Impact of Stage II Periodontitis on Oral Health

Impact of Stage II Periodontitis on Oral Health: A Case Study on Non-Surgical Periodontal Therapy in a Medically Compromised Patient Arielvys Fernandez Febles MCPHS February 18, 2024 Using Non-Surgical Periodontal Therapy in Managing Stage II Periodontitis The patient considered for assessment is a Hispanic female 36 years old. The patient had a history of hypercholesterol, hypertension, and poor oral health practices but is currently improving on these conditions. She was using Atorvastatin and Lisinopril to manage her hypercholesterol and hypertension, which appeared to be closely associated with her oral health issues. The 36-year-old Hispanic female patient suffers from several serious medical problems that have a substantial impact on her oral health. Several studies have found associations between periodontal disease and markers of cardiovascular risk, including high cholesterol levels. One possible explanation for this connection is that both conditions involve inflammation as a common underlying mechanism. Inflammation is vital in developing and progressing both periodontal disease and atherosclerosis. The patient class IV Mallampati classification, and while there is no direct correlation between Mallampati classification and sleep apnea, mouth breathing can affect oral tissues in several ways. Mouth breathing can lead to decreased saliva production, resulting in xerostomia. Saliva is crucial in maintaining oral health by lubricating the mouth, neutralizing acids, washing away food particles, and preventing bacterial overgrowth. A dry mouth environment can increase the risk of oral health issues such as cavities, gum disease, and bad breath. The plaque index gave critical information about the efficacy of the patient’s home care program. Biofilm is a significant factor in developing many oral health issues, including cavities, gum disease, bad breath, and tooth discoloration. Regular and effective oral hygiene practices prevent plaque buildup and maintain optimal oral health. This case study investigates the complex interaction between the patient’s medical issues and their influence on oral health, particularly in designing a personalized non-surgical periodontal treatment strategy. Medication reviews, complete risk assessments, detailed assessment results, essential subjects to examine, preventive tactics, and suitable treatment options are all vital components of this project. We strive to provide thorough and effective treatment using a non-surgical approach that considers the patient’s underlying medical issues and her periodontal health. History Review Condition Research suggests that various medical disorders affect oral health. According to Haas et al. (2021), people with a history of hypercholesterolemia and hypertension may have alterations in taste perception, oral lesions, and xerostomia as a result of drugs like lisinopril and atorvastatin. Individuals with particular oral symptoms are more likely to develop dental caries and periodontal disease (PD). According to research by Haas et al. (2021), periodontal disease and hypertension are symbiotic, which implies that if one is not addressed, the other will worsen. Those using high blood pressure and cholesterol medications should prioritize good dental hygiene to reduce their risk of developing periodontal disease and other oral health problems. Comprehensive management strategies are required to treat or prevent oral and systemic health problems. This is owing to the oral-systemic link between hypercholesterolemia, hypertension, and periodontal disease. Haas et al. (2021) state that only multidisciplinary collaboration between medical and dental health specialists can achieve optimum patient outcomes and general well-being, especially among vulnerable populations. Teaching people with particular medical conditions how to care for their teeth is essential. Proper care includes: • Regular dental appointments. • Tongue and teeth cleanings. • Taking the medicines for hypertension and hypercholesterol as directed. Increasing patient participation and awareness may aid in managing oral health difficulties in conjunction with systemic diseases, which is critical for maintaining overall well-being. Medication Review According to the patient’s medication history, the drugs that she is currently using include Fenofibrate, Lisinopril, and Atorvastatin to manage hypertension and hypercholesterolemia. When prescribing these medications to a patient, it is critical to understand their drug classification, actions, side effects, and oral health implications to ensure improved patient education and comprehensive patient care (Khan et al., 2021). Through such understanding, a healthcare provider must understand the oral side effects that these medications could have. Fenofibrate: Fenofibrate, a fibric acid derivative, is often administered to patients with hypertriglyceridemia. Its main mechanisms of action include increased HDL cholesterol and reduced triglyceride levels. Despite being typically well tolerated, fenofibrate may cause gastrointestinal problems such as nausea, diarrhea, and stomach discomfort. These adverse effects may cause dental health difficulties, influencing what patients eat and how often they wash their teeth (Khan et al., 2021). Additionally, this medicine has been linked to relatively uncommon side effects such as rhabdomyolysis and myopathy. Lisinopril: Lisinopril, an ACE inhibitor that reduces blood pressure by relaxing blood arteries. Despite being tolerated well, lisinopril can harm dental health in those with recurrent dry cough. If this medicine causes continuous coughing, mouth disorders including angular cheilitis, ulceration, and mucosal irritation, may develop (Khan et al., 2021). Furthermore, lisinopril, like other enzyme inhibitors that cause angioedema, may cause swelling in the lips, tongue, and neck, which may restrict airways and be fatal. Atorvastatin: Atorvastatin, an HMG-CoA reductase inhibitor, is used to treat hypertriglyceridemia. It mainly decreases LDL cholesterol levels, lowering the