Case Study By: Brianna Carpenter

Patient Information 64 Year Old Male Calculus Class III / Periodontal Class II ASA II Recall Patient

Medical History ASA II Type 2 Diabetes High Blood Pressure Vitals BP Pulse Respiration Temperature His vitals were WNL for each appointment. But, I did make sure to mention that a side effect presenting with Lisinipril is hypotension, which in fact he had experienced at times. Therefore, I made sure to bring him up slowly and whenever I was to bring him up he was to relax before he got out of the dental chair.

Appointments Appointment 1 : 3/4/2015 Medical history, informed consent, vitals, intraoral/extraoral exam, radiographs (4 HBWX), periodontal charting, CSI, hard tissue charting, referral letter, PHP, CAMBRA, treatment planning, and patient education. Appointment 2: 8/27/2015 Medical History recheck, vitals, intraoral/extraoral exam recheck, radiographs (panoramic picture), PHP, patient education, scale/ultrasonic quads 1 and 4, identified teeth present with calculus for Mock Board throughout quad 3. Appointment 3: 10/9/2015 Medical History recheck, vitals, intraoral/extraoral exam recheck, PHP, patient education, scale/ultrasonic quads 2 and 3, polish, floss and fluoride.

Current Medications Metformin Levothyroxine Atorvastatin Lisinopril Metoprolo Baby Aspirin Metformin: Managment of type 2 diabetes and the adverse effects in dental treatment is taste disorder. However, patient never claimed to have taste disorder. Levothyroxine: Used for hypothroidism. Not dental interactions. Atorvastatin: Cardiovascular disease. Causes muscles weakness, therefore difficulty brushing. Patient claimed that had never been an issue. Lisinipril: Hypertension and heart failure. Patient may experience hypotension, which in fact he claims he does at times. Metoprolol: Hypertension and angina pectoris. Interaction to dental treatment would be that local anesthetic is used with a vasoconstrictor. Baby Aspirin: Used for pain and inflammation. The interaction with dental treatment would be excess bleeding.

Dental History Extractions Last Visit to Dentist All 4 wisdom teeth extracted in high school Brushes Once Daily/Flosses when needed Receives Regular Cleanings About once a year Medium Bristles Toothpaste Crest No Mouth Rinse Fluoride Took pills as a child Last Visit to Dentist June 2014 for cleaning Last Radiographs HBW 3/4/2015 Panoramic 8/27/2015 Previous Orthodontic Treatment He tends to go to the dentist about one time a year. He had braces when he was in high school and had all 4 wisdom teeth extracted just before his braces. He doesn’t ever use mouth rinse and recalls taking fluoride pills as a child.

Panoramic Image

4 BWX As you can see there is calculus present on the radiographs throughout all 4 quads. This was a great road map for me while I was scaling and using the ultrasonic. He presents with generalized horizontal bone loss and some slight vertical bone loss. I made sure to point out these areas to him, and I informed him that without good home care, this slight periodontal disease can become worse and that it’s irreversible.

Gingival Assessment This patient presented with generalized McCall’s festoon, or rolled gingiva and generalized areas of bleeding. I made sure to show my patient this, which then gave me the opportunity to talk about the importance of home care. Please continue onto the next slide for more information.

Gingival Assessment First I showed my patient his inflamed tissue throughout the mouth and informed him how easily his tissue bled. As for patient education, I recommended that he were to use the antigingivitis/antimicrobial mouthwash in the morning and then use total care, which is a mouth wash with fluoride in it before bed. I then went on to talk about his brushing habits, which is only once a day, and explained to him that the plaque biofilm is mineralizing and becoming calculus and the irritated tissue is responding with inflammation. Since he only flosses “when needed” I explained that since he isn’t flossing daily, he isn’t disrupting the plaque biofilm building up in the “pockets” surrounding his teeth.

TMJ This patient presented with popping and crepitus on the left side upon opening, but not pain has ever been present.

Occlusal Assessment I noted that this patient is a class I and that his overbite and overjet were both at 4 mm. His midline did slide to the left about 1 mm, but not pain or problem was presented with that.

Occlusal Assessment This patients dental classification presents as a class I. As you can sort of see the interdental papilla between the molars and pre-molars are beginning to present itself with a clefting appearance. This may be due to the use of medium bristles, lack of flossing or tooth brush abrasion. This was shown to my patient, which then enabled me to talk about using a soft tooth brush instead of a medium toothbrush and using a light, circular tooth brushing technique, and of course the importance of flossing.

Habits Tab The patient noted that he doesn’t every recall grinding his teeth, but attrition is present on both the maxillary and mandibular anteriors.

Mandibular Arch My patient claimed that he doesn’t ever recall grinding his teeth, but attrition has a tendency to increase with age. With that being said, I informed him that this may encourage sensitivity issues, therefore sensydone or any sensitivity tooth paste can help with this irritant if ever present.

Head Tab Within the head tab I noted my patients white coated tongue, varicosity, fordyce granules, and mandibular exostosis. I will talk about these individually in the following slides.

