Case StudyAnnie Hoyle Han

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Assessment

Bob Jones Male 58 White 6’ 0” 195 Construction Worker/Contractor Married

Chief Complaint

“I would like to have my teeth cleaned because it has been a while since I have been to the dental school. My bridge also needs adjustment.”

History of Present complaint Patient used to go to a private practice

near his home, but was unhappy with the bridge that he received, so he decided to start coming to the dental school for dental care. He was previously on a regular 4-6 month recall.

Medical History Patient was hospitalized for 10 days in 2004 when he

had three heart attacks. Patient has been under regular Cardiologist’s care every six months.

Mr. Jones reports having stopped smoking one year ago, but he still struggles with smoking relapses.

Vital signs: 9/12: 145/98, 11/10: 114/89, 10/17: 155/96 3/12: 128/77, 3/14: 141/83.

Patient has high blood pressure and takes Toprol (metoprolol)- 50 Mg per day

Patient also takes Natto Vitamin which acts as a blood thinner- 100 Mg per day.

Patient is allergic to Penicillin and gets a rash

Dental History Patient had bridge done in private practice where he

was on a regular 4-6 month recall. He was dissatisfied with the treatment done in private practice and chose to come to the dental school where he has been very satisfied with his treatments.

Frequency of visits: Every 4-6 months Patient had SRP 4342 from Dental student in 2010. Patient had several class V restorations which he had

the margins smoothed off and polished. Upper and lower impressions taken for fabrication of

bridges.

Dental Hygiene Habits Mr. Jones reports having always brushed

his teeth at least 2x/ day. Mr. Jones currently uses as soft bristle

toothbrush and flosses occasionally (1-2x/wk)

While there was no Plaque index documented prior to our treatent, his PI ranged from 18-38% throughout appointments.

Personal and Social History Mr. Jones has Highschool level education,

is happily married, and reports enjoying spending time with his grandkids.

Mr. Jones reports that his job can be stressful at times since he is doing dangerous work (welding, metal work, etc.)

Mr. Jones likes to be outside a lot and enjoys gardening.

Family History Mr. Jones does not report his parents

having any dental history, but his father died of heart failure and his mother died of COPD.

Since his stint operation failure, he has been interested in EDTA alternative medication and after one year of regular treatment has seen improvement with his heart.

Extra Oral Exam Mr. Jones has thin hair and reddish skin due to

being outside most of the day. He has never had skin cancer, but reports seeing a dermatologist regularly. He has several age spots on his face and neck. He also had cuts and scrapes on his fingers due to welding and metal working.

Mr. Jones hunches slightly and has a concavity in his forehead due to accident where he had a metal plate placed in his forehead.

Intraoral Mr. Jones has Maxilary and Mandibular Tori,

his tongue is white and coated, the dorsum of the tongue has multiple blue vericosities and tissue tags. His teeth have moderate staining from smoking habits. His gingiva is firm yet erythemic with loss of stippling, has rolled margins and loss of interdental papillae especially on mandibular anteriors.

Patient has moderate dry mouth and malodor.

Patient’s bleeding Index was 7%

Photos

Photos

Photos

Periodontal charting

Periodontal Charting Analysis Mr. Jones had a class I furcation on #31 and

#18, a II furcation on #2 and #30, and a class III furcation on #3. He did not have any mobility. His bleeding index was 7% and his plaque index was 35%.

Mr. Jones had one periodontal chart in EPR from his dental student. In addition to there not being any recession charted, there were areas where the probing depth had increased by 2mm. Due to this, I determined that Mr. Jones periodontal status was unstable.

Periodontal Risk Assesment

Periodontal Classification and Calculus Level Mr. Jones was a Type III 03 Classification

and Calculus level based upon his probing depths, amount of bleeding, furcation involvement, and CAL.

Dental Charting

Dental Charting Summary Mr. Jones reported having mild to moderate

sensitivity that was localized around certain teeth that had “lost gum tissue.”

Mr. Jones has multiple PFM crowns, class V restorations, malalignment on his mandibular anteriors, mild attrition on both maxillary and mandibular anteriors, functional shift, has an edge-to-edge bite in the front and a crossbite #13-15 where the bridge is located.

Dental Pathology Mr. Jones had no history of any dental

pathology

Caries Risk Assesment

Radiographs

FMX

Radiographic Interpretation Mr. Jones did not have any new caries or

failed restorations. His class II and III furcations are easily

detectable, as are his class V restorations and crown and bridge work.

There is also visible calculus in the posterior areas especially.

Nutritional Risk Assesment Mr. Jones was put in the medium risk for

caries because of his CAL, insufficient flouride exposure, and plaque index.

Mr. Jones does not drink soda, does not snack in-between meals, and eats lots of fruits and vegetables from his garden that he keeps at home. He reported spending at least 30 minutes a day exercising and being outside with his dog.

Dental Hygiene Diagnosis Patient’s Unmet human need of Wholesome

facial image related to malocclusion, auto accident and work- lots of time in the sun, as evidenced by cross bite, age spots, concavity in the forehead.

Patient’s Unmet human need of Protection from health risks related to smoking as evidenced by staining, constricted blood flow.

Patient’s Unmet human need of Biologically Sound and Functional Dentition related to bruxism, functional shift, perio disease and lack of dental care, evidenced by missing teeth, bone loss, attrition, and crossbite.

