Download Senior year case documentation project

Case Documentation Project
DENH 437/447 Clinical Dental Hygiene II/III
Submitted to:
M. Anjum Shah, B.S.D.H., R.D.H., M.S.
By: Mallery Kibby
April 13th, 2015
Introduction
Ms. Planters is a 71 year old Caucasian female. She presented to clinic for a six month dental hygiene
recall appointment with no chief complaint. She has been diagnosed with hypertension, which is well controlled
with the medications Amlodipine, Carvedilol, Losartan, and Spironolactone. She additionally takes 81 mg of
Aspirin once a day per her physician’s request, and Seroquel as needed to help with sleeping. She suffers
from severe osteoarthritis, to the point where deformities in both hands and all of her fingers has developed.
She was hospitalized in 2012 due to blood clots in her left lung, which resulted from a fall. However, she fully
recovered with no complications. After thoroughly updating her medical history and medications list, her ASA
classification was determined to be a class II.
Dental History
Upon her initial visit, Ms. Planters brushed twice a day and flossed two to three times a day. She was
not currently using a mouth rinse, but was extremely interested in oil pulling. She stated that her hair dresser
began oil pulling, and has had excellent results from it. She was strongly contemplating replacing her daily oral
hygiene regimen with oil pulling, as she had difficulty flossing due to osteoarthritis. Unfortunately, she grew up
in an area which lacked fluoridated water. She occasionally experienced xerostomia, which is believed to be
drug induced. According to Lexicomp®, Seroquel has an adverse side effect of xerostomia.1 She stated she
was recently using Biotene®, but she did not like the consistency or taste of it. She wears a maxillary partial
denture, which she has had for the past ten years. Due to recent decay and xerostomia, she was considered to
fall into the high caries risk category.
Social History
Ms. Planters is a recent widow, as her husband passed away over the past year. She is retired and
spends the majority of her time gardening, cutting the grass, cleaning, and walking her dog. She partakes in a
moderate level of physical activity daily by walking a minimum of 1.5 miles a day. She has a close knit group of
friends that she enjoys spending time with. However, she chooses to spend the majority of her time by herself.
Initial Visit and Justification for Case Documentation Patient Selection
During Ms. Planter’s initial visit, the dental hygiene process of care was initiated. Assessments were
completed and analyzed to develop a dental hygiene diagnosis, and a treatment plan was developed. Upon
completing extra-oral and intra-oral examination, asymptomatic bilateral subluxation and asymptomatic
crepitus on her right TMJ were documented. Occlusal wear was noted, including generalized attrition and
abfraction due to bruxism. Enamel erosion was present on several maxillary teeth. She stated that she lost her
own occlusal guard, so she would occasionally use her husbands at night. Xerostomia was clinically visible.
Her gingiva appeared generalized coral pink, with localized erythematous and rolled margins around her
posterior teeth. She had blunted papilla and edematous gingiva. Her deposits consisted of generalized slight to
moderate plaque, with generalized slight calculus, predominately on interproximal surfaces.
A full mouth periodontal chart was completed and revealed the following:
PD’s
Generalized 2-3 mm’s with localized 4-5 mm’s; Localized 7 mm on #4-DF due to root fracture
BOP
Localized on interproximal surfaces
Recession
Generalized 1-3 mm with localized 4-5 mm mainly on mandibular anteriors
AL
Generalized severe
Furcations
Class I: #30-B
Mobility
Class I: #24, #25
Class II: #19-B, #31-B
Assessments indicative of DH diagnosis: Generalized slight gingivitis with localized severe chronic
periodontitis
The remaining teeth entailed several restorations including crowns, root canal treatments, composite and
amalgam fillings, and a maxillary bridge.
Ms. Planter’s periodontal findings were discussed with her, in addition to the fractured root on #4. She
stated that her previous dentist had already told her that she had a vertical root fracture which needed
extracted. She was additionally told that she would have to have a new maxillary partial denture completed.
She insisted that this tooth was asymptomatic, and that she planned on keeping it until it caused her pain. She
was stubborn and insisted that it was not problematic. She was informed that her fractured root was harboring
plaque and bacteria, as she is not able to keep a 7 mm PD clean on her own. It was explained to her that this
could ultimately result in an infection. According to a study on vertical root fractures, the most common
treatment method is extraction. They concluded that various irritating agents like bacteria and food debris are
forced into the fracture site during mastication. This results in the periodontal breakdown and deep probing
depths associated with the vertical root fracture.2 After a long discussion, she agreed to have a dental exam
during her next visit to obtain a second opinion. However, she warned me that her opinion was not going to
change.
