Download Case Study - Kaley O`Brien RDH

Case Study
Kaley O’Brien
David
• The patient is a 54 year old male who has had multiple contributing factors
to increase his severe periodontal disease. Multiple previous conditions
leading to multiple medication, deep pockets with progressive bone loss, and
lack of knowledge have all lead to the severity of this patients condition.
With a 5 sub rating, a case type IV, and 28 teeth this patient is ideal for my
case study. The goal was to perform NSPT to arrest the disease and provide
improvement to his periodontal condition. Initial Appointment: 1/15/15
Health History
• Age: 54
• Last prophy: unknown
• Systemic diseases: High Blood Pressure, Type II Diabetes, stroke in 2001, and
kidney removal in 2013.
• Medication: Omeprazole, Carvedilol, Amlodipine, Tamulosin, Hydrochlorothiazide,
Simvastatin. Glipizide, Aspirin (.81 mg), and potassium.
• Dental Information: Gums bleed upon brushing, brushing 1x per day in AM with
fluoride toothpaste
Vital Signs
Date:
Blood Pressure
Repiration
Pulse
1-8-15
141/93
14
76
1-21-5
154/94
16
67
1-28-15
151/94
16
70
1-29-15
139/88
16
72
2-6-15
139/86
18
65
2-13-15
149/96
16
74
IO/EO Findings
•
•
•
•
Nothing abnormal
Class I Occlusion
Overjet 4mm
Overbite 4mm
Dental Charting
Existing
Proposed
2-MO amalgam
2-MO amalgam
3-DO amalgam
3-DO amalgam
8-PFM
9-PFM, RCT
14-O amalgam, O
amalgam
15-O amalgam, B
amalgam
18-O amalgam, B
amalgam
19-DO amalgam
29-DO amalgam
30-O amalgam
31-O amalgam
Periodontal Assessment
Teeth
Sites
Bleeding
28
167
Suppuration
1
1
Furcations
8
20
Mobility
17
Pockets > 4
24
86
CAL 1-3
17
46
CAL 4-5
25
64
CAL +6
21
58
Microscope Evaluation
• Risk Factor C:
• TNC WBC’s, spirochetes, gliding and spinning rods
• All very motile
Intraoral Photos
Radiographic Findings
• Impacted third molars
• Generalized severe bone loss
• Calculus interproximal of almost every tooth.
Study Models
Dental Hygiene Diagnosis
• Case Type IV
• 2/5 calculus rating
• Gingival Description:
• Generalized severe papillary and marginal hyperemia
• Generalized severe papillary and marginal enlargement
• Generalized fibrotic
• Generalized spontaneous bleeding
• Generalized severe papillary and marginal inflammation
Dental Hygiene Diagnosis cont.
• Radiographs show generalized severe bone loss with generalized heavy
interproximal calculus
Periodontal Risk Analysis
N/A
Infectious diseases
LOW
MODERATE
Irregular Dental Care
Systemic Diseases
Existing Conditions
HIGH
Medications
Caries Risk Analysis
N/A
Deep pits and fissures
LOW
Visible carious/ white
spots
MODERATE
Root Exposure
Recently restored fillings Saliva Reducing Factors
Frequent sugar exposure
Appliances
HIGH
Visible dental biofilm
Patient Goals
Patient wants to get teeth cleaned, get rid of the bacteria seen on
microscope slide, and do any restorations needed
Interventions
NSPT full dentition with aid of local anesthetic, teach good home
care, gingival curettage, Arestin placement, and have the dentist
diagnose any caries.
Expected Outcomes
NSPT will help reduce the bacteria and take away the environment
in which they flourish. Proper home care will help to disrupt that
bacteria and stop it from recolonizing. Restorations will be
scheduled or referred out accordingly.
TREATMENT PLAN
1
-D0150- Comprehensive Oral Evaluation, -D0210-FMS, -D0330- Panoramic Image, -D1330OHI, Oral B toothbrush, Impressions, Checkin
2
-D-4341 UR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage
3
-D-4341 LR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381Arestin (5-8)
4
-D-4341 LL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381Arestin (31B,30L, 27L)
5
-D-4341 UL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Laser Curettage, -D4381- Arestin
(9,18,19), -D1206- Fluoride Varnish
6
-D0170- Re-Eval, -D1206- Fluoride Varnish, -D1330- OHI, -D4381-Arestin (27M and 11F)
TREATMENT PLAN
1
-D0150- Comprehensive Oral Evaluation, -D0210-FMS, -D0330- Panoramic Image, -D1330OHI, Oral B toothbrush, Impressions, Checkin
2
-D-4341 UR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage
3
-D-4341 LR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381Arestin (5-8)
4
-D-4341 LL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381Arestin (31B,30L, 27L)
5
-D-4341 UL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Laser Curettage, -D4381- Arestin
(9,18,19), -D1206- Fluoride Varnish
6
-D0170- Re-Eval, -D1206- Fluoride Varnish, -D1330- OHI, -D4381-Arestin (27M and 11F)
Treatment Plan Rationale
• Based on the severity of the patients periodontal disease, the patient was
needing to undergo NSPT.
