Case Documentation

in the Senior Year

Fall 2016
Chart # 14045
Janet Lee
Rationale

The patient identified for this report was based on the

severity of his periodontal disease and the challenges in
which the clinicians faced while treating this patient.

The clinician hoped to learn how to improve scaling and

root planing (SRP) skills. Because this was the most difficult
patient the clinician had seen, there had been a lot to learn
throughout his appointments.
 Patients chief complaint

The patient presented to the Pacific Dental Hygiene clinic in spring of

2016 for a screening with pain in the upper right quadrant. He was
prescribed Chlorhexidine, which he used for about two weeks, and
reported no pain thereafter.
The patient presented to clinic in the fall of 2016 with concern regarding
tooth #3, which had gross decay, but he did not report any pain
associated with it.
Patient Profile

Age: 43 years old

Gender: Male
Ethnicity: Hispanic
Primary language: Spanish
Employment: Construction
Residence: Hillsboro, OR
Family: The patient was married and lived with his wife and four
children
 Medical History (pertinent
information)

Last visit to physician: The patient did not seek regular care. He
reported going to Virginia Garcia as needed with his last visit being in
September of 2015 for a regular check up.
Existing conditions: The patient reported having lower levels of oxygen.
He had seen a physician regarding this, however, he was told it was still
within normal limits. He was not taking any medications for this.
Medications: The patient was not taking any medications
Initial vital signs:
Blood pressure: 124/88 mmHg
Pulse: 76 RPM
Respiration: 20 RPM
 Dental History

The patient received irregular dental care

Last dental visit: The patients last dental visit was in
2005 for a cleaning and a partial fitting. This was in
Mexico.
Dental radiographs: The patient was unsure whether
or not he had ever had any dental radiographs taken.
History of caries: The patient had a history of caries
as well as current decay.
Personal profile
Maslows Hierarchy of Needs: Safety and security
The patient was at the level of safety and security. Although he seemed interested
in improving his oral health, he had a lot of responsibilities at home to tend to.
From conversations with the patient, the clinicians learned that his main daily
concerns included working and caring for his wife and children. It seemed as
though he may have been pre-occupied satisfying his familys financial security to
be able to take the necessary time and effort to care for his oral health.
Learning Ladder: Unawareness
Transtheoretical Model: Pre-contemplative
The patient was at the level of unawareness on the Learning Ladder and pre-
contemplative in the Transtheoretical Model because the patient did not know that
there needed to be a change in his oral self care. The patient not aware of the
state in which his oral health was in.
Current Oral Self Care

The patient reported using a manual toothbrush two

times a day for approximately one minute using Crest
toothpaste.
The patient reported using a floss pick about one time
a week. He revealed that he did not like flossing and
used floss picks infrequently because his gums bled
when he flossed.
The patient reported using Scope mouth rinse
occasionally
Plaque and Gingival
Descriptions

The patients initial plaque index score was

100%. This meant that he had plaque on all six
surfaces of every tooth. The plaque was thick
and mature.
The patients initial gingival index score was 2.0.
This meant that he had bleeding and/or
moderate inflammation around each tooth.
Assessments
Intra-oral/extra-oral findings:
There werent any findings that required follow-up
Missing teeth: #1, 16, 18, 19, 20, 29, 30, 31.
Occlusion:
Right molar: Not applicable due to missing teeth
Right canine: Class II
Left canine: Class II
Left molar: Not applicable due to missing teeth
Periodontal findings:
Generalized moderate with localized severe (#9) chronic periodontitis
Pocket depths
Generalized 4-6 mm pocket depths throughout
7 mm pocket depths on the mesiobuccal of #7, distobuccal of #8, and the distolingual of #14
10 mm pocket depth on #9
Recession
1 mm of recession noted on the buccal surfaces of #4, buccal surfaces of #5, and buccal surfaces of #14
2 mm of recession noted on the buccal surfaces of #21
Mobility
Class I mobility noted on teeth #7, 8, 10
Class III mobility noted on tooth #9
Suppuration
Suppuration noted on tooth #9
Assessments
Radiographic findings:
Calculus: Radiographic calculus noted on #2 mesial, #3 distal, #4 distal and mesial, #5 distal, #6 mesial, #7
distal and mesial, #8 distal and mesial, #9 mesial, #10 distal, #11 mesial, #14 distal and mesial, #17 mesial,
#21 distal and mesial, #22 distal and mesial, #23 distal and mesial, #24 distal and mesial, #25 distal and
mesial, #26 distal and mesial, #27 distal and mesial, #28 distal and mesial, #32 mesial
Decay: Radiographic decay noted on #3 (mesial, occlusal, buccal, lingual - MOBL), #4 (distal - D), #21 (distal)
Bone loss: Generalized moderate bone loss, localized severe vertical bone loss (#9)
Fractures: Fractured restoration on #21
Risk assessments:
Caries: High due to active decay, poor oral hygiene, and irregular dental care
Periodontal disease: High due to high plaque index, high gingival index, and irregular dental care
Oral cancer: Low no known risk factors
Dental examination findings (Dr. Saunders):
Decay noted on #3 MOBL, #4 D, #14 occlusal recurrent, #21 DO fractured with recurrent decay
Urgent need for treatment on #3 and #9
Referrals: General dentist for comprehensive care and periodontist for management of periodontal disease
Treatment Plan
Treatment needed:
Scaling and root planing on 4+ teeth in all four quadrants with local
anesthesia
Oral hygiene instructions
Nutritional counseling