Her plaque free and gingival index scores were conducted to provide a base line for comparison at
subsequent visits. Her initial gingival index (GI) score was 0.88, and her initial plaque free score (PFS) was
14%. After obtaining her written consent, a series of intra-oral photographs were taken for additional
comparison. She was then sent home with a three day dietary intake journal and behavior form. This would
show whether or not her dietary intake was playing a negative role in her overall oral health.
Ms. Planters was carefully chosen as a case documentation patient due to her osteoarthritis. This
condition was making her daily oral hygiene regimen difficult, and her GI and PFS’s were showing this.
According to the Centers for Disease Control and Prevention (CDC), 52.5 million adults in the United States
have been diagnosed with some form of arthritis.3 Moreover, by 2030, an estimated 67 million Americans ages
18 and older are projected to have doctor-diagnosed arthritis. According to a review of literature on the
influence of osteoarthritis on oral health, osteoarthritis in the hands is correlated with impaired functional ability.
Therefore, many people with osteoarthritis in their hands are unable to maintain proper oral hygiene without
appropriate intervention and adaptation.4 With the high prevalence of osteoarthritis, it is critical for dental
hygiene clinicians to be able to tailor oral hygiene instructions to meet their specific needs.
Furthermore, Ms. Planters required an intervention before she replaced her entire oral hygiene regimen
with oil pulling. This was worrisome, as this oral hygiene regimen is still fairly knew to the United States
dentistry field. She was kindly asked to defer this method, until research could be conducted. She was
informed that evidence based practice minimizes potential harm to the patient, and improves patient outcomes.
Furthermore, being a recent widow, nutritional counseling was of high importance to ensure recent dietary
habits were not negatively impacting her overall oral health. Due to the recent death of her husband, she was
constantly on edge and her stressful situation was clearly visible. She was easily angered and was not afraid to
speak what was on her mind. She was additionally in need of treatment in the oral disease control phase. It
was evident that this patient required a series of appointments in order to take her treatment plan one step at a
time.
Treatment Plan
Seq.
1
Tooth/Quad
N/A
Surface
N/A
2
All quads
All surfaces
3
#4
All surfaces
4
5
6
#21
Quads 3 & 4
All quads
MOD
N/A
All surfaces
Treatment
D1330- Oral hygiene instructions
D1310- Nutritional counseling
D1110- Adult prophylaxis
D0120- Periodic oral evaluation
D11206- 5% NaFl Varnish
D0220- PA
Extraction
Amalgam
Fabrication of mandibular occlusal guard
D1110- 3 month DH recall
D0274V- 4 vertical BWs
Second Visit
Ms. Planters presented to her second visit with her three day dietary intake journal and behavioral
information sheets. These were held onto until her third visit, so that she was not overloaded with too much
information during this visit. In the beginning of the appointment she was disclosed with a plaque disclosing
tablet. A second PFS was obtained of 14%, and a second GI score of 0.88. Ms. Planters decided upon a goal
herself to reach 40% plaque free by her next appointment. After disclosing the patient, a second series of
intraoral photographs were taken. She was then instructed to demonstrate her current flossing technique. She
was clearly struggling to floss with standard dental floss. She spent more time trying to wrap it around her
index fingers then flossing. Furthermore, she was completely missing the cervical and middle thirds of all of her
teeth. It was then obvious that this patient needed an alternative to standard floss. In addition to flossing, it was
highly important to demonstrate a proper manual brushing technique due to the severity of her recession. She
had already mentioned that she did not have sufficient funds to purchase an electronic toothbrush. She stated
that she plans to in the future, but not anytime soon. Therefore, there was no need to reiterate the benefits of
an electronic toothbrush in those with osteoarthritis. When she demonstrated her brushing technique, she was
missing all of the surfaces apical to her cementoenamel junction. Using a patient mirror and the plaque
disclosing tablet enabled her to see the remaining plaque. The pink areas indicated areas that she missed. The
sulcular brushing technique was then demonstrated, emphasizing angling the bristles of the brush at a 45
degree angle towards the gingival margin. While brushing, she was instructed to gently pull out her lower lip so
that she could visibly see her gingival margin. Doing this helped her identify how far apically she needed to
brush. The patient was then able to comfortably and properly demonstrate this method back correctly.
