New York City College of Technology Department of Dental Hygiene DEN 2300 Case Presentation

Anita Dema December 14, 2019

PATIENT PROFILEMrs. AL is a 69 year old Chinese female.

She currently is on medicaid and her plan does not include dental insurance.

She is married and has 3 children and 2 grandchildren. She is retired and during her free time, she tutors young children in math and volunteers in her community.

Her last dental visit was 4 years ago. An exam, cleaning and a filling were done at this time as well as 4 HBW radiographs. Patient reports she only goes to the dentist when she is in pain.

Patient reports she is brushing with an electric toothbrush two times a day using whatever toothpaste is on sale, not flossing, not using a tongue cleaner, and uses whatever mouth wash is on sale one time a day.

Photo Source: https://clipartion.com/free-clipart-14021/

CHIEF COMPLAINT

Patients states: “I would like a cleaning to help reduce my gum inflammation and the tenderness I feel.”

She is also concerned about her “gums bleeding” when she brushes and would like to do something to help that issue.

Mrs. AL also reports having “dry mouth” throughout the day.

She also has had some dental work which include fillings, veneers, crowns, and an onlay. She would like to make sure all of these restorations are still holding up and she doesn’t have any cavities.

Photo Source: https://pngtree.com/freepng/dentist-chair-icon-outline-style_5099009.html

HEALTH HISTORY OVERVIEW

Blood pressure: 124/68

Pulse: 66

ASA: II

Medical Conditions: Diabetes Type II. Hypercholesterolemia.

Current Medications: Metformin 1,000mg BID for treatment of Diabetes Type II for the last 14 years. Lisinopril 10mg QD for Cardiovascular disease prevention for the last 14 years. Atorvastin 20mg QD for treatment of Hypercholesterolemia for the last 17 years. Daily Multivitamin 1 tablet 1x a day for vitamin sufficiency for about the last 10 years.

Photo Source: https://www.123rf.com/photo_73506986_stock-vector-medical-diagnostics-icon-stethoscope-and-diagnose-healthcare-vector-illustration.html

EXPLANATION OF CONDITIONS- DIABETES TYPE II

A patient that presents with Diabetes Type II will have blood glucose levels that are too high. The body does not make or use insulin well. Insulin is a hormone that helps glucose get into your cells to give them energy. Without insulin, too much glucose stays in your blood. Over time, high blood glucose can lead to serious issues with your heart, eyes, kidneys, nerves, gums and teeth.

Diabetes Type II can be a result of family history of diabetes, obesity, and not exercising.

The signs and symptoms of this condition may include excessive thirst, urinating often, feeling hungry or tired, weight loss, poor healing with sores, and blurry eyesight.

Irregular oral conditions are often reported with patients with Diabetes Type II. These include: xerostomia, hypogeusia, delayed mucosal wound healing, increased bleeding and inflammation, oral infections such as candidiasis, and increased risk of periodontal disease, tooth loss, and carious lesions.

Sources: “Diabetes Type 2.” https://medlineplus.gov/diabetestype2.html “Diabetes Type 2.” https://www.diabetes.org/diabetes/type-2 Photo Source: https://idf.org/52-about-diabetes.html?tmpl=response&tmpl=response

HOW DIABETES TYPE II IS MANAGED

Suggested treatment for the management of Diabetes Type II includes oral hypoglycemic medications, a nutritional diet and physical activity. Depending on the severity of the disease, patient’s may be prescribed injectable insulin medications if they are not responding well to oral medications. Due to the relationship between diabetes and cardiovascular disease, many patients are prescribed a cardiovascular medication as well as a hypoglycemic medication.

Mrs. AL is currently managing her Diabetes Type II with Metformin 1,000mg BID as well as Lisinopril 10mg QD for the prevention of cardiovascular disease. Mrs. AL is currently under the care of a physician that she visits every 3 months and her last HBA1C level was a 5.4.

Sources: “Diabetes Type 2.” https://medlineplus.gov/diabetestype2.html “Diabetes Type 2.” https://www.diabetes.org/diabetes/type-2 Photo Source: https://www.everydayhealth.com/type-2-diabetes/guide/treatment/

DENTAL HYGIENE MANAGEMENT- DIABETES TYPE II

Contraindications of Diabetes Type II to dental hygiene care include a patients HBA1C level being above the therapeutic range of (7.0) and a patient being non-compliant with medications.

