Casestudy 2 Theory

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Case study- Fall semester 2023
Mesa Community College Dental Hygiene Program
Jacob de Werd
Department of dental hygiene, Mesa Community College
DHE 212: Theory II
Professor Dawn Brause
November 12, 2023

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Case report
A 51-year-old male patient presented to Arizona School of Dentistry and Oral surgery for
dental hygiene services. The patients chief concern at the beginning of our series of
appointments was “nothing at this time (appendix A).” When examining the medical history, the
patient marked to be adequately motivated with their oral health by brushing twice a day with a
manual toothbrush and flossing only when food was stuck in their teeth.
Medical History
When reviewing health history, the patient presented with type 2 diabetes that was well
controlled with medication and had an HBa1C that was at 6.3%. Patient also revealed that they
had been smoking on and off throughout life and had been recently started smoking a pack a day.
Although the patient’s diabetes was controlled, many other systemic manifestations occurred due
to the disease; the patient also developed GERD and had been experiencing dry mouth from
medications. The patient also has history of high blood pressure, which is being monitored
closely by their primary care provider. Health history also revealed a full left shoulder
replacement back in 2019, no premed was indicated by PCP or Dr. Greene (Appendix A).
Patient was taking multiple medications as followed. For diabetes the patient was taking
Trulicity, Jardiance, and pioglitazone. For weight loss and weight control the patient was taking
phentermine, topiramate, hydrocholorothiazide. For acidreflux/GERD the patient was taking
omeprazole, and for cholesterol the patient was taking atorvastatin. For sleep the patient was
taking doxepin and for heart disease preventative the patient was taking aspirin. The patient also
took multi vitamins and magnesium for muscle pain. Most medications had dental manifestations
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of xerostomia as well as possibly causing gingival hemorrhaging and orthostatic hypotension
(Appendix A).
Vitals were taken upon the patients first visit on August 31, 2023. Vitals read BP 120/78
mm Hg (slightly elevated), Pulse: 88bpm, Respirations: 20 rpm. Glucose:130 mg/dL before 9
that morning. Although blood pressure was slightly elevated, in later appointments it would
fluctuate into stage 1 hypertension with the average reading being 130/80 mmHg. Overall, the
patient was decided and confirmed to have an ASA of II due to the stability of systemic diseases
and being under the care of a physician (Appendix A).
Dental History
The patient presented with cold sensitivity and dry mouth. The patient disclosed that
their last dental visit had been around 5-6 years but stopped going primarily due to the office
moving to a location further away and COVID-19 pandemic (Appendix A). When assessing
dentition charting the patient presented with restorative care on most posterior teeth. Amalgam
composites were located on teeth 2(O), 14 (MO), 15(O), 20(DO), 30(O), and 31(O), composite
restorative care was located on tooth 3(MOD), 18(MOD), and 29(O), and porcelain crown with
root canal therapy on teeth 12 and 19 (Appendix A, B, E).
Clinical assessment
Both CAMBRA and tobacco cessation forms were filled out at the beginning of the
appointment. The CAMBRA form indicated a high risk for caries due to the medication and not
having a dental home for 5-6 years (appendix C). It was recommended that the patient use
Biotene or All-day spray to help reduce xerostomia and find a dental home to receive routine
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care visits. Tobacco cessation form indicated that the patient had been smoking on and off for a
long part of his life and had currently been smoking a pack a day (Appendix D). Tobacco
cessation was implemented on the patient during treatment to help promote oral health.
Extra-oral and intra-oral assessment was performed on the patient at each reoccurring
appointment. Extra-oral examination revealed 4x7 bilateral brown patches posterior to the ears.
The patient was unaware of the lesions; no new growth or changes occurred throughout the
appointments. Additionally, the E/O exam revealed 1x1 scattered brown papule lesions on the
lower portion of the neck indicative of skin tags, the patient is aware of the lesions and stated
that they have had been there for most of his life (Appendix A).
I/O exam revealed a 1x1 pale pink papule lesion on the mandibular gingiva inferior to the
central mandibular incisors; patient was unaware of lesion which was monitored on reoccurring
appointments. 1x1 scattered erythematic lesions on left buccal mucosa indicative of cheek biting,
patient was aware of the lesions and had stated they had bitten their cheek prior to the
appointment (Appendix A). Furthermore, a leukoplakic lesion was presented on the gingiva were
tooth 4 was missing due to a prior extraction (Appendix. Due to smoking the patient presented
with nicotinic stomatitis on the hard palate. The patient presented with a Mallampati score of 3,
which the patient is aware of and sleeps with a sleep apnea device. Throughout the appointments
the lesions were monitored and had lessen or resolved.
Periodontal examination
Full intraoral photos were performed on the patient (Appendix F). Gingival description
indicated signs of disease as it was generally pale pink in color with areas of red. Additionally
the texture of the gingiva was generally spongy and shiny in texture with blunted papilla, as well
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as localized edematous pertaining to sextant 5 (Appendix A, F). The patient presented with a
thick bio type with a normal vestibular height.
There were no significant findings with hard tissue, however the patient presented with a
bilateral class I malocclusion with a posterior open bite. Over jet and overbite are not within
normal limits with a probe reading of 4mm and edge-to-edge overbite. Additionally, the patient
presented with signs of fremitus on teeth 7, 9, and 10 (Appendix A, F).
Periodontal charting was performed on the entire mouth. Patient presented with
generalized probe depths of 4-5mm (34%) with one localized area of 7mm along with
generalized bleeding of 30%. The patient also presented with gingival recession of 1-2mm on all
molar teeth. Class 1 furcations were located on teeth 3 (B), 14(B), 15(B), 18(B), 30(B, L), and
31(B, L). Additionally, class II furcations were located on 2(B, D) and 19 (B) (Appendix G).
Radiographic examination
Radiographic examination was completed by Dr. Huffman examined radiographs and no
significant findings were found. However, the radiographs did indicate a generalize distribution
of horizontal bone loss (20%). Additionally, radiographs confirmed restorations to be porcelain
only and that root canal therapy was done on 12 and 19 (Appendix E).
Oral hygiene examination
Patient was provided with a fluorinated mouth rinse and rinsed for 30 seconds prior to
assessments. The entire mouth was explored during assessments for calculus detection. Calculus
detection revealed that the patient has generalized roughness and speed bump calculus along the
roots and in furcations of the teeth and with the majority of subgingival binding calculus
pertaining to sextant 5 and lower quadrants. (Appendix H, F-4).

