“I would like to have my teeth cleaned because it has been a while since I have been to the dental school. My bridge also needs adjustment.”
History of Present complaint Patient used to go to a private practice near his home, but was unhappy with the bridge that he received, so he decided to start coming to the dental school for dental care. He was previously on a regular 4-6 month recall.
Medical History Patient was hospitalized for 10 days in 2004 when he had three heart attacks. Patient has been under regular Cardiologist’s care every six months. Mr. Jones reports having stopped smoking one year ago, but he still struggles with smoking relapses. Vital signs: 9/12: 145/98, 11/10: 114/89, 10/17: 155/96 3/12: 128/77, 3/14: 141/83. Patient has high blood pressure and takes Toprol (metoprolol)- 50 Mg per day Patient also takes Natto Vitamin which acts as a blood thinner- 100 Mg per day. Patient is allergic to Penicillin and gets a rash
Dental History Patient had bridge done in private practice where he was on a regular 4-6 month recall. He was dissatisfied with the treatment done in private practice and chose to come to the dental school where he has been very satisfied with his treatments. Frequency of visits: Every 4-6 months Patient had SRP 4342 from Dental student in 2010. Patient had several class V restorations which he had the margins smoothed off and polished. Upper and lower impressions taken for fabrication of bridges.
Dental Hygiene Habits Mr. Jones reports having always brushed his teeth at least 2x/ day. Mr. Jones currently uses as soft bristle toothbrush and flosses occasionally (1- 2x/wk) While there was no Plaque index documented prior to our treatent, his PI ranged from 18-38% throughout appointments.
Personal and Social History Mr. Jones has Highschool level education, is happily married, and reports enjoying spending time with his grandkids. Mr. Jones reports that his job can be stressful at times since he is doing dangerous work (welding, metal work, etc.) Mr. Jones likes to be outside a lot and enjoys gardening.
Family History Mr. Jones does not report his parents having any dental history, but his father died of heart failure and his mother died of COPD. Since his stint operation failure, he has been interested in EDTA alternative medication and after one year of regular treatment has seen improvement with his heart.
Extra Oral Exam Mr. Jones has thin hair and reddish skin due to being outside most of the day. He has never had skin cancer, but reports seeing a dermatologist regularly. He has several age spots on his face and neck. He also had cuts and scrapes on his fingers due to welding and metal working. Mr. Jones hunches slightly and has a concavity in his forehead due to accident where he had a metal plate placed in his forehead.
Intraoral Mr. Jones has Maxilary and Mandibular Tori, his tongue is white and coated, the dorsum of the tongue has multiple blue vericosities and tissue tags. His teeth have moderate staining from smoking habits. His gingiva is firm yet erythemic with loss of stippling, has rolled margins and loss of interdental papillae especially on mandibular anteriors. Patient has moderate dry mouth and malodor. Patient’s bleeding Index was 7%
Periodontal Charting Analysis Mr. Jones had a class I furcation on #31 and #18, a II furcation on #2 and #30, and a class III furcation on #3. He did not have any mobility. His bleeding index was 7% and his plaque index was 35%. Mr. Jones had one periodontal chart in EPR from his dental student. In addition to there not being any recession charted, there were areas where the probing depth had increased by 2mm. Due to this, I determined that Mr. Jones periodontal status was unstable.
Dental Charting Summary Mr. Jones reported having mild to moderate sensitivity that was localized around certain teeth that had “lost gum tissue.” Mr. Jones has multiple PFM crowns, class V restorations, malalignment on his mandibular anteriors, mild attrition on both maxillary and mandibular anteriors, functional shift, has an edge-to-edge bite in the front and a crossbite #13-15 where the bridge is located.
Dental Pathology Mr. Jones had no history of any dental pathology
Radiographic Interpretation Mr. Jones did not have any new caries or failed restorations. His class II and III furcations are easily detectable, as are his class V restorations and crown and bridge work. There is also visible calculus in the posterior areas especially.
Nutritional Risk Assesment Mr. Jones was put in the medium risk for caries because of his CAL, insufficient flouride exposure, and plaque index. Mr. Jones does not drink soda, does not snack in-between meals, and eats lots of fruits and vegetables from his garden that he keeps at home. He reported spending at least 30 minutes a day exercising and being outside with his dog.
Dental Hygiene Diagnosis Patient’s Unmet human need of Wholesome facial image related to malocclusion, auto accident and work- lots of time in the sun, as evidenced by cross bite, age spots, concavity in the forehead. Patient’s Unmet human need of Protection from health risks related to smoking as evidenced by staining, constricted blood flow. Patient’s Unmet human need of Biologically Sound and Functional Dentition related to bruxism, functional shift, perio disease and lack of dental care, evidenced by missing teeth, bone loss, attrition, and crossbite.