After the loss of her husband, Ms. Planters struggled with allowing herself to receive help. She was
adamant on figuring out how to maneuver the floss around her fingers, and did not want to give up. While she
continued to struggle with the floss, she was informed that there are alternative methods for removing
interproximal plaque and debris. According to the ADHA, the elderly who suffer from arthritis or other
conditions that compromise their hands may find the Water Flosser easier to manage and control. It has
additionally been recommended for those whom display inadequate interdental cleansing skills.5 In a recent
study, the water flosser was compared to standard floss when used in combination with manual brushing,
using the sulcular method. Results concluded that the water flosser group had a 74.4% reduction in whole
mouth plaque, compared to a 57.7% reduction with standard floss.6 In a separate study, it was stated that
when combined with manual tooth brushing, the use of an oral irrigator was significantly more effective in
reducing gingival bleeding scores as compared to the use of dental floss.7
Several studies have collectively proven the efficacy of plaque removal using the Waterpik® Water
Flosser. Due to her financial situation, one was purchased for Ms. Planters to begin implementing twice a day.
Proper use was demonstrated through the use of videos and the product itself. She was instructed to use the
Classic Jet Tip in healthier areas, and the Pik Pocket® tip for areas with 4-5 mm probing depths. As per the
instructions, she was instructed to use the Classic Jet Tip aiming it just above the gingival margin at a 90
degree angle. Starting posteriorly, she were to continue to follow the gingival margin while briefly pausing
interproximally. She was then instructed to set the unit to the lowest pressure setting, and insert the Pik
Pocket® tip. She was then to place the tip against the tooth at a 45 degree angle. While gently placing the tip
under the gingival margin into the pocket, she were to continue to trace the gingival margin.8
Ms. Planters presented to her initial visit stating that she did not particularly like Biotene® mouth rinse.
Therefore alternative methods to relieve her xerostomia were discussed. In a recent review of literature, olive
oil is effective in improving xerostomia secondary to medication use.9 Therefore, she was instructed to rub
olive oil around her alveolar mucosa after using Listerine® mouth rinse morning and night. Studies currently
indicate that alcohol-based mouth rinses do not negatively affect the flow rate of saliva.10 However, if she did
happen to experience discomfort, she was instructed to switch to Listerine Zero®.
Furthermore, Ms. Planters was presented with information provided by the ADA on oil pulling. Oil
pulling has been around for centuries, however, it is new to the ADA. Oil pulling is a practice which originated
as an ancient traditional Indian folk remedy for several years to prevent decay, oral malodor, bleeding gingiva,
dryness of throat, and cracked lips.11 In addition, it has been claimed that it cures approximately 30 systemic
diseases ranging from headaches to diabetes. This regimen entails using a tablespoon of oil (sunflower oil,
sesame oil, or coconut oil), and moving it around in the mouth using a “sip, suck, pull through teeth” method.
This is done for approximately 15-20 minutes, or until the oil turns white and is no longer yellow.11 According to
the American Dental Association® (ADA), oil pulling is not currently recommended as a replacement for
standard time-tested oral health behaviors and modalities due to the lack of currently available evidence.12 Ms.
Planters was informed that it is per my philosophy of practice to incorporate evidence based care when
recommending alternative oral hygiene regimens. Therefore, it was up to her discretion to decide whether or
not she were to “oil pull”. Ms. Planters insisted on doing it anyway. However, she was instructed not to replace
her recommended daily oral hygiene regimen with it. If she were to do it, it were to be supplemental to her new
oral hygiene regimen. She was additionally warned to stop oil pulling if she begins to feel discomfort. Due to
her bilateral subluxation and crepitus present, caution was warranted to prevent future complications.
It was initially planned for a dental student to take alginate impressions in order to begin fabrication of
an occlusal guard. She had already presented with 25-30% incisal wear on her maxillary and mandibular teeth.
However, after reviewing the periodontal chart completed at the previous appointment, it was concluded that
this patient’s mobility on #4 increased to a class III. After collaborating with a dental student and the attending
dentist, it was recommended that #4 needed to be treated prior to fabricating an occlusal guard. This was due
to the possibility of the occlusal guard creating further damage to #4. Due to lack of time, a complete dental
exam was to be completed at the following visit after her adult prophylaxis.