• With pockets being this deep and the patient being so infected there was no
way this could be performed without aesthetic.
• In hopes to help progress the healing of the tissue curettage was performed
on every quadrant and Arestin was placed in any pockets that were still not
showing signs of progress at the subsequent appointment.
OHI
• Initial Recommendations:
• Brush with new Oral B toothbrush with Bass method for 2 full minute twice daily, flossing with “c” shape, use of
perio aid to clean deep pockets, talked about possibility of waterpik, and brushing tongue as well.
• Patient advised at initial appointment to focus on brushing twice daily for 2 full minutes
• Compliance:
• Great effort, but patient still not consistently brushing twice per day. Patient also found perio aid difficult to
manipulate
• Modifications
• Brought up possibility of waterpik again and talked to patient again about importance of brushing more.
• Compliance to modifications
• By the re-evaluation appointment I could see great improvement in David’s brushing compliance and that David had
invested in a Waterpik.
Motivation Strategies
• Intrinsic
• Proper OHI to “get rid” of all the bacteria
• Brushing to reduce patients discomfort in mouth
• Extrinsic
• Arresting periodontal disease in order to avoid toothloss.
• Proper OHI to decrease negative appearance of mouth
• OHI utilization
• I was able to use the microscope, intraoral photos, and the discomfort to help motivated the
patient to have great home care compliance.
Re-Evaluation Appointment
•
•
•
•
•
•
Date: 4/7/15
2/2
Case Type III with Localized Case Type IV
Microscope Risk Factor B
OHI Compliance: great compliance with water pik, but patient still working on brushing morning and night
Gingival Description:
•
•
Generalized moderate papillary and marginal hyperemia with localized severe on 3-4, 13-14, 24-25, and the maxillary anterior
•
Generalized moderate papillary and marginal inflammation with localized severe on on 3-4, 13-14, 24-25, and the maxillary
anterior
Generalized moderate papillary and marginal enlargement with localized severe on on 3-4, 13-14, 24-25, and the maxillary
anterior
Re-Evaluation Appointment cont.
• Patient motivation is still the same and is what is helping him maintain
progress.
• The expected outcomes were reached as far as removing all of the calculus
and teaching proper home care techniques. Patient still needs to have routine
cleanings and have restorative work completed.
Periodontal Assessment
Teeth
Sites
Bleeding
23
80
Suppuration
2
2
Furcations
8
20
Mobility
12
Pockets > 4
20
58
CAL 1-3
22
73
CAL 4-5
22
60
CAL +6
14
35
Intraoral Photos
TREATMENT PLAN
1
-D0150- Comprehensive Oral Evaluation, -D0210-FMS, -D0330- Panoramic Image, -D1330OHI, Oral B toothbrush, Impressions, Checkin
2
-D-4341 UR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage
3
-D-4341 LR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381Arestin (5-8)
4
-D-4341 LL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381Arestin (31B,30L, 27L)
5
-D-4341 UL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Laser Curettage, -D4381- Arestin
(9,18,19), -D1206- Fluoride Varnish
6
-D0170- Re-Eval, -D1206- Fluoride Varnish, -D1330- OHI, -D4381-Arestin (27M and 11F)
Comparison
1/15/15
4/17/15
Calculus Deposit
2/5
2/2.5
Case Type
IV
III localized IV
Microscope
Risk Factor C
Risk Factor B
Reflection
• I thought that overall my case study was an amazing patient. I do however wish that
he would have been more dedicated to his oral health. It seemed that he would do
really good for a while, but then he would revert back to old habits and only brush
once per day. There was some dexterity restrictions with David, but this was not to
the degree that would prevent him from performing any of the things I instructed
him on. I feel that it was more of a laziness factor when it came to David! I would
have like to have been able to accomplish more as far as motivating him to want to
brush twice a day, but I exerted all capabilities that I had. This was an awesome
learning experience and made my overall oral hygiene education better!