Simulated Patient Case –

Nancy Carp
This patient case was designed to
 Reinforce course content

 Simulate critical thinking

 Incorporate comprehensive, multidisciplinary, phased

and sequenced treatment planning
 Integrate common clinical decisions encountered in
managing patient with periodontal disease
 Showcase outcomes of periodontal therapies
“What if…” Scenarios and Questions
The symbol  indicates a hyperlink to supplemental
slides that provide “What if…” scenarios and questions
meant to enhance student learning opportunities
 Scenarios/questions provide further ways to
– Identify important patient management issues
– Emphasize clinical relevance of course content
 Students should answer posed questions and be
prepared to discuss them during seminar

Note: In order for hyperlinks to function, you must use the PowerPoint Presentation mode.
When you point to a hyperlink, the pointer becomes a hand, indicating that symbol  will link
you to the appropriate supplemental slide.
Simulated
Patient Case –
Nancy Carp **

Part 1
 Patient Case – Nancy Carp
Your tasks for Part 1 are to
 Review patient case

 Provide
– Contraindications/precautions to dental treatment
– Radiographic interpretation
– Gingival description
– Diagnoses
– Etiologies and risks for oral diseases
– Responses to “What if…” scenarios/questions
Your responses for Tasks 1-5 and What if scenarios 1-8 should be recorded on your response
sheet.
Your Response Sheet will be turned in and given back to you during the seminar.
You will need the Response Sheet for Part 2 of this case.
 Patient Demographics
 Age - 57 years old
 Race - African-American
 Gender - female
 Occupation - human resource assistant
 Marital status - married, two children 23 and 26

**
 Chief Dental Complaint
 “I don’t like the way my front teeth look and I’m afraid of
the dentist”
 Medical History
 Hospitalizations
– Childbirth x 2
– Shoulder replacement (3 years ago) 
 Systemic diseases
– Diabetes (Type II)
– Hypertension
 Medications
– Glynase® 5 mg BID
– Glucophage® XR 500 mg QD
– Prinzide® 20/12.5 mg QD
– Aspirin 81 mg QD 
 Allergies - Penicillin (usage results in hives)
 Medical History
 Chemistry 
– Plasma glucose concentration (non-fasting) - 140 mg/dl
– HbA1c - 6.5%
 Respiratory rate - 14 per minute
 Blood pressure - 110/72 
 Pulse rate - 68 beats per minute and regular
 Task 1 – Provide Medical
Contraindications and/or
Precautions to Dental Treatment
Guidelines
 Consider the following in patient management
– Systemic diseases/conditions
– Medications
– Antibiotic prophylaxis
– Stress/anxiety management
– Vital signs
– Chemistry
– Other
 Dental History
 Lost tooth # 9 due to trauma as a child
 No dental treatment in the past 20 years
 Fluoride exposure - < 3 times per day
– Uses Nutrismile® all natural toothpaste
– Consumes fluoridated water
 Sucrose exposure - < 2 times daily
 No report of xerostomia
 Previous restorative or periodontal treatment - none
 Family dental history - noncontributory
 Oral habits - none
Initial Examination
Sextant 1 - Initial
Initial
Sextant 2 - Initial
Initial
Sextant 3 - Initial
Initial
Sextant 4 - Initial
Initial
Sextant 5 - Initial
Initial
Sextant 6 - Initial
Initial
 Intra-oral Findings - Initial
 Extra-oral findings - within normal limits
 Missing - tooth #9
 Fixed prosthesis - teeth #8 -10
 Caries - teeth #4 mesial and #21 facial
 Marginal and papillary gingiva generally edematous
 Supragingival and subgingival calculus detected
 Intra-oral Findings - Initial
 Plaque index (% surfaces plaque free) - 8%
 PD ranged from 2-7 mm with 44% ≥ 4 mm
 CAL ranged from 1-5 mm with 14% ≥ 4 mm
 BOP - 49% of the sites
 Furcation involvement - none
 Intra-oral Findings - Initial
Occlusal Evaluation
 Class III molar and canine relationship bilaterally
 Overbite and overjet - 1 mm
 End to end contact with remaining anterior teeth
 CR to CO slide - ≤0.5 mm
 Fremitus - Tooth #12
 Mobility - Class I, tooth #12
 Wear facet
– Tooth #3
– Tooth #14
 Intra-oral Findings - Initial
Occlusal Evaluation
 Right working guidance
– Teeth #5 and 28
– Teeth #6 and 27
 Left working guidance
– Teeth #11 and 22
– Teeth #12 and 21
 Protrusive guidance
– Teeth #6 and 28
– Teeth #11 and 21
 Retruded contacts
– Teeth #2 and 31
 Task 2 – Provide Gingival
Description
Guidelines
Describe the following per sextant 
 Color
 Contour
 Consistency
 Task 3 – Provide Radiographic
Interpretation
Guidelines
Note significant findings per sextant 
Consider the following
 Caries
 Signs of periapical pathology
 Alveolar bone loss
– Type
– Severity of bone loss
– Extent
 Signs of occlusal trauma
 Crown/root ratios
 Root proximity
 Root anatomy
 Opacities suggestive of calculus
 Task 4 – Provide Diagnoses
Guidelines
Consider the following per sextant
 Caries

