Case Studies inDental Hygiene

Volume 3 2012 Number 3

Many habits threaten oral and systemic health. Poor nutrition, compromised oral hygiene care, tobacco use, and alcohol consumption are but a few. Aconstellation of negative health behaviors is not uncommon, particularly amongyoung adults who are beginning to assume control of their own healthcare.1,2 Mr. D,the subject of today’s case, engages in highly destructive health behaviors that haveresulted in rampant caries, generalized erosion, and threats to systemic health. Hisexcessive consumption of sugared soft drinks, a low dental IQ, alcohol and tobaccouse, and a reluctance to assume responsibility for his own healthcare are theprimary etiologies.

Excessive soda consumption is commonplace in today’s society.3,4 Americanchildren and adults consume approximately 56 gallons of soft drinks per year,equivalent to over 600 twelve-ounce servings per person per year.3 Soft drinkconsumption has doubled among women and tripled for men, with males betweenthe ages of 12–29 consuming the most.5,6 Beverages high in sugar content increasea person’s risk for rapid progression of dental caries and erosion, and can adverselyaffect overall health.4

Increased risk for dental caries and extrinsic enamel erosion depends on thebeverage’s level of cariogenicity, acidity, and the time, quantity, and frequency ofconsumption.7-9 Sugary soft drinks contain acids, typically phosphoric, citric,and/or carbonic acids that injure enamel hydroxyapatite, causing erosion, a non-bacterial chemical wearing away of the tooth due to depletion of the enamelcoating.9,10 Individuals who consume excessive amounts of sugary soft drinks gainweight and put themselves at greater risk for type II diabetes and cardiovasculardisease.11 Research shows that when soft drink consumption is increased, theintake of nutrient-rich foods and beverages such as milk is reduced. 12

A component of oral health literacy involves a patient’s ability to understand howunhealthy habits affect their oral wellness; for example, understanding thatexcessive drinking and cigarette use increase the risk for oral cancer.13,14 Dental

EditorFrom the SeriesGreetings Colleagues …

I am happy to share with you the third case study for 2012.Once again, with the generous support of Colgate, we are able toexpand our intellectual horizons and maintain our goals to belifelong learners.

By the time you see this case, our visions of summer should stillbe bright with autumn beckoning. As I was editing this case,summer was just on the horizon, and I thought of the manyyoung adults who often visit their parents at this time. Many ofthese young adults live on their own in other geographic areas.Since we are oral healthcare providers, we tend to be diligentabout ensuring that our own young adult children get the dentalcare they need. My oral surgery friends tell me that summer is apopular time for young adults to have their wisdom teethextracted! However, many young adults are not as fortunate asours, often struggling to obtain oral healthcare. Whether it is amatter of not having a “dental home away from home,” orsimply not having the motivation to access care, this age groupoften falls through the cracks.

Mr. D, a young man who is the subject of today’s case, hasshrugged off his responsibility to maintain his own oral health.He has adopted lifestyle behaviors that have resulted in rampantdecay and erosion and that pose risks to his general health.Initially, he blames his parents for his unmet needs, butultimately, with the help of his dental hygienist, he realizes thatto become healthy, change must come from him.

All too often we encounter patients with low dental IQs and alack of oral health literacy. To aid these patients, we must knowabout the best approaches to health education and motivation,and be aware of the best practices and therapeutics available.Through Case Studies in Dental Hygiene we are able to learntechniques and approaches that enhance our capabilities andeffectiveness. Colgate offers us this opportunity to ponder howwe practice and to consider alternatives to providing care.Continued learning is a hallmark of our profession. To Colgate, Isay thank you.

Sincerely,

Jacquelyn L. Fried, RDH, MSAssociate Professor and Director of Inter-Professional Initiatives University of Maryland School of Dentistry

Young Adulthood: A Time of Transition andIncreased Responsibility

Introduction

Tara L. Newcomb, BSDH, MSAssistant Professor and Clinical Instructor

Old Dominion University School of Dental Hygiene

Case Studies in Dental Hygienehygienists, by working on a one-on-one basis with their patients, canincrease patient oral health literacy.

Effectively motivating patients to modify destructive habits ischallenging, particularly when multiple behaviors are involved.Knowing how to manage a particular patient is complex. Helpingreduce risk factors for oral and systemic disease is a dental hygienist’sethical responsibility. Enhancing biological, behavioral, and/orsocioeconomic contributors to systemic and oral health requires astrong knowledge base, intuition, and perseverance, skills dentalhygiene professionals possess.

Mr. D is a 24-year-old man with a low dental IQ who has not takenresponsibility for his oral or general health. He blames his parents forhis dental disease and does not realize that his excessive sodaconsumption, alcohol use, smoking, and poor dietary habits threatenhis well-being. The dental hygienist meets the complexities of thiscase by challenging Mr. D to take responsibility for his well-being, andmodify or eliminate risk behaviors that threaten his oral andsystemic health.

Background and Health History

Mr. D: 24-year-old single, Caucasian male presenting for a “check-up and cleaning.” He has had no routine dental hygiene care in oversix years; he has no dental insurance coverage despite full-timeemployment at a local scrapyard. His parents no longer schedule hismedical or dental appointments, nor cover related expenses. Hereluctantly assumes responsible for his own care.

