periodontal case study project dental hygiene clinical practice ii diem le
TRANSCRIPT
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PERIODONTAL CASE STUDY PROJECT
DENTAL HYGIENE CLINICAL PRACTICE IIDIEM LE
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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
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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
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GINGIVAL DESCRIPTION
Generalized moderate redness, shiny, spongy, enlarged, rounded slight edematous tissue with rolled margins and bulbous papillae
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INTRA ORAL PHOTOS
-Photo was taken on 01/28/14-Green Arrow- generalized mod attritionRed Arrow- Tobacco stain on buccal of tooth #8
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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
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DENTAL CHART
NOTE:-Green arrows-Carious lesions on occlusal of Teeth #14, #30, #31-Red arrows- fractured tooth, needs restorations
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PERIODONTAL CHARTING
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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
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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
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FACTORS
• Periodontal Risk Factors• -Smoking• -Stress
• Contributory Factors• -Calculus, malocclusion, OH care
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PERIODONTAL DIAGNOSIS
• Generalized slight active Chronic Periodontitis with moderate active chronic Periodontitis on teeth #3,15,18, 28,29
• AAP II
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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
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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.
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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.
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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
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• 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
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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
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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.