Download Case Documentation

Case Documentation
Jessica Stewart
DENH 437/447
April 5, 2015
Mr. Upside Down Smile
Mr. Upside Down Smile is a 77 year old married Caucasian male who is retired. He
presented to the dental clinic for his periodontal maintenance on August 18th, 2014. At his
previous appointment he was placed on a 3 month recall, but presented to the clinic at 5 months
instead. Upon doing the assessments at the first appointment he presented with generalized 23mm probing depths with localized 4-5 mm PD. His recession was generalized 2-4 mm with
localized 5-7 mm. He had class 1 furcation’s on #2, #17, #18 and class 2 on #14. His gingival
description was generalized redness, edematous, and blunted papilla. He has a severe under
bite giving him a class 3 occlusion, which is why he is given the name Mr. Upside Down Smile.
Even though it had only been 5 months since his last cleaning he presented with
generalized heavy plaque and calculus build up. His present illnesses include arthritis mostly in
thumbs, hiatal hernia, coronary artery disease (CAD) and gastroesophageal reflux disease
(GERD). His tonsils were removed at age 20, he had appendicitis in 1962 and had three stents
placed, once in 1997 and once in 2001. He has an allergy to Meclizine (a medication to treat
vertigo), the patient will break out in hives within minutes of taking medication. He currently is
taking Crestor®, aspirin, trazodone, and omeprazole. Lexicomp states that trazodone and
omeprazole have a dental side effect of xerostomia.1 When going through the patient’s dental
history, the patient stated he suffers from dry mouth clinically known as xerostomia.
”Saliva is an important component of the mouth. Dry mouth can have consequences on
elderly people’s oral health (caries, mucous pathology) and their health related quality of
life. They usually suffer from side effects of medications, and dry mouth is a common
side effect.”2
Mr. Upside Down Smile is a high caries risk patient and presented with an abundant
amount of restorations- including restorative work done within the past three years. The most
challenging restoration to clean was his composite periodontal splint from #23-#26 which is a
plaque and calculus trap. Splinting teeth to each other allows weakened teeth to be supported
by adjacent teeth, although the procedure can make oral hygiene procedures difficult.
At his first appointment four vertical bitewings were taken and a full periodontal chart
was completed including a plaque free score. According to the radiographs and periodontal
chart, the patient has generalized moderate with localized severe horizontal bone loss.
Radiographs allow the practitioner to determine the pattern of bone loss; horizontal or
vertical. Horizontal bone loss describes height loss around adjacent teeth in a region. In
horizontal bone loss, both buccal and lingual plates have been resorbed as well as the
intervening interdental bone. Horizontal bone loss occurs in a plane parallel to the
cementoenamel junctions (CEJ) of adjacent teeth.3
The plaque free score was documented in the periodontal chart and assessed by the patient
chewing a disclosing tablet. His results revealed he was 0% plaque free. This patient was
chosen for this case doc project due to his poor control of his oral hygiene. After speaking with
the patient about the details of the case doc project, he complied with what would be needed to
complete this project. The clinician and patient discussed his assessments and his plaque free
score. It was determined that the patient needed to improve his plaque free score and the goal
was set at 10%. He was given a three day dietary analysis form as well to fill out over the
weekend.
Within the next week the patient returned to the clinic. He completed the dietary analysis
form. Upon reviewing these forms in the clinic it was discovered that he consumes the same
breakfast every day, his wife does the cooking, and his wife does the grocery shopping.
Knowing this information limited the improvement on his nutrition unless the wife was willing to
be involved. However it was noted that the patient never consumed water to drink, just Pepsi™
and tea. It was recommended to the patient that he start to consume water on a daily basis. It
was expressed this could help with his xerostomia as well. Mrs. Kelly recommended the patient
drink a cup of water every morning. Knowing that the patient has CAD and that heart attacks are
more likely to occur in the morning, she recommended drinking a cup of water in the morning to
decrease the chance of a heart attack.
After this discussion, the patient demonstrated how he brushes at home. He was given a
mechanical soft bristled tooth brush with Crest toothpaste. It was timed that the patient only
brushed for 35 seconds, he focused his brushing more on his left buccal surfaces (the patient’s
dominant hand is his right hand). It was further noted that he was not brushing at a 45 degree
angle. The focus of this case doc project was to improve his poor plaque control by improving
his poor brushing habits.
The first recommendation was to have the patient brush longer than 35 seconds. It was
discussed that the patient needed to brush for 2 minutes a day twice a day. It was broken down
to brush each quadrant for 30 seconds to achieve the desired time of 2 minutes. It was also
discussed that the patient needed to angle the brush towards the gingival margin at a 45 degree
angle. The ADHA recommends the first step at proper brushing is to “place bristles along the
gum line at a 45-degree angle. Bristles should contact both the tooth surface and the gum line.”