White Coated Tongue As you can see the patient presented with white coated tongue, he claimed that he never brushed his tongue. Therefore, during patient education from his first appointment, I showed him how to use a tongue brush. While demonstrating the use of the tongue brush, I explained to him the purpose/advantages of maintaining a clean tongue: Overall mouth cleanliness, reduces the number of bacteria available for biofilm formation, and fewer mouth odors.

Calculus buildup is visibly present on the lower anteriors Calculus buildup is visibly present on the lower anteriors. I explained to my patient that this certain area is prone for calculus buildup. Because we have a salivary gland beneath our tongue that is constantly releasing saliva, the constant saliva/bacteria contact with our teeth mineralizes and becomes calculus.

Varicosity My patient actually asked me what this red-to-purple enlarged vessel was. I told him that it was a variant of normal and that they are usually seen in older individuals.

Fordyce Granules These are fordyce granules on the commisures of the mouth, another variant of normal. They appear as white clusters of sebaceous glands and are considered asymptomatic and require no treatment; which I was able to inform my patient about.

Mandibular Exostosis Mandibular exostosis is a variant of normal. There was difficulty while taking the pre-molar shot for the bitewings, therefore I applied the blue spongy pads in order to avoid any pain.

Periodontal Charting He turned out being a class II perio. As you can see his main concerns is the pocket depths of his posterior teeth and the amount of bleeding present. I did explain to him what these numbers meant and how this slight periodontal disease is irreversible. He understands that flossing and rinsing with mouth wash can prevent the pocket depths from becoming any deeper and less bleeding to occur.

Hard Tissue Chart

Assessment PHP: Score: 2.6 CSI: - Areas of Calculus -Score: 60 3 8 14 D B M F Student X Instructor L 30 24 19 PHP: Score: 2.6 CSI: - Areas of Calculus -Score: 60 As you can see he had a good amount of calculus present. As for his PHP, his score came out to be 2.6, representing as “fair” patient hygiene performance. This gave me the opportunity to talk about a tooth brushing technique. Since most of the PHP existed within the cervical areas, I decided to teach my patient the Modified Stillman’s Method of tooth brushing. #3 Buccal #8 Facial #14 Buccal 3 2 #30 Lingual #24 Labial #19 Lingual

Treatment Planning Dental Concerns Etiology Plan CC: Bleeding Gums Plaque biofilm accumulation Flossing and fluoride treatment frequency Periodontal Disease: Slight Slight bone loss/Pocketing Patient education on Periodontal disease. BOP Medication/Increase plaque biofilm Brushing Technique: Modified Stillmans White Coated Tongue Not brushing/Biofilm accumulation Patient education: Tongue scraper CAMBRA: Medium Risk Flossing/Plaque Patient education: Fluoride treatments Attrition Grinding of teeth Night guard/Sensodyne toothpaste Plaque Bacteria accumulation Changing toothbrush more frequently/Fluoride treatments Hypotension Medication Sit up slowly

Preventive Counseling Re-care Every 3 Months Brushing Two Times Daily Flossing Few Times a Week More Fluoride Exposure Changing Toothbrush Every 3 Months I scheduled my patients recall date 3 months from his last appointment with me. Since my patient stated that he brushes 1X daily and flosses when needed, I asked him to increase his brushing to 2X daily and flossing to at least a few times a week. The reason I asked for him to only floss a few times a week is because I think if you ask too much from your patient right away, they may think its too overwhelming and then are more than likely to give up. I made sure he understood the importance of adding in a rinse after he brushes or flosses and to change his toothbrush every 3 months so that his bristles don’t become frayed.

Goals My Goals Patient Goals Remove all calculus and biofilm and restore tissue to normal health Adequate education on home care Establish regular 3 month care Patient Goals Leave with a clean/healthier mouth and take continued education advice seriously Brush and floss as instructed Attend re-care appointments every 3 months As a dental hygienist my goals for the patient was that he had left the clinic with a clean and healthier mouth, due to my removal of all calculus and biofilm. While also being more educated/informed about his home care. My patient was concerned about his bleeding gums, therefore I made sure he understood the importance of fluoride treatments and brushing/ flossing more consistently.

Outcomes Treatment was completed based on the treatment pan Patient left with no calculus or plaque present Patient was knowledgeable about importance of home care Patient will come back for his 3 month re-care When the patient left he reported that his mouth felt “nice and smooth.” He seemed motivated to take home care more seriously and to implement at home what he learned at his appointments. I also made sure he was going to come back for his re-care in 3 months. Lastly I mentioned that slight periodontal disease was present, which I think alarmed him.

Lessons Learned Highlight positive habits and behavior Appointment timing I learned that it’s important to also point out positive outcomes throughout the appointment, so not everything I am explaining or teaching is demanding or negative. I noticed a two month time span between the second and third appointment, this was way too long. Therefore, now when I’m scheduling class three and class four patients I make sure they are set for at least two appointments right away, knowing they will have to come at least twice.