Goals to be Achieved by Next Appointment
 Obtain PFS of 40% by implementing new OHI
 Reduce interproximal plaque by utilizing the Waterpik® Water Flosser twice a day
 Reduce plaque along gingival margin by implementing sulcular brushing technique
 Alleviate xerostomia by using olive oil after Listerine® mouth rinse
Third Visit
Ms. Planters presented to her third visit with excellent results in just a short amount of time. Over the
previous month, she began implementing her new Waterpik® Water Flosser twice a day, morning and night.
She stated that she did not like the olive oil, so she switched back to Biotene®. After discussing other
alternatives to alleviate her xerostomia, she stated that she would like to stick with Biotene®. She additionally
stated that upon her own will, she was oil pulling once a day. She stated that it made her mouth feel excellent
and very clean. Moreover, she stated that she limited it to approximately five minutes as it was a struggle to
swish any longer than that. Next, using a plaque disclosing tablet, a new plaque free score of 31% was
documented. Despite her not reaching her goal of 40% plaque free, the plaque accumulation was much
thinner. Her new GI score was 0.44. The patient agreed upon a new goal to reach 50% at her final case
documentation visit.
A new full mouth periodontal chart was then completed to compare with her initial chart. This revealed a
significant reduction in the localized 4-5 mm PD’s from her initial visit. There was no longer bleeding upon
probing. Her gingiva appeared generalized coral pink and firm with blunted papilla. She had localized
erythematous, edematous, and rolled margins around #4. Her deposits consisted of generalized slight biofilm,
with generalized slight calculus. The remaining 5 mm probing depth was located on #13-DL and L. This tooth
had radiographic evidence of widened periodontal ligaments, and it was clinically showing abfraction along the
cervical margin. Therefore, it was most likely that this tooth was suffering from secondary occlusal trauma. Her
new assessments were indicative of localized severe chronic periodontitis. An adult prophylaxis was deemed
appropriate for this patient and was completed. However, she was placed on a three month recall appointment
to continue to evaluate the probing depth on #13. If it did not improve by the next appointment, treatment was
going to be deemed necessary.
At the previous visit, Ms. Planters brought back her completed three day dietary intake journal and
dietary behavior form information sheets. Despite her recent loss of her husband, she still managed to cook
three nutritional meals a day for herself. Her meals and snacks consisted of mainly cariostatic foods. Her go to
snacks consisted of almonds, peanuts, sunflower seeds, and vegetables, all of which are considered
noncariogenic. However, there were areas of concern that increased her risk for dental decay. Her daily routine
consisted of several cups of coffee, lemonade, and tea. This finding was significant due to the fact that she had
erosion present on several maxillary teeth. Dental erosion is defined as loss of tooth structure by a chemical
process that does not involve bacteria. Acidic drinks, such as those that Ms. Planters consumes, lower the pH
level of the oral cavity. Once the pH lowers below 5-5.5, it can ultimately lead to demineralization and erosion
of enamel. In a study conducted on fruit juices, tea, and carbonated beverages (orange, lemon, and cola),
conclusions were drawn that all of the listed beverages had an initial pH below 5.5, and thus had the potential
to cause erosion.13 It was explained to Ms. Planters that it is more important to limit the frequency of these
acidic beverages then the quantity, in relation to her oral health. She was instructed to try and drink her coffee,
tea, or lemonade with her meals, and drink water in between. She was asked to swish with water after she
consumes these beverages, in order to aid in buffering the pH of her saliva. Lastly, she was instructed to chew
a gum which contained the ingredient xylitol immediately after her acidic beverages to aid in buffering her
saliva. This was based off of scientific evidence that chewing xylitol gum stimulates saliva flow, leading to pH
recovery and a reduction in S. mutans in saliva.14
As agreed upon during the previous visit, a periodic oral evaluation was completed by the dentist.
