Final Year DDS Perio Case
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Transcript of Final Year DDS Perio Case
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33332
Changes in clinical attachment levels after Non-Surgical Therapy in a female patient with Moderate to Severe Generalized Chronic Periodontitis A Case of Restoration of Function and Patient Comfort: Examining the role of stress in Periodontal Disease
The purpose of this report is to highlight the factors involved in the management of Moderate to Severe Generalized Chronic Periodontitis. The patient, AJ presented to The UWI Dental School complaining of mobile teeth. Her condition was investigated and was found to be plaque induced Periodontitis modified by a stressful lifestyle. Outcome measures used included plaque and bleeding scores, BPE scores and full periodontal assessment including full mouth radiographs. Her main mode of treatment included non-surgical scaling and root planing the success of which was monitored using the same measures. Treatment saw a reduction in the general inflammatory state of the periodontium including a reduction in probing pocket depths with some areas proving to be a challenge. Overall this case emphasizes the point that in patients exhibiting a generalized advanced breakdown of the periodontal tissues, but with an intact number of teeth, considerable efforts should be made to address all contributing factors with the concept of “individualized dentistry in mind”.
Page2
The Point of It All • • •
A healthy or a stable
periodontium is an
important prerequisite
both for the
maintenance of a
functional dentition
and to ensure a long-
term, successful
outcome of restorative
dental treatment.
Changes in clinical attachment levels after Non-Surgical Therapy in a female patient with Moderate to Severe Generalized Chronic Periodontitis A Case of Restoration of Function and Patient Comfort: Examining the role of stress in Periodontal Disease
SECTION 1: PRE TREATMENT ASSESSMENT PATIENT DETAILS
Initials: AJ
Sex: Female
Date of birth: 18/05/57 (55 years)
Occupation: Dress maker
REFERRAL
The patient was referred by Dr. Wiseman (General Dentist) and Dr.
Harper (Orthodontist) both advising that there were severe
periodontal disease that necessitated close attention. Dr. Wiseman’s
initial referral was to Dr. Brown (Periodontologist) but financial
constrains were problematic.
Page3
Table of Contents SECTION 1: PRE TREATMENT ASSESSMENT................................................................................................. 2
PATIENT DETAILS ........................................................................................................................................ 2
REFERRAL ................................................................................................................................................... 2
PATIENT COMPLAINTS ..................................................................................................................................4
PATIENT EXPECTATIONS ...............................................................................................................................4
RELEVANT MEDICAL HISTORY ......................................................................................................................4
DENTAL HISTORY ........................................................................................................................................4
SOCIAL HISTORY/FAMILY HISTORY ............................................................................................................... 5
PRESENTING ORAL HYGIENE ........................................................................................................................ 5
CLINICAL EXAMINATION: EXTRA ORAL .......................................................................................................... 5
CLINICAL EXAMINATION: INTRA ORAL ........................................................................................................... 5
PERIODONTAL DIAGNOSIS (OVERALL): ....................................................................................................... 17
PRE TREATMENT ASSESSMENT: GENERAL RADIOGRAPHIC EXAMINATION ........................................................ 17
AIMS AND OBJECTIVES OF TREATMENT ....................................................................................................... 23
TREATMENT PLAN 30/04/12 ........................................................................................................................ 23
SECTION 2: TREATMENT ............................................................................................................................ 28
ORAL HYGIENE INSTRUCTION AND MOTIVATION ......................................................................................... 28
PLAQUE SCORE MONITORING ..................................................................................................................... 30
1ST RE-ASSESSMENT .................................................................................................................................. 40
2ND RE-ASSESSMENT .................................................................................................................................. 47
SECTION 3: CASE DISCUSSION ............................................................................................................................... 48
PERIODONTAL DISEASE ............................................................................................................................................ 48
SUMMARY OF AJ’S MANAGEMENT ............................................................................................................................. 51
TREATMENT PLANNING ............................................................................................................................................ 53
DIAGNOSIS ............................................................................................................................................................... 53
PREDISPOSING, INITIATING AND AGGRAVATING FACTORS ..................................................................................... 54
TREATMENT .............................................................................................................................................................. 58
CRITICAL APPRAISAL ................................................................................................................................................ 64
OPPORTUNITIES FOR LEARNING .............................................................................................................................. 65
CONCLUSION ............................................................................................................................................................ 65
References ................................................................................................................................................................... 68
Page4
PATIENT COMPLAINTS
AJ complained of buildup around her teeth and that they were drifting (progressing mobility) and taking
up strange angulations. A tooth in the upper right anterior sextant was described as having “dropped”.
Dr. Harper advised her that there was bone loss. The general dentist suggested antiseptic mouthwash
and had general debridement done to alleviate the complaint but commented that buildup would come
back quickly. She began noticing symptoms in 2008. There was associated bleeding (occasionally
spontaneous upon waking up), halitosis but no pain or soreness.
PATIENT EXPECTATIONS
1. To restore cavities
2. Have teeth cleaned
3. Address spontaneous bleeding and bone loss
4. Address tooth malposition, possibly with orthodontic treatment and tooth adjustment
RELEVANT MEDICAL HISTORY
1. Gastro-duodenal ulcers
2. Fibroids
3. Periodically swollen ankles
4. Removed cyst from right breast in ’83 with no complications
5. Blood smear showed oddly shaped cells (not specified), findings of little significance according
to the physician
DENTAL HISTORY
AJ was not a regular dental attender. As mentioned previously, she has undergone “cleanings” and has
had extractions of carious teeth (2010, patient bled a lot). A history of blunt force trauma to the upper
front teeth was reported.
Page5
SOCIAL HISTORY/FAMILY HISTORY To the knowledge of the patient she has no family history of periodontal disease. She is a non-drinker
and non-smoker, single mother of two (one being murdered in 2002). She was previously in a marriage
that caused her extreme stress due to abuse and financial strain and which she says led to her son’s
death. AJ admitted to binge eating especially of sweet snacks when under stress often before bedtime
without toothbrushing.
PRESENTING ORAL HYGIENE
AJ’s methods of personal oral care included a toothbrush of medium texture. She used Aquafresh®
toothpaste to brush manually twice daily for approximately 2 minutes. Flossing was not part of her
cleansing routine, while CARE ® mouthwash (prescribed by the GD) along with Listerine® were used
occasionally for symptomatic bleeding.