 Endodontic

 Periodontal disease 

 Occlusal trauma

 Mucogingival defects 

 Partial edentulism

 Other
 Task 5 – Provide Etiologies and
Risks for Oral Diseases
Guidelines
Consider the following per sextant for all diagnoses
 Bacterial plaque

 Periodontal risks

 Local factors

 Oral hygiene habits

 Trauma

 Other
 Patient Case – Nancy Carp
This is the end of Part 1
Be sure you provided the following
 Contraindications/precautions to dental treatment

 Radiographic interpretation

 Gingival description

 Diagnoses

 Etiologies and risks for oral diseases

 Responses to “What if…” scenarios/questions

Your Response Sheet should contain responses for Tasks 1-5 and What if scenarios 1-8.
Your Response Sheet will be turned in and given back to you during the seminar.
You will need the Response Sheet for Part 2 of this case.
Simulated
Patient Case –
Nancy Carp **

Part 2
 Patient Case – Nancy Carp
Your tasks for Part 2 are to
Review patient case
Provide
 Initial examination
– Prognoses
– Treatment plan
 ODCT, EIT and Evaluation Phase/ODCT completion*
Update of *Oral Disease Control Treatment (ODCT)
– Gingival description is Phase II therapy. Initial periodontal
therapy and evaluation of initial
– Diagnoses periodontal therapy (EIT) occurs within
– Etiologies and risks for oral diseases this phase. Evaluation Phase is Phase III
therapy and is synonymous with ODCT
– Prognoses completion.
– Treatment plan
 Response to “What if…” scenarios/questions
Your responses for Tasks 6-18 and What if scenarios 9-11 should be recorded on your
response sheet.
Your Response Sheet will be turned in and given back to you during the seminar.
 Task 6 – Provide Prognoses
Guidelines
Based on initial examination findings
 Determine restorability per tooth
 Determine periodontal prognoses per tooth
– Good
– Fair
– Poor
– Hopeless
 Task 7 – Provide Treatment
Plan
Guidelines
Generate a phased, sequenced, multidisciplinary,
comprehensive initial treatment plan
Consider the following
 Identification of procedures that address all
diagnoses/etiologies/risks
 Identification of all treatment options; especially
reconstructive phase options
 Organization of procedures into the five phases of
treatment
 Logical sequencing of procedures within each phase
 Timely referral and co-management with other dental
professionals
Initial Therapy

 NC’s initial therapy was as you outlined.

