Kristina Hemstead

Adam Lang
Patient Description:
James - 25-year-old male; hasnt been to the dentist for 4 years. Is coming to
the dentist because spouse continues to complain of bad breath so he
figures a cleaning will help. Upon further questioning, patient has a history of
smoking (8 years), is prescribed an albuterol inhaler for his asthma causing
xerostomia, and a history of familial type 1 diabetes on his moms side, but
claims he does not have it. Patient has not been to a physician in 4-5 years
as well. Family history of denture wearers and periodontal disease.
Patient brushes maybe 1 time daily, about 1 minute each time with manual
soft toothbrush. Flossing is not part of his routine as well as any mouth rinse.
Scrub method. Bruxism.
Mr. Hertwig, I am pleased to meet with you. I extend much gratitude for allowing
me to become your partner in positive oral health. Thank you for taking the time to
complete your health history.
No problem. I arrived kind of late, and didnt have much time to fill it out. I think I
answered all the questions. Ok. I only have so much time here today, when does
the cleaning start, soon I hope.
I would like to take a moment to review the information with you. I want to ensure
the information is very clear, so that we can treat you safely and as a whole.
Todays visit isnt just a simple cavity check, cleaning and x-rays, its much more
than that. Current medical and dental literature supports the notion that your oral
health is very much indeed related to your overall health.
Oh, ok. Yeah I didnt think it was so involving, and you can call me James by the
way. What do you mean, whole person? Well now that you mention it, I guess my
mouth has been affecting my life in more ways than one, and I just got insurance
through my job. The reason I came in today, well it concerns intimacy with my
spouse, thats why I decided I needed to do something.
Thank you for sharing that with me, James. I want nothing more than to include you
in the decision making process regarding your treatment. Together, we work as
partners in oral health, and you play just as an important role in the approach and
follow through in overcoming your chief concern today than we do. We are all here
to help you.
You are 25 years old, and you just started your job at Neenah foundry. Your last
visit to the dentist was five years ago, you had 4 bite wings, a cleaning, and exam.
Do you recall hearing the words, deep cleaning?
All that information is right. Yeah its been about five years, and I cant remember
what they told me, its been so long.

You have noted that your mother has type II diabetes, and it is well controlled. You
also note she is wearing a plate. Do many people in your family have dentures,
or concerns about their teeth as well?
Not exactly, they dont have any concerns, because they dont have many teeth!
Maybe if we just pull all mine, I can get dentures! My gums bleed all the time when
I brush, thats why I only brush once a day, and thats in the morning.
Nothing functions best like the teeth you have. Dont get so down on yourself, I
know we can do it! Do you see a physician, now that you have insurance?
Its mandatory for work, I guess I should, its been a long time, like over five years.
Well I went to the emergency room because I had trouble breathing, they gave me
an albuterol inhaler and said I have asthma. I know its bad, Ive smoked now for 8
years too. Not doing the asthma any help. But I do pay out of pocket for the
inhaler, and carry it with me.
Some dental side effects are dry mouth, or a white growth on the roof of your
mouth, have you noticed anything like that? Describe your diet, please.
Yeah, dry mouth in the morning especially. I usually dont eat breakfast, just coffee
and off to work. I usually stop at the gas station in the morning on the way, and
usually grab an energy drink and one of those breakfast sandwiches. Once I get
home, Ill have something easy like Hot Pockets.
Thank you for sharing that information with me. I understand your time is valuable,
lets move on. This chart Im holding represents the progression of periodontal
disease(RDH utilizes the periodontal flip chart to explain disease progression). The
first diagram, (#1) shows a healthy tooth, with a collar of tissue which fits snugly to
the neck of the tooth. It is this collar of tissue that can be tricky to clean. First Im
going to take a specialized ruler with millimeter markings on it and measure, just
like in the image, the depth of the tissue. You will also hear me rattling off
numbers. 1-3mm is considered healthy. Anything 4mm+ will tip us off to draw
additional attention, perhaps this is the start of a disease process. Does anything
sound unclear?
No not really, I remember this part now!
Within minutes of brushing, a sticky film grows on the teeth. The longer the deposit
remains on the tooth undisturbed, the number of bacteria grow rapidly. They send
signals to their neighbors and invite them to join in the party. Multiple colonies
start to form, and form a sticky substance around them. This sticky mass is
referred to as plaque.
Yeah, that makes sense. I know exactly what youre taking about; throughout the
day my mouth gets so dry, I can feel the fur growing. It does feel better once I
brush through. Sometimes I do brush at night.
After more time passes, imagine the bacterial party grows down in between your
gums. This is illustrated in image #2. Your tissue and bone dont like that so they
become inflamed, red, and irritated; and they begin to pull away from your tooth.

