PERIODONTAL CASE STUDY PROJECT

DENTAL HYGIENE CLINICAL PRACTICE IIDIEM LE

PATIENT PROFILE• 33 year old Asian male• Health history reveals:

• a current heavy smoker, been a smoker for 15 years

• Family history of Diabetes• School related stress • No medications• Minor Dental Anxiety• Vitals WNL• ASA Class II

• Dental history reveals:• Brushes with soft

toothbrush 2x daily• Flosses 3x daily• TMJ pain and click • No night guard• Grinds and clenches his

teeth• Last dental visit was 1 year

ago

EXTRA ORAL AND INTRA ORAL FINDINGS • TMJ:

• Bilateral crepitus• pain in cold seasons

• Generalized attrition• Hypocalcification

mesial of #7-#10, and cervical 1/3 on #9

• Angles classification of occlusion: Tendency to class II on molar right, canine right, and canine left. Class I occlusion on molar left.

• 75% overbite• 4 mm over jet• Slight crowding on lower

anteriors which lead to torsoversion on mandibular anteriors

• Decalcification on cervical 1/3 on #29

• Short Lingual Frenum• Moderately coated tongue• Tonsils slightly enlarged,

nicotine stomatitis on hard palate

GINGIVAL DESCRIPTION

Generalized moderate redness, shiny, spongy, enlarged, rounded slight edematous tissue with rolled margins and bulbous papillae

INTRA ORAL PHOTOS

-Photo was taken on 01/28/14-Green Arrow- generalized mod attritionRed Arrow- Tobacco stain on buccal of tooth #8

INTRA ORAL PHOTOS

Photos were taken on 01/28/14

Notes:Green Arrow- generalized mod attritionRed Arrow- Generalized mod tobacco stain on linguals Black arrow- Fracture and tobacco stain on tooth #29Yellow arrow- Generalized slight marginal rednessWhite arrow- Torsoversion on mandibular anteriors due to crowding

DENTAL CHART

NOTE:-Green arrows-Carious lesions on occlusal of Teeth #14, #30, #31-Red arrows- fractured tooth, needs restorations

PERIODONTAL CHARTING

ASSESSMENT FINDINGS• No furcations• No mobility or mucogingival involvement• BOP was observed on all teeth• Generalized slight marginal redness• Generalized heavy ledges of supragingival

calculus on mandibular anteriors • Generalized heavy ledges of subgingival

calculus • Generalized heavy biofilm on the cervical 1/3 of

the teeth & interproximally • Plaque Control Record was 48% • Generalized tobacco stain• Carious lesions on occlusal of Teeth #14, #30,

#31• Average CAL were 2

PERIODONTAL EVALUATION

Note-General average CAL is 2, with localized CAL of 3 and one CAL of 4 on tooth #18 Distal. No noticeable recession

FACTORS

• Periodontal Risk Factors• -Smoking• -Stress

• Contributory Factors• -Calculus, malocclusion, OH care

PERIODONTAL DIAGNOSIS

• Generalized slight active Chronic Periodontitis with moderate active chronic Periodontitis on teeth #3,15,18, 28,29

• AAP II

RADIOGRAPHS

*Radiographs were taken at patient dentist office on 02/27/14. These were the only available radiographs since patient’s dentist did not approve to retake another FMX at MCC due to ALARA principles.

• Generalized slight vertical bone loss• -Crestal Irregularities on teeth #11,12,14,15,18,19• -Green arrows indicate calculus subgingivally on mesial and distal of tooth #3

RADIOGRAPHS

• Generalized slight bone loss with localized moderate bone loss on teeth # 20, 28,29, 30

• Green arrows indicate impacted wisdom teeth on teeth #17, 32.

• *Radiographs were taken at patient dentist office on 02/27/14. These were the only available radiographs since patient’s dentist did not approve to retake another FMX at MCC due to ALARA principles.

Treatment Plan

Client Name: _________________ Student Name: ____Diem Le________________ Date: _2-4-14___ Dental Hygiene Diagnosis: Issues that need to be addressed with Dental Hygiene Treatment Circle issues present and provide summary below Wellness Systemic Head & Neck Pathology Tobacco Nutrition Malocclusion/Parafunctional habits Dental Condition/Caries/risk Periodontal condition/risk Self-care Trauma Staining/Esthetics Other: Dental Hygiene Diagnosis: High oral cancer risk related to tobacco use and moderate active perio related to tobacco use and infrequent recalls. Goals Client Goals: Remove calculus, stain , and smoke less.

Treatment goals: Reduce plaque indices, educate about restoration needs and help patient quit smoking.

Assessments (after initial assessments) Implementation Appt. 1

Appt. 2 Appt. 3 Appt. 4 Appt. 5 Re-evaluation

Radiographs Additional diagnostics

Time needed Disease Prevention/Health Education Implementation

Appt. 1 Appt. 2 Appt. 3 Appt. 4 Appt. 5 Re-evaluation

Brushing Techniques x x Interdental Aids x Periodontal Disease x x x Dental Decay x x Tobacco Cessation x x Nutritional Education x x Fluoride Therapy x Systemic Disease Other

Time needed 20 mins 20 mins 20 mins 30 mins 20 mins Procedures Implementation

Appt. 1 Appt. 2 Appt. 3 Appt. 4 Appt. 5 Re-evaluation

Review health history, oral exam, Indices x x x x x Re-assess previously treated areas x x x x Anesthesia (Type: Drug & delivery method) local x x x x Power Driven Debridement /Area Max R Man R Max L Man L x Hand Activated Debridement/Area Max R Man R Max L Man L x Chemotherapeutic Procedures (type) Plaque Removal (method) x Fluoride treatment (Type of fluoride) X Tray Desensitization Amalgam Polishing x Athletic Mouth Protectors Study Models Sealants