Mr. D does not use any prescription medications. He has a historyof seasonal allergies treated with OTC antihistamine medications,p.r.n.; he suffered with asthma as a child with no attack in over 10years. He has had emergency room visits and dermatologicalprocedures, including a broken collar bone in a motor bike accident(2005); removal of four dysplastic nevi, two of which were facial(2006); work-related broken leg requiring placement of two screws infibula (2008); car accident with trauma to the right side of face,broken rib, and minor cuts on the head and chest (2010); and deeplaceration (work injury) of right palm of hand with localized infectiondue to patient negligence (2011). This was treated with oralantibiotics and first aid antibiotic ointment; residual numbness inhealing site reported.

Chief Complaint: “I need to have my teeth cleaned, they are getting brown.”

Physical Assessment: Height 5’11”; weight 142 lbs. (medium frame);visible dirt in nail beds and on face and clothing, possibly work-

related. Lack of good personal hygiene; patient states that being tiredafter working long days outdoors doing manual labor makes “itdifficult to come to dental appointments or to make other doctors’appointments.”

Vital Signs: BP: 120/80 mm Hg, RAS; pulse: 68 BPM; respirations: 16 RPM;

Family History: Father: age 58, divorced; history of diabetes, highblood pressure, high cholesterol and heart disease; suffered a heartattack followed by double by-pass surgery (2010). Mother: age 57,divorced, history of anxiety and depression, removal of basal cellcarcinomas on face and arm (2007).

Social History: Employed in manual labor since entering job market(construction work, landscaping, and the scrapyard); schedules noexercise. Has used tobacco products for the past five years, smokingone pack of cigarettes/day; drinks 5–6 alcoholic beverages, mostly onthe weekends when “hanging out with friends,” sometimes consumesbeer and liquor mixed with soft drinks during the week; has noformal education or job skill training; started working right aftergraduation from high school; lives with one roommate; likes to partyand play pool on the weekends with friends; hunts and fishes yearround.

Nutrition History: Since living independently, has not establishedskill set to purchase and prepare nutritious meals. Generally eatsprepackaged meals or fast food (high in fat, sodium, andcarbohydrates) “picked up” on the way home from work; rarely eatsfruits or fresh vegetables; typically eats in front of the TV (sometimesfalling asleep on the couch without showering or brushing teeth), orgoes to happy hours and skips dinner. Reports drinking at least 12sugared carbonated soft drinks per day.

Past Dental History: Has received comprehensive dental hygienecare in the past (when under parental supervision); has had some ofhis carious lesions restored; blames current untreated carious lesionson his parents, who he claims did not take him back for additionalplanned restorative appointments when he was a teenager.

Relevant Clinical Assessment Data

Extraoral: Signs of sun exposure and damage on face and lips;chapped, dry lips. Several small (under 2 mm in circumference) darkbrown nevi on forehead near hairline, nose, and cheeks; frecklesacross the upper cheeks and bridge of nose. One mole noted for itssize (3 mm), irregular border, darker color and scaly appearance.

Intraoral: Small 4x2 mm piece of black rubbery material lodged intoexisting buccal caries #2, removed. Patient shredded over 150 tiresprior to appointment; maxillary tori and brown coated tongue.

2

Case Report

Slightly decreased salivary flow. Angles Classification I, bilaterally.Two mm midline deviation to the left; 5 mm overjet; overbite atmiddle third. Crossbite, teeth numbers 13–19, 14–20.

Radiographic Findings: Slight posterior vertical bone loss; anteriorand posterior fillings, some with obvious secondary caries; numerousprimary caries; multiple restorations present (Figure 1).

Hard Tissue Findings: Twenty-eight teeth present; wisdom teethextracted at age 18; 18 areas of suspected caries: four interproximal,four occlusal, ten with active root caries and/or erosion; chalky whitespot lesions generalized at gingival margins in plaque stagnationareas; cervical decay and erosion, brown in appearance; soft andrough upon light exploration (Figure 2).

Accretions: Generalized heavy marginal and interproximal plaquebiofilm; moderate posterior occlusal plaque deposits on surfaces andin areas with deep decay; generalized, moderate extrinsic brownstain; tire remnants lodged in two mandibular molars with deepcervical decay. Silness and Löe15 Plaque Index score of 2.0, indicatingpoor oral hygiene; calculus generalized; heavy, lower anteriors,moderate subgingival deposit interproximally.

Caries Risk Assessment: Overall high risk for caries per ADA ClientCaries Risk Assessment Form (Table 1). Mr. D is at high risk due toconsumption of sugary or starchy foods or drinks with a frequency ofprolonged between-meal exposure/day; at moderate risk due to nodental home care and not being an established patient of recordreceiving regular or routine dental care; at low risk for general healthconditions; and at high risk for having cavitated or incipient cariouslesion or restorations, three or more carious lesions or restorations inthe last 36 months; visible plaque, interproximal restorations, andexposed root surfaces contribute moderate risk.

Oral Hygiene Behaviors: Brushes every two days with mediummanual toothbrush, sometimes without toothpaste; no interdentalcleansing; occasional rinsing with essential oils mouthrinse.

Case Studies in Dental Hygiene 3

Figure 1. Full mouth series

Figure 2. Erosion and interproximal lesions.

I.

II.

III.

IV.

I.

II.

III.

IV.

V.

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

IX.