You may notice bleeding when you brush. Your bodys immune system is constantly
mounting an offensive on this plaque biofilm. Your immune systems byproducts,
from constantly fighting the gum infection causes your tissue to become inflamed,
red, and irritated; and they begin to pull away from your tooth.
In the image #3, further destruction takes place. The tissues around your tooth
continue to pull away due to destruction of specialized fibers which hold your tooth
in the socket, along with bone loss which is irreversible, yet maintainable.

Clinical Findings:
Tissue appearance: generalized a reddish pink, glossy appearance. Papillary
is blunted and enlarged. Probe readings of 1-5 mm; SBI 92%, PCR 80%.
Localized red, puffy, rolled margins with recession on the buccals of
mandibular posterior. Probe readings of 3-5 mm pockets with 2-3 mm of CAL.
Class 1 furcation on tooth #19. Mucogingival involvement on tooth number
19 as well. Areas of decay interproximal of tooth 5 and occlusal of tooth
number 18 and 31.
Radiographic Findings:
Generalized loss of crestal lamina dura with widened periodontal ligament
space. Calculus throughout.
Localized crestal bone height from CEJ at 1-2 mm apically. #19 no
radiographic evidence of furcation involvement.
Local contributing factors overhangs on tooth number 18. Disease site 18
distal due to bony defect resulting from surgical extraction of tooth 17
impaction.
Initial Diagnosis: Slight chronic periodontal disease; active due to the bone
loss and widened PDL since last radiographs.
IN-OFFICE CONSULTATION (CONSULT ROOM)
(Mr. Hertwig and the RDH take a look at the radiographic findings
as well as the periodontal assessment. It is first brought to the
patients attention that we would not be getting their teeth cleaned
today; rather setting up another appointment to come back for the
cleaning.)
The diagnosis we came to is slight chronic periodontal disease.
What exactly is that, it sounds serious when you put it like that. Youre
saying I have an infection my mouth, pretty much.

What that means is that the infection in your mouth has now begun to break
down the bone supporting your teeth as well as the ligaments that attach to
your teeth and bone. If you recall when I brought out those illustrations?
I think I do, I didnt get all the particulars from them.
With the bone loss, the pockets around your teeth are 1-5 mm, you may
recall anything 1-3mm is healthy, whereas anything above 4mm is an area of
question. The information gathered from your clinical exam and radiographs
serve as pieces of the pie which provide a clearer picture of the disease
process.
(Blank look from patient. Patient offers no response, and remains
focused and reserved on the computer screen)
You seem like you stuck on something. Whats on your mind?
with everything that is going on right now...this new job, I thought things
were just starting to look up. Now I hear this newsI just dont know how
this is going to be fixedI just cant imagine
You owe this to yourself, to your growing family. This is has been an ongoing
infection that may give rise to a more serious systemic health complication.
We need to act now. You have us behind you.
I wonder if my parents were in the same shoes Im in right now. Im sure
they were, they just got their teeth taken out. I dont think I could live
without my teethit tears me up inside to think of myself looking in the
mirror with no teeth, I just cant do it.
Use that as motivation. Allow me to continue with the results from my
evaluation, in the mean time I can have Diane look over our proposed
treatment, and she will follow up before you leave today with how your
insurance will cover the treatment costs.
Some areas in the back of your mouth deeper than 5 mm due to the
recession along your gumline. The bone loss has also started to break down
bone between the roots of your lower right first molar.
Slight means that there is 1-2 mm of bone loss around the teeth, and in your
situation, a localized area on the lower left area of your mouth. There is a
loss of crestal lamina dura throughout the rest of the mouth, which indicates
to me that there is bone potentially breaking down in other areas of the
mouth as well.
The only way to arrest the progress of this disease is to intervene with what
you may have referred to as a deep cleaning. We will have to set up a
separate appointment for this procedure, as it needs to be approved by your