Referrals:
General dentist to establish a dental home and for treatment of decay
Periodontist for management of periodontal disease
Primary care physician: The patient was already being seen by Virginia
Garcia regarding his lower levels of oxygen
Treatment Goals
Goal #1: To give the patient proper referrals to resolve
his chief complaint (gross decay on #3)
Goal #2: To educate the patient on the importance of
oral self care the patient will be able to demonstrate
proper brushing technique
Goal #3: To improve the health of the patients gingival
tissue through scaling and root planing treatment by
reducing pocket depths by at least 1 mm on all surfaces
Goal #4: To achieve a gingival index of less than one
 Prognosis

The general overall prognosis for this patients dentition

is fair
There is less than 25% attachment loss (generalized)
The patient seemed to be eager to improve his oral health
No furcation involvement
Prognosis for #3: Hopeless due to gross decay
Prognosis for #9: Questionable due to vertical
attachment loss on one side of the tooth that is more
than 50%
Intra-oral photos before treatment
Appointment #1: 09/07/2016
Vital signs:
Blood pressure: 124/88 mmHg
Pulse: 76 BPM
Respiration: 20 RPM
Treatment:
Radiographs - Periapical films and a panoramic radiograph
Oral hygiene instructions
Assessments (incomplete)
Plaque description: The patient had heavy, dense, sticky plaque in all areas
recorded (100% of surfaces)
Gingival description: Generalized moderate inflammation characterized by bulbous
and erythematous gingiva
Oral hygiene instructions (OHI): Bass method of brushing using tell show do on a
typodont and again in the mouth when the patient had disclosing agent on
Appointment #2: 09/14/2016
Vital signs:
Blood pressure: 112/88 mmHg
Pulse: 76 BPM
Respiration: 20 RPM
Treatment:
Comprehensive periodontal evaluation with Dr. Saunders
Completed assessments
Nutritional counseling
After the patient had disclosed that he consumed a lot of carbohydrates, the effects of complex carbohydrates and sugar on his
oral health was discussed with him. He was counseled to rinse his mouth with water after eating carbohydrates and the
importance of brushing and flossing.
OHI
Plaque description: Generalized heavy plaque, especially on the gingival third of the tooth
Gingival description: Generalized moderate inflammation characterized by bulbous and
erythematous gingiva and papilla
OHI: Reinforced correct brushing method, adding the importance of angling the toothbrush at a
45 towards the gingiva
Appointment #3: 09/21/2016
Vital signs:
Blood pressure: 124/80 mmHg
Pulse: 76 BPM
Respiration: 16 RPM
Treatment:
Scaling and root planing (SRP) on the lower right quadrant to completion using a Cavitron and hand scaling
20% Benzocaine applied to injection sites
Right inferior alveolar (IA) injection with a 25-long needle - 1.5 mL
Right lingual injection with a 25-long needle - .3 mL
Right long buccal (LB) injection with a 25-long needle - .3 mL
Left infiltration on #24 with a 27 short needle - .3 mL
Anesthetic used: 2% Lidocaine hydrochloride (HCl) with epinephrine 1:100,000. Total administered: 2.4 mL
OHI
Plaque description: Generalized heavy, dense, sticky plaque
Gingival description: Generalized moderate inflammation characterized by bulbous and blunted
papilla and erythematous gingiva
OHI: Discussed the correct method of flossing with the patient
Appointment #4: 09/28/2016
Vital signs:
Blood pressure: 124/84 mmHg
Pulse: 80 BPM
Respiration: 12 RPM
Treatment:
SRP on the upper right quadrant to completion using a Cavitron and handscaling
20% Benzocaine applied to injection sites
Right posterior superior alveolar (PSA) nerve block with a 27-short needle - 1.8 mL
Right infraorbital (IO) nerve block with a 27-short needle - 0.9 mL
Nasopalatine (NP) injection with a 27-short needle - 0.45 mL
Infiltration on #8 with a 27-short needle - 0.6 mL
Anesthetic used: 4% Articaine HCl with epinephrine 1:100,000. Total administered: 3.75 mL
OHI
Plaque description: Generalized light plaque (especially on the lower right quadrant)
Gingival description: Generalized moderate inflammation characterized by bulbous, blunted papilla and
erythematous gingiva the tissue in the lower right quadrant had improved (less edema and erythema),
however, the generalized description was still moderate inflammation.
