Transcript Periodontal Case Study Project Dental Hygiene Clinical Practice II

PERIODONTAL CASE STUDY
PROJECT
DENTAL HYGIENE CLINICAL
PRACTICE II
DIEM 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 attrition
INTRA ORAL PHOTOS
Photos were taken on 01/28/14
Notes:
Green Arrow- generalized mod attrition
Red Arrow- Generalized mod tobacco stain on linguals
Black arrow- Fracture and tobacco stain on tooth #29
Yellow arrow- Generalized slight marginal redness
White 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
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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
NoteGeneral 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
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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 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.
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
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 #910. He has moderate
tobacco stain so I
recommended motor
polishing and Sodium
Fluoride Tray.
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
Implementation
Appt. 1
x
Appt. 2
Appt. 3
Appt. 4
Appt. 5
Re-evaluation
Radiographs
Additional diagnostics
Time needed
Disease Prevention/Health Education
Brushing Techniques
Interdental Aids
Periodontal Disease
Dental Decay
Tobacco Cessation
Nutritional Education
Fluoride Therapy
Systemic Disease
Other
x
x
x
x
x
x
x
Time needed
Procedures
Review health history, oral exam, Indices
Re-assess previously treated areas
Anesthesia (Type: Drug & delivery method) local
Power Driven Debridement /Area
Hand Activated Debridement/Area
Chemotherapeutic Procedures (type)
Plaque Removal (method)
Fluoride treatment (Type of fluoride)
Desensitization
Amalgam Polishing
Athletic Mouth Protectors
Study Models
Sealants
Total Appointment Time
Re-care Interval : 3 months
Referrals needed: General dentistry
20 mins
Implementation
Appt. 1
x
x
Max R
Max R
x
x
x
20 mins
Appt. 2
20 mins
Appt. 3
30 mins
Appt. 4
x
x
x
Man R
Man R
x
x
x
Max L
Max L
x
x
x
Man L
Man L
x
x
20 mins
Appt. 5
Re-evaluation
x
x
x
x
x
X Tray
x
2.5 Hrs.
2.5 Hrs.
2.5 Hrs.
2.5 Hrs.
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 Dental floss/tape
Wax floss 1x/day
Oral rinse(s)
tb, 2x/day
Specialty Brush
Electric
Floss threader/Aid
Other:
Interproximal device
Fluoride product(s)
2 Hrs.
Listerine 1x/day
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: __________
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
Procedures
• 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
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
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•
•
•
• 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.