Case Study Presentation

Completed by Mindy Duran, DH2

Pretreatment Assessment

64 year old male

Health history summary: Lisinopril (for hypertension), simvastatin (for

cholesterol). Allergic to Doxycycline and Penicillin. Blood pressure within
normal limits at every appointment.

Chief Concern: None at first appointment, future appointment decides that

having a crown placed on tooth #18 is important to me, will schedule to have
completed.

Radiographic findings: gen moderate horizontal bone loss

Microscope Evaluation: Risk Factor: B-/C+ ; Mobility: moderate, Quantity:

TNC, Quality: Gliding Rods, Spirochetes, Cocci

Rationale

Sub gingival calculus test patient 3 out of four times second year

Great experience with very heavy sub gingival calculus : 4 Sub

Great experience with very heavy supra gingival calculus: 3 Supra

Patient was able to come in for multiple appointments to help

contribute to the learning experience

Pretreatment assessments

Intra oral findings: NSF, during 4th appointment patient

reported a canker sore. Intraoral picture taken of lesion.

Radiographic Evaluation
FMS shows moderate horizontal bone loss and heavy calculus.

Calculus Charting

Study Models

Perio Assessments

Intra Oral Pictures

Pre treatment

Dental Hygiene Diagnosis

Periodontal Case type: General moderate periodontitis, Perio Case

type III

Calculus deposit: 3 supra /4 sub

Gingival Description: Gen mod hyperemia, Gen mod enlarged, gen

recession, Gen mod fibrotic with gen mod delayed BOP, CAL: gen 1-2
mm recession, loc 3-4 mm recession (molars)

Radiograph findings that support diagnosis: Gen mod horizontal bone

loss, loc severe (#1). Patient had gen heavy sub gingival calculus

Risk Assessment

Periodontal risk factors: moderate periodontal risk factor

due to: irregular dental care, medications, root exposure,
visible plaque, xerostomia/saliva reducing factors (use of
C-pap machine), calculus, tooth position, and CAL

Caries risk factors: moderate caries risk factor due to:

irregular dental care, medications, white spot lesions,
deep occlusal pits and fissures, root exposure, visible
plaque, diet/frequent sugar exposure, tooth position, and
CAL

Risk Assessment (cont)

Patient goals: Interdental piks and sulcular brushing

Interventions: Comp exam, OHI, NSPT, and topical fluoride

varnish

Expected outcomes: reduce risk of further periodontitis

and caries, maintain bone level and improve tissues.

Treatment plan and rationale

Treatment plan: OHI, comp exam, FMS, local anesthesia, NSPT

(perio scaling by quad), and topical fluoride varnish

Rationale based on clinical knowledge: interventions along with

regular home care routine should reduce the accumulation of
calculus and reduce the presence of harmful bone deteriorating
bacteria. Fluoride varnish will help reduce demineralization and
sensitivity

Rationale based on behavioral and cultural knowledge: I

suggested use of Xylitol Ice chips after sugar intake to help
reduce the risk of decay. For dry mouth I suggested mouth rinse
and biotene products before use of C-pap machine at night

Treatment Progress Notes

1st Appointment 11/25/14

Services provided/completed: comprehensive oral evaluation

with Dr. Dunham, and FMS
Vitals: BP: 123/71, resp: 16, pulse: 71
19 FMS with no retakes
Restorative recommendations: 13-MOD (recurrent decay) & 18-MOL
(chipped tooth)
Anesthesia- Right PSA and MSA

0% benzocaine topical and 4% septocaine; 1 cartridge used

Hard/soft deposits: Heavy supra and sub gingival deposits, gen mod
marginal and papillary inflammation
Notes: Patient dismissed early- did not complete perio scaling

Treatment Progress Notes

2nd Appointment 12/5/14

Services provided/completed: OHI

Vitals: BP: 118/79, resp: 16, pulse: 64

Client compliance with OHI: slight compliance- brushing teeth morning and night

Gen mod bleeding, gen plaque, gen mod marginal and papillary inflammation

Home care modification: Perio aid (tell, show do)

Anesthesia Right (PSA, MSA,ASA), left (ASA), NP, SP (#s 8, 9, 11B, 6L); 3 cartridges

20% benzocaine topical anesthetic and 4% Septocaine

Hard/Soft deposits: generalized tenacious sub and supra calculus with gen mod
bleeding upon scaling

Notes: Completed fall term sub gingival competency,

Treatment Progress Notes

3rd Appointment 1/30/15

Services Provided/Completed: Intra-oral images (12), OHI

Vitals: BP: 136/80, resp: 16, pulse: 68

Client compliance with OHI: Fair compliance- brushing and using tooth
picks

Sl BOP, gen sl plaque interproximally, gen sl marginal and papillary

inflammation

Home care modifications: Work on Interproximal brush for areas with

space, dry brushing before regular sulcular brushing

Anesthesia: Left (PSA & MSA)

20% benzocaine, 4% Septocaine

Hard/Soft deposits: Tenacious calculus and heavy sticky/grainy calculus

Notes: Minis work well in areas with furcation involvement

Treatment Progress Notes

4th Appointment 2/2/15

Services Provided/Completed: OHI, Perio scaling by arch (UR), and topical

fluoride varnish

Vitals: BP: 121/73, resp: 15, pulse: 73

Client compliance with OHI: fair compliance, patient used and liked the larger
interproximal brushes.

