Case Study 2016

Rachel Cowger, DH2

Patient Selection Rationale

This patient qualified for the case study project because they were Periodontal Case Type
II/III and had a subgingival calculus deposit of a 3

I explained that both NSPT and Continuing Care would be included as part of this project,
and the patient agreed to be my case study

NSPT Dates

Began treatment: February 22nd, 2016

Completed treatment: March 7th, 2016

Pretreatment Assessment: Health History

Summary

I: none

S: Type II Diabetes

M: Metformin may cause taste disorder

E: none

A: none

D: patient brushes once daily with fluoride paste

Pretreatment Assessment: Vital Signs

Patient vital signs were within normal limits

ASA Class II

Pretreatment Assessment: I/O Findings

No significant findings

Pretreatment Assessment: Dental Charting

Following our dental exam, these findings were recorded in the dental chart as proposed restorations:

#1 O

#2 DO

#3 DO

#4 DO

#18 DO

#19 DO

#19 BV

#30 O

#31 O

#32 O

Pretreatment Assessment: Dental Charting

Following our dental exam, these findings were recorded in the dental chart as watch
surfaces:

#8 M

#9 M

#25 BV

Pretreatment Assessment: Perio

Assessment

Pretreatment Assessment: Perio

Assessment

Pretreatment Assessment: Microscope

Evaluation

Patient falls into Risk Factor C category

High Risk

High counts of spinning and gliding rods

High counts of spirochetes

Pretreatment Assessment: Radiographic

Findings

Bone loss: Generalized slight horizontal with localized moderate

Decay as previously listed (10 surfaces decay, 3 watch surfaces)

Molar Projections

Premolar Projections

Maxillary Anterior Projections

Mandibular Anterior Projections

Pretreatment Assessment: Study Models

Pretreatment Assessment: Study Models

I did my best, but the impressions did not include the entire crown of the third molars
present

The pour up had air bubbles in the base and in a couple anterior teeth on the mandible

The buzz trim went well, but the models ended up being off center

These models were made with the intent to be used in patient education, but
unfortunately my patient never returned after I had completed them, so they were never
used.

Dental Hygiene Diagnosis: Periodontal

Case Type

I diagnosed this patient as being a generalized periodontal case type II with localized
periodontal case type III

Generalized slight periodontitis with localized moderate periodontitis

Dental Hygiene Diagnosis: Calculus

Deposit

This patient originally was evaluated as a 2/2.5

Upon completion of assessments and a calculus chart, the deposit was changed to 2/3

Dental Hygiene Diagnosis: Gingival

Description

Color: Generalized slight-moderate hyperemic

Contour: Generalized slight-moderate enlarged with generalized slight recession

Consistency/Texture: Generalized slight-moderate edematous

Statement of Inflammation: Generalized slight-moderate papillary/marginal inflammation

Dental Hygiene Diagnosis: Radiographic

Support

The radiographs support the diagnosis by showing generalized slight horizontal bone loss;
this represents the slight periodontal involvement

There is localized moderate horizontal bone loss which shows more involved areas of
moderate periodontitis

Intraoral Photos

Intraoral Photos

Intraoral Photos

Intraoral Photos

Intraoral Photos

Risk Assessment: Periodontal Risk Factors

Dental Biofilm: Moderate risk; generalized moderate cervical and interproximal plaque

Calculus: Moderate risk; 2 supragingival and 3 subgingival

Bleeding on Probing: Low risk; localized slight BOP

Contributing Factors: Low risk; slight crowding in lower anteriors

Loss of Attachment: Moderate risk; generalized 1-2mm and localized 3-4mm CAL

Risk Assessment: Caries Risk Factors

Visible caries of white spot lesions: High risk; 10 surfaces of decay

Recently restored caries: N/A

Deep occlusal pits and fissures: High risk

Root exposure: Low risk; generalized slight recession

Visible dental biofilm: Moderate risk; generalized plaque along gumline and interproximal

Diet/frequent sugar exposure: Low risk; once or twice weekly

Xerostomia or saliva reducing factors: Low risk; patient has noticed dry mouth before, but
not often

Appliances: N/A

Risk Assessment: Patient Goals

This patient expressed a desire to work towards having a healthy mouth. After the
microscope assessment, they were very concerned about bacteria.