 The following slides depict her response to treatment as
compared to initial examination.
Initial Examination
EIT Examination
Sextant 1 - Initial
Sextant 1 – EIT
Initial EIT
Sextant 2 - Initial
Sextant 2 - EIT
Initial EIT
Sextant 3 - Initial
Sextant 3 - EIT
Initial EIT
Sextant 4 - Initial
Sextant 4 - EIT
Initial EIT
Sextant 5 - Initial
Sextant 5 - EIT
Initial EIT
Sextant 6 - Initial
Sextant 6 -EIT
Initial EIT
 Intra-oral Findings - EIT
 Extra-oral findings - within normal limits
 Caries - none
 Marginal and papillary gingiva firm and pink with
localized erythema and edema
 Supragingival and subgingival calculus - none detected
 Intra-oral Findings - EIT
 Plaque index (% surfaces plaque free) - 93%
 PD ranged from 2-5 mm with 38% ≥ 4 mm
 CAL ranged from 1-5 mm with 10% ≥ 4 mm
 BOP - 16% of the sites
 Furcation involvement - none
 Intra-oral Findings - EIT
Occlusal Evaluation
No new occlusal findings
 Class III molar and canine relationship bilaterally
 Overbite and overjet - 1 mm
 End to end contact with remaining anterior teeth
 CR to CO slide - ≤0.5 mm
 Fremitus - tooth #12
 Mobility - class I, tooth #12
 Wear facet
– Tooth #3
– Tooth #14
 Intra-oral Findings - EIT
Occlusal Evaluation
No new occlusal findings
 Right working guidance
– Teeth #5 and 28
– Teeth #6 and 27
 Left working guidance
– Teeth #11 and 22
– Teeth #12 and 21
 Protrusive guidance
– Teeth #6 and 28
– Teeth #11 and 21
 Retruded contacts
– Teeth #2 and 31
 Task 8– Provide Gingival
Description
Guidelines
Note differences in gingival presentation between
initial and EIT examinations
 Color

 Contour

 Consistency
 Task 9 – Provide Diagnoses
Guidelines
Update diagnosis based on EIT examination findings
Consider the following per sextant
 Caries

 Endodontic

 Periodontal disease

 Occlusal trauma

 Mucogingival defects

 Partial edentulism

 Other
 Task 10 – Provide Etiologies
and Risks for Oral Diseases
Guidelines
Update etiologies and risks based on EIT examination
findings
Consider the following per sextant for all diagnoses
 Bacterial plaque

 Periodontal risks

 Local factors

 Oral hygiene habits

 Trauma

 Other

Record your responses on the Periodontal Assessment Form, Etiology

 Task 11 – Provide Prognoses

Guidelines
Update prognoses based on EIT examination findings
 Determine restorability per tooth
 Determine periodontal prognoses per tooth
– Good
– Fair
– Poor
– Hopeless
 Task 12 –Treatment Plan
Guidelines
Update treatment plan based on EIT examination
findings 
Consider the following
 Changes to ODCT, surgical periodontal treatment
plan
 Changes to reconstructive phase
 Timely referral and co-management with other dental
professionals
 Timeframe for completion of ODCT
ODCT Phase -
Surgical
Periodontal
Therapy
 NC’s surgical periodontal therapy included four
quadrants of osseous resective surgery, posterior areas
 The following slides depict osseous resective surgery
performed on quadrant 3
Osseous Resection Surgery - Quadrant
3 and Extraction Tooth # 17

Note: Position of the free gingival margin

Pre-op Lingual

Note: Position of the free gingival margin

 Pre-osseous Buccal

Note: Position of the alveolar crest and boney architecture

How do probing depths and radiograph findings relate to the boney architecture?
Pre-osseous Lingual

