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CAP STONE PROJECT

Senior Capstone Project

Leena Ung #28

Lake Washington Institute of Technology

DHYG 438 – Senior Capstone & Portfolio

Cecilia Baca, RDH, BSDH, Med
Spring 2018
May 23, 2018
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Assessments

Medical History

A 65 year old female comes into the LWTech dental clinic stating a chief complaint that

she would like to get her teeth cleaned. During the first appointment, we begin new patient

assessments in sequential order. Following the review of her medical history, she presents with

various medical conditions such as, gout, depression, inflammation in the knee, high blood

pressure, hypothyroidism, high cholesterol, and type II diabetes mellitus. She is currently taking

numerous medications for these medical conditions indicated in the table below:

Medication Medical Condition

Allopurinol Management of uric acid excretion
Citalopram Depression
Clobetasol Short-term relief of oral mucosal inflammation
Ibuprofen Inflammation for knee
Losartan Type II diabetes mellitus
Metformin Type II diabetes mellitus
Amlodipine High blood pressure
Atenolol High blood pressure
Levothyroxine Hypothyroidism
Atrovastatin High cholesterol

The patient was diagnosed with breast cancer in the past, which resulted with a lumpectomy in

1998. The treatment was successful and she no longer battles breast cancer. When vitals are

taken, the patient states that she gets her A1C level checked every 6 months to a year. Her most

recent A1C level read 6.2, meaning she is in a healthy and controlled state. However, she does

not check her blood glucose level regularly because she claims she manages her blood glucose

level efficiently without blood testing. Additionally, she sees her primary care provider regularly

and has her medical conditions under control. Therefore, she satisfies an ASA II classification.
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Extra oral and Intraoral Exam

An extra oral exam was completed and presented results within normal limits. Her right

ramus is slightly shorter than the left side. There are generalized scattered nevi present, which

may be due to genetics, age, or sun exposure. A 4 X 3 mm scar is present on the left side of her

forehead due to excision of a mole at the age of 13. An intraoral exam was completed next,

which also presented results within normal limits. The patient’s vermillion zone was slightly dry,

but easily resolved with Vaseline during treatment. Her palate was rounded with slight palatal

tori. Lastly, she presented with a heavily coated geographic tongue. She was educated on the

importance for brushing her tongue or using a tongue scraper to remove plaque. Due to her

geographic tongue, the fissures act as a nidus for bacteria and can result with halitosis or limiting

and altering taste.

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Pre-treatment Intraoral Photos

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Gingival Description

Despite the numerous medical conditions and medications taken, the patient exhibited

overall healthy gingival tissue. The marginal gingiva is generally coral pink with localized slight

erythema on the mandible, the buccal of #15, and lingual of #20, 27, 28. She has generalized

knife edged marginal gingiva with localized rolled margins on the buccal of #29-31 and lingual

of #13. The contour of papillae are generally pointed with localized blunted papilla in between #

2-5 and #19-20. Localized bulbous papilla are present between #12-13, #8-9, and #22-27.

Overall, there is a firm consistency and texture.

Tooth Chart and Occlusal Assessment

During the doctor exam, the occlusal assessment was verified as a class I Angle’s

classification for both the right and left molars and canines. She has a slight overbite, 2 mm

overjet, and no crossbite. This patient’s hard tissues include 6 crowns (#3, 8, 14, 19, 30, and 31),

6 composite fillings (#2, 4, 5, 9, 24, and 25), 2 root canal treatments (#3 and #8), and localized
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attrition is noted on the incisal edges of the mandibular anterior teeth. These restorations are a

result from tooth decay and act as a secondary preventive measure. The habit of bruxism and

normal tooth wear also contribute to the presence of attrition. Due to numerous restorations, it is

important to monitor them for recurrent decay by maintaining periodic x-rays and exams in recall

appointments. Also, the patient was educated about the importance for maintenance of the

existing crowns. The patient received extra homecare aids such as, stimudents, soft picks, and

interproximal brushes. Each product was demonstrated to the patient for appropriate use.

Periodontal chart

The initial periodontal chart presented with generalized 2-3 mm pockets, localized 4-5

mm pockets, localized 1-2 mm recession, and localized slight heme. These results are related to

the presence of gram negative bacteria, which play a role in gingivitis and periodontal disease.
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Additionally, recession results from toothbrush abrasion, the patient’s habit of bruxism, and bone

loss. The goal for this patient includes completion of an initial therapy Scaling and Root Planing

(SRP). Following the initial therapy SRP, the patient will then be under periomaintenance for 4

month recalls. Furthermore, the bass brushing technique was demonstrated to the patient. She

was educated on proper gentle tooth brushing strokes to avoid further toothbrush abrasion and

was also informed that the ideal toothbrush should have soft bristles.