Total Appointment Time 2.5 Hrs. 2.5 Hrs. 2.5 Hrs. 2.5 Hrs. 2 Hrs. Re-care Interval : 3 months

Referrals needed: General dentistry

Oral Self-Care Current Oral Self-Care Methods: TB 2x/day, floss 3x/day, rinse 3x/day with Listerine Recommendations: Indicate recommendations below and include type method and frequency as necessary Brush Mod. Stillman, soft

tb, 2x/day Dental floss/tape Wax floss 1x/day Oral rinse(s) Listerine 1x/day

Specialty Brush Electric Floss threader/Aid Other: Interproximal device Fluoride product(s)

I agree to the above Dental Hygiene treatment plan. The plan and its risks and benefits have been described to me and I fully understand them. I understand that changes in the accepted treatment plan may be necessary during the course of treatment and I will be informed of the changes.

Student Name: _____________________________________ Student Signature: ____________________________________ Date: __________ Faculty Name: _____________________________________ Faculty Signature: ____________________________________ Date: __________ Patient Name: _____________________________________ Patient Signature: _____________________________________ Date: __________

This is the patient treatment plan. I diagnosed that he had high oral cancer risk due to smoking habits and active moderate perio due to smoking and infrequent recalls. I recommended the modified Stillman method due to his interproximal calculus and slight localized recession on teeth #9-10. He has moderate tobacco stain so I recommended motor polishing and Sodium Fluoride Tray.

PROCEDURES• First Second, and Third visit completed assessments – Took intra-oral photos

on second visit-01/28/14• Fourth visit

• Medical History, EOE, IOE, Vital Signs• Plaque index & home care

• Review Brushing technique- focus on the cervical 1/3 of the tooth w/ a modified Stillman method

• Local anesthesia administer by Professor Ligor, 5% lidocaine Topical applied to all injection sites, Right PSA and Right MSA Lidocaine, 2% with Epinephrine 1:100,000, 1 cartridge, (36 mg Lido, .018 mg Epi)

• Debridement on on teeth #2-3 using magnetostrictive power inserts and hand scaling

• Fifth visit• Medical History, Vital Signs, EOE, IOE• Plaque index, Re-assess upper right• Local anesthesia administer by Dr.Terkoski, 5% lidocaine Topical applied

to all injection sites, Right MSA and Right ASA Lidocaine, 2% with Epinephrine 1:100,000, 1 cartridge, (36 mg Lido, .018 mg Epi)

• Debridement on on teeth #4-9 using magnetostrictive power inserts and hand scaling

• Sixth visit-Medical History, Vital Signs, EOE, IOE-Plaque index, Re-assess upper right-Local anesthesia administer by Professor Fernandez, 5% lidocaine Topical applied to all injection sites, -Right IA and Right Buccal Lidocaine, 2% with Epinephrine 1:100,000, 1 cartridge, (36 mg Lido, .018 mg Epi)-Debridement on on teeth #25-31 using magnetostrictive power inserts and hand scaling

• Seventh visit-Medical History, Vital Signs, EOE, IOE-Plaque index, Re-assess lower right-Local anesthesia administer by Professor Ligor, 5% lidocaine Topical applied to all injection sites, -Left PSA and Left MSA, Left ASA,l Lidocaine, 2% with Epinephrine 1:100,000, 1 cartridge, (36 mg Lido, .018 mg Epi)-Debridement on on teeth #9-15 using magnetostrictive power inserts and hand scaling

Procedures

PROCEDURES• Eighth visit• Medical History, Vital Signs, EOE, IOE• Plaque index, Re-assess upper left• Local anesthesia administer by Dr. Terkoski, 5% lidocaine Topical

applied to all injection sites, -Left IA and Left Buccal Lidocaine, 2% with Epinephrine 1:100,000, 1 cartridge, (36 mg Lido, .018 mg Epi)

• Debridement on on teeth #25-31 using magnetostrictive power inserts and hand scaling

• Motor polishing

• Ninth visit • Medical History, Vital Signs, EOE, IOE • Plaque index, Re-assess all teeth• Motor polishing• Fluoride Tray Treatment with Sodium Fluoride 1.23%, 4 minutes• Handed patient dental hygiene report• Patient survey

SUMMARY Even though this was my first patient, I am glad I got the toughest periodontal case as my first

patient. I was able to learn how to perform a thorough periodontal assessment and practice my debridement skills. When reviewing the photos, I realize that one would not have guessed that the patient’s periodontitis was not that bad due to his smoking which masks the effects on his gingival margins. I was only to really determine that he had generalized slight bone loss due to the x-rays sent from his dentist. I think his bone loss is worse now since those x-rays were from almost 2 years ago. My goal was to reduce his calculus and plaque index by 50% and to have him gradually quit smoking. He stated that he does want to quit smoking eventually as well but did not give me a start date. I realized that after 2 weeks of not seeing my patient due to spring break, calculus built up on areas that I had already debrided because he smokes more when he is working or stressed. I continue to encourage him to have a start date or short term goals to cut down on the number of cigarettes per week.

I was able to determine that my patient had slight active chronic periodontitis with active moderate chronic periodontitis on tooth #15, 18. This patient has been smoking heavily for 15 years which was a big risk factor contributing to his bone loss as well as malocclusions and lack of professional dental hygiene care. I hope that he continues a 3-month re-care, improve his oral hygiene care, and set a start date to quit smoking. There is no date for re-evaluation because patient will be busy working and have no time to come back for a re-evaluation.