Additionally, a new treatment plan was developed by the dental hygienist and dental student. Tooth #4 had a
hopeless prognosis, so plans were discussed for future loss of this tooth. Due to #4 being the last available
tooth for the metal clasp of her maxillary partial to hold on to, it would no longer fit properly if that tooth were
missing. She would ultimately be missing teeth #1-#6. Therefore, options were discussed including implant
placement to keep her maxillary partial, or possible extraction of remaining maxillary teeth to have a complete
maxillary denture created. It was concluded that tooth #21 had an open margin occlusally, so the current MOD
amalgam restoration needed to be redone. A mandibular occlusal guard was then recommended over a
maxillary occlusal guard due to the mobility of #4, and possible future extraction. At that time, the patient
denied the treatment plan, and refusal of treatment was obtained.
Upon walking Ms. Planters out of the clinic, she stated that the dental student was “looking for
production points”, and that her teeth were fine. She was very angered and frustrated, and stated that she
would let the dentist know when she had a tooth that was bothering her. This patient was intrinsically
motivated, and was not going to give consent for treatment until she felt in control of the situation. Strategies
(discussed under her last visit) were developed in order to allow this patient to feel comfortable agreeing to
treatment.
Three Month Recall/Last Visit
Ms. Planters presented to clinic for her three month dental hygiene recall appointment. Upon updating
her dental history, she stated that she has continued to love her Waterpik® Water Flosser. Although it felt time
consuming at first, she stated that it had become of habit to use it twice a day. She stated that she has still
continued to do oil pulling several times a week. She no longer desires the need to replace her daily oral
hygiene regimen with oil pulling. However, she explained that her teeth have never felt as clean as they do
after using it. She has additionally continued to use Biotene® twice a day to alleviate her xerostomia
symptoms.
Her gingiva now appeared to be generalized coral pink and firm, with blunted papilla and slightly rolled
margins. Localized edematous and erythematous gingiva was still present around tooth #4. Her deposits
consisted of generalized very slight biofilm. A new GI score was obtained of 0.31, which had significantly
improved since her initial visit. Her new plaque free score obtained at this visit was 7%, which was well below
her previous score of 31%. She was unable to reach her goal. However, the plaque accumulation was much
thinner than her initial visit. Moreover, her probing depths and gingival appearance had substantially improved.
She explained that she had left her house at 5:30 that morning, so she had not been able to brush since then.
A new full mouth periodontal chart was then completed. She now has generalized 2-3 mm probing depths, with
two localized 4 mm probing depths on #11-ML and #13-DL. Tooth #13-DF now has a 6 mm probing depth,
which will be examined at her next scheduled appointment with a dental student. It was assumed that this is
due to either her need for an occlusal guard, or the need for an occlusal adjustment of teeth #13 and #19. Her
assessments were now indicative of a dental hygiene diagnosis of localized severe chronic periodontitis.
The pocket depths on #4-DB, B, and DL had increased to 10 millimeters since the previous
appointment. Suppuration and bleeding were additionally present. Ms. Planters confirmed that she felt it had
become more mobile, but it was still asymptomatic. After her previous negative experience with the dentist and
dental student, it was decided that a new approach needed to be taken. Prior to the patient’s appointment, the
scenario was discussed with a different attending dentist. A different dentist was introduced due to his strong
positive background in treating patients such as Ms. Planters. Motivational interviewing was the plan of action,
which is defined as a collaborative conversational style for strengthening a person’s own motivation and
commitment to change.15 This behavior theory entails the clinician to abandon the impulse to solve the patients
problems, and instead allow the patient to articulate his or her own solutions. This ultimately allows the patient
to have complete autonomy in the decision making process.15 Ms. Planters was simply asked open ended
questions by the dentist and hygienist, allowing her to hear herself discuss the problem at hand. She was
asked questions like “what do you think will happen if you leave the tooth untreated?” and “what would you like
us to do to solve the problem?” The dental clinicians avoided overloading the patient with information by only
responding to the topics she wanted to discuss. Once Ms. Planters felt in control of the situation, she began
discussing replacement options if she were to get that tooth extracted.
To give Ms. Planters time to think about what was discussed, she was asked to give us her solution
after her cleaning. Her three month adult prophylaxis was completed, and 5% NaFl varnish was applied. A final
series of intraoral photographs were taken. Furthermore, four vertical bitewings were taken, along with a
periapical radiograph of #4. It had been a year since her last radiographs were taken. Due to her high caries
risk, it was necessary to take them at this time. The periapical radiograph was necessary due to the 10 mm
probing depths and root fracture. Upon walking Ms. Planters out of the clinic, she shockingly decided to
schedule an appointment to get tooth #4 extracted. However, due to financial issues, she denied remaining on
a three month recall. She now has been placed back onto her original six month recall. It is now up to her new
dental student to complete her treatment plan. This entails fabrication of an occlusal guard, and #21 MOD.
