American Board of Periodontology Narrative Report

Slide#:
1. AAP title slide
2. Personal profile:
The patient was referred to OHSU Department of Periodontology for a comprehensive
periodontal examination by her general dentist on Oct 16, 2006. The patient is a 53 year
old Caucasian female who resides in SE Portland, OR. She works as a self employed
graphic artist. The patient was asymptomatic at her initial visit and her chief complaint
was, I want to save my teeth from falling out.
3. Medical and Social History:
Vital signs were recorded on Oct. 16, 2006 and were WNL. The patient considers herself
to be in good health. The patient sees a medical doctor twice a year for routine checkups. The patient has been diagnosed with hypercholesterolemia and depression at the
time of the comprehensive periodontal examination. Patient reports no history of
inheritable diseases and both parents have healthy dentitions. The patient states she
socially smoked cigarette tobacco and socially imbibes alcohol. During the course of
treatment, with encouragement, the patient quit smoking. Patient denies recreational use
of drugs. Patient shows great motivation in achieving oral health and retaining teeth.
4. Medications:
She reports ingesting prescription medications of Fluoxetine-20mg/day for depression
and Atorvastatin-20mg/ day for high cholesterol.
The patient states she is allergic to penicillin.
5. Extra/Intraoral History and Findings:
Clinical extraoral history and findings, intraoral history and findings including
periodontal examination, occlusal analysis, and radiographic findings were documented.
Please refer to your case report summary.
6. Pre-Treatment Chart:
CAL, BOP, probing depths, presence of plaque, gingival recession, furcation
involvement, tooth mobilities, and other clinical findings are illustrated. Please refer to
the pre-treatment case report record for further details.
7. Disclaimer:
None of the photographs in this presentation have been altered with the exception of
cropping out background images and re-orientation of the photographs so that they
appear as if the viewer is looking directly into the patients mouth. The exception being
the maxillary/mandibular anterior lingual teeth, which are projected as if you are sitting
on the patients tongue.
8. Anterior View:

Gingiva appears pink to erythematous

Papillary gingival contour appears pointed to blunted
Marginal gingival contour appear rolled and thickened
Gingival texture is smooth with localized areas of stippling
Gingival consistency was boggy and edematous
Missing teeth #s 6 and 11
Gingival recession on teeth #s 7-10 and #s 22-27
Porcelain fused to metal restoration tooth #8 with metal margin evident
Incisal wear tooth #9
Materia Alba between #26 and 27
9. Maxillary Anterior Palatal View:
Palatal rugae and incisive papilla are present
Papillary and marginal gingiva appear erythematous and edematous
Papillary gingival contours appear pointed
Marginal gingival contour appears knife edge to rolled and thickened especially on
mesial of tooth #8
Gingival texture is smooth
Gingival consistency is firm
Discolored composite restoration mesial lingual tooth #7
Porcelain fused to metal restoration tooth #8 with over contoured cingulum
Pronounced triangular cingulum tooth #10
10. Mandibular Anterior Lingual View:
Gingiva appears erythematous and edematous
Papillary gingival contour appears slightly blunted
Marginal gingival contour appears rolled and thickened
Gingival texture is smooth and consistency is boggy
Slight extrinsic stain interproximally
Gingival recession teeth #22-#27
Slight incisal wear #22-#27
Slight crowding and rotation of teeth #22-27
11. Right Buccal View:
Marginal gingiva appear slightly erythematous and edematous
Papillary contours are blunted to pointed
Marginal gingival contours appear slightly rolled
Gingival texture is smooth and glossy
Gingival consistency appears slightly boggy
Class V amalgam restorations on teeth #29 and 31
Porcelain fuse to metal restoration on tooth #2
Composite class V restorations teeth #s 3 -5 and 30
Materia alba present gingival margin #31
12. Maxillary Right Palatal View:
Papillary and gingival appearance slightly erythematous and edematous