risk of cardiovascular disease. Two of the most common adverse effects of atorvastatin include alterations in taste and dry mouth (Martignon et al., 2019). Because xerostomia weakens the mouth’s natural defenses and reduces salivary flow, it raises the risk of oral infections such as periodontal disease and dental caries. Flavor differences may impact what people eat and how often they brush their teeth, exacerbating oral health problems. Risk Assessment Caries Risk Assessment We employ the Caries Management by Risk Assessment (CAMBRA) technique to assess a patient’s risk of acquiring dental caries. This assessment tool estimates an individual’s risk by considering systemic conditions, oral hygiene practices, dietary habits, past caries encounters, and dental exam results (Martignon et al., 2019). The patient’s oral health is jeopardized due to inadequate dental hygiene habits and a family history of tooth decay. Sugary meals and drinks increase acid production, which increases the risk of caries and enamel demineralization. Even worse, inadequate dental care increases plaque formation and inflammatory gingiva, breeding grounds for germs. If dental caries run in the family, a genetic predisposition raises the risk. The risk of these disorders may be reduced by changing one’s diet, improving dental hygiene habits, utilizing fluoride, and scheduling frequent dentist visits for exams and operations. Periodontal Risk Assessment: The AAP risk assessment technique is used to calculate the risk of periodontal disease. Considerations include smoking status, systemic health, gingival health, and oral hygiene behaviors (Raison et al., 2020). Patients with poor dental hygiene are more prone to develop periodontal disease, which may lead to gum inflammation and plaque buildup. Poor plaque management may promote the development of bacteria and inflammatory reactions, causing periodontal tissue damage. Systemic diseases, such as hypercholesterolemia and hypertension, are linked to an increased risk of periodontal inflammation, which vascular alterations and immunological dysregulation may cause. The mitigation strategy comprises optimal practices for plaque management, frequent dentist visits for periodontal evaluations, and consistent use of the prescribed oral hygiene products. Oral Cancer Assessment: The clinical examination and the patient’s medical history are the two most essential factors in determining the risk of developing oral cancer. The patient’s medical history is reviewed to identify risk factors such as alcohol and tobacco use, mouth cancer, and human papillomavirus (HPV) infections. A thorough clinical examination of the oral mucosa, lymph nodes, and soft tissues is required to detect malignancy (Rajendiran et al., 2021). Because Hispanics are more susceptible to acquiring oral cancer, extraoral tissues and other parts of the mouth cavity should be thoroughly evaluated for abnormalities. Any abnormality, such as red or white patches, ulcers that do not heal, indurations, or nodules, need further diagnostic testing, typically includes a biopsy for confirmation. Assessment Findings Extraoral/Intraoral Examination Several findings were made during the extraoral/intraoral examination. One of them involved prominent papillae and a coated tongue. These findings indicate poor oral hygiene practices, contributing to bacteria accumulation on the tongue surface. Based on these findings, the patient should be educated on appropriate tongue-cleaning techniques for improved oral hygiene (Rajendiran et al., 2021). The second one involved gingival redness and edema. Marginal redness and generalized gingival edema are indications of inflamed gingival inflammation caused by poor oral hygiene and plaque accumulation. These oral indications show the need for periodontal therapy and thorough plaque removal to restore gingival health and address inflammation. Another finding involved extrinsic stains. Based on this finding, extrinsic stains were noted in the entire mouth, indicating the possibility of poor oral hygiene and poor dietary habits (Rajendiran et al., 2021). Radiographs Numerous radiographic findings were obtained. Bone loss, caries, and radiographic calculus were mainly noted. For instance, 15%—33% bone loss was evident among patients with Stage II periodontitis. This bone loss level shows moderate periodontal disease that should be addressed immediately to prevent tooth loss and further progression of the disease. The radiographic findings also show the need for treatment planning and restorative interventions. Critical Considerations Periodontal Probing Periodontal probing considers various aspects, especially bleeding points and pocket depths. Accurate assessment and identification of these aspects provide critical information regarding the presence of active inflammation and the severity of periodontal disease. In this case, 3-4 mm of probing depth implies mild to moderate periodontitis, while 5 mm of localized pockets show advanced periodontitis. Clinical Attachment Level (CAL) CAL calculation determines the distance between the cementoenamel junction (CEJ) and the gingival margin or periodontal pocket base. This measurement shows periodontal attachment loss and assists in determining periodontal disease severity. As per the described patient, the CAL is six sites per tooth for comprehensive attachment level assessment. Any issue noted between clinical attachment levels and probing depths may be explored later to enhance the understanding of the possible diagnosis and necessary treatment plan. Mucogingival Considerations Mucogingival junction identification and attached gingiva assessment are critical in periodontal evaluation. As per the patient assessment, the mucogingival junction was assessed visually during probing for reference. Besides, the attached gingiva width was determined between the mucogingival junction and the gingival margin by applying a periodontal probe (Seyam et al., 2021). Different regions with inadequate attached gingiva of less than 1mm were identified due to their susceptibility to recession and need special