Morgan Bowles

Process of Care
When patient T was assigned to me I reviewed his hard tissue chart first. I
originally thought to myself he would not be a difficult patient. Charted he only had
a couple missing teeth and a root canal. This was not the case though, his real hard
tissue chart was never approved after his current dental student completed his
plans and therefore was not showing up in Axium. The real story was revealed after
viewing Ts radiographs on Mipacs. This is when I discovered T had rampant caries
throughout his entire mouth. He was a very unique case for me, one I had not
experienced in person thus far. is why I chose him for this paper.
The only medications T was currently taking were Abilify, Trazodone, and
Cogentin. Abilify is a drug taken for bipolar disorders, schizophrenia, Tourette
disorder, and irritability associated with autistic disorder. Ts chart said that he was
taking it for anxiety which he confirmed. The Trazodone was taken to help with
insomnia and is also an antidepressant drug. T said he was taking Cogentin to help
with the side effects of the other drugs he was currently on. The adverse effects for
all three of these drugs is xerostomia, which T reported he currently had no issues
with. There were no blood related adverse effects listed in Lexi comp for any of the
medication T was taking. He also reported having a drug allergy to codeine. The
only previous surgeries/hospitalizations was surgery for perforated ear drum in
2004. T was very soft spoken making understanding him difficult. He answered
most of my question with two to three word answers and kept headphones in his
ears throughout our whole appointment. Only turning the volume down only when I
was having a conversation with him. This may have been a coping mechanism to
deal with being at the dentist. I someone expected he could possibly be a little

stand offish or uneasy before meeting him because the alert in his chart said he had
emotional difficulties.
T was seen by a dental student the week before he came in for his cleaning
with me. During the visit he told the dental student that he was not using any
recreational drugs, did not smoke, and did not use any alcohol. When I asked him
these same questions at our appointment however, he reported smoking a pack a
day, drinking occasionally, and still denied any drug use. In the patients chart, a
note was made about a discussion the dental student had with Ts mother about a
payment plan during the previous appointment. If she was present during the
medical history with T this could potentially explain why he changed some of his
answers when I asked these same questions. His mother did bring him to this
appointment as well, but she stayed in the waiting room when I called T back. He
also revealed drinking multiple sodas throughout the day. This is most likely one of
the main factors contributing to the rampant caries present. After reviewing the
dental history with T, I discovered that he currently did not floss at all or use any
type of mouth rinse. He also informed me that he brushed twice a day and grew up
with fluoridated water.
T was currently missing teeth #1, 16, 17, 32, 14, and 20. He had a root canal
and an amalgam restoration on tooth #21. Plans were already been made for
composite restorations on all of his remaining teeth along with endodontic
treatment on #15. The patient was an obvious high caries risk. He was already
scheduled to come back to the school a couple days after our appointment to begin
filling a few of his cavities. A full mouth periodontal chart was completed the day of
our appointment revealing generalized 1-4mm pockets with localized 5mm pockets
on #27M and #22D. T also had generalized 1-3mm of recession with no mobility

noted. The patient was indicative of generalized moderate with localized severe
chronic periodontitis. After periodontal charting and exploring I noticed that there
was generalized moderate biofilm, especially around the gingival margins, along
with localized calculus in sextant 5. Sextant 5 also had the deepest pockets which
was most likely due to the localized calculus in the area. He also presented with
localized tobacco staining on the maxillary and mandibular linguals of the anterior
teeth.
Because a full mouth series had been taken the week before T presented to
the hygiene clinic, no new radiographs were necessary the day of our appointment.
After speaking with faculty, it was decided not to use the cavitron on T. His teeth
were very fragile and jagged from the extreme amount of decay present. I did not
want to risk breaking any pieces of tooth structure off or cause any hypersensitivity
to the area. Instead it was decided that I would rubber cup polish first to remove as
much of the biofilm present as possible before attempting to hand scale. I then used
hand instruments to remove the calculus in sextant 5 and remove the subgingival
biofilm in all 4 quadrants. After hand scaling, I rubber cup polished a second time
and flossed between all of Ts teeth. Even after all of that, slight amounts of biofilm
were still present in some areas subgingival, so I decided it would be a good time to
go over OHI. I did not disclose him because I felt it would be too difficult for him to
remove the coloring from the scooped out areas of decay present and would not be
an effective method of demonstrating proper oral hygiene.
I wanted to keep OHI simple for T so that it would be more realistic and
effective. Based on my assessments, his home care was very minimal so we started
with the basics. I tried not to throw too much at him at once so that he would not be
too overwhelmed. I started with demonstrating the modified bass method with him