OHI: Reinforced flossing now that half of his mouth had received SRP treatment. The patient showed the
clinicians the C-shaped method of flossing that was discussed at the previous appointment
Appointment #5: 10/10/2016
Vital signs:
Blood pressure: 128/86 mmHg
Pulse: 86 BPM
Respiration: 12 RPM
Treatment:
SRP on the lower left quadrant to completion using a Cavitron and hand scaling
20% Benzocaine applied to injection sites
Right inferior alveolar (IA) injection with a 25-long needle - 1.5 mL
Right lingual injection with a 25-long needle - .3 mL
Right long buccal (LB) injection with a 25-long needle - .3 mL
Left infiltration on #24 with a 27 short needle - .3 mL
Anesthetic used: 2% Lidocaine hydrochloride (HCl) with epinephrine 1:100,000. Total administered: 2.4 mL
OHI
Plaque description: Generalized light plaque (especially on upper right and upper left quadrants)
Gingival description: Generalized moderate inflammation characterized by bulbous, blunted papilla and
erythematous gingiva the right half of his mouth had improved significantly. The tissue had become
much more taut and there was much less inflammation
OHI: Reinforced flossing now that half of his mouth had received SRP treatment. The patient showed the
clinicians the C-shaped method of flossing that was discussed at the previous appointment
Appointment #6: 10/24/2016
Vital signs:
Blood pressure: 128/86 mmHg
Pulse: 84 BPM
Respiration: 12 RPM
Treatment:
SRP on teeth #12-15 to completion using a Cavitron and hand scaling
20% Benzocaine applied to injection sites
Left PSA injection with a 27-short needle - 1.3 mL
Left greater palatine (GP) injection with a 27-short needle - 0.9 mL
Anesthetic used: 2% Lidocaine hydrochloride (HCl) with epinephrine 1:100,000. Total administered: 2.2 mL
OHI
Fluoride varnish
Plaque description: The patient had heavier plaque around the molars at this appointment.
Generalized light with localized moderate (new, heavy, white) plaque.
Gingival description: Generalized mild inflammation characterized by bulbous papilla and coral colored
gingiva with localized moderate inflammation characterized by erythematous gingiva (in quadrant II)
OHI: Reinforced proper brushing and flossing technique due to an increase in plaque since the previous
visit
Appointment #7: 11/02/2016
Vital signs:
Blood pressure: 130/85 mmHg
Pulse: 70 BPM
Respiration: 16 RPM
Treatment:
SRP on teeth #9-11 completion using a Cavitron and hand scaling
20% Benzocaine applied to injection sites
Left anterior superior alveolar (ASA) nerve block with a 27-short needle - 1.8 mL
NP injection with a 27-short needle - 0.9 mL
Anesthetic used: 2% Lidocaine hydrochloride (HCl) with epinephrine 1:100,000. Total administered: 2.7 mL
OHI
Warm salt water irrigation on #9
Localized fluoride varnish on #14
Plaque description: Generalized light, translucent plaque
Gingival description: Generalized mild inflammation characterized by bulbous papilla and coral colored
gingiva with localized moderate inflammation characterized by erythematous gingiva (in quadrant II)
OHI: The patient was shown a CAESY video on periodontal disease. The clinicians then discussed the
process of periodontal disease with the patient and the importance of oral self care.
Re-evaluation appointment:
12/05/2016
Generalized 3-4 mm probing depths
Generalized improvement of 1-3 mm
Some areas remained stable (most areas with 2-3 mm pockets remained)
Localized 7-12 mm probing depths on #9 with suppuration
Differential diagnosis: Systemic condition (possibly elevated blood pressure or his lower
levels of oxygen) or inability of the patient to properly care for the deep pockets at home
Additional treatment:
Lavage of full mouth using Piezo and hand scaling
Debridement of plaque and new calculus
20% Benzocaine applied to injection site
Infiltration #9 with a 27-short needle - 0.5 mL
Anesthetic used: 2% Lidocaine hydrochloride (HCl) with epinephrine 1:100,000. Total administered: 0.5mL
Chlorhexidine irrigation on #9
Oral hygiene instructions
Re-evaluation Continued
Oral self care:
The patient reported brushing 2x/day using a manual toothbrush for 2-3 minutes using
Crest toothpaste. He also reported flossing about 3-4x/week and using Scope mouth rinse
occasionally
Plaque description:
Plaque index was 30% at the re-evaluation appointment
The plaque that was present looked thin, translucent, and new
Gingival description:
Gingival index was 0.13
