A 54-year-old female patient came to the observation in May 2022, complaining of gingival bleeding during brushing: the patient was unaware of her periodontal problems and did not have a regular professional oral hygiene session.
The medical history shows a familiarity with periodontal disease attributable to the father; the patient suffers from McArdle's disease, glycogenosis GSD V, due to the lack of the enzyme glycogen-phosphorylase muscle. McArdle is a serious disease, characterized by muscular intolerance to stress, associated with myalgia, cramps, fatigue, and muscle weakness. McArdle sufferers experience pain or fatigue during some repetitive movements such as chewing and washing their teeth. About 33% of sufferers of this disease complain of a permanent weakness of the muscles closest to the trunk, such as the shoulder muscles. The patient also says she needs many small snacks rich in complex carbohydrates.
The diagnosis made by the periodontist was Stage 3 generalized periodontitis, Grade B. At the baseline, the patient had 82 pockets with probing pocket depth (PPD) equal or greater than 4 mm: of these 82 pockets, 50 have PPD equal to or greater than 5 mm. The values of the inflammation indices are 48% for full mouth bleeding score (FMBS)and 73% for full mouth plaque score (FMPS). Figures 1, 2, 3, and 4 show periodontal charting, RX, and photos of the patient at baseline.
When periodontal disease was intercepted, the patient was instructed and motivated by the "tailored brushing method" (TBM) approach, to promote correct lifestyles, reduce the greater number of periodontal pockets 5 mm, reduce FMBS and FMPS below 15%, and recreate a healthy oral microbiota with revaluation after 3 months.
Once the periodontal disease was diagnosed, radiographic and photographic data were collected, and the periodontal clinical record and motivational interview (T0) were compiled. After 7 days, the patient was instructed to have an effective and efficient control of oral biofilm through the personalized and shared TBM approach. It was recommended to replace the manual toothbrush with a sonic electric toothbrush, which helps her with a minimal physical effort to improve her oral hygiene (DiamondClean 9000, Philips, Amsterdam, Netherlands).
The use of toothpaste with probiotics was suggested (Peribioma Pro Gengive Piu, Coswell, Fano, Italy), which counteracts the symptoms and causes of periodontitis by promoting the rebalancing of the oral microbiota. The use of a mouthwash with probiotics (Treatment Mousse Peribioma, Coswell, Fano, Italy) was recommended twice a day for 1 minute without rinsing, drinking, and eating for at least the first 30 minutes. For the cleaning of the interdental spaces, it was recommended to use antibacterial rubber brushes. To complete the oral hygiene at home, the importance of the use of chewable gum with probiotics (Peribioma Pro, Coswell, Fano, Italy) was explained. The latter are enriched with BIOMA microRepair (added with three billion specific probiotics), vitamin C, and D3, which help to protect the gums making them stronger and keeping the microbiota in balance even with a diet not properly correct.  Table 1 shows the compositions of the domiciliary products used.
Using the 4.3x prismatic magnification technology, the etiological factor over gingival tissue inflammation was removed. The clinical method D-BioTECH, which allows to realize a deplaquing and a debridement above and below minimally invasive gingival, was performed.
During these maneuvers, a high-volume suction cannula with an integrated mirror was used (Purevac HVE), which ensures a greater reduction of fluids, optimized acoustics, and a decrease of up to 90% of aerosols and splatter compared to a traditional saliva vacuum (T1).
After a further 7 days, before continuing with the instrumentation under gingival, the patient's motivation was strengthened. Plaque detectors were used to share biofilm with the patient using photographic images. The instrumentation under gingival in full mouth (FM) regime in 2 days was performed. Ultrasonic inserts of different shapes were used, and some periodontal pockets were also equipped with mini-five curettes (T2).
After 21 days, the dental team received the patient for a motivational session and D-biotech (T3).
To strengthen the motivation and engraftment of probiotics in the oral cavity, the patient after another 21 days was reviewed, where the clinical approach D-BioTECH was used (T4).
Figures 5, 6, and 7 show photos of the patient at first deplaquing.