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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