CLINICAL EXAMINATION: EXTRA ORAL
General Appraisal: AJ appeared healthy, alert and demonstrated a very good awareness of her
personal hygiene and dress.
Specialized: Examination also revealed deviation to the left on closing and forced lip competency.
CLINICAL EXAMINATION: INTRA ORAL
Soft tissues: Within normal limits
Gingival health: The gingiva appeared pink with some patches of brown racial pigmentation. Areas of
attached gingiva were paler in comparison to the free gingiva. A firm consistency and a particularly
round form were noted. There was some stippling still evident. There was also extensive recession on
the upper palatal incisor region (Miller’s classification III).
Oral hygiene: Plaque deposits were found to be distributed in all interproximal areas and generally on
the palatal and lingual aspects of the teeth.
Page6
PRE TREATMENT ASSESSMENT: DENTAL
CHARTING
• Findings: • #13 – Supra-erupted • #12 - shallow palatal groove in enamel (corono-radicular) • #17 – occlusal caries • #21 - grey discoloration • #27 – buccal root caries • #47 - occlusal caries
Page7
PRE TREATMENT ASSESSMENT: VITALITY TESTING
Tooth Endo Ice Electric pulp tester
#11 No response No response #21 No response No response #27 No response No response
Plaque Score: 72%
BPE scores: 4* 3 4*
4* 2 3*
Occlusion: Anterior open bite with proclined upper incisors and associated increased overjet. The
upper central incisors were also supra-erupted. An occlusal analysis post extraction was conducted and
is to be reported
BOP: Probing resulted in a generalized distribution of immediate bleeding.
Page8
PRE TREATMENT ASSESSMENT: PRE TREATMENT PHOTOGRAPHS
Labial and buccal segments
Page9
PRE TREATMENT ASSESSMENT: PRE TREATMENT PHOTOGRAPHS
Upper and Lower Arches
Page10
PRE TREATMENT ASSESSMENT: STUDY MODELS
Page11
PRE TREATMENT ASSESSMENT: STUDY
MODELS
Page12
PRE TREATMENT ASSESSMENT: FULL PERIODONTAL ASSESSMENT 02/03/12
Periodontal chart: Buccal Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17 8 5 8 5 5 2 3
16 6 1 5
15 3 2 5
14
13 1 2 6
12 5 1 5 1
11 6 2 6 3
M MID D M MID D
21 3 2 3 3
22 5 2 5
23 1 1 4
24 2 1 7
25 4 6 7
26
27 7 8 5 3
28
Page13
MANDIBLE
38
37 5 5 4
36
35 3 3 2
34 4 2 2
33 3 2 2
32 2 2 3 1
31 2 1 2 1
M MID D M MID D
41 2 1 2 1
42 5 3 2 1
43 1 1 3
44 5 1 5
45 5 1 6 0 4 0
46
47 7 6 7 3
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
Page14
Periodontal chart : Palatal/lingual Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17 7 10 8 III 2 1 0 3
16 5 1 7
15 3 1 5
14
13 4 4 6 2 3 2
12 7 5 7 1 3 1 1
11 6 6 8 2 4 2
M MID D M MID D
21 5 3 5 0 6 0 3
22 5 2 4 2 3 2
23 2 1 5
24 1 1 6 0 2 3
25 3 4 6 3 5 3
26
27 12 7 7 III 3 5 2 3
28
Page15
MANDIBLE
38
37 5 1 6
36
35 2 1 1 0 4 0
34 1 1 1
33 2 1 2
32 2 1 3 1
31 1 1 1 1
M MID D M MID D
41 2 1 2 1
42 1 1 3 1
43 3 1 3
44 5 1 5
45 3 1 6
46
47 7 5 5 III 3
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
Page16
PRE TREATMENT ASSESSMENT: FULL PERIODONTAL ASSESSMENT
Summary of periodontal assessment:
Full Mouth Plaque Score - 72%
Full Mouth Bleeding Score – 53%
Deepest pockets –10mm (mid-palatal of #17), 12mm (mesio-palatal of
#27)
Diseased sites- 40%
Upper right
quadrant 16% Upper left quadrant 11%
Lower right
quadrant 10% Lower left quadrant 3%
Pockets ≥ 6mm - 25% of all sites
Recession ranging from 0 mm to 6 mm with the greatest recession seen
on #21
Degree 1 mobility was associated with: #12, , #31, #32, #41, #42,
Degree 3 mobility was associated with: #17, #27, #47
Grade 1 Furcation Involvement was associated with: #47
Grade 3 Furcation Involvement was associated with: #17, #27
Page17
PERIODONTAL DIAGNOSIS (OVERALL):
Moderate to Severe Generalized Chronic Periodontitis with a primary etiology of plaque retention and extreme stress and calculus as a secondary etiologic factors.
PRE TREATMENT ASSESSMENT: GENERAL RADIOGRAPHIC EXAMINATION
Key
Horiz
Horizontal bone loss
PL
Periodontitis levis
PG
Periodontitis gravis
PG et co
Periodontitis gravis et complicata
S Secure Q Questionable
H Hopeless
*Percentages suggest the percentage bone loss on the Mesial (M) or Distal (D)
Bitewings Taken on 14/02/12
Right Bitewing
Distal caries into dentine
Left Bitewing
Mesial caries into dentine
Page18
Periapicals Taken on 02/03/12
Upper right posterior sextant
#17 100%
Horiz H PG et co
#16 50%(D)
30%(M)
Horiz Q PG
#15 30%(D)
60%(M)
Horiz Q PG
Calculus deposits on root surfaces of
#17, distal of #16, mesial of #15, #14
is a root stump
Upper anterior sextant (right half)
#13 10%(D)
50% (M)
Horiz Q PL
#12 60%(D)
70%(M)
Horiz Q PG
#11 100%
Horiz H PG
Calculus deposits on the mesial root
surface of #13, mesial of #12, distal of
#11. Periapical radiolucency #11
Page19
Upper anterior sextant
(left half)
Calculus deposits on the root surfaces of #21, #22, mesial of #23
#21 100% Horiz H PG
#22 60%(M)
70%(D)
Horiz Q PG
#23 25%(M)
30%(D)
Horiz S PL
Upper left posterior sextant
Calculus deposits on the distal root surface of #24, on the root surface of #25. #26 is a root stump with apical radiolucencies. A large radiolucency is present mesial to the root of #27. Mesial interproximal caries is evident once more.