Note: Position of the alveolar crest and boney architecture

Post-osseous Buccal

Note: Position of the alveolar crest and boney architecture

Post-osseous Lingual

Note: Position of the alveolar crest and boney architecture

Sutures Buccal

Note: Position of the gingival margin

Sutures Lingual

Note: Position of the gingival margin

Post-op Buccal - 2 Week

Note: Position of the free gingival margin

Post-op Lingual - 2 Weeks

Note: Position of the free gingival margin

What oral hygiene aid best removes plaque from these interproximal areas?
Evaluative Phase/
ODCT Completion
 NC had all four osseous resective surgeries completed
within 3 months
 Full mouth scaling therapy and oral hygiene instruction
were provided as needed during this timeframe
 The evaluation phase examination is now performed 6
weeks following the last surgically procedure
Initial Examination
Evaluative Phase
Sextant 1 - Initial
Sextant 1 – Evaluative Phase
Initial Evaluative Phase
Sextant 2 - Initial
Sextant 2 – Evaluative Phase
Initial Evaluative Phase
Sextant 3 - Initial
Sextant 3 – Evaluative Phase
Initial Evaluative Phase
Sextant 4 - Initial
Sextant 4 – Evaluative Phase
Initial Evaluative Phase
Sextant 5 - Initial
Sextant 5 – Evaluative Phase
Initial Evaluative Phase
Sextant 6 - Initial
Sextant 6 – Evaluative Phase
Initial Evaluative Phase
 Intra-oral Findings – Evaluative
Phase
 Plaque index (% surfaces plaque free) - 88%
 PD ranged from 2-4 mm with 1% = 4 mm
 CAL ranged from 1-5 mm with 12% ≥ 4 mm
 BOP - 6% of the sites
 Furcation involvement - none
 Intra-oral Findings - Evaluative
Phase
Occlusal Evaluation
 Class III molar and canine relationship bilaterally
 Overbite and overjet - 1 mm
 End to end contact with remaining anterior teeth
 CR to CO slide - ≤0.5 mm
 Wear facet
– Tooth #3
– Tooth #14
 Intra-oral Findings - Evaluative
Phase
Occlusal Evaluation
 Right working guidance
– Teeth #5 and 28
– Teeth #6 and 27
 Left working guidance
– Teeth #11 and 22
 Protrusive guidance
– Teeth #6 and 28
 Retruded contacts
– Teeth #2 and 31
 Task 13 – Provide Gingival
Description
Guidelines
Note differences in gingival presentation between
initial and evaluation phase examinations
 Color
 Contour
 Consistency
 Task 14 – Provide Diagnoses
Guidelines
Update diagnosis based on evaluative phase examination
findings
Consider the following per sextant
 Caries
 Endodontic
 Periodontal disease
 Occlusal trauma
 Mucogingival defects
 Partial edentulism
 Other
 Task 15 – Provide Etiologies
and Risks for Oral Diseases
Guidelines
Update etiologies and risks based on evaluative phase
examination findings
 Bacterial plaque

 Periodontal risks

 Local factors

 Oral hygiene habits

 Trauma

 Other

Record your responses on the Periodontal Assessment Form, Etiology

 Task 16 – Provide Prognoses
Guidelines
Update prognoses based on evaluative phase
examination findings
 Determine restorability per tooth
 Determine periodontal prognoses per tooth
– Good
– Fair
– Poor
– Hopeless
 Task 17 –Treatment Plan
Guidelines
Update treatment plan based on evaluative phase
examination findings
Consider the following
 Updating reconstructive and maintenance treatment
plans
 Readiness for reconstructive phase treatment
 Initiation of maintenance therapy
 Interval of maintenance therapy
 Maintenance
Phase
 NC is in maintenance phase having completed her
prescribed dental treatment 3 years ago.
 She has been receiving routine comprehensive dental
examinations and periodontal maintenance every 3
months since completing ODCT. 
 Patient Case – Nancy Carp
This is the end of Part 2
Be sure you provided the following
 Initial examination
– Prognoses
– Treatment plan
 ODCT, EIT and Evaluation Phase/ODCT completion
Update of
– Gingival description
– Diagnoses
– Etiologies and risks for oral diseases
– Prognoses
– Treatment plan
 Response to “What if…” scenarios/questions
 What If….

 The following slides present scenarios 1-8 pertaining to

Part 1 of simulated patient case, Nancy Carp
 What if…
Scenario 1

NC had a heart valve replacement (3 years ago)

 Does she need premedication?

 What are the indications for prophylaxis?

 If you were going to prescribe pre-medication, what

would you prescribe? Give medication, dosage and
regimen.

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 What if…
Scenario 2

NC took Plavix or Coumadin

 How do these drugs work?

 Would the use of these drugs impact patient

management? If so, how?

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 What if…
Scenario 3

NC’s had the following blood chemistry

– Plasma glucose concentration (non-fasting) - 180 mg/dl
– HbA1c – 9.8%
 Would this impact patient management? If so, how?

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 What if…
Scenario 4

NC’s blood pressure was 160/90

 What is the current classification for a blood pressure of
160/90?
 Would this blood pressure impact patient management?
If so, how?

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 What if…
Scenario 5

The gingiva had these appearances.

 How would you describe the gingiva in terms of color,
contour, and consistency for clinical photographs (A-D)?

