CAPSTONE PROJECT

Capstone Project: Assessment, Diagnosis, Planning, Implementation, Evaluation,

Documentation, & Reflective Conclusion

Simone Schuling

Theory and Practice

Spring Quarter, 2018

04/15/2018
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Assessment

My capstone patient presented with active periodontal disease that required initial non-

surgical periodontal therapy. He was a current smoker which could involve systemic issues.

Health History

Patient is a 30 year old male; vital signs are 132/78 mm Hg, 65 BPM. He is a current

smoker who smokes 1/2 pack per day and not currently under the care of a regular physician.

Patient stated he has an irregular heartbeat but has not had proper tests done to confirm

diagnosis. He is currently taking Oxycodone and Diclofenac, daily, for chronic back pain from a

car accident 9 years ago. It has been over six years since patient has had a regular dental cleaning

and exam due to patient not having insurance.

Extraoral & Intraoral Assessment

EO: Facial Symmetry- Ramus is shorter on the left side. Visual Inspection- 3x3 raised skin

colored nevi located superiorly on the left side by the angle of the mandible (pt. stated he has

never noticed it change in size or color), scattered macules. TMJ- Subluxation on left side when

opening, lateral deviation to the right when opening and closing, and slightly tender when

opening and closing. Lymph Nodes- Submandibular lymph nodes on the right side, slightly

enlarged and mobile (pt. stated he felt like he was coming down with a cold).

IO: Lips- Slightly dry, pt. had a 2x2 cut on lower left lip. Hard Palate- rounded, normal color.

Oropharynx- anterior and posterior pillars slightly red (pt. stated he felt he was coming down

with a cold). Retromolar Pad- lower left white raised keratinized lesion (#16 is supraerupted, pt.

may be masticating food in that area due to #17 not being present.) Tongue- moderately coated.
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Gingival Description

Patient presented with generalized moderate erythematous tissue with localized cyanotic

margins. Contour of margins were generalized moderately rolled margins. Contour of papilla

was generalized moderately bulbous papilla with localized edema.

Tooth Chart & Occlusion

Patient had no previous restorations but presented with interproximal decay on the distals

of #20 and 29. Watches were placed on mesials of #19 and 30. There was attrition noted on the

incisal edge of #24, and 25 and teeth #26-23 were linguoverted. Teeth #6 and 11 are rotated

mesially. Teeth #1, 16, and 32 need to be extracted and #16 is supra erupted. He had class I

occlusion on molar and canine right and left sides with a 3mm overjet and normal overbite.
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Periodontal Chart

Patient presented with generalized moderate bone loss, 3-4mm pockets and localized 5-

6mm pockets on the posterior molars. There was also localized 1mm recession and generalized

bleeding on probing. There was localized CL I furcation involvement on 18, 19, 30 and 31.

Risk Assessment & Oral Hygiene

The patient’s daily hygiene includes brushing with a soft manual toothbrush 1-2x daily;

he is currently flossing 1x weekly and not using any other aids. The patient is at risk for caries,

dry mouth. The patient clinically presents with periodontal disease, caries, misaligned teeth,

generalized heavy interproximal and subginival calculus and generalized moderate plaque.

Patient stated he has a medium fear of dental treatment, sensitive teeth, sore bleeding gums, and

bad breath. The patient understands his oral status, values prevention, and wants homecare and
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product recommendations and is open to new information. He states his stress levels are high due

to financial reasons and exercise is low with a moderately medium intake in carbohydrates. The

plaque index taken was at 42%.

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Radiographs

The patient has not had an FMX in over five years so during his initial appointment a full

FMX was taken. He also had 3rds molars present so a pano was taken as well.

Chief Complaint & Dental Examination

The patient’s chief complaint was concern about the discoloration on the mesial of tooth

#9 and wanted a cleaning. He was also experiencing some bad taste in his mouth which could be

caused from his active perio disease. During his examination by the Dentist tooth #29 and 20

were found to have decay present and both needed restorations treatment planned to arrest the

decay. There were also two areas of watches where the teeth had potential to turn into caries. The

patient also needs tooth #1, 16, and 32 extracted due to impactions and caries.
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Dental Hygiene Diagnosis

Attached is the dental hygiene diagnosis which was used to help determine a care plan for

the patient. By assessing the patient’s current needs, we were able to come up with a plan to help

arrest and maintain the patient’s active periodontal disease and determine ways to help the

patient with his homecare. Methods to be used will include initial non-surgical periodontal

therapy (4341), Chlorhexidine rinses, and using Clinpro 5000 daily. After initial therapy has

been completed the pockets will be re-measured and evaluated and determined if Arestin is

needed. The patient has been very compliant and motivated to treatment options and has asked

what he can do at home to help with the overall care to his mouth.

Currently the caries status of my patient is moderate. He presents with two areas of decay

and four areas of watches that could potentially turn into carious lesions. My patient is currently

not using any additional sources of fluoride. I recommended the use of Clinpro 5000 2x daily

until his next recall appointment. The goal of using Clinpro 5000 will help remineralize the areas

of decalcification and help reduce the chances of them turning into carious lesions. He also

completed a dietary log to evaluate his risk for caries. This was motivational for the patient

because he was able to evaluate his eating habits and realize what he was eating and drinking

exposed his teeth to an increasing amount of sugar. Some examples from the patient’s diet log

included daily energy drinks, pastas, and chips.

