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Case Documentation Project
DENH-437-001/447-001 Clinical Dental Hygiene II/III Seminar Course
Session: Spring
Submitted to:
Christy Casella, R.D.H., B.S., M.Ed.
By: Kathryn Knight
April 13th 2015
Mr. Ok is a 67 year old African American male who presented to the VCU School of
Dentistry clinic for his routine dental hygiene appointment. Mr. Ok missed his last recall
appointment and had not been to the dentist in ten months. He began dental treatment at the
VCU School of Dentistry in 2008 where initial therapy took place from May 2008 to July 2008.
His initial therapy included scaling and root planning of three quadrants, restorative and
endodontic therapy. Periodontal maintenance began in August of 2009. Mr. Ok has had multiple
restorations and presents as a high caries risk. At some point Mr. Ok was taken off of
periodontal maintenance and put back on regular recalls.
His extensive medical history revealed history of asthma, sleep apnea, hypertension,
high cholesterol, arthritis, an enlarged prostate and history of prostate cancer. Mr. Ok is
currently taking 13 different medications, many of which have negative dental side effects. Mr.
Ok’s medical history and medications put him at a higher risk for medical emergencies during
dental appointments and poor oral hygiene.
Many of Mr. Ok’s asthma medications have the dental side effect of xerostomia. These
medications are Symbicort, albuterol, and spirivia with handihaler. Symbicort can cause
localized candida albicans. Along with multiple medications that cause xerostomia, Mr. Ok
suffers from dry mouth from the use of his CPAP machine. The CPAP machine is used in
treatment of sleep apnea. His hypertension medication, amlodipine, has the dental side effect of
gingival hyperplasia.1 Gingival hyperplasia risk increases with patients using calcium channel
blockers.2 Research shows that there is a correlation between both xerostomia and gingival
hyperplasia with gingivitis and periodontal disease.3 While these medications can have a
potentially harmful effect on the oral cavity, they are required to regulate his existing medical
conditions.
Extraoral examination revealed a nodule on the left side of Mr. Ok’s neck near the base
of his skull, subluxation and bilateral crepitus that were asymptomatic. The attending dentist
recommended keeping an eye on the mass on his neck and having his primary care physician
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take a look at his next physical. Intraoral examination revealed coated tongue, xerostomia,
lingual varicosities, gingival hyperplasia, and a short lingual frenum. Full periodontal charting
was done and indicated pink erythematous gingiva with rolled margins. Probing depths were
generalized 2-3 mm, with localized 4-7 mm, and generalized bleeding on probing. Along with
periodontal charting Mr. Ok had generalized moderate biofilm, with localized moderate calculus
in sextant five. Four horizontal bitewings were also taken.
The clinician decided that due to Mr. Ok’s medical history, medications and current oral
health state that a specialized treatment plan was needed. The treatment plan included
completion of dietary analysis, gingival index and plaque free scores, specialized oral hygiene
instructions and intraoral photos. A series of appointments would be needed to complete the
treatment plan. Consent for treatment was obtained from Mr. Ok prior to the start of treatment.
Evaluation of the completed dietary analysis indicated that Mr. Ok was maintaining a healthy
diet after suffering from prostate cancer. While diet contributes to oral health, the clinician
believed Mr. Ok’s oral health status was due to other factors. Together Mr. Ok and the clinician
discussed attainable goals for his treatment and personal goals that Mr. Ok had for himself.
Intraoral photographs were taken at the beginning of treatment. Mr. Ok’s gingival health
was measured by the clinician using a gingival index. The clinician then used a disclosing agent
to record a plaque free score. His gingival index was 1.125, and his plaque free score was 32
percent. The data indicated that Mr. Ok had plaque present on 68 percent of his teeth and
presence of redness, bleeding and inflammation on his gingiva. The clinician used this as an
opportunity to educate and help improve Mr. Ok’s oral health and overall wellbeing.
The treatment plan for Mr. Ok involved very specialized oral hygiene instructions. The
oral hygiene instructions given were formulated around the presence of xerostomia, gingival
hyperplasia and hard and soft debris. Proper brushing instructions were given to Mr. Ok using
the modified bass technique. The demonstrated technique would help remove more biofilm from
the gingival margin. The clinician emphasized using his sonicare toothbrush more frequently. He
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was given instructions on how to use an end tuft brush to remove plaque from interproximal and
posterior plaque biofilm. Mr. Ok indicated an understanding and was able to demonstrate the
new techniques back to the clinician. The clinician and Mr. Ok set the goal for him to 40 percent
plaque free at his next appointment.
At Mr. Ok’s follow up visit, the clinician reevaluated his oral health by recording another
gingival index and plaque free score. Mr. Ok’s gingival index improved by 0.455 to a 0.67 which
indicated an improvement in gingival health. His plaque free score decrease to 29 percent.