A B

C D

The next few slides show select treatment outcomes

Pre-op, 30 year old male,
Aggressive Periodontitis

Post-op, 6 weeks, Sc/RP, OHI, and

systemic antibiotics
(Metronidazole 250mg and Augmentin 375mg
tid 7 days, began 2 days prior to Sc/RP)
 Pre-op, Gingival
Overgrowth Gingivectomy

Post-op, 8
weeks

Gingivectomy, Immediately Post-op Gingivectomy, Post-op 3 Weeks

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 What if…
Scenario 6

Osseous defects had these appearances.

 How would you describe the osseous defects (A-C)?

A B
C

The next few slides show select surgical photographs, osseous defects and treatment
outcomes
Pre-op Guided tissue regeneration,
debrided defect
What is the etiology of this
defect?

Post-op,
4 months
Pre-op Pre-op Vertical Root
Fracture

Osseous defect Guided bone

regeneration, future
implant site
 Pre-op
Pre-op

Guided tissue regeneration, defect Guided tissue regeneration, bone

debrided graft and membrane
What is the etiology of this defect?

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 What if…
Scenario 7

A 30 year old patient had no systemic health conditions and

this clinical presentation.
 What type of periodontal disease does this patient have?

Radiographs are on the following slide

The next few slides show select surgical photographs, osseous defects and treatment
outcomes
 Pre-op
Pre-op

Bone and membrane Post-op, 10 days

Osseous defect placement

Membrane
removed, 6 weeks
Note newly formed
tissue Post-op, 8
months
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 What if…
Scenario 8

Mucogingival defects had these appearances.

 How would you describe the mucogingival defects (A-D)?

A B

C D

The next few slides show select surgical photographs, osseous defects and treatment
outcomes
 Pre-op Pre-op

Free gingival graft, sutured Post-op, 6 weeks

In which phase of therapy does
this treatment occur?
 Pre-op Pedicle flap

Flap sutured

Alloderm sutured
 Pre-op

Pre-op

Post-op, free gingival graft, 2 months

 Pre-op

Pre-op

Connective tissue graft surgery Post-op, 2 months

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 What If….

 The following slides present scenarios 9-11 pertaining to

Part 2 of simulated patient case, Nancy Carp
 What if…
Scenario 9

NC had the following intra-oral findings at EIT

 Intra-oral findings
– Marginal and papillary tissues - erythema and edema
– Supragingival and subgingival calculus detected
– Plaque index (% surfaces plaque free) - 10%
– PD ranged from 2-7 mm with 38% ≥ 4 mm
– CAL ranged from 1-5 mm with 10% ≥ 4 mm
– BOP - 80% of the sites
 Would these findings modify your management of the
patient? If so, how?

The next slide presents another clinical scenario

 What if…
Scenario 10

NC had the following intra-oral findings, quadrant 4, at EIT

 Intra-oral findings, quadrant 4
– Marginal and papillary tissues firm and pink with localized
erythema and edema at tooth #19 mesial
– Supragingival and subgingival calculus - none detected
– Plaque index (% surfaces plaque free) - 86%
– PD < 3 mm except tooth #19 mesial 6 mm
– CAL < 5 mm, tooth #19 mesial 5 mm
– BOP - tooth #19 mesial and lingual
 Would these findings modify your management of this
quadrant? If so, how?
 What is the evaluation interval?
 What is the recommended if these findings persist?

The next slide presents another clinical scenario

 What if…
Scenario 11

An symptomatic patient presented with the following treatment

needs upon initial exam. How would you sequence these
procedure descriptions of the ODCT plan? Use the table
provided on your worksheet.
– Resin Rest #7 I
– Resin Rest #18 O
– Sc/RP 4+ teeth LL
– Sc/RP 1-3 teeth UL
– ODCT complete
– Extraction #19
– Extraction #32
– Extraction #30
– Prevident 5000
– Resin Rest #31 O
– Sc/RP 1-3 teeth UR
– Sc/RP 4+ teeth LR
– Nutritional Counseling
– Evaluation of initial therapy
– Oral hygiene instruction

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 Acknowledgement

 VCU Periodontal Residents provided the clinical

photographs featured in this case. A special thank you is
extended to Dr. Jeremy Diehl, who provided the
treatment and clinical documentation of “Nancy Carp”.