#24 50%(D)
25%(M)
Horiz Q PG
#25 60%(M) lamina dura
unremarkable(D)
Horiz Q PG
#27 100% distal
aspect is
unremarkable
Horiz H PG
et
co
Page20
Lower left posterior sextant
Calculus deposits on the root
surface of #37 just below the
cervical regions.
#34
15%
Horiz S PL
#35
15% Horiz S PL
#37
35%
(D) The distal
root apex is
not seen
here
55%(M)
Horiz Q PG
Page21
Lower anterior sextant
Calculus deposits on the root surface of #43, #42.
#43
35%(D)
30%(M)
Horiz
S
PG
#42
60%
Horiz
Q
PG
#41
20%
(D)
30%(M)
Horiz
S
PL
Calculus deposits on the mesial surface of #31
#33
40%
Horiz
S
PG
#32
10%(D)
15%(M)
Horiz
S
PL
#31
15%
(D)
10%
(M)
Horiz
S
PL
Page22
Lower right posterior sextant Calculus deposits on the distal root surface of #46; #46 is a root stump with apical radiolucencies. Calculus deposits on the distal root surface of #45. Periapical of the same premolar region on 25/10/12 (7 months later)
#45
60%(D)
30%(M)
Horiz
Q
PG
#44
60%(D)
30%(M)
Horiz
Q
PG
#47 50%(D)
55(M)
Horiz
S
PG
et co
Page23
AIMS AND OBJECTIVES OF TREATMENT
1. < 10 %, of sites BOP
2. No sites with PPD > 5 mm, but preferably < 4 mm
3. No furcation involvement of degree II or III.
4. Satisfy the patient's demands regarding esthetics and masticatory function.
TREATMENT PLAN 30/04/12
I. Initial phase therapy
1. Motivation and OHI
2. Extraction of hopeless teeth and root stumps
3. Restore #16M and #47O
4. Scaling and root planing
5. Reassess 6-8 weeks
II. Corrective phase
1. Adjunctive antibiotic treatment if necessary in local areas
2. Transitional denture in lower arch for posterior support with
concurrent adjustment of the supra-erupted #13 effort to address
occlusal discrepancy (modified 01/02/12)
3. Transitional denture for upper arch (decision to replace teeth on the
free end saddle is tentative) to be modified and include #11 and #21
post extraction
Page24
III. Final Reconstructive phase
1. Orthodontic treatment if feasible
2. Final removable/fixed prosthodontic therapy
3. Supportive periodontal care during reconstructive/orthodontic phase
4. Referral for psychological counseling
Final 3 month evaluation
IV. Supportive periodontal therapy or maintenance
Page25
CONSULTATIONS
• Periodontology
o Extraction of hopeless #11 and #21 along with other hopeless
teeth considering aesthetic value?
Result: Extraction of the same teeth should be done at a time that
an immediate interim denture can be provided. Thus scaling and
root planing will be attempted on the both teeth.
• Orthodontics
o Fixed appliances to close spaces and correct angulation
especially proclination of lower incisors.
Result: Patient seems to be having a “mid –life crisis” and
concerns may be over emphasized by emotional state. Attempt to
convince patient that esthetics of lower may improve with
prosthetic replacement of upper central incisor. However patient
will still be assessed for treatment.
• Prosthodontics
o Fixed prosthodontic option (bridge) preferred by patient for
replacement of upper central incisors.
Result: Due to the patients high smile line (excess of 2mm gingival display) and expected retraction of gingiva post scaling
a removable prosthesis with a flange to overcome these issues
are best option to avoid teeth appearing to be “floating in air”.
Patient reactions
• Agreed to see wax up and approved of attempt to camouflage
lower incisor proclination. However she still would like to have the
teeth “braced to prevent further movement”
Page26
• Agreed to accept removable prosthesis instead of bridge
o Occlusal analysis post extractions of posterior teeth:
Upper arch: Kennedy Class 1 Mod 1 (bilateral free end saddle)
Lower arch: Kennedy Class 3 Mod 1
The cusp of #13 is proving to be working side interference.
Occlusal contact is solely occurring between #13 and #44 and
#15 and #45. This is the only support and means of mastication
with group function in lateral excursion to that side.
Result: In order to address the discomfort experienced by the
contact of the supraerupted #13 with the lower arch, occlusal
adjustment will have to be carefully carried out while making
occlusal (wax rim) adjustments in the jaw registration phase of
the transitional denture. This should be done first on a working
cast to gauge the amount of tooth structure adjustment required
without causing the tooth to become symptomatic. A transitional
denture for the upper arch can only be fabricated after this
adjustment is made as the denture teeth will not come into
contact with the lower arch. After this phase the patient should be
more acclimatized to the removable prosthesis and consequently
more accepting of the proposed extractions and denture
replacement planned for #11 and #21.
Patient reactions
• Agreed to use the first transitional denture as a “training
mechanism” before extracting the central incisors and was very
willing to accept it also as treatment for the troublesome #13.
Page27
DIAGNOSTIC WAX UP
Page28
SECTION 2: TREATMENT ORAL HYGIENE INSTRUCTION AND MOTIVATION
• Generally the modified bass technique and flossing methods were
demonstrated on the models.
• Patient was asked to mimic methods with mirror held in front of her.
Plaque disclosing agent was applied prior to her attempt.
• Different aids were issued due to different needs of individual and groups
of teeth.
• Aids and advice given
1. Brushes:
i. Soft toothbrush
ii. Interproximal brush (purchased personal set as well)
iii. Round headed brush for lone standing molars
Page29
iv. Angled single tufted
brush for palatal aspect of upper
incisors
2. Floss:
• To be used where contacts existed
3. Mouthwash
• AJ was told to discontinue Listerine® and was instructed to use CARE®
mouthwash at least a half hour after brushing as well as occasionally.