Despite the numerical decrease in plaque free score, there appeared to be a decrease in the
quantity of biofilm present. The clinician and faculty discussed with Mr. Ok how there was a
decrease in the quantity of plaque present but still wanted to see 40 percent plaque free at the
following visit. Mr. Ok showed resolution in pocket depths by 1-2 mm in localized areas. This
appointment consisted of Mr. Ok’s adult prophylaxis, application of fluoride and introduction to a
Waterpik water flosser and a floss holder. The clinician explained thorough instructions on how
to use the water flosser and floss holder. The importance of using the Waterpik in conjunction
with the floss holder was reinforced. Mr. Ok demonstrated continued motivation to learn and
improve his oral health. Information on the difference between plaque and calculus was given
upon request from Mr. Ok.
Mr. Ok returned to the clinic a month later for evaluation of treatment and reassessment
of oral hygiene methods. The appointment consisted of new intraoral photo graphs, gingival
index and plaque free score. Mr. Ok showed continued improvement from 0.67 to 0.46 for
gingival index, but showed a significant decrease in plaque free score from 29 percent to 11
percent. The clinician removed calculus buildup in sextant 5 with complimentary rubber cup
polish and floss.
The clinician discussed with Mr. Ok different possibilities as to why his plaque free score
was not improving. He stated that he was alternating being using a manual toothbrush in the
morning and a sonicare at night. Studies have shown that sonicare toothbrushes can remove
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significantly more plaque than a manual toothbrush.4 The clinician explained to Mr. Ok that the
sonicare may be doing a better job at removing the biofilm from his teeth and recommended
some ways for him to distinguish which one worked better. Mr. Ok’s homework assignment was
to use the sonicare in the morning and then following brushing, use a disclosing tablet to see
what was left behind. Then in the evening use his manual toothbrush and disclose after. The
clinician recommended Mr. Ok try this at home because it would give him an insight and firsthand look at what areas he needed to brush better, and what areas he was effectively removing
the biofilm. Mr. Ok stated to the clinician that he thought the “floss holder was awkward, but that
the Waterpik was easy to use and he liked it”. The clinician encouraged Mr. Ok to continue the
use of his Waterpik. Research shows that the Waterpik can remove 29% more plaque than
regular string floss.5 Due to Mr. Ok’s dislike for the floss holder it is better for him to utilize a
Waterpik in place of regular flossing.
Mr. Ok had stated before beginning treatment that he did not like using his CPAP
machine because it was causing him dry mouth. The use of Mr. Ok’s CPAP machine and
xerostomia was further discussed at his evaluation appointment. He stated he was only wearing
it for about four hours a night. The clinician saw the situation as a great opportunity to educate
Mr. Ok on how sleep apnea uncontrolled can have an association with other systemic diseases.
She printed an article from The Journal of the American Medical Association for Mr. Ok to take
home and read more on the association of systemic diseases and sleep apnea. New data is
suggesting that obstructive sleep apnea, may have an association with ischemic stroke.6 Due to
Mr. Ok’s race, gender, and history or hypertension he is at higher risk for stroke.6 Mr. Ok’s
infrequent use of his CPAP machine puts him at a higher risk for incidence of stroke and other
cardiovascular events. It was recommended to Mr. Ok that he should discuss with his sleep
specialist the different treatment options other than the CPAP machine so that he can get his
sleep apnea under controlled. Mr. Ok utilizes Biotene mouth rinse currently to help relieve his
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xerostimia. The clinician suggested keeping water next to him to rinse with throughout the night
to help prolong his CPAP machine and alleviate his dry mouth.
Mr. Ok was set on a four month recall which he did not uphold despite his motivation. He
was supposed to return to the clinic for his four month recall in February but would not return
until April despite efforts from the clinician to bring Mr. Ok back in. In April Mr. Ok finally
returned for his adult prophylaxis appointment. Review of medical history reveled that Mr. Ok
had sprained both wrists, and an ankle since the last time he was seen. No other changes to
medical history were noted and no chief complaints. Intraoral and extraoral findings were all the
same, and within normal limits with the exception of the mass located on Mr. Ok’s neck. Mr. Ok
has had the mass checked multiple times by his primary care physician and his oncologist with
the ok to continue to keep an eye on it. His gingiva indicated generalized firm, pink, knife-like
papilla with localized areas of redness. He had generalized slight biofilm with localized
moderate calculus in sextant 5. Periodontal charting indicated generalized 2-3 mm with
localized 4-6 mm and pocket reduction of 1-2 mm in localized areas. With the exception of
pocket reduction and presenting with slight biofilm instead of moderate Mr. Ok did not appear to
be making anymore improvements in his oral health. He did however state that using the
waterpik really helped when both wrists were sprained and he could not floss.