attention when developing a treatment plan. Mobility Tooth mobility assessment is critical in periodontal ligament integrity and alveolar bone support. In evaluating the described patient, every tooth was palpated gently, and then its mobility was determined by applying a Miller classification system with a range of 0-3. The fremitus presence determined through teeth palpation when a patient taps the teeth together or biting down shows the possibility of tooth malalignment or occlusal trauma causing mobility (Seyam et al., 2021). The patient’s mobility measurement was recorded as 0-1 to assist in determining the prognosis and making the treatment decisions. Furcation Involvement Furcation involvement’s accurate identification and classification are critical when assessing patients with periodontal diseases to determine the severity of the condition and the necessary treatment plan. Regarding the patient’s furcation involvement, it was evaluated visually and determined through a clinical process applying a furcation probe. The furcation involvement degree was noted as Class I by considering bone loss extent and furcation area accessibility. Class I furcation involvement, the bone loss is limited to the area immediately below the gumline and does not extend to the full extent of the furcation. Furcation involvement’s accurate documentation enhances periodontal health monitoring and appropriate management. Other Critical Aspects Prognosis As per the assessment information, the patient will likely experience a fair to good prognosis. However, this can only be achieved if a timely treatment intervention is considered (Weik et al., 2023). The general prognosis is determined through various considerations, especially the tissue response to therapy and the patient’s oral hygiene. Staging and Grading According to the information available, the patient was diagnosed with Stage II periodontitis and Grade B. The factors considered in staging and grading include the severity and extent of periodontal destruction. The staging can be confirmed through clinical attachment loss (CAL) and radiographic bone loss (RBL). The grading can be attributed to the destruction of biofilm. Treatment Plan An evidence-based treatment plan must be developed for the assessment of the patient’s effective treatment. This involves considering non-surgical periodontal therapy and dental caries management. Creating a treatment plan aims to restore periodontal health, arrest caries progression, and prevent future disease. The plan designed for this patient included scaling and root planing by quadrant with local anesthesia, along with subgingival irrigation with Chlorohexidine Gluconate 0.12% and Arestin. Informed Consent Ethical considerations are critical when assessing and treating patients with various health issues. One of the most appropriate ethical principles to consider in the assessed patient case is informed consent (Slot et al., 2020). This involves informing the patient about the procedures to be conducted and their risks and benefits. The patient’s acknowledgment allows healthcare providers to proceed with the treatment. Prevention Patient Education Various aspects are considered when preventing various oral health issues, such as periodontal disease (Weik et al., 2023). However, one of them is patient education. As per the patient’s assessment, the education necessary should focus on dietary modifications and oral hygiene. The education considered should aim to prevent the disease from progressing. Oral Self-Care Another appropriate strategy for preventing periodontal disease progression is oral selfcare. This strategy involves effective tongue cleaning, flossing, brushing, and increased dental visits (Slot et al., 2020). A dental professional should assess the patient regularly to ensure she adheres to these practices. Adjunctive Products Various products can be used to manage periodontal disease through oral health promotion. Some include antimicrobial mouthwash and fluoride toothpaste to minimize the risk of periodontal disease and caries (Slot et al., 2020). These products have been proven effective through evidence. The patient was prescribed Chlorohexidine rinse and Prevident 5000 dentifrice. Nutrition Counseling Nutritional counseling has been considered one of the most effective strategies for addressing oral health issues (Van der Weijden et al., 2019). This involves educating the patient on the food types to avoid and the ones to prioritize. For instance, the patient’s recommendations should reduce sugary foods and increase a balanced diet. Pain and Anxiety Control Treatment approaches necessary to the described should effectively minimize pain and anxiety. The use of local anesthesia was utilized to reduce the patient’s pain, thus reducing the patient’s anxiety. Constant communication with the patient was also used to reduce her anxiety during treatment. The patient was also recommended to use her headphones to listen to music to relieve stress. Re-Evaluation A follow-up plan involving the appointment for the patient’s return to the clinic was developed. This will ensure an effective re-evaluation of the patient’s health condition and adjustment in the treatment plan. The tissue response for the previous quadrant was evaluated during each treatment. The patient reported little to no bleeding during brushing or flossing. The patient was scheduled to return in four weeks to assess the complete tissue response and pocket depths. Self-Assessment The practice involving comprehensive assessment and treatment of a 36-year-old Hispanic female diagnosed with Stage II periodontitis was much educative and beneficial to my clinical practice. I effectively performed the necessary clinical practices through evidence-based approaches and consideration of patient-centered care services. The disease identified was significantly supported by evidence, thus making it easy to develop a prevention and treatment plan. If the patient adheres to the developed treatment plan, she will likely experience improved outcomes.

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