Fluoride Exposure (through drinking water, supplements,professional applications, toothpaste)

Sugary Foods or Drinks (including juice, carbonated or non-carbonated soft drinks, energy drinks, medicinal syrups)

Caries Experience of Mother, Caregiver and/or other Siblings(for patients ages 6-14)

Dental Home: established patient of record, receiving regulardental care in a dental office

Special Health Care Needs*

Chemo/Radiation Therapy

Eating Disorders

Medications that Reduce Salivary Flow

Drug/Alcohol Abuse

Cavitated or Non-Cavitated (incipient) Carious Lesions or Restorations (visually or radiographically evident)

Teeth Missing Due to Caries in past 6 months

Visible Plaque

Unusual Tooth Morphology that compromises oral hygiene

Interproximal Restorations - 1 or more

Exposed Root Surfaces Present

Restorations with Overhangs and/or Open Margins, Open Contacts with Food Impaction

Dental/Orthodontic Appliances (fixed or removable)

Severe Dry Mouth (Xerostomia)

Yes

Primarily at mealtimes

No carious lesions inlast 24 months

Yes

No

No

No

No

No

No new cariouslesions or restorations

in last 36 months

No

No

No

No

No

No

No

No

No

Carious lesions in last7-23 months

No

Yes (over age 14)

Yes

Yes

Yes

1 or 2 new cariouslesions or restorations

in last 36 months

Yes

Yes

Yes

Yes

Yes

Yes

Frequent or prolongedbetween mealexposures/day

Carious lesions in last6 months

Yes (ages 6-14)

Yes

3 or more cariouslesions or restorations

in last 36 months

Yes

Yes

TOTAL:

0

10

0

1

0

0

0

0

0

10

0

1

0

1

1

0

0

0

24

Contributing Conditions

General Health Conditions

Clinical Conditions

Low Risk (0)

PatientRisk

Moderate Risk (1)

High Risk (10)

Patient Name: Mr. D Score: 24

Birth Date: 3/13/1988 Date: 2/25/2012

Age: 24 Initials: XXX

Caries Risk Assessment Form (Age >6)

Table 1. Caries Risk Assesment Form

Case Studies in Dental Hygiene

Periodontal Findings: Bleeding on probing, all sites; 2–5 mmreadings generalized, 6 mm pseudo-pocketing on #s 5 DB and #15 MB; moderate recession localized to mandibular posteriors.Classification: severe gingivitis; moderate periodontitis (3–4 mm Calculated Attachment Loss). Erythematous, edematous tissue (Figure 3).

Periodontal Risk Assessment: High risk due to smoking, recession,existing caries, and defective restorations with secondary caries, poororal hygiene and diet, lack of professional care, and bouts of oraldryness.

Clinical: Rampant caries and erosion, extensive plaque accumulations,suspect extra-oral lesions, high bleeding scores; minimal to moderatebone loss.

Psychosocial: General lack of health knowledge; reluctance to assumecontrol over his well-being; engages in destructive health habits, includingpoor to no oral hygiene, excessive consumption of sugary carbonatedbeverages and alcohol, tobacco use, and unacceptable dietary practices;appears “accident prone” and lackadaisical about his lifestyle.

Additional time will be spent on behavior modification andimplementing strategies to help Mr. D assume control of his well-being. Judiciously approaching and discussing his lack of desirablehealth habits and motivating him to change will require intuition andpatience. Although dental hygienists focus on motivating patients toadopt and maintain healthy oral hygiene and wellness behaviors,patients first must take responsibility for their own health.15 Based on

his interests and lifestyle, the dental hygienist believes Mr. D can bestbe motivated by appealing to his sense of self-determination. Theinitial step is to strongly reinforce any positive efforts he makes.Making a dental hygiene appointment is a major accomplishment, asMr. D has not visited his family dental office since he was a youngteenager, still under the supervision of his parents. Legally, persons18 years of age and older gain adult privileges, such as consent tohealthcare.16 Young adults, such as Mr. D, may need helptransitioning from family supervision to independence. By givinghim autonomy and reinforcing his decision-making, Mr. D mayrespond favorably to recommended change. Goals must be related tohis individual needs, values, and ability level.15 Treatment planningmodifications will require providing increments of information ateach appointment. Mr. D will be asked to set his own goals, so theyare realistic and patient-centered. Honoring his work commitmentsalso will provide a basis for earning his respect.

Health Education Topics: Assuming personal responsibility for oraland systemic health, connections between rampant caries, sugarconsumption, and poor oral hygiene, and between carbonatedbeverages, poor oral hygiene, and erosion; need for regular dentalhygiene care and caries prevention strategies, including nutritionalcounseling; limiting alcohol consumption and smoking as both poseincreased risk for oral cancer and periodontal disease; teachingpatient self-examination to reduce risk of oral and skin cancer;addressing xerostomia, caused by combined use of tobacco, alcohol,and caffeinated carbonated beverages.

Home Care: Introduce oral hygiene measures, emphasizingfrequency; prescribe fluoride therapy and non-alcoholic mouthrinse;assess and modify diet and food plan; emphasize reduction (withultimate elimination) of sugary sodas and suggest alternatives;approach tobacco cessation and reduction in alcohol use; discussskin protection to avoid facial lesions.

Periodontal Debridement: Non-surgical periodontal therapy (NSPT),including scaling and root planning four quadrants using localanesthesia with epinephrine. Local anesthesia with a vasoconstrictorcan be used to help control bleeding during NSPT and reducediscomfort.17-19 Mr. D experiences pain upon probing and presentswith moderate generalized bleeding; his use of alcohol may furtherincrease bleeding.20,21 Hand scaling in areas of demineralization isrecommended; power-driven scalers are contraindicated fordemineralized areas and can cause surface defects and damagemarginal integrity of restorations.22-24 Selective polishing is indicatedwith fluoride varnish applied after treatment.