This appointment would be the last time the clinician would see Mr. Ok before
graduating. Despite previous efforts and small improvements, the clinician reinforced the
modified bass technique to continue to improve Mr. Ok’s effort to remove plaque biofilm from
the gingival margin. The clinician and Mr. Ok discussed his homework assignment of using the
sonicare one night and the manual one night, and evaluating using the disclosing tablets. Mr.
Ok continued to show internal motivation to improve his oral health. By using the disclosing
tablets after brushing Mr. Ok was able to see that he could remove more plaque more efficiently
with the sonicare. He stated he would continue to utilize what he had been taught and work to
improve his oral hygiene practices.
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As the clinician, I gained a great deal of knowledge from this experience. The project
emphasized how every treatment plan is different for individual patients. Mr. Ok was a special
case that was not straight forward. Despite making a specialized treatment plan for him,
modifications were made constantly. He showed a great deal of motivation throughout my
clinical time with him but never showed significant clinical. I feel that despite the internal
motivation Mr. Ok demonstrated, other factors fought against his clinical improvement. The
injuries he sustained during the 6 months between appointments I feel had a large impact on his
oral hygiene practices at home. Regular c-shape flossing was not something Mr. Ok was able to
do, so his Waterpik was utilized. The purchase of the waterpik and introduction of it to Mr. Ok is
one of the biggest victories I believe I had with him. I was able to introduce an oral hygiene aid
that my patient liked and utilized. I feel with continued use of the Waterpik and sonicare
toothbrush Mr. Ok will continue to show improvement.
One part of Mr. Ok’s oral and health condition I wish I could have helped improve was
his sleep apnea and use of his CPAP machine. From lectures in school I know that sleep apnea
can play a large role in contributing to other serious systemic diseases. Not only did Mr. Ok’s
sleep apnea affect his oral cavity, it is something that could ultimately affect his overall health
and wellbeing. I think giving Mr. Ok more information on sleep apnea and more ways to treat it
could have benefited him in many ways. I did not ask about how much he was using his CPAP
machine at his last visit or how his sleep apnea was. Mr. Ok appeared fatigued and kept falling
asleep in my chair during treatment. My lack of focus on the topic taught me that in the future to
focus more on sleep apnea. When I get out into private practice I hope to work with a doctor that
focuses on the importance of treating sleep apnea and has a sleep specialist that we can refer
to.
Overall I feel there was success with improving my patient’s oral health. Despite the lack
of significant changes in clinical data, Mr. Ok improved in other significant ways. His continued
internal motivation and willingness to learn is an improvement itself. Without internal motivation
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and willingness to learn from a patient, improvements won’t happen. The same goes for the
clinician. In order to continue to help improve patient oral health, motivation and willingness to
learn needs to be present.
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References
1) Lexicomp [internet]. Hudson, OH:Wolters Kluwer Health; [updated 2015; cited 2015
April 6] Available from:
https://online.lexi.com/lco/action/home?siteid=2
2) Kaur G, Verhamme K, Dieleman J, Vanrollegham, Soest E, Stricker B, Sturkenboom
M. Association between calcium channel bloockers and gingival hyperplasia. Journal
of Periodontology 2010 June 10;37(7):625-630 Available from:
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-051X.2010.01574.x/full
3) Thompson A, Herman W, Konzelman J, Collins M. Treating patients with druginduced gingival overgrowth. Journal of Dental Hygiene 2004;78(4):1-13 Available
from:
http://jdh.adha.org/content/78/4/12.full.pdf
4) Putt M, Milleman J, Jenkins W, Schmitt P. Comparison of plaque removal by novel
Philips Sonicare sensitive brush head and a manual toothbrush. 2010; cited April 6
Available from:
http://www.sonicare.com/professional/en_US/pdf/Plaque_SBH_2010_Putt.pdf
5) 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. Journal of Clinical
Dentistry 2013;24(2):37-42 Available from:
https://www.waterpik.com/oral-health/pro/clinical-research/pdfs/Goyal-Waterpik-vsString-Floss-for-Plaque-Removal-2013-Full-Clinical-Study.pdf
6) Redline S, Yenokyan G, Gottlieb D, Shahar E, O’Connor G, Resnick H, Diener-West
M, Sanders M, Wolf P, Geraghty E, Ali T, Lebowitz M, Punjabi N. Obstructive sleep
apnea-hyponea and incident stroke. American Journal of Respiratory and Critical
Care Medicine 2010 Jul 15;182 (2):269-277. Available from:
http://www.atsjournals.org/doi/full/10.1164/rccm.200911-1746OC#.VSqx8Y54ohs
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