4
The patient was disclosed at this visit after instructing him on proper brushing and his plaque
free score was 17%. This excessed his previous goal of 10%. His next goal would be set at 25%
plaque free.
The patient was compliant of all treatment and oral hygiene instructions the clinician
recommended at each appointment. In October at his third appointment, suggestions were
given on healthier food options for each meal of the day. Based on where the patient was
lacking in certain vitamins and nutrients, even though the patient mentioned he would never
stop eating his Kellogg’s® cereal for breakfast. He did state that he was drinking water at home
and drinking Pepsi™ or tea at restaurants which is a good improvement.
During this appointment the patient received new oral home aids to improve his poor oral
hygiene. The patient was given a battery operated Sonicare®, a Reach® floss holder, and
Listerine® Total Care Zero. The Sonicare® was recommended for various reasons. A recent
study concluded that Sonicare® has a reduction in caries rate among patients with xerostomia
using the powered toothbrush.5 The larger handle is easier for the patient to grip due to the
limited dexterity. Phillips states that “Sonicare® also removes up to 6x more tooth decaying
plaque which will help avoid cavities.”6 There is also a 2 minute timer built in to inform the
patient when to stop brushing, this will eliminate the problem of the patient brushing only for 35
seconds.
The Reach® floss holder was given for easier dexterity on the patient’s hand, since the
patient is suffering from arthritis in his hands. Listerine® Total Care Zero was given due to the
patient being high caries risk. It has 7x greater fluoride uptake than leading brands. Listerine®
Total Care prevents cavities, restores enamel, and builds stronger teeth than brushing alone.7
The patient was advised to use his new tooth brush with the proper OHI the clinician had given
him at his previous visit. After disclosing the patient it was revealed that the patient was 27%
plaque free, the goal of 25% was met. His final goal was set at 35% plaque free. Intraoral
photos were taken prior to disclosing and after disclosing. The perio maintenance was
performed with a cavitron, hand instruments, and rubber cup polishing. 5% NaF varnish was
applied “Adults at higher caries risk should also receive fluoride varnish to control caries.”8 The
patient was placed on a 4 month recall.
In February, the patient returned to clinic for evaluation of his progress on his oral
hygiene and the evaluation of the perio maintenance. The patient seemed to have good
improvements. His gingival description improved from generalized redness, edematous, blunted
papilla to generalized pink, blunted papilla with localized redness. Deposits improved from
generalized heavy plaque and calculus to generalized moderate plaque and calculus. Certain
probing depths decreased, many 5 mm became 4’s and many 4 mm previously became 3’s.
Some probing depths did increase however and this is most likely due to the removal of
subgingval calculus. Example #31 lingual had probing depths of 3,3,4 mm in August, but in
February they read 4,6,5 mm. Further furcation’s were documented the class 1 on #17B
became a class 2 and #31 now has a class 1 on the buccal and a class 2 on the lingual. Just
like the probing depths these furcations could now be documented and detected due to the
calculus removal.
The patient’s plaque free score was taken and improved to 29% plaque free, but
unfortunately the patient did not meet his goal of 35% plaque free. Intraoral photos were taken
prior to disclosing and after disclosing. The patient continues to struggle with removing plaque
on lingual surfaces of his teeth, especially the mandible and most interproximal areas. The
lingual surfaces on the mandible showed plaque on every surface. Due to this issue the clinician
physically demonstrated circular brushing at a 45 degree angle towards the gingival margin. C
shape flossing was also demonstrated with the patients Reach® floss holder to help remove the
patients interproximal plaque.
Two weeks later the patient returned to the clinic for his final cleaning. The clinician and
patient discussed the same oral hygiene instructions the clinician demonstrated to the patient at
his last visit. The perio maintenance was documented as an adult prophylaxis (AP) so the
patient could receive his “free cleaning” for participating as the clinicians case doc patient. A
cavitron, hand instruments, and rubber cup polisher was used to complete the treatment.
Sextant 5 lingual was again very difficult to clean due to the amount of calculus and stain on the
etched composite periodontal splint. The clinician placed the patient back on a 3 month recall
instead of another 4 month recall. Selecting the appropriate recall interval is based off the
individual patient. “Identifying specific factors that should be taken into account when assigning
a recall interval for each patient.” 9 The patient’s specific factors effected his recall change due
to the amount of calculus and plaque buildup. The patient’s calculus and plaque is not as
controlled as expected and probing depths on certain teeth are still not within healthy limits.
This project showed me the amount of attention that some patients need, such as an
extensive treatment plan or thorough oral hygiene instructions to maintain or return them back
to health. Giving the patient proper OHI was essential because he lacked the proper knowledge
of how to brush properly and floss. When instructions were discussed and physically shown the
patient did have improvement of his plaque control. He also suffered from things that were not in
his control such as arthritis and xerostomia. In which we can still cope with and advise other
options to help with these conditions. This project personally showed me the importance of
taking accurate notes. Having to do a project based off previous notes over the past years
shows firsthand how important it truly is for our note to document everything. This allows other
clinicians to be able to rely back on the note. The only change I would make to this project is
having our faculty interact in our blogging.