insurance. Rest assured, Dianne and our front office team with escort you
through the entire process.
The RDH explains to James that nonsurgical periodontal therapy
includes self-care and instrumentation involving in plaque and
calculus removal of all teeth surfaces. The goal of nonsurgical
periodontal therapy is to bring the disease under control, and for
James situation, prevent further attachment loss (recession), bone
loss, and bring the plaque and calculus down to a level that is
biologically acceptable eliminating any inflammation in the mouth.
Our treatment plan and goals for James includes the following:
The following will be written out for the patient to take home.
1. Periodontal debridement This involves disrupting and removing any
biofilm such as plaque and calculus on the tooth surfaces. This will be a
very important step in the process of healing and getting the gum
tissue back to a normal state. This will also allow for the bacteria in Mr.
Hertwigs mouth to be that of a healthy mouth. Xerostomia will be
discussed and James will be given products used to stimulate saliva
production, and coached to keep a water bottle handy; that proper
instruction on how to remain hydrated throughout the day contributes
to a more moistened mouth. A pamphlet involving xerostomia will be
given as well as a list of products he can find at any local retail store.
2. Customized self-care Including brushing at least 2 times daily for 2-3
minutes each with the modified bass technique. Introduction of
interdental brushes to properly cleanse tooth surfaces with a class II or
III embrasure, and the start of the clinically evident #19-L class I
furcation. A dental water jet with subgingival as well as the standard
tip will be shown to James and demonstrated on a typodont as an
adjunct Mr. Hertwig can look into purchasing. Introducing a fluoridated
mouth rinse with once daily at bed time following brushing to
strengthen overall enamel matrix, and areas of recession.
3. Control of local risk factors Referral to DDS schedule in 15 minute
time slot, preferably before SRP implementation to remove the
overhang on tooth 18-OD alloy. Further restorative on occlusals of #19
and #30 may be carried out after hygiene treatment has been
completed.
4. Control of systemic risk factors Tobacco cessation materials to county
aided quit lines Approach tobacco cessation delivery to Mr. Hertwig by
introduction of Ask. Advise. Refer. method. Recommending James
goes to the doctor for a physical and blood panel to uncover diabetes
prevalence. So that if its concluded that Mr. Hertwig does indeed have
diabetes, he can get it under control immediately. It was advised

patient contact the office once appointed with physician. Medical

referral will be sent to appropriate office once patient has become
established.
5. Reevaluation in 4-6 weeks to check for progress. The reevaluation
process/rationale will be outlined to Mr. Hertwig. Emphasis made that
re-eval 4-6 weeks following, is essential to not only a more proper
diagnosis, possible modified periodontal treatment, curtail treatment
needs as necessary pending re-eval results; coupled with sound home
care instruction and patient compliance.
Limitations of nonsurgical periodontal therapy
The patient and RDH will have a conversation about limitations
with therapy and the possible need for periodontal surgery
should there be nonresponsive disease sites and disease
progresses. Intraoral images of the mucogingival junction and
recession are taken for a visual of the area the RDH is cueing in
on. Limitations of therapy will include any areas of deep pockets
that hand scaling and ultrasonic devices are unable to reach.
Because of this, some biofilm and calculus are unable to be
eliminated, which would require the referral of a periodontist for
surgery. Also, if the patient is able to control the biofilm as well
as the inflammation, areas in the mouth that may look worse to
the patient will be the areas of recession that will be visible after
inflammation is reduced. Along with the MGJ, the patient may
benefit with a tissue graft to cover exposed root surfaces. The
biggest importance following nonsurgical periodontal therapy is
James as a co-therapist throughout the process. Mr. Hertwig
continues to show adequate self-care following the NSPT, the
need for the referral can stay minimal.
The information provided above is stated only for educational
discussions contained with this assignment. Suggesting or
outlining prospective treatment with the perio office, opens an
office to legal liability, distorts patients image of our office, and
ultimately does not contribute to effective patient care resulting
in severe disservice to patient and practice overall.
PATIENTS ROLE
The patients role in post nonsurgical periodontal therapy is to
effectively implement sound home-care to effectively disrupt
dental plaque biofilm daily, which ultimately serves toward
positive control of slight chronic periodontitis.