while he watched in the mirror. I explained the importance of removing bacteria and
biofilm not only from the tooth surfaces, but also tilting the brush 45 degrees to
clean out the sulcus. Afterwards, I had him demonstrate it back to me and I showed
him where the most calculus can build up due to the locations of salivary glands. I
explained that an electric toothbrush with soft bristles may be ideal for him since he
has so much decay and biofilm present. In a study done by Pizzo et al., they
compared two different manual toothbrushes to a power brush. The power brush
proved to be more effective when removing plaque especially in hard to reach
areas. I believe that power brushes can be more effective for patients having a hard
time with brushing, which is why I recommended he purchase one. I explained to
him that once he starts having some of his restorations placed he will want to keep
them as clean as possible in order to maintain them and to prevent any further
decay. Knowing that money may be an issue for him due to the many expenses with
all the new restorations planned in his chart, we discussed that Target and Walmart
sell spin brushes that are not as pricey as some of the ones sold in dental offices.
Next, I showed him how he can floss using the C- shaped method and he
demonstrated the technique back on two to three teeth for me. I showed him how
much of the decay/caries in his mouth is interproximal and that flossing between
these areas will help to keep them clean and disrupt the bacterial colonies
preventing the decay from spreading further. I also explained to him that by
wrapping the floss around the tooth instead of punching it straight down into the
gingiva will prevent trauma to the papilla, so he would not cause trauma in the
process of flossing. T told me in the beginning of the appointment that he does not
floss at all. He was not able to tell me why he didnt floss other than the fact that I
just dont. I could see that he wasnt thrilled with the string floss and

recommended getting the floss picks. We discussed how floss picks are easy to grab
on the go and a great way to begin integrating flossing into his daily routine. We
also discussed how the c-shaped method can be used when using floss picks.
Since T currently was not flossing at all, he is most likely going to bleed while
flossing for at least the first week. I should have explained to him that this is a
normal occurrence do to the infection in his gums so that he will not be alarmed by
it. I do not want him to see that he bleeds every time he flossing and not floss for
that reason.
Even though Ts chart stated a dental exam was not needed the day of his
appointment, I felt T would greatly benefit from Prevident toothpaste. Dr. Webb in
AEGD agreed with this suggestion and wrote T a prescription. T and I discussed the
importance of fluoride varnish and Prevident toothpaste. I used C-A-R-D (caries, antimicrobial, remineralize, desensitize) to have this conversation with him and explain
the benefits of fluoride with him. This information helped him to make an informed
decision about having fluoride varnish applied, which he agreed to let me apply to
his teeth the day of his appointment. We then discussed how Prevident would
provide a daily dose of fluoride for his teeth. Fluoride exposure everyday will
provide all the benefits of C-A-R-D including making restorations last longer, which
would save him money in the long term. Another suggestion I gave him was to drink
his sodas with meals throughout the day and in between meals to try just drinking
water. This would further cut down on the prolonged pH drop in his mouth resulting
in less opportunities for new caries to develop.
I felt that baby steps were the proper way to deal with this case. I think that a
lot was covered in our appointment as far as OHI and if any more had been given he
would have just tuned me out completely. I do feel that more insight is needed at

our next appointment to see if we can discover something besides just the sodas
causing the rampant caries present. Considering that he admitted to drinking
alcohol and smoking to me after previously denying both the week before to his
dental student makes me think that maybe there are other questions that may have
not been answered truthfully. With the amount of biofilm in his mouth its possible
he isnt actually brushing twice a day.
T was put on a 3-month recall due to the amount of decay present in his
mouth and the generalized plaque and biofilm. I found it interesting that Ts chief
complaint was that he wanted his teeth to be whiter. This shows that he does
somewhat care about the appearance of his teeth. I thought it would be appropriate
to have T on a 3-month recall until he reduces the generalized moderate biofilm
present in his mouth and starts practicing better home care. This way we can
hopefully stop the progression of decay present.
I think this appointment could have been improved if I would have discussed
smoking cessation with T. Patient T and I had our appointment prior to the theory
tobacco paper and tobacco cessation activity in class. Before the tobacco activity I
was not sure how to do smoking cessation and didnt feel comfortable giving him
advice on a topic I didnt know much about. After reading the articles Mrs. Shah
provided on tobacco products and cessation as well as what I have learned in perio
class this year I feel more knowledgeable on the subject. I know now I could have
explained how smoking is a risk factor for periodontal disease and related it to some
of his 4 and 5mm pockets. I also could have asked him how ready he is to quit and
just had a two to three minute conversation with him about smoking. Another area I
feel could have used improved during this appointment is nutritional counseling.
Other than the sodas I was not able to figure out an alternative reason for the