Papillary gingival contours appear slightly blunted and pointed

Marginal gingival contour appears rolled
Gingival texture appears smooth
Porcelain fused to metal restoration present on tooth #2
Class V amalgam restoration present tooth #3
Occlusal palatal composite restoration tooth #3
13. Mandibular Right Lingual View:
Marginal gingiva appears edematous
Papillary gingival contours appear slightly blunted
Marginal gingival contours appear rolled
Gingival texture appears smooth and glossy
Gingival consistency appears soft
Amalgam restoration present on tooth #29 and 31
Occlusal composite restoration on tooth #30
Extrinsic stains and hypocalcification present on tooth #31
14. Left Buccal View:
Papillary and marginal gingiva appears slightly erythematous and edematous
Papillary gingival contours appear slightly blunted
Marginal gingival contours appear rolled and thickened
Gingival texture appears smooth and glossy
Gingival consistency appears soft
Gingival recession #12-14 and 19-21
Porcelain restorations on teeth #18 and 19
Class V composite restoration teeth #20 and 21
Buccal version of tooth #15
15. Maxillary Left Palatal View:
Papillary and marginal gingiva appears erythematous and edematous
Papillary gingival contours appear slightly blunted
Marginal gingival contours appear rolled and thickened
Gingival texture appears smooth and glossy
Gingival consistency appears soft
Amalgam restoration on tooth #12 and #14
Extrinsic stain between teeth #13 and 14
Gingival recession #14 and 15
16. Mandibular Left Lingual View:
Marginal gingiva appears slightly erythematous and edematous
Papillary gingival contours appear slightly blunted
Marginal gingival contours appear slightly rolled
Gingival texture appears smooth and glossy
Gingival consistency appears soft

Slightly raised round blackish blue lesion distal to tooth #18.

Porcelain restorations on teeth #18 and 19
17. Radiographs:
Radiographs projected were taken November 11, 2007
18. Maxillary and Mandibular Anterior Periapicals:
Horizontal slight bone loss (<20%) is visible on tooth # 8 and 9
Horizontal moderate bone loss (20-40%) is visible on tooth #22 and 27
Horizontal severe bone loss (> 40%) is visible on teeth #23-26
Root proximities on teeth #7 and 8, 9 and 10, and 23-26
Radioopacites interpretd as root canal therapy tooth #8 with fill that does not reach the
radiographic apex and all root apices appear normal with no evidence of periapical
pathology
Radioopacities interpreted as crown restoration on tooth #8
Lamina dura and PDLs appear continuous
Bone trabeculation appears normal
19. Right Posterior Periapicals
Horizontal slight/moderate bone loss is visible on #2-5 and #28-31
Conical roots #2,3, and 31
Medium root trunks is visible on #30 and 31
Radioopacities interpreted as amalgams is visible on #3,29 and 31, composite restoration
on teeth #3,4, and 30 and crown on tooth #2
Pulp canals and root apices appear normal with no evidence of periapical pathology
Lamina dura and PDLs appear continuous
Bone trabeculation appears normal
20. Right Bitewings
The projected radiographs verify generalized horizontal bone loss.
Marginal ridge discrepancy between #28/29, 29/30, and 30/31
21. Left Posterior Periapicals
Horizontal moderate bone loss is visible on #12-15 and #18-20
Conical roots #14 ,15 and 18
Radioopacities interpreted as amalgams is visible on #12 and 14, and crown on tooth #18
and 19
Pulp canals and root apices appear normal with no evidence of periapical pathology
Lamina dura and PDLs appear continuous
Bone trabeculation appears normal
Open contact evident between #18 and #19
22. Left Bitewings
The projected radiographs emphasizes horizontal pattern of bone loss.
Confirms open contact evident between #18 and #19 seen in PA radiographs

Open contact evident between #19 and 20

23. The periodontal diagnosis is
Plaque Induced Gingivitis
Generalized Severe Chronic Periodontitis
Other Diagnoses
Secondary occlusal trauma #14
Caries #3, 14, 15
Nocturnal Bruxism
24. Etiology:
Primary Factor:
Dental Plaque Biofilm
Host response and susceptibility
Risk Factor:
Poor oral hygiene
Cigarette smoking
Subgingival restorations
Open contacts
Depression
25. Prognosis
Long Term
All teeth except those below