Strengths from the project are the patient seemed to be more compliant with my
instructions compared to past clinician notes with his oral hygiene. Patient’s plaque free score
increased continuously at each visit. Weaknesses from the project are the patient’s nutrition
needs to be improve, but the patient’s wife does all meal prepping and shopping. I also wish the
patient could have met his final goal of 35% plaque free. Ways to improve would be having wife
involved in nutritional aspects. Thirdly I wish I would have recommended a triclosan/copolymer
toothpaste to help with his poor calculus control. A study showed after six months of use,
triclosan/copolymer toothpaste may have reduced the mean total calculus per participant by
2.12 mm (MD -2.12 mm, 95% CI -3.39 to -0.84, two studies, 415 participants, low-quality
evidence). The control group mean was 14.61 mm, representing a 15% reduction in calculus.10
The greatest take away from the project is conveying the fact that oral care, demonstrating and
discussing proper oral hygiene instructions are very pertinent. Seeing the patient’s plaque free
score improve reinforces the success of the patient learning ways to remove his plaque when
given thorough OHI.
References
1. Lexicomp [Internet]. Hudson, OH: Wolters Kluwer Health; [updated 2015; cited 2015
March 28] Available from: https://online.lexi.com/lco/action/home?siteid=2
2. A. Desoutter, M. Soudain-Pineau, F. Munsch, C.Mauprivez, T. Dufour, J-L. Ceuriot.
Xerostomia and medication: A cross-sectional study in long-term geriatric wards. TH
Journal of Nutrition, Health, & Aging. [Internet]. 2012 Nov 6 [cited 2015 March 23]; 16.
Available from:
http://web.b.ebscohost.com.proxy.library.vcu.edu/ehost/pdfviewer/pdfviewer?sid=1fc1c3
c5-4cc4-4cc0-8442-293ec000ccac%40sessionmgr111&vid=1&hid=118
3. E. Thomson, O. Johnson. Essentials of dental radiography for dental assistants and
hygienists. [Internet]. 2012 [cited 2015 April 2]; 9th. Available from:
http://www.r2library.com.proxy.library.vcu.edu/Resource/Title/0138019398
4. American Dental Hygiene Association. Proper brushing. [Internet]. [cited 2015 April 1].
Available from https://www.adha.org/resources-docs/7221_Proper_Brushing.pdf
5. Papas, A. S., Singh, M., Harrington, D., Ortblad, K., de Jager, M. and Nunn, M.
Reduction in caries rate among patients with xerostomia using a power toothbrush.
[Internet]. Special Care in Dentistry. 2012. [cited 2015 April 2] 27: 46–51.Available from:
http://onlinelibrary.wiley.com.proxy.library.vcu.edu/doi/10.1111/j.17544505.2007.tb00327.x/abstract#
6. Philips Sonicare. Why Sonicare. [Internet]. Koninklijke Philips N.V.; 2013[cited 2015 April
5]. Available from:
http://www.sonicare.com/professional/en_US/WhySonicare/Default.aspx
7. McNeil-PPC. Listerine® total care. [Internet]. Johnson & Johnson; [updated 2015; cited
2015 April 2]. Available from: https://www.listerine.com/mouthwash/anticavity/listerinetotal-care-anticavitymouthwash?utm_source=google&utm_medium=cpc&utm_campaign=Branded++Total+Care&utm_term=listerine%20total%20care&utm_content=Total+Care|mkwid|shp
nuKuSb_dc|pcrid|56198695214
8. G. Davies. The application of fluoride varnish. [Internet]. Dental Nursing Mark Allen
Publishing Ltd.; 2012 July [cited 2015 April 2]. Available from:
http://web.b.ebscohost.com.proxy.library.vcu.edu/ehost/pdfviewer/pdfviewer?sid=c09f94f
5-356e-41b8-bdf2-eadf08a672d5%40sessionmgr[Int112&vid=1&hid=118
9. NICE Clinical Guidelines. Implementing the clinical recommendations – selecting the
appropriate recall interval for an individual patient. [Internet]. National Collaborating
Centre for Acute Care; 2014 [Cited 2015 March 30]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK54548/
10. Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health (Review)
[Internet]. Cochrane Database of Systematic Reviews 2013 [cited 2015 April 8], Issue
12. Art. No.: CD010514. DOI: 10.1002/14651858.CD010514.pub2. Available from:
file:///C:/Users/jessi_000/Downloads/Triclosan%20copolymer%20containing%20toothpa
stes%20for%20oral%20health.pdf