Periodontics · patient case with 3 questions
Deep pockets on molars and incisors only
Patient: Female, 22 years old
Chief Complaint: “My front teeth feel like they are moving.”
Background: Healthy. No medications, no allergies, non-smoker. No family history recorded.
Vital Signs: BP 112/70 mmHg · HR 72 bpm · RR 15 · T 98.4°F
Findings: Probing depths 8–9 mm at first molars and 5–6 mm at incisors. Other sites are 2–3 mm. Plaque and calculus deposits are minimal relative to the destruction. Dark, hard subgingival deposits are visible after retraction.
Question 1
Based on the information given, what is this patient's ASA physical status classification?
Show answer and explanation
Correct answer: D. ASA I
- A. ASA II requires a mild systemic disease with no functional limitation — controlled hypertension, well-controlled diabetes, pregnancy, active smoking, obesity with BMI 30–40. Nothing in the history meets that.
- B. ASA IV is severe systemic disease that is a constant threat to life — recent MI or stroke, unstable angina, severe valve dysfunction.
- C. ASA III means severe systemic disease with functional limitation, such as poorly controlled diabetes, a myocardial infarction more than three months ago, or dialysis dependence.
- D. CORRECT. The ASA scale grades SYSTEMIC physical status, not oral disease. This patient has no systemic illness, takes no medications, does not smoke and has normal vital signs — she is ASA I. Periodontitis, however severe, is a local condition and does not by itself move a patient up the scale.
Note: The recall offered no key. Some study sources reflexively assign ASA II to any patient with periodontal disease; that is wrong. ASA is a systemic scale. Expect the exam to test exactly this distinction.
Question 2
The subgingival deposits are grey to black in colour. What accounts for this?
Show answer and explanation
Correct answer: A. Breakdown of red blood cells from the inflamed sulcus
- A. CORRECT. Subgingival calculus is dark because it forms in a sulcus that bleeds. Blood enters the crevicular environment, haemoglobin degrades, and the resulting pigments are incorporated into the mineralising matrix, giving the grey-black to dark-brown colour. Supragingival calculus, forming in a bloodless environment, is whitish-yellow.
- B. Subgingival calculus is indeed denser and harder than supragingival calculus, but mineral density is not what makes it dark — blood pigment is.
- C. Dietary chromogens stain supragingival surfaces where saliva and food reach; they do not reach the base of a periodontal pocket.
- D. Chromogenic bacteria produce the black or green extrinsic stain seen along the cervical margins of children's teeth, which is a surface film, not calculus.
Question 3
Which organisms predominate in these deep periodontal pockets?
Show answer and explanation
Correct answer: A. Gram-negative anaerobes
- A. CORRECT. As a pocket deepens the oxygen tension falls and the flora shifts decisively toward GRAM-NEGATIVE ANAEROBES — Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola (the red complex), together with Fusobacterium, Prevotella and, in this molar-incisor pattern, Aggregatibacter actinomycetemcomitans.
- B. Obligate aerobes cannot survive the hypoxic pocket environment at all.
- C. Gram-positive rods such as Actinomyces are prominent in early plaque maturation and in root-surface caries, not in the deep anaerobic pocket.
- D. Gram-positive facultative cocci such as Streptococcus sanguinis dominate early supragingival plaque and healthy sulci — the starting point, not the diseased end point.