agglutination

28. BLOOD EXAMINATION Done for patients scheduled for periodontal surgery and patients who are suspected to have any kind of bleeding disorder Routine blood examination is mandatory before any surgical procedure If the patient has any systemic disease, corresponding blood tests should be advised Cell type Normal parameter Haemoglobin 14-18 mg/dl RBC count 4.5-5.5 million/ cubic mm WBC count 4000-11000/ cubic mm Platelet count 1.5-4.5 lakhs/ cubic mm Bleeding time 2- 6 minutes Clotting time 2-8 minutes INR/ PT 1.5

29. BIOPSY Excisional or incisional biopsy should be taken in case of growth and sent for histopathological investigation

30. STUDY CASTS Useful for occlusal evaluation of the patient If patient has any kind of occlusal disharmony, these casts are articulated on a fully adjustable articulator and selective occlusal reduction is carried out to achieve occlusal harmony which is then replicated on the patient

31. FINAL DIAGNOSIS Complete and accurate diagnosis is required to make an appropriate treatment It should include all the periodontal and systemic conditions of the patient which affect periodontal disease progression for which patient requires treatment

32. PROGNOSIS Prognosis is a prediction of the probable course, duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease. Overall prognosis: Prognosis based upon sum of various local, systemic, environmental and other factors which may affect the overall periodontal health of teeth. Factors which affect the influencing the overall periodontal prognosis include age, genetics, oral hygiene, systemic conditions, smoking, patient compliance and economic consideration.

33. Individual prognosis: Prognosis of individual teeth, based upon local and prosthetic/restorative factors that have a direct effect on their prognosis. These factors include attachment loss, probing depth, furcation involvement; crown-to-root ratio, fixed abutment status and percent bone loss are the most important factors in determining tooth loss.

34. Parameters for determining prognosis % of attachment loss : Attachment loss(mm)/ length of root from CEJ to root apex x 100 Furcation involvement : - Class 1- incipient Class 2- cul de sac Class 3- through and through; tissue fills the furcation Class 4 – Through and through, exposed

35. Tooth mobility: Miller Classification - Class 1: < 1 mm(Horizontal) - Class 2: > 1 mm(Horizontal) Class 3: > 1 mm ( Horizontal+vertical mobility) Crown root ratio : Ideal- 1:2 Optimum- 1:1.5 Minimum- 2:1

36. Root form: Number of roots- multirooted teeth offer better prognosis than single rooted teethe Root curvatures- Dilacerated roots have better retention ability and less prone to mobility

37. Concavities in root surfaces- developmental grooves and fluting on roots make it more difficult for the periodontist to reach these areas and for the patient to maintain cleanliness Example : Mesial aspect of maxillary 1 st premolar, deep mesiolingual developmental groove on maxillary 1 st molar Root shape - triangular shaped roots > ovoid/ flat roots

38. TYPES OF PROGNOSIS By McGuire and Kook GOOD Control of etiologic factors and adequate periodontal support ensure the tooth will be easy to maintain FAIR Approx 25% attachment loss and/or Class1 furcation involvement ( Location and depth allow proper maintenance with good patient compliance) POOR 50% attachment loss, Class2 furcation involvement (Location and depth make maintenance possible but difficult) QUESTIONABLE More than 50% of attachment loss, poor crown-root ratio, poor root form, Class2 furcation involvement (Location and depth make access difficult) or Class3 furcation involvements, more than grade2 mobility, root proximity HOPELESS Inadequate attachment to maintain health, comfort and function

39. Kwok and Caton FAVOURABLE Comprehensiv e periodontal treatment and maintenance will stabilize status of the tooth. Future loss of periodontal support is unlikely QUESTIONABLE Local and systemic factors if controlled, periodontal status can be stabilized with comprehensive periodontal treatment. If not, future periodontal breakdown may occur UNFAVOURABLE Cannot be controlled. Comprehensive periodontal treatment and maintenance are unlikely to prevent future periodontal breakdown HOPELESS Tooth must be extracted

40. Conclusion: Evidence based approach is essential in determining an accurate diagnosis Updating oneself with the latest journals containing randomized clinical trial articles, surveys and systematic reviews and meta analyses is key to repeatedly arrive at an accurate diagnosis Clinical diagnosis and assessment is just as important as the radiographic and special investigations and should not just be limited to intraoral area

41. The Treatment Plan

42. Introduction After the diagnosis and prognosis has been established, the treatment is planned The aim of the plan is TOTAL TREATMENT i.e. coordination of all procedures for creating a well functioning dentition in a healthy periodontal environment The primary goal is elimination of periodontal inflammation and correction of conditions that cause it