4. Plaque disclosing tablets
• This was issued to AJ in order for her to grow accustomed to the difficult
areas as well as the new technique that was learnt.
5. Toothpaste
• Colgate TOTAL® was given to AJ
Page30
PLAQUE SCORE MONITORING
Graph showing plaque deposit levels over the course of 9 months after oral
hygiene advice was given. Along the way the technique had to be personalized.
The first greatest reduction was seen after all hopeless posterior teeth and root
stumps had been extracted (8%). The trouble areas responsible for the
increases seen subsequently included the lone standing lower molars (#37 and
#47) and the palatal aspect of the upper incisors (see mapping below) due to
the very deep pockets and associated recession. As a result brushes with
features that could overcome the shortcomings of the regular tooth brush
0%10%20%30%40%50%
Date
Date
AJ thought that proxa- brushes
were for one time use and discarded
them
Inconsistency with cleaning palatal of upper
incisors47%
8%
11%25%
All extractions of hopeless posterior teeth
and root stumps complete
Neglect of lone standing molars were noted; round
head brush given
Plaque Score
Page31
OTHER TREATMENT COMPLETED TO DATE
• Extraction of all root stumps and hopeless teeth.
• Scaling and root planing of all four quadrants.
• Restorations (amalgam) of #16M and #47O.
• Periodontal re- assessment.
• Fabrication of temporary denture to replace #11 and #21 (not in use)
• Re-scaling of upper anterior sextant
• Periodontal re-assessment
KEY STAGES IN TREATMENT
DATE STAGE 1. 14.02.12 First visit 2. 28.05.12 Extraction of #27 3. 12.06.12 Extraction of #18, # 17, #14 and #46 4. 26.06.12 Extraction of #26 5.
18.09.12
Scaling and root planing of the upper
right quadrant 6.
04.10.12
Scaling and root planing of the upper
left quadrant 7.
11.10.12
Restoration of #16 (Class II amalgam) 8. 18.10.12 Scaling and root planing of the lower
left quadrant
Page32
9. 25.10.12 Scaling and root planing of the lower
right quadrant and consultation with
conservative department concerning
prosthetic replacement of #11 and #21 10. 29.11.12 1st Periodontal Re-assessment
11. 12. 13.
22/11/12 07/01/13 31/01/13
Restoration of #4.7(Class I amalgam
and class V composite).
Re- scaling of the upper anterior
sextant
2nd Periodontal Re- assessment
Page33
POST TREATMENT PHOTOGRAPHS
Page34
Page35
Periodontal chart :
Buccal
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17
16 2 1 1
15 2 1 1
14
13 2 2 5
12 2 1 2 1
11 2 2 4 2
M MID D M MID D
21 6 2 4 3
22 5 2 4
23 2 1 3
24 2 2 1
25 2 3 4 0 1 2
26
27
28
1ST PERIODONTAL REASSESSMENT 29/11/12
Page36
MANDIBLE
38
37 5 5 4
36
35 3 3 2
34 4 2 2
33 3 2 2
32 2 2 3 1
31 2 1 2 1
M MID D M MID D
41 2 1 2 1
42 5 3 2 1
43 1 1 3
44 5 1 5
45 5 1 6 0 4 0
46
47 7 6 7 3
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M MANDIBLE
38
37 4 2 5
36
35 2 1 2
34 2 1 2
33 3 1 2
32 1 1 2 1
31 2 1 1
M MID D M MID D
41 2 1 2
42 2 2 4
43 2 1 2
44 5 1 5 1
45 2 2 3 0 0 2 1
46
47 3 3 5 I 3
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
Page37
Periodontal chart :
Palatal/lingual Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17 7 10 8 III 2 1 0 3
16 5 1 7
15 3 1 5
14
13 4 4 6 2 3 2
12 7 5 7 1 3 1 1
11 6 6 8 2 4 2
M MID D M MID D
21 5 3 5 0 6 0 3
22 5 2 4 2 3 2
23 2 1 5
24 1 1 6 0 2 3
25 3 4 6 3 5 3
26
27 12 7 7 III 3 5 2 3
28
Periodontal chart :
Palatal/lingual Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17
16 3 2 3 1 1 1
15 3 2 5
14
13 3 3 4
12 4 5 6 4 4 3 1
11 6 6 6 3 4 3
M MID D M MID D
21 3 4 3 5 6 6 3
22 2 2 2 3 3 3
23 2 2 4
24 2 3 4 2 3 4
25 3 3 3 3 5 6
26
27
28
2 2
Page38
MANDIBLE
38
37 5 1 6
36
35 2 1 1 0 4 0
34 1 1 1
33 2 1 2
32 2 1 3 1
31 1 1 1 1
M MID D M MID D
41 2 1 2 1
42 1 1 3 1
43 3 1 3
44 5 1 5
45 3 1 6
46
47 7 5 5 III 3
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MANDIBLE
38
37 4 4 4
36
35 2 2 1 0 4 0
34 4 4 3
33 1 1 2
32 3 3 5
31 3 1 1
M MID D M MID D
41 2 1 2
42 6 4 3
43 3 1 3
44 6 2 5 1
45 1 4 4 1
46
47 3 3 5 I
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
1
1
Page39
SUMMARY OF 1ST PERIODONTAL RE-ASSESSMENT
Full Mouth Plaque Score - 9% Full Mouth Bleeding Score – 32%
Deepest pockets –6mm (palatal of #11, mesio-palatal of #21, mesio-
buccal of #21 and mesio-lingual of #44 ),
Diseased sites- 14%
Upper right
quadrant 5% Upper left
quadrant 2%
Lower right
quadrant 5% Lower left
quadrant
2%
Pockets ≥ 6mm – 5% of all sites with #11 and #21 still to be extracted
(carrying a hopeless prognosis)
Recession ranging from 0 mm to 6 mm with the greatest recession
still seen on #21.
Degree 1 mobility was associated with: #12, #41, #42 #44, and #45.
Degree 2 mobility was associated with: #11
Degree 3 mobility was associated with: ##21.