Patient management strategies that need to be considered include always asking about patients last meal, most recent blood sugar levels and HBA1C levels.

Sources: “Diabetes and Your Smile.” https://www.cdc.gov/diabetes/library/spotlights/diabetes-and-dentalhealth.html “Oral Health Fact Sheet for Dental Professionals-Adults with Type 2 Diabetes.” https://dental.washington.edu/wp-content/media/sp_need_pdfs/Diabetes2-Adult.pdf Photo Source: https://www.aarogya.com/articles/dentistry/dental-and-oral-care-for-people-with-diabetes.html Wynn, Richard L., et al. Drug Information Handbook for Dentistry: Including Oral Medicine for Medically Compromised Patients & Specific Oral Conditions. 24th ed., Lexicomp, 2018.

Patients with Diabetes Type II taking Metformin should be appointed morning appointments for dental treatment to minimize chance of stress-induced hypoglycemia. I will schedule Mrs. AL morning appointments and confirm she has taken her medications and has eaten before beginning treatment.

Patients taking Lisinopril may experience orthostatic hypotension as they stand up after treatment, especially if lying in a dental chair for extended periods of time. I will adapt treatment by being mindful that I am not suddenly changing the chair position often during dental treatment and helping her get into and out of the chair slowly.

EXPLANATION OF CONDITIONS- HYPERCHOLESTEROLEMIA

Hyperlipidemia means your blood has too many lipids—fats, such as cholesterol and triglycerides. One type of hyperlipidemia , hypercholesterolemia, means there’s too much LDL cholesterol in your blood. This condition increases fatty deposits in arteries and the risk of blockages. Mrs. AL has this type of hyperlipidemia, which is often referred to as “high cholesterol.”

High cholesterol can be inherited, but it's often the result of unhealthy lifestyle choices, such as poor diet and obesity. Hypercholesterolemia may also be a result of old age, smoking, high blood pressure, and diabetes.

High cholesterol usually has no symptoms. That’s why its important to have your regular physician check your cholesterol levels with blood tests.

Sources:

“Prevention and Treatment of High Cholesterol.” https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia.

“High Cholesterol.” https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/symptoms-causes/syc-20350800

Photo Source: https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-understanding-and-managing-familial-hypercholesterolemia/

HOW HYPERCHOLESTEROLEMIA IS MANAGED

Suggested treatment for the management of Hypercholesterolemia include becoming more physically active, quitting smoking, having a healthier diet and losing weight. High cholesterol is preventable and treatable. However, if lifestyle changes do not improve cholesterol levels, medication may be prescribed. Medical management may include omega 3 fatty acids, and antihyperlipidemic agents such as niacins, statins, bile-acid-binding resins, fibrates, and ezetimibe to help reduce cholesterol levels.

Mrs. AL is currently managing this condition with Atorvastatin 20mg QD prescribed and monitored by her physician as well as trying to eat a healthy, low-salt, diet and staying active by walking about 30 minutes a day.

Sources:

“Prevention and Treatment of High Cholesterol.” https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia.

“High Cholesterol.” https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/symptoms-causes/syc-20350800

Photo Source: https://www.healthline.com/health/atorvastatin-oral-tablet

DENTAL HYGIENE MANAGEMENT-HYPERCHOLESTEROLEMIA

Contraindications of Hypercholesterolemia to dental hygiene care include if a patient is noncompliant with their medication, cardiovascular disease or heart attack.

Patient management strategies that need to be considered include detailed medical history, asking the patient about recent cholesterol levels, measurement of blood pressure, and instructing patient to be compliant with their medication.

Sources:

“Dental Considerations in Patients with Heart Disease.” http://www.medicinaoral.com/odo/volumenes/v3i2/FFcedv3i2p97.pdf

“Managing Dental Health with Cardiovascular Issues.” http://www.taktent.org.uk/articles/cardiovascular-issues.html

Photo Source: https://healthblog.uofmhealth.org/heart-health/having-heart-surgery-why-good-dental-health-matters

Wynn, Richard L., et al. Drug Information Handbook for Dentistry: Including Oral Medicine for Medically Compromised Patients & Specific Oral Conditions. 24th ed., Lexicomp, 2018.