The patient may be speculatively here in the clinic for four hours: One
hour each for each quad of SRP. Many more hours will be spent with his
own will in deciding positive nutritional, lifestyle, and dental health
decisions. The patient will be posed with a myriad of behavioral
challenges throughout each day: Upon waking, does he choose to hit the
snooze multiple times, and after he does actually get up, light a smoke,
and grab a carb filled meal on his way to work? Thats only the first
couple HOURS of his day. He must maintain positive choices throughout
the day to make a difference. This, I believe is the conundrum the RDH
faces with each patient. Sure prophys occur one after another, but how
can we inspire to make a difference within the patient, when we spend so
little time with them?
According to Nield-Gehrig, the optimal device which drives effective selfcare, is that there is no single accepted definition of self-care, it is the
personal care performed by the patient usually in collaboration with and
after instruction by the healthcare professional. (2011)
Mr.Hertwig, what you see on this sheet of paper is the time we are willing
to dedicate to you in the removal of the aged plaque build-up above and
below your gum tissue, (which is contributing to not only slight chronic
periodontitis) but to your overall health. What I want to build is a bridge
between you and this office. We can only do so much.
Alright. Im on board. What do you need me to do?
I would first like to outline, like I have outlined initially, to stress your right
to understand the treatment that is being proposed to you, and what
options you have in addition.
Ok, what do you need me to do?
We are proposing that you return, at a time which works for you, for what
is termed a scale and root planning. This is also referred to more
commonly as a deep cleaning. This would be four separate
appointments, which can be scheduled back to back. Once this has been
performed you will return to the office within 4 weeks to evaluate the
healing process overall.
Why do I have to wait four weeks? Really? I dont have that much time.
Can I just go to sleep and you fix everything?!
Once mechanical removal of the primary contributing factors, such as the
calculus throughout your mouth, the structure of the tissue that
regenerates during the healing process may result in tissue that is slightly
weaker or additionally prone to periodontal disease. The etiology or

progression of the disease you presented to the clinic may not respond to
the deep cleaning.
So you are saying Im going to front almost $1000 in deductables just to
have this addressed, really?!
Mr. Hertwig, you may recall the reason you first opened the doors to this
clinic and before we shoot hands; your chief complaint was your wife
doesnt even kiss you, is this right?
It is. It is.
What I am saying here is that, yes there will be an added investment by
you not only through dollars, but also a commitment at home. After you
speak with Dianne I will ensure at your next visit we can work through a
prescribed home-care regimen that it you abide by, will only offer the best
outcome for you.
Here is a standard consent form simply stating the procedures which are
being proposed as treatment. Take this home and review it. You will also
note at the end there are requirements that need to be made with home
care, which can be discussed at the first appointment.
Should James choose to discontinue his periodontal maintenance
appointments, it will
be in writing that all RDH and DDS in the dental
office are not held responsible for the
disease progression and possible
need for periodontal surgery. The RDH will continue to
deplaque and
suggest adjustments on self-care as needed. The RDH will strive to keep
the periodontium in a healthy state, but if the appointments are not
consistent, there is
not promise that the disease will stay in a stable
state.
Consent form will be given to the patient to be signed after all information
has been given, alternative plans, cost, and risks have been discussed
and the patient has come to a decision regarding their oral health.

SUPPORTIVE PERIODONTAL MAINTENANCE

Maintenance appointments for James will be drawn out in 3 month
intervals. The objectives of each appointment will be:

Medical history update Assess progression/barriers with tobacco

cessation following Ask. Advice. Refer. A call should be placed
prior to re-evaluation to learn of diabetes prevalence, and
xerostomia assessment and control.
Clinical assessment Restorative integrity performed by RDH,
radiographs, control of inflammation in the periodontium, observe
areas of bleeding, loss of attachment, probe depth gains/losses,
mobility prevalence, EO/IO cancer screen.
Build patient up, praise patient for efforts, positively coach barriers.
Evaluation of Mr. Hertwigs home self-care; reiterating that this is a
disease will not disappear, but finding time throughout the day to
integrate positive plaque control methods.
Periodontal instrumentation to disrupt the plaque biofilm
Patient counseling Supporting James during his time of treatment
and revisit patient improvement/decline in chief concern
accomplishment: Lack of intimacy with spouse because of rotten
mouth.
Fluoride varnish

Should James choose to discontinue his periodontal maintenance

appointments, it will be in writing that all RDH and DDS in the dental office
are not held responsible for the disease progression and possible need for
periodontal surgery. The RDH will continue to deplaque and suggest
adjustments on self-care as needed. The RDH will strive to keep the
periodontium in a healthy state, but if the appointments are not consistent,
there is not promise that the disease will stay in a stable state.
Mr. Hertwig, do you have any questions regarding the information we have
provided for you? I know its a lot to take in.
No, I understand what needs to be done. I totally trust you, and I think Im
up for the challenge. Can I schedule today?
Actually I can schedule here if you would like. Ill also not your chart with a
message for my associates here, that you will be following up with us once
you find a physician. That way we can have everything in line when you
return.
Can I just schedule when I get home. I have so much to share with my wife.
You know, she will probably come in, to be a patient here.

Tell her to stop by! I have a folder here with all the information we have
discussed today. Please call any time if you need anything at all. It was a
pleasure to meet you, Mr. Hertwig.