Dental Hygiene Diagnosis Patient’s Unmet human need of Skin and

Mucous Membrane Integrity of Head and Neck related to Inadequate Oral care and biofilm accumulation, evidenced by multiple furcation, bleeding, erythemia, type III/03 calculus.

Patient’s Unmet human need of Conceptualization and Understanding, related to Inadequate plaque control, use of products ineffectively, as evidenced by high plaque index, irregular use of floss.

Dental Hygiene Care Plan Plan to perform periodontal

debridement over a three appointment sequence using oraqix and local as needed.

Also plan to perform OHI, tobacco cessation, Fluoride treatment, and Arestin placement.

Dental Hygiene Treatment PlanningMedical History and Vital Signs: 5 min each appointmentAssessment/Re-Assessment/PI: 30 minutes at first appointment and 10 minutes following.1330-Oral Hygiene Instruction: 10 minutes at each appointment. 1320-Tobacco cessation counseling: 10 minutes9210-Local Anesthesia: Qt. I: 20 minutes4342 Scaling Qt. I,IV in first and second appointment and Qt. II, III at third appointment. (45 min for each quadrant)1206- Flouride Varnish at the end of appointment: 5 minutes

Arestin Placement Arestin was planned for placement

around #3M&D and #18, #30. 3 month evaluation occurred on 2/9/12 Pt. declined additional placement of

Arestin after re-evaluation.

Dental Hygiene Care Plan At each follow up appointment, I will ask

my patient how his at-home care is progressing and encourage him where he is doing well and follow up with motivational Interviewing in the areas that he his lacking.

Implementation

Appointments Appt #1 (9/12)- BP 145/98 Pulse 68- Reviewed health

history, performed EO/IO exam, took photos, took plaque index: 35%, BI:7%, performed nutritional assessment and Oral Hygiene instruction, had DDS exam. Pt. does not use interdental brush or floss regularly, so encouraged use and instructed patient how to use Proxabrush. Began scaling Qt. I with oraqix.

Appt #2 (10/17)- Reassessed, re-evaluated.Plaque index: 31% Used local on Qt. I and completed Qt. I &IV

Appt #3 (11/10)- Plaque Index: 28%. Pt. reported smoking 10 cigarettes every day, so talked with patient about smoking cessation methods/options. Pt. seemed open and interested. Sites of prior scaling appeared to be healing well. Used oraqix on Qts. II, III. Placed arestin at sites #3M&D, 30, 18. Pt. also received Flouride Varnish Treatment.

Appointments, continuedAt 3 month recall (2/9)- Patient returned and had minimal improvement with arestin therapy and was determined to be an 03. Pt. requested to not have local used, but consented to oraqix. Began scaling Qt. I and heavy subgingival calculus was found. Pt. was unaware of correlation between plaque in the mouth and heart issues. PI: 30%(3/12)- Pt. returned for cleaning and Qt. I, IV, and II were completed. PI: 25%(3/14)- Pt. returned for final cleaning and had a lower plaque score of 18%, He reported flossing more and using his interdental cleaner more often. Qt. III was finished and . Patient received fluoride varnish treatment.

Evalutation

Gingival Analysis As the appointment sequence

progressed, Mr. Jones gingiva had a bulbous appearance at the 3 month recall, but upon retreatment, gingiva became less erythmic and became more pink.

Postoperative Photos

Postoperative Photos

Postoperative Photos

Periodontal Charting Comparison

Periodontal Charting Comparison At Mr. Jones three month evalution, his

probing depths were similar to initial therapy. Following his retreatment, Mr. Jones gingiva appeared to have healed better than the first treatment sequence.

Dental Hygiene Habits Throughout my time with Mr. Jones, he was a

very willing and compliant patient, but he was unaware of the fact that floss alone could not reach into his furcations or that plaque in the mouth can have correlation with heart disease.

After my time with him, he was more aware of how important his home care was to the success of treatment at the dental school. Despite my attempts at using MI for retreatment with Arestin, he declined.

Dental Hygiene Goals Encourage Patient to decrease smoking Help educate patient about health risks Help educate patient about proper OHI

aids so that he can decrease PI, BI, and amount of subgingival calculus.

Perform periodontal debridement Administer Arestin

Evaluation of Arestin Placement Upon evaluation of Arestin, patient did

not seem to have improvement around tooth #3, but did have slight improvement around #18 and #30.

Continuing Care Recommendations Mr. Jones still has two areas where we

talked about him improving: decreasing smoking and using his interdental cleaner.

Patient Satisfaction Survey

Case Based Question What oral therapy aid would be most

useful for Mr. Jones when cleaning around teeth #2&3?

A: Floss B: Gum stimulator C: Interdental proxabrush D: Chlorhexadine rinse E: Floss holder

Scientific Article The potential impact of periodontal

disease on general health: a consensus view.

Williams RC, Barnett AH, Claffey N, Davis M, Gadsby R, Kellett M, Lip GY, Thackray S.

Source: University of North Carolina, School of Dentistry, Chapel Hill, NC 27599, USA. ray_williams@dentistry.unc.edu

Case Study Summary Throughout my time with Mr. Jones, I

learned how many people are simply unaware or uneducated about their oral health status. It is our responsibility as hygienists to educate them so that they can have the tools to succeed.

I also enjoyed having the opportunity to see my patient regularly.