I will be evaluating the patient in 4-6 weeks at his tissue revaluation. At that time, I will

perform a PC to identify reduction in pocket depth and a decrease in areas of bleeding. I will also

check for a reduction in plaque levels and determine any OHI adjustments if needed.
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Planning

Dental Hygiene Treatment Plan

The dental hygiene treatment plan is for four quads of scaling and root planning (4341),

due to the generalized 3-4mm pockets in the anteriors and generalized 5-6mm pockets in the

posteriors. The patient was also given Clinpro 5000 toothpaste for his moderate caries risk and

Chlorhexidine rinse to help arrest the bacteria and improve therapy. The treatment plan was

signed by patient prior to treatment beginning.

Goals & Expected Outcomes

The goals of treatment and education are to arrest patient’s active periodontal disease and

maintain bone levels. Therapy will allow patient to be able to keep the pockets clean by daily

plaque removal and coming in for regular recall cleanings. The main goal is to decrease pockets

depth so patient is able to keep those areas clean. If pockets depths don’t decrease by the tissue

evaluation Arestin will be placed in the deeper pockets to help those pockets reduce in depth.

Another goal is educating the patient on good daily biofilm removal; this will help with the

gingival tissue and helping to break the bacteria colonies up that reside under the gum line to

prevent further bone loss and destruction to the tissues.

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Patient Education

During the risk assessment a plaque index was performed, it was noted that there was

42% plaque present on the teeth. The patient was able to see areas where he was missing during

daily plaque removal. I demonstrated modified bass toothbrush method and the c-shape floss

technique in the mirror, then had the patient show me in the mirror so we were able to perfect the

method and he felt more comfortable about brushing at home. The patient was also educated on

the caries process and what he could do to prevent caries in the future, by daily biofilm removal

and using Clinpro 5000 2x daily. By also evaluating his eating habits, the patient was able to

understand the acid attack he exposes his teeth to by the foods he eats. Smoking cessation was

another educational tool used; the patient has a goal of quitting by January 31st. I educated the

patient on how smoking is a risk factor for periodontal disease and how it affects our bodies the

longer we use.

Therapeutic Interventions

The therapeutic interventions to be used are Clinpro 5000 2x daily and chlorhexidine

rinses daily for 3-4 weeks. During initial therapy after each quadrant is finished I plan to use

subgingival irrigation to help cleanse the pockets and reach any remaining bacteria. At the tissue

evaluation, any pockets deeper than 4mm will have Arestin placed after the pockets have been

irrigated.

Implementation

The patient was scheduled for four appointments of SRP 4341, one for each quadrant.

One of the patient’s main concerns was the staining he had between numbers 8/9; he thought he

needed a filling done. I explained to the patient that because there was calculus there it’ll stain
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easily due to the fact he is a smoker and is a heavy coffee drinker. I wanted to make sure that his

first two appointments we would do SRP on the UR and UL quadrants. The instruments chosen

for each procedure required ultrasonic scaler, gracey curettes, and files.

During instrumentation, due to the deeper pockets, the gracey curettes were used to help

access the calculus. The files were used due to the large ledges of calculus to help break them up

in order to remove them with the graceys. I started with the blue tip insert with the ultrasonic to

help break up the large pieces of calculus. I then went in with the graceys, when I was unable to

remove the larger ledges of calculus I would use the file to help break up the larger pieces. The

first two appointments I had a harder time removing the calculus. I decided when I was on the

mandible to use the ultrasonic longer to help with removing calculus. I also utilized advanced

fulcruming to help aid in removing the calculus. This allowed me to remove the calculus better

on the mandible.

Additional services I provided to the patient during SRP treatment was subgingival

irrigation and soft tissue curettage. Due to the amount of bleed and deeper pockets I felt that

doing subgingival irrigation with CHX would greatly enhance the healing of each quadrant after

SRP. The patient also had boggy tissue between 14/15 and 18/19, so by removing the necrosis

tissue would allow better healing and tighter tissue. After SRP was completed on each quadrant,

when the patient would return for the next quadrant, Arestin was placed in the deeper pockets to

help aid in further healing.

The patient’s motivation after the first two appointments changed dramatically. The

patient started to notice his gums weren’t bleeding as much and that his breath smelled better. He

was also incorporating flossing more often and being more aware of what he was eating. I think
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the huge impact for him was his girlfriend noticed the changed, which was even more of a

motivating factor. At each SRP appointment we would review brushing and flossing, especially

making sure he was able to reach the back molars. I would then have him show me what I had

demonstrated to him, by him showing me I was able to see that he could understand the

technique. The patient experienced some low-moderate levels of sensitivity after each quadrant

of SRP. We discussed what he could do at home to help decrease some of these sensitivities,

these included using at home fluoride rinses, warm salt water rinses, and taking ibuprofen at the

end of each appointment. I would then follow up with the patient and ask him what did or did not

work.