Conclusion
Ms. Planters turned out to be a patient that required unique and individualized care. The majority of her
appointments resulted in going back and forth between the various treatments discussed above. They became
a little stressful at times, and therefore I became overwhelmed once it was time for documentation. During her
initial visit, I failed to document generalized slight gingivitis in her note. Furthermore, I did not originally
prescribe this patient with PreviDent® due to her three month recall intervals. In addition, 5% NaFl varnish was
applied at both recall appointments. However, at her last visit she requested to be placed back on a six month
recall interval. Due to her xerostomia and high caries risk, this patient would definitely benefit from PreviDent®.
This case documentation project is a prime example of the several various roles that a dental hygiene
clinician entails. Our specialization and knowledge in oral health disease prevention provides us with limitless
opportunities to aid each patient in unique individualized ways. Furthermore, it shows how important it is to
connect with our patients on a personal level. Discovering what drives the patient, and whether they are
intrinsically or extrinsically motivated, are key factors in achieving behavioral change. Ms. Planters was
struggling with not only her physical and medical condition, but her physiological health as well. Due to the
recent passing of her husband, change was not something that she felt comfortable with. She was a challenge
and difficult to manage, but she ultimately provided me with an excellent learning experience.
References:
1. QUEtiapine (Dental Lexi-Drugs) [Internet]. 2015; Available from:
https://online.lexi.com/lco/action/doc/retrieve/docid/dental_f/47510. Accessed March 20, 2015, 2015.
2. Khasnis S, Kidiyoor K, Patil A, Kenganal S. Vertical root fractures and their management. J Conserv
Dent. 2014;17(2).
3. Arthritis-Related Statistics [Internet]. Georgia: Centers for Disease Control and Prevention. 2014- [cited
2015 Mar 8]. Available from: http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm#2.
4. Kelsey J, Lamster I. Influence of muskuloskeletal conditions on oral health among older adults. Am J
Public Health. 2008 Jul;98(7).
5. Fried, J. J Dent Hyg [Internet]. 2012 [cited 2015 Mar 15]. Available from:
https://www.adha.org/resources-docs/7123_Waterpik_Irrigation.pdf
6. Goyal C, Lyle D, Qaqish J, Schuller R. Evaluation of the plaque removal efficacy of a water flosser
compared to string floss in adults after a single use. J Clin Dent. 2013;24(2).
7. Rosema N, Hennequin-Hoenderos N, Berchier C, Slot D, Lyle D, Weijden G. The effect of different
interdental cleaning devices on gingival bleeding. J Int Acad Periodontol. 2011;13(1).
8. Waterpik® Water Flosser Model WP-100/105/ 110/112. 2014 [cited 2015 Mar 20]. Available from:
https://www.waterpik.com/oral-health/pdfs/WP-100-instruction-manual.
9. Villa A, Connell C, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin
Risk Manag. 2015;11:45-51.
10. Osso D, Kanani N. Antiseptic Mouth Rinses: An Update on Comparative Effectiveness, Risks, and
Recommendations. J Dent Hyg. 2013 Feb;87(1).
11. Singh A, Purohit B. Tooth brushing, oil pulling and tissue regeneration: A review of holistic approaches
to oral health. J Ayurveda Integr Med. 2011 Apr-Jun;2(2):64-68.
12. The Practice of Oil Pulling. 2014 [cited 2015 Mar 25]. Available from: http://www.ada.org/en/scienceresearch/science-in-the-news/the-practice-of-oil-pulling
13. Singh S, Jindal R. Evaluating the buffering capacity of various soft drinks, fruit juices and tea. J
Conserv Dent. 2010 Jul-Sep;13(3):129-131.
14. Llop M, Jimeno F, Acien R, Dalmau L. Effects of xylitol chewing gum on salivary flow rate, ph, buffering
capacity and presence of Streptococcus mutans in saliva. Eur J Paediatr Dent. 2010;11(1).
15. Williams K, Bray K. Motivational Interviewing: A Patient-Centered Approach to Elicit Positive Behavior
Change. 2014 [cited 2015, Mar 25]. Available from: http://media.dentalcare.com/media/enUS/education/ce381/ce381.pdf