Risk Assessment: Planned Interventions

Ultrasonic

Hand scaling

Use of dental floss or other interproximal aid

Risk Assessment: Expected Outcomes

Reduced inflammation

Better plaque control

Risk Assessment: Greatest Disease Risk

The greatest disease risk at this time is caries

Treatment Plan and Rationale: Treatment

Plan

Appointment #1:

D0120 Periodic Oral Evaluation

D4341 Periodontal Scaling and Root Planing UR

D1330 Oral Hygiene Instructions

Appointment #2:

D4341 Periodontal Scaling and Root Planing LR

D1330 Oral Hygiene Instructions

Appointment #3:

D4341 Periodontal Scaling and Root Planing UL

D4341 Periodontal Scaling and Root Planing LL

D1330 Oral Hygiene Instructions

D1206 Topical Application of Fluoride Varnish

Appointment #4:

D4910 Periodontal Maintenance Procedures

D1330 Oral Hygiene Instructions

D1206 Topical Application of Fluoride Varnish

Treatment Plan and Rationale: Clinical

Knowledge

Based off of the findings from assessment procedures, this patient needed NSPT

The deposit level and level of sensitivity the patient had during probing/exploring
confirmed the use of local anesthesia

Treatment Plan and Rationale: Cultural

Knowledge

This patient was Hispanic and spoke very little English, so I had a hard time communicating
all of the necessary information

I was very fortunate to have a fellow student and instructor who were willing to be
available to help me translate

Treatment Plan and Rationale: Behavior

Modification Strategies

This patient was concerned about how the appearance of their teeth

There has been extractions done a couple weeks prior to NSPT and they were upset that you
could see teeth missing when they smiled

I tried to use appearance as a motivational tool in homecare. I had my instructor talk to the
patient about the gingival inflammation and plaque being visible, and that it can be controlled
with proper brushing technique

I also tried to motivate behavior change by discussing the amount of restorative work needing
to be done. We talked about the teeth needing priority, and then how to prevent future decay

Another way I tried to motivate behavior change was talking about injections. The patient did
not want any injections for anything, but knew they were necessary. I talked to them about
taking better care of their teeth so that they wouldnt need more restorations or NSPT and
wouldnt be needing injections

Treatment Progress Notes

2/19/16 Patient was in for NPI appointment

2/22/16 Patient was in for NSPT in UL

2/24/16 Patient was in for FMX in DH1 lab

2/29/16 Patient was in for NSPT in LR

3/7/16 Patient was in to complete NSPT in LL and UR

Patient did not return for continuing care

Oral Hygiene Instruction: Initial

Recommendations

Initially the patient said they were not doing anything to clean interproximally

We went over sulcular brushing technique, recommended twice daily

Demonstrate c-curve flossing and recommended this once daily, or as often as they could

Oral Hygiene Instruction: Patient

Compliance

At the second appointment the patient said they were brushing twice a day, but still were
not flossing

Oral Hygiene Instruction: Modifications

The only modification was to try and incorporate flossing

I talked to the patient to see if they would be willing to try another interproximal aid, but
they said that they would floss they had just forgotten the c-curve technique, so we
demonstrated that again

Oral Hygiene Instruction: Patient

Compliance with Modifications

At the final scaling appointment, the patient reported that they were brushing twice and
flossing once daily

Motivation Strategies: Patient Intrinsic

Motivation

This patient was self-conscious of their teeth and appearance, so that was the intrinsic
motivation for them

Motivation Strategies: Patient Extrinsic

Motivation

I tried to get the patient to think of taking care of their teeth as a reward system. If they
kept up on homecare and hygiene treatment, they would be rewarded with less painful
cleanings and a beautiful smile

Motivation Strategies

Ive already mentioned my motivation strategies for this patient during OHI and they
didnt change over the course of treatment

I used appearance, fear of injections, and their overall dental pain to motivate and push
them toward better homecare and dental care

Continuing Care Appointment

This patient did not return for the continuing care

When contacted to plan and schedule the appointment, the patient said that they were
no longer able to come in because they had gotten a job

I tried to get them to come in the evening or anytime that would work for them, and I
reminded them that it was a no cost appointment, but they still decided not to return

Comparison: NSPT and Continuing Care

I have not seen the patient since completing NSPT, and they have not been in to
complete any restorative work

It is unfortunate, but I have nothing to compare!

Reflection

I would give this patient the same treatment and treatment plan

I would consider trying a desensitizing pre-polish for this patient to see if that made any
difference for them. Although they did need local anesthesia, it was difficult to do the
reappoint procedures because they were so sensitive

My recommended recall interval for this patient is 3 months for periodontal maintenance. I
would want them in at 3 months for continuing care to see how everything was doing and
make sure the homecare was effective. After a few appointments of being on track I
would say that the patient could come in every 4 months, and if things were still stable
and their homecare was good, I would recommend 6 months

This patient would not benefit from seeing a periodontist unless they were considering
implants for their extracted teeth. This patient was only localized case type III, so they were
not too difficult to be seen at our clinic or at any general office

Reflection

This project was a challenge for me. In all honesty, my patient would have preferred to be
seen by someone who could communicate better in Spanish, and I believe that factor
and their extreme sensitivity kept them from wanting to come back. The language barrier
was difficult, but I did my best and felt that I was successful in keeping my patient
comfortable throughout treatment