Generalized mild inflammation characterized by stippled and blunted papilla with
localized moderate inflammation characterized by bulbous papilla and red margins along
mandibular anterior teeth
The patient was very compliant at appointments and seemed as though he was
very eager to improve his oral health
Re-evaluation continued
Goal #1: To give the patient proper referrals to resolve his chief complaint (gross decay on
#3)
Solution: The patient was given a referral to a general dentist. An extraction was recommended for
#3 due to the extent of decay.
Goal #2: To educate the patient on the importance of oral self care the patient will be
able to demonstrate proper brushing technique
Solution: At the re-evaluation appointment, the patient demonstrated how he had been brushing his
teeth. The technique shown by the patient was good, however, it was suggested to him that he
change the angle of his toothbrush so that the bristles of the brush are getting underneath the
gingiva.
Goal #3: To improve the health of the patients gingival tissue through scaling and root
planing treatment by reducing pocket depths by at least 1 mm on all surfaces
Solution: All pocket depths improved by at least 1 mm with the exception of surfaces that were
already at a healthy depth of 1-3 mm.
Goal #4: To achieve a gingival index of less than one
Solution: The patients gingival index at the time of his re-evaluation appointment was 0.13
Intra-oral photos after treatment
Recare interval
The recare interval that was assigned to this patient was 3
months
There are several deeper pockets that are difficult to maintain at
home
However, after careful review of this patients case, it was
determined that he may benefit from a shorter recare
interval (2 months)
At the re-evaluation appointment one month after his final SRP
treatment, it was noted that there was an increase in plaque levels.
This showed that the patient had a difficult time with oral self care
and may been additional oral hygiene instruction or motivation.
Case Management
Size of the patient and the size of the clinician
With the patient being more barrel chested and the clinician having a
shorter torso and shorter arms, the clinician had a difficult time with
ergonomics while sitting in the chair
This was managed by elevating the patients chair and having the
clinician provide treatment standing up
Decreased levels of oxygen
The patient stated during his medical history that he had decreased levels
of oxygen. This condition required additional management, especially
during SRP treatment when there was a lot of water in his mouth
This was managed by sitting the patient up to near a 150 angle to help
increase the flow of oxygen through his nose
Identify what you learned from
this case?
Refer back what to what you had hoped to learn; were you able to accomplish all items listed?
This is your opportunity to reflect on the care you provided and decide if you would have liked to have done
something differently. This may involve patient education, tx provided, spacing of appointments, case
management, communication, referrals, documentation, etc.
Was there unexpected learning that took place during the care of this patient? Be specific.
Be sure to tie everything together with a sentence or two at the end regarding the value of reflecting on patient
care and/or the care of future patients.
Radiographs: Because this patient did not have some of his molars, I had a difficult time taking radiographs on
this patient. I was able to use the Snap-A-Ray with the help of my faculty member. This was the first time Id
used that tool and found it to be very helpful in this kind of situation
Probing: This was the first time Id probed on a patient that had large deposits of calculus. Because of this, I
had a difficult time getting an accurate probing depth. From this experience, Id learned how to maneuver
around large deposits of calculus to get a more accurate reading.
SRP on deep pockets: With this patients extremely deep pockets (one of them being 9mm), I was able to try
out and learn about all of the new instruments we had available to us. This included using the file and the mini
instruments for the first time.
Irrigating with warm salt water: Although wed discussed this process during the summer semester, this was
the first patient that Id used the irrigating needle on.