Risk Assessment

Xerostomia is a common result from taking numerous medications. Patients with

xerostomia are at higher risk for caries because the dry environment allows plaque to calcify into

calculus. Saliva also plays an important role in neutralizing acid attacks from food, as well as

cleansing the mouth to help with movement of debris and swallowing. Based upon all the initial

assessments, it is evident that this patient would benefit from incorporating fluoride into their

diet.

Radiographs
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The patient stated at the first appointment about being hesitant with taking radiographs

due to her history of breast cancer. Therefore, it was really important to consider patient

management and educate the patient about the importance about having up to date radiographs to

effectively diagnose needed treatment in conjunction with an intraoral examination. It was also

expressed that dental radiographs have little radiation compared to other x-rays and exhibit less

or equal to the radiation from a plane ride. According to the radiographs, general horizontal bone

loss is evident. According to the doctor exam, no new restorative treatment was diagnosed for

this patient.

Plaque Index and Oral Hygiene

The patient is very conscientious of her oral homecare and does not exhibit much

calculus buildup. After assessing intraorally, the periodontal chart, and radiographs, the patient

classified as an AAP III/2/D1. After completing the first initial plaque index, the patient

presented with a score of 9.82%. The patient uses both a mechanical and power toothbrush two

times daily. Other homecare aids include stimudents, soft picks, and a rubber tip stimulator.

Dental Hygiene Diagnosis

The dental hygiene diagnosis served as an individualized outlined care plan for the

patient. The patient was informed of the benefits from frequent scaling and root debridement and

how it leads to maintenance of her periodontal health status. Due to her medically involved
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health history, it was recommended that she increase the frequency of her recall appointments

from the standard 6 month recall to a 4 month recall. The recall frequency would be determined

after her initial SRP treatment at her tissue re-evaluation appointment. Significant findings from

the EO/IO exam were noted and the patient was told to monitor the findings for any issues or

changes. She must visit her primary care provider, or report to the dental hygiene student, for any

concerns or complications. Her gingival condition and periodontal findings were due to

periodontopathogenic bacteria and lack of professional dental care. Modifications to her oral

hygiene routine were made. She was told to switch to a soft manual toothbrush with a

demonstration of bass method brushing and gentle circular motions towards the gingiva. She was

also instructed on how to use a rubber tip stimulator and super floss to clean the margins of her

existing crowns. Her only source of fluoride comes from drinking tap water and tea. However,

this patient can benefit from purchasing Clinpro5000 due to her history of medication induced

xerostomia, as well as the presence of recession. Through examination hard tissues, the patient

presented with attrition on the mandibular anterior teeth. She confirmed her habit for grinding

and clenching her teeth at night due to stress. Therefore, she was advised to get a night guard.

The patient seemed to be compliant during her initial therapy. The main method for evaluating

the success of treatment was through a tissue re-evaluation. Additionally, plaque indices and

perio charting were scheduled to be recorded at three intervals: initial therapy, tissue re-

evaluation, and at her first periodontal maintenance appointment.

Planning
The goal of non-surgical periodontal therapy is to reduce pocket depths and stabilize the

progression of periodontal disease. It is intended to bring the patient back to health while

incorporating new oral hygiene practices. The patient agreed to use a soft toothbrush two times a
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day in conjunction with the c-shaped flossing technique every other day. At a later visit, we will

promote increasing her flossing frequency to every day. The main objective through the oral

hygiene instruction was to increase the patient’s health literacy. Upon explaining the importance

of oral health and it’s relation to systemic health we hope to see improvement in homecare. As

mentioned earlier, plaque indices will be measured again at the subsequent tissue re-eval and

continuing care appointments. The dental hygiene treatment plan diagnosed was a 4342 code in

non-surgical periodontal therapy. This was the recommended treatment because the patient

satisfies the requirement of having one to three teeth periodontally involved in each quadrant.

Further considerations included the presence of recession, furcations, and pockets equal to or

greater than 4mm. Clinpro 5000 was suggested to the patient due to her health history of being

medically compromised, medication-induced xerostomia, and exposed root surfaces from

localized recession. She was educated on the benefits of fluoride, such as preventing caries,

aiding in sensitivity, and replenishing the natural fluoride found in tooth structure after the

completion of SRP. However, the patient decided not to purchase the prescription strength

fluoride due to financial reasons. She stated that she may choose to purchase it in the future.

Implementation
Treatment was planned to take 4 appointments, but was completed in 5 appointments.