rampant caries. I could have done the 24- hour dietary analysis with him to see
what types of foods he is consuming on a regular basis and see if they are possibly
contributing to the carious lesions.
This assignment has helped me to realize aspects I need to work on in clinic
and how important documentation really is when it comes to referring back to what
said and done the day of an appointment. Sometimes we learn new material in class
but have a hard time understanding where/how to fit it into our appointments or
how it applies to our patients. This project was a great way to see how materials
discussed in class are important tools to use to learn about our patients and why
their oral cavity appears the way it does in clinic. For example, I find nutritional
counseling is difficult for me to bring up with patients but I can now see what poor
dietary habits such as drinking sodas all day can affect the oral cavity. I will use
both my downfalls and successes I had with patient T to do better with future
patients.

Notes:

Appt.
#

Treatment Plan:
Tooth/Quad Treatment

Justification for tx

Prognosis
Statement

Realistic goals for this patient

4 quads

AP

Remove all plaque,

biofilm, localized
calculus

Decline
progression of
rampant caries and
attachment loss

Use prevident at least once a day,

brush using to bass method twice a
day to reduce the amount of biofilm
and prevent calculus from forming
and floss 3 times a week to disrupt
interproximal bacterial colonies

4 quads

AP
and dental
exam

Remove all plaque,

biofilm, localized
calculus

4 quads

AP
and dental
exam

Remove all plaque,

biofilm, localized
calculus

Continue the goals listed about,

discuss smoking cessation to see if
quitting is an option for him and
add mouth rinse to his daily routine
Continue the goals listed about and
add any new goals that are address
during the appointment

4 quads

AP and
dental
exam

Remove all plaque,

biofilm, localized
calculus

Decline
progression of
rampant caries and
attachment loss
Decline
progression of
rampant caries and
attachment loss
Decline
progression of
rampant caries and
attachment loss

Caries Risk:

Continue the goals listed above

and add any new goals needed

Lesion
s

Fluorid
e
Exposu
re

Sucros
e
Freque
ncy

Salivary
flow

Dental
Visits

Biofilm
Presen
t

Management

Low

No new
lesions
present,
no
incipien
1-2

Adequa
te
fluoride
exposur
e3
Fluoride

Sucrose
exposur
e
betwee
nSucrose
meals,

Normal

Minimu
m
preventi
ve visits
once
Infreque

Minimal

-Monitor compliance
-Document findings
and
recommendations
-Continue
6-12 month
Provide risk

carious
lesions
or
incipien
Frank
carious
or
incipien
t lesions

exposur
e 1-2
times
per day
No
daily
fluoride
exposur
e

exposur
e
betwee
n meals,
Sucrose
exposur
e
betwee
n meals,

High Moderate

Cari
es
Risk

Xerosto
mia
induced
by meds,
age,
Xerosto
mia
induced
by meds,
age,

nt
preventi
ve visits

Modera
te

management
program including:
-fluoride, OHI,
nutritional counseling,
No
Heavy
Provide risk
preventi
management
ve visits
program, including:
-fluoride, OHI,
nutritional counseling,
Provide risk
management
References:
program, including:
-fluoride, OHI,
Pizzo, Giuseppe, et al. "Plaque Removal Efficacy of Power and Manual Toothbrushes:
nutritional
A Comparative
Study." Clinical Oral Investigations 14.4 (2010): 375counseling, saliva
381. Dentistry & Oral Sciences Source. Web. 26 Mar. 2016.
substitutes,
antimicrobials
-referral for tx needs
-document findings
and