Evaluation

During patient’s tissue re-evaluation, the maxillary arch was evaluated 6 weeks after SRP

completion, the mandibular arch had not been scaled yet. The maxillary arch was probed during

the tissue re-evaluation and maxillary arch was hand and ultrasonic scaled. The comparison of

pre periochart and post periochart show a significant decrease in pocket measurements and

bleeding sites. The posterior pockets decreased from 5-6mm pockets to 3-4mm pockets and

bleeding sites were reduced from all teeth on the maxillary arch to being localized to a few teeth

posteriorly. On the post treatment periochart there was generalized 2-3mm pockets with

localized 4mm pockets on #1-3, 14-16, localized 1mm recession on #3, 14, and localized BOP

on teeth #1-3, 13-16. The gingiva also showed notable changes; pretreatment gingiva was

generalized moderate erythematous tissue with localized cyanotic margins. Contour of margins

were generalized moderately rolled margins. Contour of papilla was generalized moderately

bulbous papilla with localized edema. Post treatment gingiva was slightly localized erythematous
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on posteriors, contour of papilla was localized slight blunting on the maxillary anterior, and

contour of margins had localized slight rolled margins on #3, #14.

Additional assessments were performed at the patient’s tissue re-evaluation as well;

tobacco cessation and phase contrast microscope. Tobacco Cessation: Ask: ask patient if he is a

smoker, pt. said yes and said he smokes 5 cigarettes per day and has been smoking for 16 years.

Advise: discussed pts current perio status and related benefits of quitting smoking to helping

tissues heal better after SRP. Assess: Asked pt. if he would like to pick a quit date and pt. said

yes. Assist: asked pt. how soon he would like to quit pt. picked a quit date of Jan. 31st. Arrange:

asked pt. if it was alright if I check in with him in two weeks to follow-up and pt. said yes.

During microscope I showed pt. a sample of bacteria found in a 6mm pocket of tooth #31 under

the microscope, and explained to pt. that in deeper pockets we will find more motile bacteria and

those are the bad bacteria that we try to eliminate during a cleaning and by increasing homecare

he can help these pockets to continue to shrink after his deep cleaning.

During the tissue re-evaluation the patient stated he had noticed a major change in his

tissue. He noticed the tissue wasn’t as red before and he felt that there wasn’t “a bad taste” in his

mouth anymore. At home preforming homecare, patient stated he noticed his gums weren’t

bleeding as much as they used to. During the plaque index, the patient still had plaque present on

the posterior molars, on the buccal surface, where he was missing during brushing. We reviewed

in the mirror how to effectively remove the plaque at the gum line on the buccal of the maxillary

molars and I had the patient demonstrate what I had showed him.

On the dental hygiene diagnosis, we had decided the patient should be on a three-month

recall interval. The three-month recall was due to patients AAP III status, his homecare routine,
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and rate of calculus build-up. Until the patient is completely stable and is able to perform

homecare effectively, a three-month recall is appropriate. Since the pockets responded well to

SRP and are shrinking, at this time there is no need for a referral to a periodontist. The areas of

BOP were treated with sub gingival irrigation with 0.12% CHX. The patient doesn’t have any

areas of width of attached gingiva that are 2mm or less and I feel we can effectively help the

patient maintain his perio status on a three-month interval.

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Post-Op Photos
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Documentation

Chart audit was preformed and there were no missed areas addressed. Due to the patient

having to come in for several appointments, all aspects of documentation were achieved and

thoroughly documented. If any areas were not addressed at one appointment, I was able to catch

it and address it at the next appointment. Any areas of treatment planning for restorative and

smoking cessation were placed under patient education.

Reflective Conclusion

During the Capstone project, all the classes I have taken up to this point have allowed me

to provide quality care to my patient at helping him establish stable periodontal status. From

learning about homecare aids to how the perio status can affect a patient’s longevity of teeth, I

have been able to help my patient understand why it is so important to care for his teeth and help

him understand his own status. Also knowing what adjuncts to include in treatment to help aid

the healing process. This includes using Arestin and sub gingival irrigation to help arrest the

bacteria. It is important to make your patient aware of all aspects of treatment and asking them if

they understand why they need treatment done and what they can do to help improve their oral

status when they are at home. When a patient doesn’t understand why they need what they need,

they aren’t motivated to improve their overall health. If a patient has systemic diseases, it’s also

important to relate to them the health risks and healing, if they don’t have those systemic

diseases under control.

The areas I excelled in during my Capstone project was finding ways to motivate my

patient to improve his homecare. By evaluating the patients homecare at each visit and pointing
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out the areas he had improved in help motivate him even more. When the patient takes notice in

their improved tissue quality, it gives them a greater sense of appreciation of what you’re doing

to help out their oral status. Areas of improvement that needed assistance was calculus removal,

the patient’s calculus was very tenacious to remove. Throughout the treatment I was able to

remove the calculus more efficiently; advanced fulcruming and instrumentation allowed me to

remove the calculus better.