Grade 1 Furcation Involvement was associated with: #47
Page40
PERIODONTAL ASSESSMENT COMPARISON
Initial Periodontal Assessment
Periodontal Reassessment
Full Mouth Plaque Score
72% 9%
Full Mouth Bleeding Score
53% 32%
Deepest Pocket 6mm 6mm
Diseased Sites 46% 27%
Pockets ≥ 6mm 25% 5%
Recession 23% of sites 20% of sites
Mobility Degree 1
Associated with 5 teeth Associated with 3 teeth
Mobility Degree 2
Associated with 0 teeth Detected in 1 tooth
Mobility Degree 3
Associated with 3 teeth Associated with 1 tooth
Furcation involvement
Associated with 3 teeth Associated with 1 tooth
Page41
IMMEDIATE DENTURE THAT WAS PREMATURELY FABRICATED
Page42
Periodontal chart :
Buccal
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17
16 2 1 1
15 2 1 1
14
13 2 2 5
12 2 1 2 1
11 2 2 4 2
M MID D M MID D
21 6 2 4 3
22 5 2 4
23 2 1 3
24 2 2 1
25 2 3 4 0 1 2
26
27
28
2ND PERIODONTAL REASSESSMENT 31//01/13
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17
16 2 1 1
15 2 1 2
14
13 2 1 5
12 2 1 2 1
11 3 1 1 2
M MID D M MID D
21 6 2 4 3
22 3 2 4
23 2 1 3
24 2 1 1
25 1 1 4 1 2 3
26
27
28
Page43
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MANDIBLE
38
37 5 5 4
36
35 3 3 2
34 4 2 2
33 3 2 2
32 2 2 3 1
31 2 1 2 1
M MID D M MID D
41 2 1 2 1
42 5 3 2 1
43 1 1 3
44 5 1 5
45 5 1 6 0 4 0
46
47 7 6 7 3
48
38
37 3 2 3
36
35 2 1 2 2 0 0
34 2 1 2
33 2 1 2
32 2 2 2
31 2 1 2
M MID D M MID D
41 2 1 2 1
42 2 1 4 1
43 2 1 2
44 7 2 5
45 3 2 3 0 0 2
46
47 3 2 5 I
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
I
Page44
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
MAXILLA
18
17
16 2 1 7
15 3 1 3
14
13 3 4 5 3 3 3
12 3 4 4 3 3 3 1
11 5 4 4 3 3 3 2
M MID D M MID D
21 2 3 2 8 8 8 3
22 2 2 2 3 3 3
23 2 1 4
24 1 2 3 1 2 3
25 2 3 3 2 5 5
26
27
28
Page45
MANDIBLE
38
37 4 4 4
36
35 2 2 1 0 4 0
34 4 4 3
33 1 1 2
32 3 3 5
31 3 1 1
M MID D M MID D
41 2 1 2
42 6 4 3
43 3 1 3
44 6 2 5 1
45 1 4 4 1
46
47 3 3 5 I
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
38
37 5 3 7
36
35 4 2 3 2 0 0
34 6 3 2
33 2 1 2
32 2 1 4
31 3 1 2
M MID D M MID D
41 2 2 1 1
42 5 2 2 1
43 1 2 2
44 6 2 5
45 3 3 4 2 3 4
46
47 3 4 2 I
48
Tooth Pocket depth Furcation Recession Tooth
involvement mobility
D MID M D M D MID M
Page46
SUMMARY OF 2ND PERIODONTAL RE-ASSESSMENT
Full Mouth Plaque Score - 9% Full Mouth Bleeding Score – 15%
Deepest pockets –7mm (Disto-palatal of #37, mesio-buccal of #44
and mesio-palatal o #16)
Diseased sites- 11%
Upper right
quadrant 3% Upper left
quadrant 1%
Lower right
quadrant 5% Lower left
quadrant
2%
Pockets ≥ 6mm – 5% of all sites
Recession ranging from 0 mm to 8 mm with the greatest recession
still seen on #21.
Degree 1 mobility was associated with: #12, #41, and #42.
Degree 2 mobility was associated with: #11
Degree 3 mobility was associated with: ##21.
Grade 1 Furcation Involvement was associated with: #47
Page47
2NDPERIODONTAL ASSESSMENT COMPARISON
Initial Periodontal Assessment
Periodontal Reassessment
Full Mouth Plaque Score
9% 9%
Full Mouth Bleeding Score
32% 15%
Deepest Pocket 6mm 7mm
Diseased Sites 27% 11%
Pockets ≥ 6mm 5% 5%
Recession 20% of sites 20% of sites
Mobility Degree 1
Associated with 3 teeth Associated with 3 teeth
Mobility Degree 2
Associated with 1 tooth Detected in 1 tooth
Mobility Degree 3
Associated with 1 tooth Associated with 1 tooth
Furcation involvement
Associated with 1 tooth Associated with 1 tooth
Page48
SECTION 3: CASE DISCUSSION
PERIODONTAL DISEASE
Gingivitis is a mild, reversible form of periodontal disease characterized by
gingival inflammation without attachment loss and is detected by bleeding on
probing. Untreated gingivitis may (but not necessarily) develop into periodontitis,
a chronic inflammatory state which leads to periodontal attachment loss.
However, the initiation of periodontitis is still unclear. Clinical indicators of
periodontitis include probing depth, recession, measure of attachment loss and
radiographic level of alveolar bone.
The inflammatory state seen in periodontitis is triggered by a persistent
microbial challenge (microorganisms vary but some are pathognomonic) at or
below the gingival margin. These microbes are present in a ubiquitous biofilm
(dental plaque) that adheres tenaciously to the non-shedding surface of the
tooth. Dental plaque that gains the opportunity to calcify (calculus), also serves
as a continued source of viable bacteria. With regard to pathogenesis, microbes
do get the opportunity to colonize, evade the host’s responses and cause tissue
damage.
Page49
Plaque and calculus are accepted to be etiologic factors. However individual
factors including co-morbidity (systemic disease), genetics, smoking, oral
hygiene and age do affect the severity of periodontitis. The role of psychological
factors is no exception and has been shown to influence other parameters of
health and disease. (Irwin M, 1990). A strong link between stress, depression
and periodontal disease has been indicated with a biologic and behavioral
mechanism being proposed and supported by recent studies. (Higert, Hugo,
Bandeira, & Bozzetti, 2006) (Ng & Keung Leung, 2006) (Peruzzo, et al., 2007)
(Rosania, Low, Mc Cormick, & Rosania, 2009).