According to the Drug Information Handbook for Dentistry, patients taking Atorvastatin may experience unusual muscle weakness or myopathy resulting from lipid therapy. Patients may have difficulty brushing their teeth or weakness with chewing and must be referred back to their physician for evaluation and to adjust medication. Mrs. AL did not report any muscle weakness and I did not notice any signs either and she has been controlled on Atorvastin for many years and does not need to change her medication. If she were to experience muscle weakness, I would continue to recommend an electric toothbrush as well as other adaptions with oral hygiene such as a Floss Reacher.

COMPREHENSIVE ASSESSMENTS: FMS RADIOGRAPH

Radiographs reveal localized moderate horizontal and vertical bone loss in all premolar and molar areas. Radiographic calculus is also

present. #21 shows carious lesion on the root.

SUMMARY OF CLINICAL FINDINGS

Extra oral and Intra Oral Examination: Bilateral linea alba, hyperkeratinized filiform papilla, keratinized tissue on lateral borders of tongue as well as scalloped tongue, low salivary flow in both submandibular and parotid salivary glands.

Bilateral Class I of Occlusion, 4mm overjet, 50% overbite.

Mild crowding of mandibular anterior teeth.

Areas of 1-2mm recession and abfractions in teeth #4, 5, 12, 13, 20, 21, and 22.

Generalized moderate to heavy supra gingival and sub gingival calculus deposits in entire dentition and localized moderate brown/black extrinsic staining on linguals of maxillary anteriors due to coffee and tea drinking.

Photo Source: https://www.chcseia.com/mouth-with-dental-mirror/

DENTAL CHARTING

#1 Missing, #2-4 bridge with #2 and #4 being PFM crowns(abutments) and #3 is the pontic PFM crown, #7-Class III MF composite, #8 and 9 porcelain veneers, #12-Class I O amalgam, #13-Class I O amalgam, #14-Class II MOL amalgam, #15-

Class II OL composite, #16 missing, #17-Class I O composite, #18-Class II DO amalgam, #19-MODBL porcelain onlay, #20-Class I O amalgam, #21- buccal root Class V caries, #29-Class I O amalgam, #30-Class II OB amalgam, #31-Class II

MO amalgam.

CARIES RISK ASSESSMENT

Patient is at a high risk of caries. Clinical and radiographic evidence of caries on tooth #21 abfraction area buccal root Class V.

GINGIVAL DESCRIPTION AND PERIODONTAL STATUSGingival description: Generalized coral pink with inter proximal and cervical redness. Generalized moderate to severe inflammation located inter proximally and marginally of all teeth. Rolled margins localized to mandibular arch. Stippled and resilient texture.

Type II/Localized Type III active periodontal disease due to 4-6mm probing depths, several areas of 1-2mm recession and abfractions, moderate to severe radiographic bone loss, moderate BOP localized to posterior teeth and generalized moderate plaque biofilm present causing inflammation and disease.

Photo Source: https://hydrofloss.com/blogs/hydro-floss-blog/h2-class-title-stages-of-gum-disease-h2

PERIODONTAL CHARTING

Generalized 1-3mm pocket depths, localized 4-6mm pocket depths in posterior teeth and #6-7 with moderate BOP in maxillary posteriors.

Areas of 1-2mm recession and abfractions in UR, UL and LL premolars.

DENTAL HYGIENE DIAGNOSIS

Periodontal Diagnosis: Type II/Localized Type III active periodontitis due to generalized 3-6mm pocket depths with localized moderate BOP in posteriors. Localized areas of 2-3mm recession and abfractions in premolars. There is also moderate localized radiographic bone loss present in posterior areas. Mrs. AL’s chief complaint report of “bleeding and inflammation in her gums” also supports her periodontitis diagnosis.

