Case Study #4

I. Assessment
A. Patient interview
Tartar build up on bridge
Bleeding gums when brushing
Sensitivity to cold, water, and air
B. Medical/Dental history
Right shoulder injury
Hepatitis A
Occasional genital herpes outbreaks
Medications: Vasotec, Diovan, Paxil, Ativan, Valtrex, Aspirin (low

dose), Aleve
Periodontal disease
Teeth #23-26 extracted and replaced with fixed bridge
Does not follow regular re-care appointments
C. Social History
Previous smoker (15 years), quit 5 years ago
D. Vital Signs
BP- 155/98
E. Intra/Extra oral
Extra oral- WNL
Intra oral- generalized recession, generalized inflammation of

gingiva, generalized extrinsic staining, localized abfraction on

lower left posterior, generalized attrition on maxillary anteriors,

plaque score- 70%, bleeding

index- 45%
F. Periodontal Exam
Generalized 4-6mm, localized 7mm on lingual of #2
Pathology on distal of #7, distal of #18
Furcation and bleeding on #14
Periodontal case type = Type II (moderate)
G. Radiographs
No significant findings
II. Dental Hygiene Diagnosis (Problem, Identification)
A. Level of Health: fair, on the verge of poor
B. Diagnosis: Periodontal Disease
III. Plan
A. Consultation Necessary
Periodontal
Caries with DDS
B. Treatment Goals
Remove plaque and calculus to help improve pocket depth and

inflammation
 Implement OHI
C. Addresses Phases of Treatment
Perform intra/extra oral exam
Probe full mouth
Full mouth SRP with local areas of anesthesia
Polish full mouth with medium prophy paste, except #23-26

(bridge)
Apply fluoride varnish
Discuss OHI and better home care
IV. Implementation
A. Consultations
Periodontist
DDS consult for caries
B. Instruments used
11/12 Explorer, Gracey 1/2 and sickle H5/33 for anteriors,

Gracey 11/12 and 13/14 for posteriors, periodontal probe, and

slow speed prophy angle

Anesthetic materials
C. Methods
(1) Extra/intra oral exam
(2) Anesthesia
(3) Probe full mouth and record findings
(4) Perform plaque score
(5) SRP full mouth
(6) Polish full mouth with medium prophy paste except the

mandibular bridge
(7) Floss full mouth
(8) Apply fluoride varnish to the full mouth except the

mandibular bridge
D. Homecare Aids
Soft bristle toothbrush
Floss threader to help get under mandibular bridge
E. Anesthetic
Topical anesthetic
Lidocaine with epinephrine

F. Prescriptions
Suggest Prevident
Patient already takes Aleve as needed, suggest to take for post

SRP pain and discomfort

V. Evaluation
A. Evaluate care
 3-4 month recall appointment; stress to patient the importance

of following recall schedule

B. Follow up charting
Plaque score
Probing depths and bleeding
Recession
Furcation involvements
Calculus detect
C. Radiographs
Periapicals and bitewings as needed
D. Patient OHI behavior changes
Compare plaque scores
Ask patient about current homecare behavior
BASS technique twice a day?
Soft bristle brush?
Flossing under bridge/full mouth?
Assess bleeding of gingival tissue

References

Wilkins, E. M. (2013). Clinical practice of the dental hygienist. Philadelphia, PA:

Lippincott Williams and Wilkins.

Wynn, R. L., Meiler, T. F., Crossley, H. L. (2014). Drug information handbook for

dentistry. Hudson, OH: Lexi Comp, Inc.