The importance of this finding is to increase awareness of psychological factors
as etiologic or contributing factors in an effort to individualize dental protocol.
Diagram showing mechanisms of proposed relationship between stress,
depression and periodontal disease of mechanisms:
Page50
BIOLOGICAL
Hypopituitary-adrenal
axis:production of cortisol
Inhibition of IgA and IgG and
PMN
Increased biofilm
colonization and reduced ability
to prevent conective tissue
invasion
Long term loss of ability to
inhibit inflammatory responses by
chronic cortisol elevation
BEHAVIOURAL Stress and depression
Increased poor health behaviors
Increased oral biofilm burden and
decreased resistance of the periodontium to inflaammatory
destruction
Page51
SUMMARY OF AJ’S MANAGEMENT
AJ presented to the UWI Dental School Polyclinic with complaints of “buildup”
around teeth, bleeding gums tooth malposition and progressing mobility.
Medical history did not reveal active disease. However a history of gastro-
duodenal ulcers, fibroids, cyst removal from right breast and periodically swollen
ankles was elicited. A stressful lifestyle stood out in AJ’s medical history,
highlighted by the loss of her son in 2002 to murder and a marital relationship
that was abusive and led to the death of her son. Clinical examination revealed
deviation to the left on closing and a forced lip competency owing to her anterior
open bite. A discolored central incisor, recession in the palatal anterior aspect
and increased overjet featured the intra-oral examination with attached gingiva
that was notably round in form. Periodontal screening revealed an initial plaque
score of 72% with a generalized distribution on all interproximal surfaces and
significant amounts on the palatal and lingual surfaces. BPE scores of asterix (*)
was present in all posterior sextants indicated furcation involvement and a need
for further investigation. Detailed full periodontal assessment inclusive of six
point charting and a full mouth radiographic series was then completed indicated
by this code.
Periodontal assessment showed generalized attachment loss with pockets as
deep as 12mm and recession as extensive as 6mm. A full mouth bleeding score
of 53% was recorded with the bleeding being spontaneous in nature. The sites
affected amounted to 40% with furcation involvement detected in three molars
and up to degree 3 mobility present in five teeth.
Page52
Radiographic assessment revealed generalized horizontal bone loss, including
bone loss to the apex and allowed the examination of several root stumps some
of which had periapical radiolucencies.
Page53
TREATMENT PLANNING
Fundamental dentistry is underscored by disease elimination and prevention as
well as the restoration of foundations. A treatment plan places structure to
therapeutic protocol and dictates the call to attention to various components that
may cause or contribute to loss of aesthetics, form and function. In addition,
instituting the periodontal treatment plan may well serve as the foundation for
further restorative work (be it basic or advanced).
In order to arrive at this treatment plan a diagnosis was made, predisposing,
initiating and aggravating factors unearthed and an appreciation for AJ’s
attitudes habits and health was gained.
DIAGNOSIS
AJ’s condition was labeled with a diagnosis of Severe Generalized Chronic
Periodontitis with primary plaque etiology and secondary factors being calculus
and stress. The following observations were made concerning the chronicity of
the condition:
1. AJ is an adult (although the disease can present at any age).
2. The amount of destruction documented was consistent with a high
plaque score of 72%.
3. Subgingival calculus was substantial.
4. May have been modified by stress (also may have worsened acutely
when her son was murdered).
A generalized distribution was given due to the involvement of 40% of the sites
(greater than 30% in the chronic form) and a severity assigned due to greater
than 6mm pocket depth and greater than one third alveolar bone loss when
seen radiographically in the worse affected sites.
Page54
PREDISPOSING, INITIATING AND AGGRAVATING FACTORS
Deposits of plaque and calculus were a significant finding. Also of note was AJ’s
repeated mention of the loss of her son and the relationship that she was
previously in. During two of the appointments she broke down in tears when
asked how he son died and about whether counseling was received. It was at
this time that she revealed that the person she entered a relationship with
caused her son to be murdered and referred to him as a “pest”. Interestingly she
asked if she” could cry” in the dental chair. AJ also admitted to binge eating
sugary foods such as cakes to feel better about her situation and did not brush
before bedtime.
There was complete bone loss recorded radiographically on #11and #21 with
the latter showing a grey discoloration. AJ reported that she suffered trauma to
this region after falling and hitting edge of a concrete staircase. This event may
have certainly exacerbated her developing periodontal condition.
Individual tooth diagnosis
Diagnoses of each tooth were made in order to treatment plan accordingly. In
addition AJ was able to be advised on how supported each tooth was (excluding
the root stumps). This diagnosis was made according the following criteria
(Nyman and Lindhe 89):
• Periodontitis levis (overt periodontitis): Horizontal bone loss less than
one third the root length, bleeding on probing
• Periodontitis gravis (advanced periodontitis): horizontal bone loss greater
than one third the root length, bleeding on probing
• Periodontitis gravis et complicata
o Angular bony defect (infrabony pocket, interdental osseous crater)
present adjacent to the tooth
o Furcation involvement of grade II and III have been identified in a
multirooted tooth.