Questionable

Short Term
All teeth except teeth those
below
2, 3, 14, 15, 22, 23, 29, 31

Unfavorable

24, 25

24, 25

Favorable

2, 3, 14, 15, 22, 23, 29, 31

26. Treatment Plan

Four Phases:
1. Phase I Treatment: Non-Surgical
2. Phase II Treatment: Surgical
3. Phase III Treatment: Restorative
4. Phase IV Treatment: Maintenance
Overall Goal:
1. To establish a dentition and periodontium which the patient and the
provider can maintain in health, comfort, function, and aesthetically
acceptable long term.
Goals would be accomplished through:
1. Elimination or control of primary factors and risk factors

2. OHI reinforcement
3. Ensuring patient compliance
27. Phase I Treatment:
Complete PARQ (informed consent for treatment)
Oral Hygiene instruction
Four quadrants scaling and root planing
Re-evaluation in 4 weeks
Smoking cessation program
Fluoride treatment
Occlusal Adjustment on tooth #14 if indicated
28. Phase II Treatment: Surgical
Osseous surgery in Maxillary Right and Left Posterior Sextants
Regenerative Surgery Mandibular Right Posterior Sextant
Open Flap Debridement Mandibular Anterior Sextant
29. Treatment Plan-Phase III
Restorations-#3, 14, 15
Occlusal adjustment if indicated-#14
Fabrication of an occlusal night guard
30. Treatment Plan-Phase IV
3- month maintenance intervals
31. Stage II Surgery: Guided Tissue Regeneration Surgery Mandibular Right Sextant
Written informed consent signed and received
32. Pre Surgical Presentation-buccal
Pre-surgical vital signs: BP -115/82, Pulse - 63
Patient premedicated at the time of surgery with 800mg ibuprofen and rinsed with 0.12%
chlorhexidine for 1 minute
Local anesthesia achieved with 2% Lidocaine HCL with 1:100,000 epinephrine (0.018
mg/carpule x 1 )
Papillary and marginal gingiva appears slightly edematous, rolled, and slightly boggy,
with smooth texture
Papillary gingival contours appear pointed to slightly blunted
33. Pre Surgical Presentation lingual
Papillary and marginal gingiva appears slightly edematous, rolled, slightly boggy, with
smooth texture around #30 and 31
Papillary gingival contours appear pointed
34. Buccal Incisions
Intrasulcular incisions to the alveolar crest was made from the distal line angle of tooth
#27 to the distal facial line angel of #31.

35. Lingual Incisions

Similar to the buccal, intrasulcular incisions to the alveolar crest was made from the
distal line angle of tooth #27 to the distal facial line angel of #31.
36. Buccal Flap Reflected
A full thickness mucoperiosteal flap was elevated, tissue degranulated, SRP completed,
and no osseous recontouring was performed. Intrabody defects were visualized on the
mesial of #29 and 31. Both defects were combination defects with three walled defects
apically and one walled defects coronally.
37. Lingual Flap reflected
Similarly, Lingual mucoperiosteal flap elevated, soft tissues degranulated, SRP
completed, no osseous recontouring performed. Angular defect on mesial of tooth #29
can be seen just below the periosteal elevator.
38. Allograft and Membrane Placed
Photo unavailable for this slide.
Root surface further modified using tetracycline burnished onto the root surface for 1
minute using cotton pellets. Defects grafted with DFDBA and covered with resorbable
collagen membrane.
39. Buccal View Sutures
Flaps replaced and secured with interrupted 4-0 silk sutures.
Post operative instruction were given verbally and written to the patient.
Ibuprofen 600mg x 28 capsules, 1 capsules by mouth 4 times a day as need for pain
Patient declined narcotic pain medications
Patient instructed to rinse BID with 0.12% chlorhexidine gluconate. Patient was to
continue with chlorhexidine for at least 1 week
Patient was scheduled for post-op visit 1 week later, OHI emphasized
40. Lingual View Sutures
Again, flaps replaced and secured with interrupted 4-0 silk sutures.
41. 2 Week Post-Op Buccal View
No complaints or complications reported and sutures removed after one week. Slide
shows 2 week post operative with tissues healing WNL, OHI reinforced
42. 2 Week Post-Op Lingual View
Tissues healing WNL.
43. 6 Month Post-Op Buccal View
No complaints reported. Tissues healing WNL.
Papillae are blunted and gingiva is pale pink
Marginal tissue is slightly rolled

