Clinical Cases in Periodontics. Группа авторов

cell carcinoma) conditions

      6 Endocrine, nutritional and metabolic diseases (vitamin C deficiency)

      7 Traumatic lesions (chemical or thermal burns)

      Questions to help develop a differential diagnosis include the following:

       How often do you brush or floss?

       Do you bruise easily?

       When you wake up do you notice any blood in your mouth?

       When you cut yourself, do you tend to clot within a normal amount of time?

       What medicines are you taking currently?

       Are you pregnant (for female patients)?

       Are you a mouth breather? Do you have difficulty breathing through your nose?

      B. A patient should ideally brush twice daily and floss once daily. Evidence indicates that use of rotary brushes is better than manual brushes for interproximal plaque removal and stain removal [6,7]. A toothbrush with soft bristles is strongly recommended. The bristles should be positioned at a 45‐degree angle to the junction of the tooth and marginal gingiva, and then the brushing should be initiated using short circular gentle motions (Bass method of brushing). The same technique should be repeated for the rest of the mouth. If a patient has gingival recession, coronal sweeping motion of bristles from the gingiva to the teeth is recommended to prevent the progression of recession (modified Stillman’s technique).

      C. Smoking has been identified as an important risk factor for periodontitis [8]. The number of cigarettes an individual smokes per day and the number of years an individual has been smoking are two important parameters strongly associated with the degree of attachment loss [9]. It is well established that smoking affects the host immune response, causes local tissue ischemia, and also alters the bacterial profile, shifting the plaque ecology and increasing the periodontal pathogens in the host [10]. This risk factor is “behavioral” and can be modified. Smoking causes an increased risk for oral and throat cancers [11]. Oral cancer is the sixth most common cancer in males and the twelfth most common cancer in women in the United States [12].

      D. A thorough extraoral examination should be conducted. Visualization and palpation of the soft tissues of the head and neck should be completed including palpation of the muscles and lymph nodes. The intraoral examination should consist of visualization and palpation of the tongue. The tongue represents the most common site (50%) for oral cancer, and the ventral and lateral surfaces (20%) in particular have a higher predilection for cancer than the dorsal surface of the tongue (4%) [12]. The floor of the mouth is the second most common site for oral cancer, and therefore careful examination of this area of the mouth should be a part of cancer screening. Other areas that should be examined specifically for oral cancer include the soft palate, gingiva, and buccal and labial mucosa [12].

      E. A periodontal examination includes visually assessing and recording the gingival color, contour, consistency, texture, presence or absence of exudates from sulcus, and bleeding on probing. Six probing depths (mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, and distolingual) per tooth should be recorded. Areas of recession, mobility, and furcation involvement are also recorded and graded according to the established classifications for each of these parameters. In addition, the width of the keratinized gingiva for each tooth is recorded. Radiographs and study models are also important because they offer valuable information that is not obtained from the clinical oral examination.

      F. The following are essential components of a periodontal chart:

       Name of the patient and the date of recording.

       Missing teeth should be recorded.

       Probing pocket depth: measured on six surfaces of each tooth in the mouth using a periodontal probe.

       Degree of recession: measured using a periodontal probe.

       Mobility: measured using two flat ends of dental instruments such as dental mirror and/or periodontal probe and pushing the teeth with one instrument against the second instrument.

       Fremitus: assessed by placing the inner pad of the fingers on the gingiva of the teeth in question and asking the patient to tap teeth three or four times. In traumatic occlusion, fremitus is usually felt by the examiner’s fingers, which is then recorded.

       Degree of furcation involvement: examined using Naber’s probe.

       Mucogingival complex: the width of the mucogingival complex (keratinized gingiva) should be measured from the gingival margin to the apical‐most part of the attached gingiva in every tooth, using a periodontal probe, and recorded.

      G. Radiographs form an essential component of a periodontal examination. Apart from providing information about the supporting hard tissue apparatus of the tooth in question, other valuable information such as root length, root form, periapical lesions, and root proximity can be ascertained. The American Dental Association recommends taking a full‐mouth set of radiographs for a full diagnosis (typically every five years). A set of four bitewings should be exposed every two years. The diagnosis of periodontal disease can be made using clinical findings and radiographic findings provided by periapical radiographs and bitewing radiographs. Bitewing radiographs are the most diagnostic for reading bone height because the head of the X‐ray tube is perpendicular to the film. Vertical bitewings are recommended for areas with extensive bone loss. In general, paralleling technique is recommended over bisecting angle technique because it reduces the errors associated with film angulations.

      H. Clinical attachment loss (CAL) (distance from the cementoenamel junction to the base of a periodontal pocket) and bone loss as seen on a radiograph are the gold standards used to help distinguish a patient with periodontitis versus gingivitis. Patients with gingivitis do not exhibit CAL and bone loss (radiographically) making it a reversible condition (with treatment), whereas if the diseases progresses to periodontitis, CAL and bone loss are characteristically observed.

      I. Referral to a physician should be made to rule out any systemic conditions.

      J. Gingivitis can occur on an intact periodontium, a reduced periodontium due to non‐periodontitis causes (mainly gingival recession induced) or a reduced periodontium induced by periodontitis (but successfully treated).

      K. The clinical signs of gingivitis include bleeding on probing, swelling, redness and sensitivity to probing. The symptoms include bleeding gums, pain, halitosis, unesthetic appearance, and difficulty in consuming food.

Case 1.3 Non‐Plaque‐Induced Gingivitis

      CASE STORY

      A 41‐year‐old Latin American female presented with a chief complaint of “My gums and teeth are sensitive.” She had been referred by her general dentist for periodontal treatment. She reported a five‐year history of gingival sensitivity and progressive gingival recession. She experienced lingering pain after drinking hot and cold liquids and also noted sensitivity when brushing.

      LEARNING GOALS AND OBJECTIVES

       To distinguish desquamative gingivitis from plaque‐induced gingivitis

       To formulate a differential diagnosis for common causes of desquamative gingivitis

       To develop a definitive diagnosis and properly manage a patient with desquamative gingivitis

Medical History

      The patient denied a significant medical history. The patient had been seeing a