Sequencing: Mr. D’s responses and requests will determine the topicsraised and the behavior modifications introduced. A daily oral home

4

Analysis of Assessment Data

Figure 3. Erythema and edema.

Modifications to Treatment

Treatment Planning

Case Studies in Dental Hygiene

care regimen must be introduced at the first appointment. Diet,alcohol use, and smoking may be addressed in relation to the EIOEand visible findings. One side of the mouth will be scaled. Atappointment two, the first two quadrants will be reevaluated to assessdeposit removal and tissue resolution. The remaining quadrants willbe scaled. Reinforcement of modifications will be included at everyappointment. A post-evaluation will be scheduled and a follow-upinterval determined.

Appointment 1

No changes in health history; blood pressure: 122/81 mm Hg, RAS.During the EIOE, signs of sun damage (dark spots across the uppercheeks and bridge of nose, and dark brown nevi on his forehead nearthe hairline, nose, and checks) are noted. The nevus with irregularborders, darker color, and scaly appearance is measured anddocumented. Upon conferring with the dentist, a dermatologicalreferral is made. To avoid skin cancer, the following recommenda-tions are made: liberal use of sunscreen and wearing treated clothingthat block the sun. Eye and mouth protection can be achieved bywearing protective eye wear and a mask when working with debris inthe scrapyard.

Mr. D discusses his present alcohol and smoking habits, seeminglyoblivious to their harmful oral and systemic effects. He learns thatthe combination of chronic alcohol consumption and smokingincreases his risk for oral cancer; specifically, with high alcoholconsumption the risk of pharyngeal cancer, esophageal cancer, andoral cancer grows.13 Mr. D will be monitored for oral cancer andperiodontal disease as they are linked to tobacco use15,25,26 and will betaught how to conduct a self-screening. Mr. D seems alarmed at theinformation and says he might consider reducing his intake of bothsubstances. Mr. D has been using tobacco for only five years, so thebenefits of using and the reasons for starting must be addressed.Given that he is employed out of doors, smoking in the workplace ispermissible. This challenge will be discussed. Mr. D is informed thatquitting smoking is difficult and multiple attempts at cessation arecommon.15,25-26 The dental hygienist will support Mr. D througheducation and encouragement. Mr. D’s chief complaint of brown stainprovides a segue to introduce home care; it also demonstrates thelink between tobacco use and staining. Mr. D is shown the brownerosion areas which he thought were simply stain. Erosion and itslink to carbonated sugared beverages are discussed. Mr. D learns thatsodas have been instrumental in his 18 new carious lesions; he alsofalls into the range of males who consume the most sugary softdrinks.5,6 He appears concerned about losing his teeth and the cost ofrestorations.

Mr. D’s deleterious habits become the focus of discussion. He isadvised to commit to healthy drinking by choosing water and milk

and limiting the use of sugary drinks. His Silness and Löe PlaqueIndex score is 2.0, indicating poor oral hygiene. As such, thefollowing oral hygiene measures using the “tell, show, do” method areintroduced: soft-bristle tooth brushing using the modified Basstechnique, applying gentle pressure due to recession and erosion; C-shaped flossing once a day or use of a flossing aid to removeinterproximal plaque and reduce bleeding; and tongue cleansing toreduce microorganisms, remove residual tobacco stain, and augmentoral cleanliness.15 Mr. D successfully demonstrates 45-degree anglesulcular brushing using short back-and-forth motions. Brushing 2–3times daily, especially at bedtime is recommended. C-shaped flossinginstructions using disclosing solution were given; Mr. D manipulatedthe floss well on the anterior teeth even with crowding, but becamefrustrated when demonstrating on posterior teeth; floss piks wereintroduced if C-shape flossing continues to be a problem. Based onhis risk assessments, a combination therapy for both high-caries riskand periodontal disease using a 5000 ppm fluoride toothpaste andchlorhexidine (CHX) mouthrinse is recommended.15,17 Using a 1.1%prescription strength sodium fluoride toothpaste daily combinesbrushing with simultaneous fluoride uptake; this one step promotesgreater patient compliance.27-29 The recommended toothpaste also issafe for exposed root surfaces, and significantly remineralizesdemineralized areas and root caries.27-29 Once-daily rinsing withchlorhexidine gluconate (0.12%) for the management of both dentalcaries and periodontal diseaseis suggested for two weeks.30,31 Mr. Dsets a goal to reduce his plaque levels by 30% for the next visit.

Mr. D has completed a 24-hour food recall form, and his nutritionhabits are addressed. The 24-hour food recall can be taken in 15 to 20minutes, showing consideration for Mr. D’s busy work schedule andlimited time for appointments. Prevention targets are to reduce cariesrisk and address systemic conditions that could arise from acompromised diet. The dental hygienist recommends the following:limiting consumption of fermentable carbohydrates to mealtime;reducing/omitting sweet foods/drinks with meals; selecting between-meal snacks that include raw fruits and vegetables, and avoiding stickycarbohydrates and sweets before bedtime; avoiding fast foods high insodium and fat; decreasing the frequency of sugar consumption;replacing cariogenic foods with those of nutritional value,32,33 and usingxylitol products to satisfy his sweet tooth and stimulate salivary flow.Xylitol tastes like sucrose, yet inhibits attachment and transmission ofbacteria and enhances remineralization of hard tissues.15,34 Chewingtwo pieces of gum or sucking on two xylitol lozenges four to five timesdaily is recommended for patients with moderate to severe cariesrisk.15,34-36 Recommended dietary allowances using the Dietary FoodGuidelines for Americans and US Department of Agriculture MyPyramid were reviewed.