44. 6 Month Post-Op Lingual View

Tissues appear to have healed WNL.
Papillae are blunted and gingiva is pale pink
Marginal tissue is slightly rolled
45. Max/Man Anterior (Post-Treatment)
Post-treatment photographs are approximately 6 months following the last surgery of the
mandibular right quadrant
Gingiva appears pink with well demarcated mucogingival junction
Papillae are generally blunted with areas that are pointed
Gingival margins appear slightly rolled
Gingival texture reveals absence of stippling
Gingival consistency firm
46. Max Anterior Palatal (Post Treatment)
Papillary and marginal gingiva is pale pink
Papillary gingival contours appear slightly blunted to pointed
Marginal gingival contour appears slightly rolled
Gingival texture is smooth
Gingival consistency is firm
47. Mandibular Anterior Lingual
Gingiva appears pink, smooth, and firm
Marginal gingival contours appear slightly rolled
Papillae appear pointed to blunted
48. Right Maxillary/Mandibular Posterior
Gingiva appears pink, firm, scalloped, and smooth
Marginal gingival contours appear slightly rolled
Papillae appear blunted
49. Right Max Posterior Palatal
Gingiva appears pink, firm
Marginal gingival contours appear slightly rolled
Papillae are blunted
50. Right Man Posterior Lingual
Gingiva appears pink, firm
Marginal gingival contours appear slightly rolled and slightly erythematous around #30
and 31
Papillae are blunted
51. Left Maxillary/Mandibular Posterior
Gingiva appears pink, firm, scalloped, and smooth
Papillae are blunted to pointed

52. Left Maxillary Posterior Palatal

Gingiva appears pink, firm
Marginal gingival contours appear slightly rolled
Papillae are blunted
Bulbous tissue evident on distal of #15
53. Left Mandibular Posterior Lingual
Gingiva appears pink with firm consistency
Gingival texture appears smooth and glossy
Marginal gingival consistency appears soft and appears slightly rolled
54. Maxillary/Mandibular Anterior Periapicals
Radiographic impression is that the alveolar bone height appears similar to that of the
pre-treatment radiographs with the apparent exception of slight bone fill in the angular
defect on the mesial of tooth #8.
55. Right Posterior Periapical
Radiographic impression of the maxillary sextant is that the alveolar bone height appears
slightly more apical compared to pre-treatment radiographs
Radioopacity on the mesials of teeth #29 and 31 is interpreted as bone fill of the angular
defects.
56. Right Bitewings
The projected radiograph verifies the interpretation of bone fill in the angular defect of
teeth #29 and 31
Alveolar bone height of the maxilla appears slightly more apical compared to pretreatment radiographs
57. Left Posterior Periapical
Radiographic impression of the maxillary sextant is that the alveolar bone height appears
slightly more apical compared to pre-treatment radiographs
58. Left Vertical Bitewings
Alveolar bone height of the maxilla appears slightly more apical compared to pretreatment radiographs
59. Maintenance
Patient to be scheduled for periodontal maintenance every 3 months, alternating between
the general dentist and OHSU.
The goal of maintenance treatment is to maintain and preserve periodontal support of the
dentition long term.
Elements of maintenance include: periodontal examination, scaling/root planing and oral
prophylaxis, OHI reinforcement, ensure patient compliance
The patient had recall maintenance during the Phase II surgical treatments, the last one
being performed on 2/27/07.

60. Evaluation of Results

Plaque free score 88%
Bleeding on probing 5% of sites
Mobility has decreased on teeth #13, 14, 22 and 23 and fremitus no longer exist
on tooth #14
Probing depths range from 2-5 mm except for one 7mm probing depth at the
distal of tooth #15
Additional surgery needed to decrease the 7 mm probing depth at the distal of #15
Overall treatment prognosis is favorable with continued treatment except teeth
#24 and 25 which are questionable
Patient is very satisfied with results of therapy
61. Thank you for your attention