New patient assessments took a total of 3 appointments. She was also given a soft tooth brush to

replace her medium toothbrush prior to treatment. After providing a demonstration for bass

brushing, the patient showed improvement and stability in plaque control with each visit. This

provided evidence of the patient’s motivation to improve homecare and to maintain overall oral

health. The full mouth 4342 SRP took place during the fourth appointment. Treatment began

with using the cavitron and the universal cavitron tip. This allows the disturbance of daily
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biofilm and irrigates the pockets. Due to her AAP III classification, both universal curets and

Graceys were needed for hand scaling. The Barnhart 5/6 was especially useful for the

mandibular anterior teeth since the instrument allowed proper adaptation around areas of

recession and wrapped easily along the line angles. The sickle scalar was mainly used to remove

roughness near tight contacts of the anterior teeth. The 13/14 and 15/16 Graceys were used for

easy access to posterior teeth due to the complex shanks and ability to go subgingival in deeper

pockets. Working strokes were only used with areas that had pieces of calculus. Considering that

this patient classified as a D1, root debridement and shaving strokes were mainly used to avoid

tooth damage from unnecessary working strokes for every surface. Each sextant was assessed

with an explorer thoroughly before moving onto the next to ensure adequate calculus removal.

Following the treatment, she was advised to do warm salt water rinses to aid with the soreness

and healing of the gingival tissue as needed. It was necessary to acknowledge and praise the

patient for her great overall homecare. With acknowledgement, she found more appreciation for

her ability to maintain her oral health status regardless of all her risk factors. It is evident that

patients are likely to respond well at remain motivated when given reassurance and praise, rather

than focusing on only improvements that could be made to their daily routine.
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Post-treatment Intraoral Photos

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Evaluation

The completion of treatment finalized with a tissue re-evaluation. The results established

the SRP as overall successful. There was localized reduction in pocket depths. Localized 4 mm

pockets were reduced to 3 mm pockets, whereas other areas remained stable. Her gingival

condition also improved in localized areas where inflammation was present. The localized

problem areas noted before treatment had slight reduction in erythema, edema, and rolled

margins. The amount of heme was also improved from occurring localized in a few areas to

none. Another plaque index was completed to compare with the previous plaque index prior to

intial therapy. The score was 9.82% initially and 14.1% at the tissue re-evaluation appointment.

This increase is not an accurate factor for assessing the patient’s improvements. The patient
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stated that she was not able to do her daily thorough tooth brushing routine in the morning due to

waking up later than usual and rushing. Due to the fact that the improvements were subtle, the

patient was not able to notice these changes. However, she was impressed to hear of these

changes and valued the process. At the end of the appointment, the patient’s recall frequency was

changed from 6 months to a 4 month recall due with consideration of her medical history and its

link to her caries risk (EX: diabetic, xerostomia, depression etc.).

Periodontal Maintenance
This patient was placed on a 4 month periodontal maintenance recall appointment

schedule. Periodontal disease cannot be cured, which is why management is key. The 4 month

recall plan is a non-surgical approach in controlling the disease while avoiding extensive and

aggressive treatment. The bacteria that cause periodontal disease reestablish within 3 months. It

is our job to disrupt bacteria accumulation to prevent an increase in pocket depths, meaning

additional bone loss. A tooth without its supporting bone will become mobile and is susceptible

to become a missing tooth. We are proficient in cleaning hard to reach areas of the mouth such as

deep pockets and furcations. Waiting more than 4 months can result in advanced inflammation.

As a result, it may require local anesthesia to reduce discomfort before scaling.

Documentation
All aspects of documentation were completed. Thorough chart notes and the patient’s

chief concern were entered into EagleSoft after each appointment indicating the procedures

performed. Moreover, all chart entries were proofread by an instructor to ensure documentation

was accurate. The chart audit was updated at each appointment as treatment progressed.

Therefore, the student’s ability to maintain accurate documentation was evident.

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Conclusion
The senior capstone project serves as a tool to assess all aspects of a patient’s wellbeing

and showcase the dental hygiene student’s ability to provide individualized quality care. It serves

as an ideal example and guide that should be followed when treating all patients. Analysis of

each phase of treatment for this patient was an effective way to demonstrate the knowledge we

received through didactic courses and clinical experiences in LWTech Dental Hygiene Program.

The preventive and pathology didactic courses played a huge role in our education to aid in

educating patients. This allowed us to self assess on the type of products our patients would

benefit most from, as well as to provide an explanation between the link of oral health and

systemic diseases. After completing our capstone patient and developing a deeper understanding

behind their individual needs, habits, and health, we were able to grow and advance with our

abilities to assess and cater to their needs. There is always room for improvement when it comes

to patient care. Both professional and personal growth will continue to progress throughout our

years of experiences. Not only did the capstone project aid in applying our didactic lessons to

real clinic, but it also challenged us by learning how to be an educator to our patients, how to be

empathetic, and how to build patient trust. The LWTech dental hygiene program has prepared us

in countless ways for the real world through various experiences, projects, and didactic courses.
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