Mr. D has agreed to reduce sugary soda intake by half, substitutingwater for rehydration. He is realizing that he can no longer blame his

6

Case Studies in Dental Hygiene 7

parents for his poor oral health, seeing that his consumption ofsugared acidic beverages, poor dietary choices, smoking, and alcoholhabits are behaviors he has chosen as an adult.

The initial restorative treatment plan will include the placement ofsealants in incipient lesions, and the use of glass ionomerrestorations that slowly release fluoride.15,34 More complex restorativetreatment may be warranted.The entire dental team will facilitateMr. D’s movement toward prevention of disease or its recurrence. Asliding scale for payment of services rendered will be established soMr. D can continue treatment and manage costs. Mr. D is grateful forthis plan.

For NSPT, the following instruments were used: a subgingivalperiodontal explorer, ODU 11/12 for calculus detection, extendedshank area-specific curets; Gracey 1/2 for anterior and premolarsurfaces and interproximal areas; Gracey 11/12 for mesial proximaland 13/14 for distal proximal surfaces of molars; and mini-bladedarea-specific curets for adaptation on narrow facial and lingualsurfaces of anterior teeth where Mr. D has crowding.15,37 Ultrasonicscalers are contraindicated for decayed and demineralized areasbecause the ultrasonic vibrations can remove the delicateremineralized cover of a vulnerable area.23-25 NSPT was implementedon the left side and topical anesthesia was applied at each localanesthesia injection site. One carpule of lidocaine 1:100,000epinephrine was administered to the maxillary left ASA, MSA, andPSA, and to the mandibular left IA and long buccal. Negativeaspirations reported. Mr. D presented with moderate supra- andsubgingival calculus and heavy plaque. Some veneer and generalizedmoderate interproximal calculus was tenacious, and bleeding uponscaling was heavy due to the amount of inflammation present. Brownstains from tobacco were removed by scaling and selectivepolishing.15 Heavy subgingival plaque was removed with debridement.

All take-home messages were reinforced. The dental hygienistadvised Mr. D to focus on a few main things, such as the reduction ofsugared carbonated beverages, practicing the recommended oralhygiene measures, and considering limited tobacco and alcohol use.

Appointment 2

No changes in medical history and EIOE; blood pressure: 122/79 mmHg, RAS. Mr. D will be seeing the dermatologist in three days and wascongratulated for that effort. He has purchased sunscreen products forhis face and lips. Tissue reassessment indicates a 25% reduction inbleeding and less edema on the previously scaled left side; pseudopocketing was reduced by 1 mm generalized, with the areas of cervicaldecay excepted. Minor bleeding upon probing was present in themandibular anteriors; an end-tuft brush was introduced for that area.Mr. D’s Silness and Löe Plaque Index score of 1.0 shows improvement

to “fair.” He has reduced his consumption of sugary sodas by one-half,choosing to drink more water instead. He now attempts to keep groceriesat home, often buying pre-cut vegetables and fruits, as recommended;he is saving money by not eating out all of the time. Mr. D reports thefollowing: twice-daily brushing with the prescribed toothpaste and dailyrinsing using CHX. He is not flossing due to dexterity issues related tohis numb hand. Floss holder and/or plastic pik use are reinforced.

Mr. D’s accomplishments after one appointment are exceptional.Since he does want to quit smoking, the dental hygienist implements the “Five A’s Approach.38 An online resource(http://www.smokefree.gov) and a national telephone quit line thatoffers immediate and local support group resources in smokingcessation (1-800-QUITNOW) are provided. The dental hygienistteaches Mr. D how to self-perform an oral cancer screening, notingcommon sites for lesions and explaining the benefits of earlydetection.39 He was also told that areas differing in color, shape, andsize in comparison to the surrounding tissue, and lesions that do notheal merit further investigation.39,40 Mr. D recognizes that stoppingsmoking will save money, reduce his risk of heart disease (a familialcondition), and prevent bone loss and oral cancer. He agrees toreduce his tobacco use to one-half pack a day by his re-evaluationappointment. Mr. D is relishing his self-determination and the dentalhygienist is somewhat amazed at his progress. After reviewing theDrug Use Continuum (Table 2), Mr. D sets a small goal to reduce hisconsumption to occasional use. He admits that after drinking severaldrinks he becomes tired and falls asleep without brushing his teeth.

Table 2. Drug Use Continuum

ClassificationBased on Use

Type 1

Type 2

Type 3

Type 4

Type 5

Abstainers (about onethird of the population)

Social drinkers or users(majority of population)

Drug abusers

Physically dependentAddicts

Psychologicallydependent addicts

Never used drugs or alcohol

Occasional useAble to drink one cup and stopDoes not result in personalproblems

Excessive use of substanceBinge drinking

Adaptation of the body’s chemistryWithdrawal signs and symptomsNot used as a coping devicePhysician-induced addictions

Alcohol or drugs used to copewith lifeCan never return to social useToleranceWithdrawal symptomsCompulsive useLoss of controlUse despite personal problemsPreoccupationDenial

Description Behavior

Case Studies in Dental Hygiene8

The dental hygienist reinforces Mr. D’s self-efficacy; however, sheadds that if alcohol and tobacco use remain problems, seeking outsupport groups or other professionals in the community may benecessary.