Caries Risk: High caries risk due to risk factors such as no stable dental home, having a new carious lesion in the last 36 months, having visible plaque, having multiple interproximal restorations, at high risk of root caries due to having exposed root surfaces with multiple areas of recession and abfractions, and having Diabetes Type II which can cause xerostomia. Decay noted clinically and radiographically on buccal root Class V of tooth #21. Patient has minimal protective factors such as not having frequent dental recare visits and not using fluoride.

DENTAL HYGIENE CARE PLAN

Dental Hygiene Care Plan: For patient Mrs. AL, I am planning to complete her treatment in three visits. Due to this patient’s Diabetes Type II, I will schedule her morning appointments. Due to her Diabetes Type II, she also experiences frequent urination so I will schedule time for her to have to use the bathroom often during appointments. This patients treatment plan did not need any pain management during treatment.

On the first visit I am planning to complete all assessments as well as expose digital FMS radiograph at 7mA and 70kVp. I am planning to do plaque score and Oral Hygiene Instruction electric toothbrushing. I am planning to scale her UR quadrant using cavitron and hand instruments.

On the second visit I plan to do plaque score and OHI flossing as well as super floss for the bridge in her UR quadrant. I plan to scale the LR and LL quadrants using cavitron and hand instruments.

On the final visit, I plan to perform plaque score and OHI antiseptic, fluoridated rinse without alcohol such as Listerine Total Zero. I will also recommend Biotene to help with Mrs. AL’s xerostomia. I plan to scale the UL quadrant using cavitron and hand instruments and engine polish using medium grit. I also plan to apply 5% NaF Fluoride Varnish.

CONSENT FOR TREATMENT/TREATMENT PLAN

pic of consent form

IMPLEMENTATION OF TREATMENT

Visit 1: All assessments were completed and digital FMS at 7mA and 70kVp exposed. I reviewed the radiographic findings of bone loss, calculus and carious lesion on #21 with the patient. Her plaque score was 2.1-Poor. I completed OHI Electric TB because this is what the patient is currently using. Her plaque was visible on lingual surfaces so I showed her how to adapt the electric toothbrush to all surfaces. I also advised her to use a fluoridated toothpaste such as Colgate Total SF.

Visit 2: The plaque score was now 1.6-Fair. I assessed previously taught homecare electric toothbrushing and adapting it to all surfaces of each tooth and I introduced OHI Flossing as plaque remained interproximally. I also educated her on how to use a floss threader and super floss for her bridge and gave her samples of floss threaders and superfloss.

Visit 3: Plaque score was now 1.9-Poor and OHI Electric TB again as plaque score had increased and newly formed calculus was present on linguals of the mandibular arch. I also recommended an antiseptic rinse with fluoride such as Listerine Total Zero. I recommended the version without alcohol because Diabetes Type II can cause xerostomia and an alcohol rinse would not be ideal for that. I also recommended Biotene to Mrs. AL to try to help her xerostomia and gave her samples to take home to try.

IMPLANTATION OF TREATMENT-CONTINUED.

Debridement Performed:

Visit 1: I scaled the UR quadrant using the power line FSI 1000 triple bend cavitron insert and hand instruments including scalers, the Nevi, and Graceys.

Visit 2: I scaled the LR and UL quadrants using the power line FSI 1000 triple bend cavitron insert as well as the Thinsert Cavitron to adapt to crowding in mandibular anteriors. I used hand instruments including the Universal Curett, scalers, the Nevi, and Graceys.

Visit 3: I scaled the newly formed calculus in the LR quadrant and scaled the LL quadrant as well using the power line FSI 1000 triple bend cavitron insert as well as the Thinsert Cavitron to adapt to crowding in mandibular anteriors. I also used hand instruments including the Universal Curett, scalers, the Nevi, and Graceys. After the full mouth debridement was complete, I completed coronal engine polishing with medium grit paste. I applied 5% NaF Fluoride Varnish and gave her post op instructions. I recommended this patient a 3 month recare schedule.

A challenge I had with debridement on this patient is calculus detection because I was having difficulty in detecting calculus and the difference between the detection of calculus and interproximal restorations.