43. The treatment plan is the Blueprint for Case management!!

44. Treatment goals The plan should encompass immediate, intermediate, and long-term goals. Immediate goals are the elimination of all infectious and inflammatory processes that cause periodontal and other oral problems This may require patient education on infectious oral diseases and disease prevention, periodontal procedures, endodontics, caries control, oral surgery, and treatment of oral mucous membrane pathologies

45. From a periodontal viewpoint: pocket reduction establishment of good gingival contours and mucogingival relationships conducive to periodontal health

46. Intermediate goals are the reconstruction of a healthy dentition that fulfills all functional and aesthetic requirements and lasts many years Restoration of health, function, aesthetics, and longevity involves endodontic, orthodontic, periodontal, and prosthodontic considerations as well as the age, health, and desires of the patient may be quickly achieved or require treatments over months or even years, depending on the complexity of the case, the therapy involved, and the financial status of the patient.

47. Long-term goal is maintenance of health through prevention and professional supportive therapy. The long-term goal is set, and both the patient and the clinician work toward it from the very first visit

48. Interdisciplinary approach In complex cases, interdisciplinary consultation with other specialty areas is necessary before a final plan can be made. The opinions of orthodontists and prosthodontists are especially important for the final decision in these patients Occlusal evaluation and therapy may be necessary during treatment, which may necessitate planning for occlusal adjustment, orthodontics and splinting. The correction of bruxism and other occlusal habits may also be necessary.

49. Systemic conditions should be carefully evaluated because: may require special precautions during the course of periodontal treatment. - The tissue response to treatment procedures may be affected

50. -the preservation of periodontal health may be threatened after treatment is completed. The patient's physician should always be consulted when the patient presents with medical and systemic problems that may affect the periodontal therapy

51. Phases of Periodontal Therapy

52. Emergency/ Preliminary phase Elimination of “pain” Incision and drainage of abscesses Emergency access opening of painful carious teeth Prescribing empirical antibiotics for any odontogenic infection Emergency extraction of tooth with pain

53. To extract or not to extract? Periodontal treatment requires long range planning Number of years of healthy functioning teeth > number of teeth retained Thus welfare of the dentition should not be jeopardized by retaining hopeless teeth

54. Teeth on the borderline of a hopeless prognosis do not contribute to the overall usefulness of the dentition. Such teeth become sources of recurrent problems for the patient and detract from the value of the greater service rendered by the establishment of periodontal health in the remainder of the oral cavity.

55. To extract It is so mobile that function becomes painful. It can cause acute abscesses during therapy. There is no use for it in the overall treatment plan

56. To retain maintains posterior stops Anterior aesthetic zone , a tooth can be retained during periodontal therapy and removed when treatment is completed and a permanent restorative procedure can be performed. The retention of this tooth should not jeopardize the adjacent teeth. This approach avoids the need for temporary appliances during therapy Extraction of hopeless teeth can also be performed during periodontal surgery of the adjacent teeth. This approach reduces the number of appointments needed for surgery in the same area.

57. Explain that holding onto hopelessly diseased teeth as long as possible is inadvisable for the following reasons : Periodontal disease is a microbial infection, and research has clearly shown it to be an important risk factor for severe life- threatening diseases Correcting the periodontal condition eliminates a serious potential risk of systemic disease, which in some cases ranks as high on the danger list as smoking It is not feasible to place restorations or fixed bridges on teeth with untreated periodontal disease

58. Failure to eliminate periodontal disease shortens the life span of other teeth Therefore the dentist should make it clear to the patient that if the periodontal condition is treatable, the best results are obtained by prompt treatment. If the condition is not treatable, the teeth should be extracted

59. Non-Surgical therapy/ Etiotrophic phase Oral hygiene assessment Patient education Diet control ( in rampant caries) Complete oral prophylaxis Excavation of caries and restoration (as they act as focus of infection)

60. Reduction of local risk factors - Removal or reshaping of overhangs and overcontoured restorations - Restoration of carious lesions Restoration of open contacts Minor orthodontic movement Provisional splinting Local antibiotic therapy (local drug delivery)

61. Patient Education Be specific . Avoid vague statements Begin your discussion on a positive note . Talk about the teeth that can be retained and the long-term service they can be expected to render. Present the entire treatment plan as a unit

62. Periodontal reevaluation Inquiry of new concerns or problems Inquiry of changes in patient's medical and oral health status Oral hygiene assessment and education Comprehensive periodontal examination Assessment of outcome of nonsurgical therapy Determination of required additional nonsurgical and adjunctive therapy

63. Surgical Phase Adjunct to nonsurgical therapy Should only occur once patient demonstrates proficient biofilm control Objectives: • Primary : Access for root instrumentation • Secondary : Pocket reduction through soft tissue resection, osseous resection, or periodontal regeneration