NSPT is begun using the same procedures and armamentarium forlocal anesthesia administration and instrumentation as at the firstappointment. Like the left side during scaling, bleeding is evoked butit is less substantial given Mr. D’s adherence to his new home careregimen. To complete the appointment, a fluoride varnish is paintedon all teeth, with a recommended application of two to three timesannually.35,36 A four-week reassessment appointment is scheduled. Mr.D has verbalized his desire to start restorative treatment soon.

Four-Week Reassessment Appointment

Mr. D’s health history and EIOE are reviewed; no changes noted.Overall, gingival health, pocket depths, and stable clinicalattachment levels are noted; full mouth probing reveals generalized 2mm pocket depth reductions, with bleeding sites reduced by 75%.Tissue is less edematous and erythematous. Mr. D met his tobaccoreduction goal and decreased his alcohol consumption during theweek; however, he is having several drinks on the weekends. Hecontinues to adhere to the prescribed home care regimen. Althoughhe flosses only 3–4 times a week, that does represent animprovement. A slight calculus build up is present on the crowdedlower anterior lingual. End-tuft brush use is reviewed. Somegeneralized brown stain from smoking and the CHX rinse hasreformed.17,26 Deposits are removed using hand instruments andprophy cup polishing for the brown stain. His Silness and Löe PlaqueIndex score is 0.9, which is “good.” He is surprised and elated by thechanges in his mouth.

Mr. D will be scheduled as the first appointment of the day so hecan get to work on time or compensate for missed work hours byworking later into the day. Teeth #s 20 and 30 are priorities and mayrequire endodontic therapy due to deep decay. An initial two-monthrecall appointment is recommended for tissue reassessment andhome care review. The dental hygienist will check up on Mr. D andreinforce his efforts during his scheduled restorative appointments.

Mr. D’s case represents several growing trends among the youngadult population. Many young adults are transitioning into adulthoodwith increased responsibilities for their own health. Patients 18 yearsof age and older are legal adults, and family members may not makeappointments for them as they might have in the past. Often youngadults live away from home with minimal parental influence.16,41

Dental offices need to maintain contact with their young adultpatients for appointment scheduling and reminders..

As in past generations, today’s young adults have high rates ofdamaging and risky health behaviors, yet the health issues of youngadulthood frequently receive less attention than those of childhoodor adolescence.16,42 When treating young adult patients, dentalhygienists need to take accurate social histories that includequestions about alcohol consumption and tobacco and drug use. Oralcancer risks are higher in patients who use tobacco and consumealcohol; alcohol consumption alone is a risk factor for oral cancers,periodontitis, loss of teeth, and increased caries, calculus, xerostomiaand nutritional deficiencies.13,15,42 In the United States, one in threeyoung adults smokes cigarettes.25 Though the smoking rate hasdecreased since 1997 by nearly 20% among women in this age group,it has not declined significantly for young men.39,40,44 Dental hygienistsalso must recognize harmful drinking and dependence.13 While lightto moderate intake (one to three drinks per day) is not deemedharmful, binge drinking (drinking five or more drinks on the sameoccasion at least once in 30 days) can be.13,15 One-fifth of young adultsare binge drinkers, consuming five or more drinks in a day on at least12 days in the past year.41-45

Diet and nutritional counseling is also important to implementwhen treating vulnerable young adult patients. Nutritional counselingfor dental caries prevention needs to include reducing sugar (liquidor solid) intake and replacing cariogenic foods with those that arenutritionally sound. Information on how frequent consumption offermentable carbohydrates subjects the tooth enamel to acid attacksand leads to caries and/or erosion also must be emphasized.29,32

Young adults are the least likely of any age group to have healthinsurance due to limited finances.16,42,45,46 From 2004–2006, 15% ofyoung adults reported not receiving dental care in the past yearbecause of out-of-pocket costs and the expense of basic dentalinsurance.42,45 As in Mr. D’s case, dental offices can develop individualfinancial plans for young adults who are no longer covered by theirfamily’s insurance and are newly employed.

Mr. D represents a population of patients who often fall through thecracks. Due to a low dental IQ, a reticence to “take charge” of hishealth, the lack of dental insurance, and the practice of destructivehealth behaviors, Mr. D was put at risk for familial systemic diseaseand suffered extensive oral disease. Dental hygienists can work toensure that young adults are kept in the practice’s data base.Continued contact may help prevent negative outcomes.Fortunately, with the assistance of his dental hygienist, Mr. D had thewherewithal to move forward with his healthcare and improve hisquality of life.

Discussion

Case Studies in Dental Hygiene 9

References

1. American Academy of Pediatric Dentistry. Pediatric Dentistry Reference Manual. 2005-2006;27(7), pp. 72–9.2. Makinen K. A dietary procedure for preventing dental caries in young adults. J Am Coll Health 1993;41(4):172–80.3. Cohen DA, Sturm R, Scott M, Farley TA, Bluthenthal R. Not enough fruits and vegetables or too many cookies, candies, salty snacks, and soft drinks?