Another challenge I had was that at her third visit, there was newly formed calculus in the LR quadrant that I scaled at the second visit. This was disappointing to me as a clinician that I failed my job at instructing this patient on how to take care of her oral hygiene at home. It assured me that the patient was also shocked that there was newly formed calculus and attentively listened to my recommendations.

Another challenge I had was that the patient was sensitive when using the cavitron on teeth with recession, she did not want any topical anesthetic gel so I adapted by only hand scaling these areas and the patient tolerated it well.

EVALUATION OF CARE/ OUTCOME OF CARE/

PROGNOSISEvaluation of care after the first visit: the oral hygiene instruction I gave this patient was on how to adapt her electric toothbrush to each surface of the teeth. I was pleased to see that the plaque on the lingual and occlusal surfaces decreased. I was happy to see that there was no residual calculus in the UR quadrant and the gingiva appeared less red and erythmetous in this area. After disclosing again at the second visit, there was plaque accumulation interproximally as well as at the cervical third. This time, I reintroduced the electric toothbrush and educated her on how to adapt it right at the gum line and I also educated her on how to floss. Mrs. AL was shocked at how Listerine Glide floss can go past the contacts in between her restorations that she had difficulty flossing before. She also informed me she had never heard of a floss threader and superfloss before, even by her dentist that placed the bridge. I informed her that it is important to remove plaque and food trapped underneath the pontic. I gave her samples of floss threaders and superfloss.

Evaluation of care after the second visit: At the third visit, I was let down to see newly formed calculus in the LR quadrant that I scaled at the second visit. Mrs. AL’s gingiva in the mandibular quadrant appeared inter proximally red and inflamed due to the biofilm. Again, I reintroduced the electric toothbrushing method to Mrs. AL and showed her how to see all areas of her teeth in the mirror, especially the lingual surfaces of the mandibular anteriors. I educated Mrs. AL on an antiseptic fluoridated rinse such as Listerine Total Zero as well as recommended Biotene rinse for her xerostomia. I gave her samples of Biotene to try at home.

Outcome of care to be expected: I predict that at this patients 3 month recare appointment, she will have a better understanding of how important it is to go to recare appointments for an exam and cleaning, and not just when she is in pain and needs restorative work. She will also report doing better with her oral hygiene care at home with her electric toothbrush technique brushing twice a day for two minutes and flossing one time a day with the technique that I have educated her on, including the floss threader and super floss. I also predict she will be able to use the Listerine Total Zero rinse because she has already reported using a rinse and now she can just change the type of rinse she uses. I predict she may be compliant with Biotene rinse 1-2x a week or whenever she would like some comfort from her xerostomia.

REFERRALS

Adult referral was given for patient to DDS for suspicious caries in abfraction area Buccal Class V of tooth #21.

CONTINUED CARE RECOMMENDATIONS

I am recommending a 3 month recare interval for this patient due to her deep probing depths and moderate radiographic bone loss, as well as her excessive biofilm and calculus formation in entire dentition and the staining on her maxillary anterior linguals.

Mrs. AL has Diabetes type II and there are many oral and dental side affects such as increased risk for bleeding and inflammation, oral infections such as candidiasis, and increased risk of periodontal disease, tooth loss, and carious lesions.

This patient is at a high risk for caries, especially in her exposed root surfaces, and due to her Diabetes induced xerostomia and should be evaluated for new carious lesions at each recare appointment. At each reacare appointment, NaF 5% Fluoride varnish should be applied.

Having a professional dental cleaning and exam every 3 months will be beneficial for this patient to stay on top of her oral health and focus on prevention of her periodontal disease from progressing further.

Photo Source: https://www.bencoprints.com/shop/wa/category?cn=Shop-Product-Types-Postcards&id=507398&m=BENCO

FINAL REFLECTIONDuring the treatment phase, patient compliance and debridement went well.

She was scheduled early morning appointments and was provided bathroom breaks due to excessive urination due to her Diabetes Type II.

The treatment plan was accurately followed and the only modification was at the third visit, I scaled the newly formed calculus in the LR quadrant.

Something I could have done differently was to recommend the anti cavity and anti septic rinse such as Listerine Total Zero as well as Biotene rinse earlier on in this patients treatment than at the last visit.