Page55
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Gingivitis Periodontitis
levis
Periodontitis gravis
-et complicata
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Gingivitis Periodontitis
levis
Periodontitis gravis
-et complicata
Page56
It was then prudent to perform a tooth by tooth risk assessment or prognosis in
order to fully present the case to AJ. The root stumps present were assigned a
prognosis for the sake of intention to extract. This was based on clinical criteria
surrounding periodontal endodontic and dental factors. These are as follows:
Hopeless prognosis
o Periodontal
Recurrent periodontal abscesses
Periodontic-endodontic lesions
Attachment loss to the apex
o Endodontic
Root perforation in the apical half of the root
Periapical pathology in the presence of obturating post
and core
o Dental
Long fracture of the root
Oblique fracture in the middle third of the root
Caries lesions that extend into the root canal
o Functional
Third molars without antagonists and with
periodontitis/caries
Page57
Questionable prognosis
o Periodontal
Furcation involvement
Angular bone defects
Horizontal bone loss involving > two-thirds of the root
o Endodontic
Incomplete root canal therapy
Periapical pathology
Presence of voluminous posts/screws
o Dental
Extensive root caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Good prognosis/
secure
Questionable prognosis
Hopeless prognosis
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Good prognosis/
secure
Questionable prognosis
Hopeless prognosis
Page58
TREATMENT
Treatment was initiated and diagnosis of moderate to severe generalized
chronic periodontal disease warranted a treatment plan that included:
I. Initial phase therapy
1. Motivation and OHI
2. Extraction of hopeless teeth and root stumps
3. Restore #16M and #47O
4. Scaling and root planing
5. Minor occlusal therapy
6. Reassess 6-8 weeks
Initial phase therapy is aimed at eliminating infection and gaining control of
plaque levels. The stage must be set for the start of healing. AJ’s motivation and
oral hygiene instruction was a challenge. Several different aids were
administered including four different types of brushes that were suited for the
wide interproximal areas, lone standing teeth, the extensively receded palatal
regions and for general cleaning. This occurred after it was noticed that the
plaque distribution but persisted in certain areas, namely palatal (particularly just
below the subgingival margin) of the upper incisors. Although the upper central
incisors were deemed hopeless they were not initially extracted for esthetic
purposes as well as to re-evaluate after scaling. It proved quite difficult for AJ to
keep these clean even after issuing an angled single tufted brush. The brush
itself cleaned well but AJ’s motivation for this area waxed and waned thus re-
establishing the prognosis of these teeth. #37 and #47 were retained in the
mouth. Their mesial interproximal surfaces were almost always covered with
plaque until a smaller round headed brush was administered for these teeth.
Ideally a single tufted brush would have been preferred. The mobility and
recession of the gingiva that occurred as a result of active disease resulted in
Page59
wide embrasure space especially anteriorly where there was loss of contact.
Various interproximal brushes became necessary. AJ even discarded her first
set thinking that they were disposable. This saw a spike in plaque score from 18
to 47%. Her lowest plaques score to date has been 9%.
At the late stage of treatment AJ was quizzed on her condition. She was asked
to tell everything she understood about her disease. This served to refresh her
knowledge mid treatment and to ensure that the goal of disease management
with regard to primary plaque etiology, remained of importance and to highlight
the susceptibility of sites to deteriorate.
Extraction of the hopeless teeth including root stumps was traumatic for AJ.
While the provision of local anesthesia was adequate she would always cry out.
AJ had to be counseled on managing her anxiety during dental extractions and
came to control it very well. Some of the root stumps, particularly #47, were
heavily invested by dense granulation tissue. This led to prolonged healing of
the extraction sites and difficulty of cleaning the teeth adjacent to them.
The two restorations outlined in the treatment plan were uneventful with the
exception of a pin point pulp exposure on #47. This was addressed with a direct
pulp cap and AJ was advised but possible sequelae. The tooth will be monitored
for symptoms of pulpitis but is expected to repair itself after the capping
procedure was done.
Scaling and root planing including deep scaling was performed. There was
difficulty in removing calculus in some areas as the deposits were highly
aggregated and surrounded by purulent granulation tissue. Marked bleeding
accompanied the procedure prompting a need on occasion to re-visit scaled
sites. This was aided by post- scaling gingival recession. A second round of
scaling was then carried out after the first re-evaluationn but this was only in the
upper anterior sextant.
Page60
Minor occlusal therapy on #13 was thought to have been necessary. However
an occlusal analysis was not carried out until the 28/01/13. In addition AJ would
always comment that the tooth “dropped” and was not always in that position.
Findings of the analysis included:
The cusp of #13 is proving to be working side interference. Occlusal contact is
solely occurring between #13 and #44 and #15 and #45. This is the only support
and means of mastication with group function in lateral excursion to that side.
The initial phase therapy terminated with two re-evaluations of all parameters
of a full periodontal assessment. A summary of the findings is as follows:
First:
Initial Periodontal Assessment
Periodontal Reassessment
Full Mouth Plaque Score
72% 9%
Full Mouth Bleeding Score
53% 32%
Deepest Pocket 6mm 6mm
Diseased Sites 46% 27%
Pockets ≥ 6mm 25% 5%
Recession 23% of sites 20% of sites
Mobility Degree 1
Associated with 5 teeth Associated with 3 teeth
Mobility Degree 2
Associated with 0 teeth Detected in 1 tooth
Mobility Degree 3
Associated with 3 teeth Associated with 1 tooth
Furcation involvement
Associated with 3 teeth Associated with 1 tooth
Page61
Second:
Initial Periodontal Assessment
Periodontal Reassessment
Full Mouth Plaque Score
9% 9%
Full Mouth Bleeding Score
32% 15%
Deepest Pocket 6mm 7mm
Diseased Sites 27% 11%
Pockets ≥ 6mm 5% 5%
Recession 20% of sites 20% of sites
Mobility Degree 1
Associated with 3 teeth Associated with 3 teeth
Mobility Degree 2
Associated with 1 tooth Detected in 1 tooth
Mobility Degree 3
Associated with 1 tooth Associated with 1 tooth
Furcation involvement
Associated with 1 tooth Associated with 1 tooth
Aims of treatment were:
1. < 10 %, of sites BOP
2. No sites with PPD > 5 mm, but preferably < 4 mm
3. No furcation involvement of degree II or III.
4. Satisfy the patient's demands regarding esthetics and masticatory
function.
The level of bleeding in the mouth reduced but is still significantly high. This
becomes important for stability as there is a 30% probability for attachment loss
for sites with repeated bleeding. While there was a general reduction in probing
depths (#11 and #21 had minor reduction but were largely unresponsive after
Page62
first re-assessment), probing depths of 5mm appeared sporadically with one site
recording 6mm in the first re-assessment and three sites recording 7mm in the
second re-assessment. Elimination of advanced furcation involvement was
achieved however furcation plasty can be considered for #47 which retained a
grade I furcation involvement.