Public Health Rep 2010;125(1):88-95. 4. Erickson P, Alevizos D, Rindelaub D. Soft drinks: hard on teeth. Northwest Dentistry: Clinical Feature; 2001 Mar [cited 2012 Feb 2]. Available from: http://www.mndental.org/_asset/

9h5zto/Soft_Drinks_Hard_on_Teeth.pdf . 5. Wilcox G, Kamal S. Soft drink advertising and consumption in the United States 1984-2007. Int J Advertising 2009;28(2):351–67.6. Valentine J. Soft drinks: America’s other drinking problem. Wise Traditions 2002;2(2):1–8.7. Bawa S. The role of the consumption of beverages in the obesity epidemic. JRSH 2005;125(3):124–8. 8. Ismail IA, Burt BA, Eklund SA. The cariogenicity of soft drinks in the United States. J Am Dent Assoc 1984;109:241–5.9. Heller KE, Burt BA, Eklund SA. Sugared soda consumption and dental caries in the United States. J Dent Res 2001;80(10):1949–53.

10. Barbour ME, Parker DM, Allen GC, Jandt KD. Human enamel erosion in constant composition citric acid solutions as a function of degree of saturation with respect to hydroxyapatite. J Oral Rehabil 2005;32:16–21.

11. Harvard Health Publication: Harvard Family Health Guide: Sweetened drinks raise women’s risk for obesity, type 2 diabetes. Massachusetts: Harvard School of Medicine; 2004 Nov [cited 2012 April]. Available at: http://www.health.harvard.edu/fhg/updates/update1204b.shtml .

12. Kanigel R. It raises diabetes risk and robs bone. It’s wrecking our teeth. And it’s making us fat. The culprit? SODA. Prevention 2006;58(10):160–207.13. Cope G. Alcohol and recreational drug use: the effect on oral health. Dent Nurs 2012;8(1):22–5. 14. Schiavo J. Oral health literacy in the dental office: the unrecognized patient risk factor. J Dent Hyg 2011;85(4):248–55.15. Darby ML,Walsh M. Dental Hygiene Theory and Practice Third Edition. Philadelphia, WB Saunders Co., 2010. 16. Park MJ, Mulye TP, Adams SH. The health status of young adults in the United States. J Adolesc Health 2006;39:305–17. 17. Bruhn A, Newcomb T. The efficacy of therapeutic mouthrinses. Dimensions Dent Hyg 2010;8(11):46–9. 18. Malamed SF. Handbook of Local Anesthesia Sixth Edition. St Louis, Mosby, 2012. 19. Goulet JP, Perusse R, Turcotte JY. Contraindications to vasoconstrictors in dentistry. Part III. Pharmacologic interactions. Oral Surg Oral Med Oral Pathol 1992;74:692.20. Tezal M, Grossi SG, Ho AW, Genco RJ. Alcohol consumption and periodontal disease: the third national health and nutrition examination survey.

J Clin Periodontol 2005;50(1):484–8.21. Jansson L. Association between alcohol consumption and dental health. J Clin Periodontol 2008;35(5):379-84. 22. Wilkins E. Clinical Practice of the Dental Hygienist Tenth Edition. Philadelphia, Lippincott Williams & Wilkins, 2008. 23. Vermilyea SG, Prasanna MK, Agar JR. Effect of ultrasonic cleaning and air polishing on porcelain labial margin restorations. J Prosthet Dent 1994;71:447.24. Rajstein J, Tal M. The effects of ultrasonic scaling on the surface of class V amalgam restorations-scanning electron microscope study. J Oral Rehabil 1984;11:299.25. National Cancer Institute: A report of the surgeon general preventing tobacco use among youth and young adults. Bethseda, MD: 2009 Apr 1 [updated 2010 Apr 15]. Available from:

http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2007&chid=71&coid=702&mid= .26. Prochaska JO, Norcross JC, DiClemente CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits.

New York (NY): William Morrow Company, Inc, 1994. 27. Baysan A. Reversal of primary root caries using dentifrices containing 5,000 and 1,100 ppm fluoride. Caries Res 2001;35:41–6. 28. MacDonald S. Tooth decay and the soda factor. Cincinnati, OH: The Cincinnati Enquirer; 1999 Apr; [updated 2000 Apr 5; cited 2012 Feb 2012]. Available from:

http://www.enquirer.com/editions/1999/04/07/loc_tooth_decay_and_soda.html . 29. ADA Council on Access, Prevention and Interprofessional Relations. Treating carries as an infectious disease. J Am Dent Assoc 1995;126:2–15. 30. Featherstone JD, Adair SM, Anderson MH. Caries management by risk assessment: consensus statement. J Calif Dent Assoc 2002;31(3):257–69. 31. Lopez L, Berkowitz R, Spiekerman C, Weinstein P. Topical antimicrobial therapy in the prevention of early childhood caries: a follow-up report. Pediatr Dent 2002;24(3):204–6. 32. Gustafsson BE, Quensel CE, Lanke LS. The Vipeholm dental caries study: the effects of different levels of carbohydrate intake on caries activity in 436 individuals observed for

five years. Acta Odontol Scand 1954;11:232–64.33. Sreebny LM. Sugar availability, sugar consumption and dental caries. Community Dent Oral Epidemiol 1982;10(1):1–7. 34. Jenson L, Brideny AW, Featherstone JDB. Clinical protocols for caries management by risk assessment. J Calif Dental Assoc 2007;35(10):714–23.35. American Dental Association (ADA) Council on Scientific Affairs. Professionally applied topical fluoride: evidence based clinical recommendations. J Dent Educ 2007;71(3):393–402.36. Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents.