64. Periodontal access surgery • Ressective osseous surgery • Regenerative osseous surgery Periodontal plastic surgery • Mucogingival surgery • Aesthetic crown lengthening Preprosthetic surgery • Prosthetic crown lengthening • Implant site preparation and implant placement

65. Restorative phase Final Restorations Fabrication of Fixed/ removable prosthesis

66. Maintenance phase Inquiry of new concerns or problems Inquiry of changes in patient's medical and oral health status Oral hygiene assessment and education Comprehensive periodontal examination Professional maintenance care • Supragingival and subgingival biofilm and calculus removal • Selective scaling and root planing Assessment of recall interval and plan for next visit

67. Sequence of therapy: Immediately after completion of phase I therapy, the patient should be placed on the maintenance phase (phase IV) to preserve the results obtained and prevent any further deterioration and recurrence of disease While on the maintenance phase, with its periodic evaluation, the patient enters into the surgical phase (phase II) and the restorative phase (phase III) of treatment. These phases include periodontal surgery to treat and improve the condition of the periodontal and surrounding tissues

68. Importance of recall Periodontal disease is a chronic disease and requires a multi disciplinary approach for its treatment. Regular recall and maintenance should be given as much importance as the other phases Patients not returning for regular recall- 5.6 times greater risk of tooth loss ( Trombelli et al 2002) Inadequate supportive periodontal therapy – greater clinical attachment loss ( Pini -Prato et al 1994) More Frequent Recall Visits (3–6 Month) = Fewer Teeth Extracted (Costa et al)

69. Recall Timetable ( Merin classification) Classification Characteristics Recall interval First year Routine therapy and uneventful healing 3 months First year Difficult case with furcation involvement, poor C:R ratio, complicated prosthesis, questionable patient cooperation 1-2 months

70. Class A Excellent results, well maintained, minimal calculus, no pockets, no teeth with <50% bone remaining 6 months- 1 year Class B Generally good results but heavy calculus, poor oral hygiene, complicated prosthesis, remaining pockets, few teeth with <50% bone support remaining, systemic disease, smoker, +family history, occlusal problems 3-4months Class C Generally poor results, poor oral hygiene, heavy calculus, systemic disease, many pockets remaining, periodontal surgery indicated but not performed, >20% bleeding on probing, complicated prosthesis, smoker, family history, recurrent dental caries 1-3 months

71. Compliance and its role in periodontal therapy The extent to which a person's behavior coincides with medical or health advice" ( Hayness 1976). Types of compliance: ( acc to Strack et al) Non-compliance (34.13%) Erratic compliance (49.43%) Complete compliance (16.44%)

72. Why do patients fail to comply 1.Negligent attitudes toward their illness 2. Patient wants to deny that they have problem at all 3. They want dentist to take responsibility 4. Fear of dental treatment is a major reason 5. Economic problems 6. Socio-economic status

73. Methods of improving compliance 1. Simplify the treatment plan 2. Accommodate to the patient needs 3. Remind patients of appointments 4. Keep records of patient compliance 5. Inform the patient (Bowden 1975)

74. 6. Provide positive reinforcement 7. Identify potential non-compliers 8. Ensure the dentist's involvement Noncompliance decreased by 50% when these general approaches were applied (Wilson et al 1993)

75. Conclusion The ultimate goal for every patient is to bring his or her mouth to a state of health and maintain it long term. This begins with educating the patient on the problems in his or her mouth and the etiologies, treatment, and prevention of these problems. A properly formulated treatment plan is paramount to achieving this goal.

76. A treatment plan is a plan for therapy formulated only after a thorough examination has been completed, diagnosis and prognosis have been determined, and the needs and desires of the patient have been taken into consideration. It must be recognized that as diagnosis and prognosis will change with treatment, therapeutic needs may also change. As such, the treatment plan must be changed accordingly.

77. References Carranza 13 th edition Image findings of bisphosphonate related osteonecrosis of jaws comparing with osteoradionecrosis- Kenichi et al Role of Radiographic Evolution: An Aid to Diagnose Periodontal Disease By Krishna Kripal and Aiswarya Dileep ;Submitted: November 14th 2018Reviewed: June 13th 2019Published: October 24th 2019 Periodontal disease and systemic conditions: a bidirectional relationship – Jemin Kim et al Dental Issues & Down Syndrome Chediak -Higashi syndrome and premature exfoliation of primary teeth- Karla M et al Appropriate Recall Interval for Periodontal Maintenance: A Systematic Review Owais A. Farooqi, Carolyn J. Wehler , Gretchen Gibson, M. Marianne Jurasic , and Judith A.Jones J Evid Based Dent Pract . 2015 Dec; 15(4): 171–181, Published online 2015 Nov 19