II. Corrective phase
1. Adjunctive antibiotic treatment if necessary in local areas
2. Transitional denture in lower arch for posterior support with
concurrent adjustment of the supra-erupted #13 effort to address
occlusal discrepancy (modified 01/02/12)
3. Transitional denture for upper arch (decision to replace teeth on the
free end saddle is tentative) to be modified and include #11 and #21
post extraction
The adjunctive antibiotic treatment was not explored to date. After much deferral,
extraction of #11 and #21 were finally decided on only to have AJ refuse on the
day of the appointment. The immediate denture was fabricated for this
appointment. However the occlusal analysis conducted after this roadblock
resulted in the realization that more effective treatment planning for the
temporary prosthesis at this stage had to be done and that replacement of the
central incisors were only for esthetics while her masticatory function was
lacking. As a result the immediate denture may not be used as AJ is currently in
the treatment phase for fabrication of a lower transitional denture instead to first
address the occlusal discrepancies including the supra-erupted #13. Extraction
of the central incisors will eventually be carried out.
Page63
Final Reconstructive phase
1. Orthodontic treatment if feasible
2. Final removable/fixed prosthodontic therapy
3. Supportive periodontal care during reconstructive/orthodontic phase
4. Referral for psychological counseling
To date this phase has not been entered. Active treatment including a third
round of scaling and root planing in persistent sites will be done before re-
evaluation for suitability for fixed reconstruction. However, referral for
psychological counseling will be embarked upon even now as this may affect
the desired outcome.
Final 3 month evaluation
V. Supportive periodontal therapy or maintenance
This phase requires stability and will be entered once there is the satisfaction of
control over the inflammatory degeneration. As mentioned previously a high
bleeding score indicates active inflammation and this along with residual sites
greater than 5mm are persisting are preventing AJ from currently entering this
phase.
Page64
CRITICAL APPRAISAL
Scaling and root planing therapy commenced in 18/09/12 and was completed on
25/10/12. This gives a time span of seven weeks. This time span was too
lengthy compared to the preferred period of two weeks. Reassessment is
recommended to be done within a 6-8 weeks following therapy. However this
was done 5 weeks after last scaling and approximately 10 weeks after scaling of
first quadrant. This lapse in time may have affected the success of the therapy.
Performing an occlusal analysis was planned to be part of the pre-treatment
analysis. However it was overlooked prior to the fabrication of the transitional
denture to replace the central incisors. This led to the neglect of the lack of
posterior support that AJ was now experiencing due to the extraction of several
hopeless teeth. The need to fabricate a new denture to accommodate the new
masticatory relationships arose when the occlusal analysis and relevant
consultations were done. The fortunate outcome is that it can be used as a
transitional denture to acclimatize her to the experience of wearing a more
permanent prosthesis. In addition AJ developed indecisiveness towards
extraction of the upper central incisors. This may have been due to lack of a
clear indication to her as to the severity of the loss of periodontal support
affecting these teeth. The transitional denture may prove to get her closer to the
point of extraction of the upper central incisors.
Skills in handling “tough” calculus could have been improved upon. This would
reduce the number of re-visits necessary to remove residual deposits
Page65
OPPORTUNITIES FOR LEARNING
Early recognition of the toll that the loss of a child had on AJ followed by quick
referral had the potential to set in motion the process of creating a
stress/depression free background to periodontal therapy. It was indeed
overlooked as she commented that she was better now until she broke down
into to tears in the dental chair on two occasions. This has certainly broadened
my scope with regard to modifying factors in periodontal disease as well as the
minor role I may play as a clinician in improving the overall health of my patients.
CONCLUSION
While the treatment of chronic periodontitis revolves around the cause related
therapy of plaque control and calculus removal, modifying factors must be
appreciated, end- treatment goals may be far off if this is not considered.
Intense life stresses and psychological factors may certainly contribute to the
falling short of these goals and thus must not be overlooked or postponed if
identified.
Page66
Referral Letter
University of the West Indies Dental School,
Eric Williams Medical Science Complex,
Uriah Butler Highway,
Trinidad
February 7th, 2013
Dr. X
Consultant Periodontologist,
Eric Williams Medical Sciences Complex,
Uriah Butler Highway,
Trinidad
Re: Periodontal Management of AJ
Dear Dr. X,
AJ is a fifty-five year old female who presented to our polyclinic on 14/02/2012
with complaints of the presence of buildup around teeth, bleeding gums and
tooth malposition.
AJ’s medical history has not revealed any particular condition of major concern.
Her lifestyle however was previously marked by extreme stress.
Clinical and radiographic examinations revealed generalised supragingival and
subgingival plaque and calculus deposits along with generalised attachment
loss. Basic periodontal examination gave (*) scores for all posterior sextants. A
diagnosis of Moderate to Severe Generalized Chronic Periodontitis was
established.
Page67
Initial phase therapy has been performed in all quadrants however most pockets
show improvements while others have worsened.
Your detailed assessment of the patient and any recommendations for further
management would be greatly appreciated.
Yours truly,
..................................
Tamika Peters
Dental Student
Page68
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inflammation....sometimes! Biol Psychiatry, pp. 280-281.
Heasman, P. (2003). Master Dentistry, Restorative Dentistry, Paediatric Dentistry and Orthodontics. Churchill Livingstone.
Higert, J., Hugo, F., Bandeira, D., & Bozzetti, M. (2006, April). Stress, cortisol, and periodontits in a poulation aged 50 years and over. Journal of Dental Research, pp. 324-328.
Iacopino, A. (2009). Relationship between stress and periodontal disease. Journal of the Canadian Dental Association, 329-330.
Irwin M, P. T. (1990, February). Reduction of immune function in life stress and depression. Biol Psychiatry, pp. 22-30.
Lindhe, J. (2003). Clinical Periodontology and Implant Dentistry. Oxford: Blackwell Munksgaard.
Ng, S., & Keung Leung, W. (2006, April). A community study on the relationship between stress, coping, affective dispositions and periodontal attachment loss. Community Dental and Oral Epidemiology, pp. 252-266.
Peruzzo, D., Benatti, B., Ambrosano, G., Nogueira-Filho, G., Sallum, E., & Casati, M. (2007, August). A systematic review of stress and psychological factors as possible risk factors for periodontal disease. Journal of Periodontology, pp. 1491-504.
Rosania, A., Low, K., Mc Cormick, C., & Rosania, D. (2009, February). Stress, depression, cortisol and periodontal disease. Journal of Periodontology, pp. 260-266.
Ramlogan, S; Raman V. Lecture notes in Periodontology. UWI School of Dentistry