Cochrane Database Syst Rev 2003;(4):CD002782.37. Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planning. J Clin Periodontol 2002;29(Suppl 2):6–16. 38. Foire MC, Bailey WC, Cohen SJ. A clinical practice guideline for treating tobacco use and dependence clinical practice guideline. JAMA 2000;283(24):3244–54. 39. National Institute of Dental and Craniofacial Research National Institute of Health. Bethesda (MD): US Department of Health and Human Services. Detecting oral cancer: a guide for

oral health care professionals. 2012 March [cited 2012 Feb 17]. Available from: http://www.nidcr.nih.gov/oralhealth/topics/oralcancer/detectingoralcancer.htm.40. Reis LAG, Melbert D, Krapcho M. SEER Cancer Statistics Review. Bethesda (MD): National Cancer Institute; 1975-2009 [cited 2012 Feb 16]. Available at: http://seer.cancer.gov/cgi-

bin/csr/1975_2009_pops09/search.pl?sort_order=&search_site=c19&search_race=&search_stat=&first_search=1&advance_options=&search_stat_list=&search_site_list=c19&search_race_list.

41. Klages U, Bruckner A, Zentner A. Dental aesthetics, self-awareness, and oral health-related quality of life in young adults. Eur J Orthod 2004;26:507–14. 42. Knopf DK, Park MJ, Brindis CD. What gets measured gets done: assessing data availability for adolescent populations. Matern Child Health J 2007;11(4):335–45.43. Da Silva Furtado Amaral C, Vettore MV, Leao A. The relationship of alcohol dependence and alcohol consumption with periodontitis: A systemic review. J Dent 2009;37(9):643–51. 44. Dental, Oral and Craniofacial Data Research Center. Bethesda, MD: Oral health U.S. Report; 2002 [cited on 2012 Feb 15].Available from: http://drc.hhs.gov/report/inside_cover.htm.45. U.S. Department of Health and Human Services. Washington, DC: Health, United States with Special Feature on the Health of Young Adults; 2008 [cited on 2012 Feb 16]/

Available from: http://www.cdc.gov/nchs/data/hus/hus08.pdf.46. Mulye TP, Park MJ, Nelson CD, Adams SH, Irwin CE, Brindis CD. Trends in adolescent and young adult health in the United States. J Adolesc Health 2009;45:8–24.

Case Studies in Dental Hygiene10

1. Which of the following treatment plan modification(s) is/are recommended for a patient at high to moderate caries risk?a. Xylitol-containing chewing gumb. Fluoride varnishc. 1.1% prescription-strength sodium fluoride

toothpasted. All of the above

2. Recommendations to a patient at high risk for oral cancer will include all of the following except one.Which one is the exception?a. Abstinence from smoking b. Abstinence from mouthrinse usec. Abstinence from tobacco products d. Abstinence from heavy alcohol consumption

3. A dental hygienist should recommend all of the following to patients struggling to quit smoking except one. Which one is the exception?a. Review oral cancer signs and symptomsb. Educate the patient on self-oral cancer screeningsc. Recommend online and community resources on

smoking cessationd. Avoid addressing smoking habits if the patient

decides not to quit smoking

4. Which of the following factors in this case can contribute to periodontal disease risk?a. Sugary soda consumptionb. Sound dental restorationsc. Smokingd. All of the above

5. Which of the following in this case contributed to caries risk?a. Poor oral hygieneb. Sugary soft drink consumptionc. Smokingd. All of the above

6. Which of the following put Mr. D at risk for systemic disease?a. Dental erosion b. Occasional alcohol usec. Consuming fast foodd. All of the above

7. Which of the following mouthrinses is a broad-spectrum antibacterial agent that can be used with fluoride therapy for dental caries?a. Chlorhexidine gluconate rinseb. 0.05% NaF rinsesc. Ethanol oral rinsesd. All of the above

8. According to the drug use continuum, Mr. D’s classification of alcohol use is a. Type 1/Abstainer.b. Type 2/Social drinker.c. Type 3/Drug abuser.d. Type 4/Physically dependent.

9. Young adult patients may not have dental treatment completed due to all of the following except one. Which one is the exception?a. They are under the legal age of 18 b. No insurance coverage c. Cost of care is too highd. Minimal parental influence

10. Which pair of periodontal instruments is used for adaptation on narrow facial and lingual surfaces of the anterior teeth?a. Gracey 11/12 and Gracey 13/14b. Mini-bladed area specific curetsc. Periodontal filed. None of the above

11. Responsibility for oral health must include all of the following except one. Which one is the exception?a. Past home care regimensb. Sense of self-determinationc. Personal commitmentd. Active participation in goal setting

12. High sugar intake combined with poor dietary habits is linked to which of the following systemic conditions?a. Obesityb. Type II diabetesc. Cardiovascular disease related to weight gaind. All of the above

13. An extraoral clinical assessment includes which of the following?a. Overall surface and lymph evaluation of the

head and neck b. Checking vital signsc. Documentation of any lesions foundd. Only A and Ce. All of the above

14. Dental hygienists should take accurate social histories to include which of the following?a. Alcohol useb. Drug usec. Smoking habitsd. All of the above

15. Frequent sugar and fermentable carbohydrate intake subjects the tooth toa. acid attacks.b. fluoride uptake.c. stain.d. mobility.

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