Sl BOP, Plaque under margins of the crown, gen sl, loc mod (9-11) marginal and
papillary inflammation

Home care modifications: Continue dry brush around the margin of the crown
before completing regular brushing, recommended daily fluoride rinse for
crown margins and having water to sip at night. Biotene spray to use at night
with CPAP machine

Anesthesia: R (PSA & MSA), L (PSA & MSA)

20% benzocaine, 4% Septocaine

Hard/Soft deposits: heavy tenacious and heavy grainy calculus and sticky plaque

Notes: patient using coconut pulling at night for two days before use of CPAP
machine to help with xerostomia, check areas of inflammation at next
appointment

Treatment Progress Notes

5th Appointment 2/13/15

Services Provided/Completed: OHI, Perio scaling by quad (LL)

Vitals: BP: 122/83, resp: 15, pulse: 71

Client compliance with OHI: Mod compliance, patient has been brushing and
using tooth picks.

Gen mod BOP, Gen mod plaque, gen mod marginal and papillary inflammation

Dental concern: sensitivity of tooth #2

Dentist comment: Extraction of #2

Home care modifications: Use dry brush at margin of crown and continue using
tooth picks in areas appropriate

Anesthesia: Left (IA and LB), SP (#13)

20% benzocaine, 4% Septocaine, 2% Lidocaine

Hard/Soft deposits: Heavy tenacious and grainy calculus and heavy sticky
plaque

Notes: Patient likes to have breaks periodically, prefers the monoject saliva
ejector

Treatment Progress Notes

6th Appointment 3/2/15

Services Provided/Completed: OHI, Perio scaling by arch (LR & UL),

intra-oral images (12), topical fluoride varnish

Vitals: BP: 121/71, resp: 16, pulse: 77

Client compliance with OHI: Mod compliance, patient stated been

brushing and using and using tooth pick and want to my keep teeth

Home care modifications: End tuft brush for margins of crown and
distal of molars (tell, show, do)

Anesthesia: Right (IA-given by Imy Cully, RDH), Right (LB), SP (#25)

20% benzocaine, 4% septocaine, 2% lidocaine

Hard/Soft deposits: Heavy tenacious calculus, heavy sticky plaque

Notes: Case study patient, will be rescheduled for re-care appointment

Intra Oral Pictures

Post treatment

Motivation Strategies

Intrinsic: Patient knows that he needs to perform more adequate

home care, and wants to get in a better habit of routine dental visits.

Extrinsic: patient really wants to keep his teeth. After needing to

have #2 removed due to bone loss, this became more important to
him.

How were intrinsic and extrinsic motivations utilized in OHI?

Every appointment, I discussed the patients home care routine with him,
if I noticed something was working, I encouraged him to continue. I like to
show home care aides that may work better at each appointment, so I
continue to show options that I feel the patient would like and use.

Continuing Care Appointment

Date of visit: 5/26/15

Vitals: BP: 123/78, resp: 16, pulse: 72

Calculus deposit: 2/1.5

Perio Case type: Gen perio case type III, gen mod periodontitis

Microscope Evaluation: Risk Factor: C; Mobility: moderate;

Quantity: TNC; Quality: Gliding Rods, Spirochetes, Cocci

Continuing Care Appointment (cont)

OHI compliance from previous recommendations: Use of Marys recipe

with the use of the rubber tip stimulator

OHI modifications and rationale for change: Urged the use of Marys
recipe to reduce bacterial load

Gingival description: gen sl, loc mod hyperemia; gen sl, loc mod
enlarged, gen fibrotic

Continuing Care Appointment (cont)

Treatment Plan: oral hygiene instructions, comp exam, recare/reevaluation

(maint), Topical fluoride varnish

Dental concern: have crown placed on #18- scheduled with front desk at the
end of this appointment

Patient motivation

Intrinsic motivation changed: same as before

Extrinsic motivation changed: same as before

Continuing Care Appointment (cont)

Services Provided/Completed: OHI, comp exam, perio

maintenance/continuing care appointment, topical fluoride varnish

Client compliance with OHI: Mod compliance

Home care modifications: discussed patients home care and

recommended use of Mary's paste with gum stimulator

Anesthesia: None

Hard/Soft deposits: Sl-mod grainy calculus and sl sticky plaque

Notes: Patient encouraged to continue 3-4 month maintenance

appointments

Continuing Care Appointment (cont)

Were expected outcomes from NSPT treatment plan met?

Yes and no

Explain:

I feel the tissues had a huge improvement and looked great at the
continuing care appointment (I failed to take intra-oral pictures);
however, the bacteria load was still higher than I would like to see
which is why I recommended the use of Mary's paste. I would like
to have patient back at least one more time to determine if a visit
to the periodontist would be appropriate.

Perio Assessment Comparison

Perio Assessment Comparison (cont)

Comparison from NSPT and Continuing

Care Appointments

Calculus deposit:

First appointment: supra 3/sub 4

Continuing care appointment: Supra 2/ sub 1.5

Perio case type: Perio case type III at both initial and continuing care
appointment

Dental Charting: Huge Improvement between initial appointment and

continuing care appointment

Initial appointment: # BOP: 57; # measurements >3mm: 34

Continuing care appointment:#BOP: 12; # measurements >3mm: 19

OHI results / recommendations: the patient showed moderate

compliance between the initial and continuing care appointment.

Reflection
I was very happy to treat this patient. I had a very big learning curve;
however, I do feel this was the patient that really taught me how to
feel sub-gingival calculus and to efficiently remove calculus. I gained
more confidence while treating this patient because I was able to
successfully complete all of my competencies with passing scores.
The tissues had a great appearance at the recare appointment so I
was happy with that part of the treatment; however, this patient still
had a big bacterial load when a microscope sample was obtained. I
encouraged the patient to continue with maintenance appointments
at this time and start with the use of Mary's paste with a gum
stimulator.