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Dental Hygiene Case Presentation

Subjective/Objective

Patient

CC: 3 mos. perio maintenance recare

Med Alert: Allergic to some BP medications

HH: High BP, allergies (seasonal, processed meats), melanoma (right leg, removed 1994)

DH: many restorations

PN: Retired

85 year old female

73.9% Plaque Indice

Subjective/Objective

Vitals: 4/16/14; BP 144/78, P 60, R 18

5/6/14; BP 130/70, P 58, R 16

5/13/14; BP 124/82, P 76, R 18

5/21/14; BP 126/76, P 64, R 16

ASA:II

Subjective/Objective

IO/EO: WNL, bilateral linea alba, bilateral mandibular tori, exostosis near #20 and #21

Occlusion: class I bilateral, with a class II tendency from a canine relation. 4mm overjet, with a moderate overbite

24 teeth present

Gingival Health: Periodontitis

Many restorations

Moderate caries risk

Treatment Planning

Analysis

Implementation

Appointment 1: HH, vitals, IO/EO, assessment, nutritional counseling, perio maintenance on quads 3 and 4, OHI brushing. Recommend: Bass method

DH Diagnosis: AAP Perio Case Type II, generalized moderate, localized severe in her molars.

Process: started on quads 3 and 4 due to heavy supra calculus build up. When patient returned at next appointment, it was all back.

Appointment 2: HH, vitals, IO/EO, velscope, complete perio maintenance quads 3 and 4, and begin on quads 1 and 2, OHI flossing with recommended floss.

Modifications: Due to not completing quads 3 and 4 at appointment 1, another appointment was needed. Biotene for patient's xerostomia was also added in.

Contributing factors: plaque biofilm, existing restorations, medications, and xerostomia.

Therapy outcomes: prevent further bone loss, improve plaque biofilm scores, home care, and xerostomia, and reduce the plaque biofilm build up.

Constraints: medications and compliance.

Success: Completed patient

Appointment 3: HH, vitals, IO/EO, complete perio maintenance quads three and four, coronal polish, and fluoride. OHI with recommended ACT rinse.

Difficulties: Patient built calculus quickly

Evaluation

Implementation

Instrumentation

Self Assessment

Plaque indice scores started as 73.9% on 5/6/14, then 68.75% on 5/13/14, finally 56% on 5/21/14.

Success: O'herir for supra calculus removal

I learned to value the relationship and trust that is built between a patient and clinician. Through treatment, I was able to show my patient the improving indice scores, and it turn I think she began to trust me more.

Difficulties: Instrumenting while patient slept

Patient was eager to learn about homecare, involved in her treatment and seemed very compliant.

I always tend to look at small details when treating a patient, and through this I was allowed to see how all of the pieces fit together.

3 Mos. Perio maintenance interval

Major learning moment: get a completion check!

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