Dental Hygiene Diagnosis Patient’s Unmet human need of Skin and Mucous Membrane Integrity of Head and Neck related to Inadequate Oral care and biofilm accumulation, evidenced by multiple furcation, bleeding, erythemia, type III/03 calculus. Patient’s Unmet human need of Conceptualization and Understanding, related to Inadequate plaque control, use of products ineffectively, as evidenced by high plaque index, irregular use of floss.
Dental Hygiene Care Plan Plan to perform periodontal debridement over a three appointment sequence using oraqix and local as needed. Also plan to perform OHI, tobacco cessation, Fluoride treatment, and Arestin placement.
Dental Hygiene Treatment Planning Medical History and Vital Signs: 5 min each appointment Assessment/Re-Assessment/PI: 30 minutes at first appointment and 10 minutes following. 1330-Oral Hygiene Instruction: 10 minutes at each appointment. 1320-Tobacco cessation counseling: 10 minutes 9210-Local Anesthesia: Qt. I: 20 minutes 4342 Scaling Qt. I,IV in first and second appointment and Qt. II, III at third appointment. (45 min for each quadrant) 1206- Flouride Varnish at the end of appointment: 5 minutes
Arestin Placement Arestin was planned for placement around #3M&D and #18, #30. 3 month evaluation occurred on 2/9/12 Pt. declined additional placement of Arestin after re-evaluation.
Dental Hygiene Care Plan At each follow up appointment, I will ask my patient how his at-home care is progressing and encourage him where he is doing well and follow up with motivational Interviewing in the areas that he his lacking.
Appointments Appt #1 (9/12)- BP 145/98 Pulse 68- Reviewed health history, performed EO/IO exam, took photos, took plaque index: 35%, BI:7%, performed nutritional assessment and Oral Hygiene instruction, had DDS exam. Pt. does not use interdental brush or floss regularly, so encouraged use and instructed patient how to use Proxabrush. Began scaling Qt. I with oraqix. Appt #2 (10/17)- Reassessed, re-evaluated.Plaque index: 31% Used local on Qt. I and completed Qt. I &IV Appt #3 (11/10)- Plaque Index: 28%. Pt. reported smoking 10 cigarettes every day, so talked with patient about smoking cessation methods/options. Pt. seemed open and interested. Sites of prior scaling appeared to be healing well. Used oraqix on Qts. II, III. Placed arestin at sites #3M&D, 30, 18. Pt. also received Flouride Varnish Treatment.
Appointments, continued At 3 month recall (2/9)- Patient returned and had minimal improvement with arestin therapy and was determined to be an 03. Pt. requested to not have local used, but consented to oraqix. Began scaling Qt. I and heavy subgingival calculus was found. Pt. was unaware of correlation between plaque in the mouth and heart issues. PI: 30% (3/12)- Pt. returned for cleaning and Qt. I, IV, and II were completed. PI: 25% (3/14)- Pt. returned for final cleaning and had a lower plaque score of 18%, He reported flossing more and using his interdental cleaner more often. Qt. III was finished and. Patient received fluoride varnish treatment.
Gingival Analysis As the appointment sequence progressed, Mr. Jones gingiva had a bulbous appearance at the 3 month recall, but upon retreatment, gingiva became less erythmic and became more pink.
At Mr. Jones three month evalution, his probing depths were similar to initial therapy. Following his retreatment, Mr. Jones gingiva appeared to have healed better than the first treatment sequence.
Dental Hygiene Habits Throughout my time with Mr. Jones, he was a very willing and compliant patient, but he was unaware of the fact that floss alone could not reach into his furcations or that plaque in the mouth can have correlation with heart disease. After my time with him, he was more aware of how important his home care was to the success of treatment at the dental school. Despite my attempts at using MI for retreatment with Arestin, he declined.
Dental Hygiene Goals Encourage Patient to decrease smoking Help educate patient about health risks Help educate patient about proper OHI aids so that he can decrease PI, BI, and amount of subgingival calculus. Perform periodontal debridement Administer Arestin
Evaluation of Arestin Placement Upon evaluation of Arestin, patient did not seem to have improvement around tooth #3, but did have slight improvement around #18 and #30.
Continuing Care Recommendations Mr. Jones still has two areas where we talked about him improving: decreasing smoking and using his interdental cleaner.
Case Based Question What oral therapy aid would be most useful for Mr. Jones when cleaning around teeth #2&3? A: Floss B: Gum stimulator C: Interdental proxabrush D: Chlorhexadine rinse E: Floss holder
Scientific Article The potential impact of periodontal disease on general health: a consensus view. Williams RC, Barnett AH, Claffey N, Davis M, Gadsby R, Kellett M, Lip GY, Thackray S. Williams RCBarnett AHClaffey NDavis MGadsby RKellett MLip GYThackray S Source: University of North Carolina, School of Dentistry, Chapel Hill, NC 27599, USA. email@example.com
Case Study Summary Throughout my time with Mr. Jones, I learned how many people are simply unaware or uneducated about their oral health status. It is our responsibility as hygienists to educate them so that they can have the tools to succeed. I also enjoyed having the opportunity to see my patient regularly.