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Human needs Theory
At the beginning of the appointments the patient presented with many unmet needs.
Protection from health risks was not met due to the patient smoking a pack of cigarettes a day.
Freedom from fear and stress need is met, the patient did not have any issues of fear or stress at
the dental appointments. Freedom from head and neck pain was not met because the patient
experienced pain or discomfort during assessments and a need for anesthesia when
instrumenting.Wholesome Facial Image need was met, patient did not have any complaints about
appearance or halitosis. Skin and mucous membrane integrity of the head and neck need was not
met due to signs of diseased gingiva, bone loss, and bleeding upon probing. Biologically sound
and functional dentition need is not met, the patient has not found a dental home and shows some
signs of mobility. Conceptualization and problem-solving need is not met. Although the patient
had adequate oral health marked on health history, the patient did not understand the disease
process and did not have a complete understanding of smoking effects on oral health, as well as
not understanding the importance of why flossing is done regularly and not with food.
Responsibility for oral health was not met, the patient had some idea on how to take care of their
oral health, but still continued to smoke and did not have a dental home.
Dental Hygiene Diagnosis and Treatment Plan
After risk assessments were completed, a treatment plan was prepared and presented to
the patient. The periodontal statement stated the patient presents with Periodontitis stage III with
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a generalized distribution with a grade C rapid rate of progression of the disease (Appendix I).
This is due to the generalized 4-5mm pockets with generalized bleeding. Although most of the
assessments indicated a stage III grade B progression, the patient presented with modifiers, in
which they had smoked a pack a day, placing them in the grade C category. The dental hygiene
diagnosis stated patient presents with bleeding on probing due to biofilm and calculus
accumulation (Appendix I). Based on this diagnosis it was recommended that the patient
received four quadrants of NSPT (4341) along with CHx irrigation. Due to the tenacity and
difficulty of location where caluculus is, it was determined that the patient was classified as a
level 3 alternative. It was recommended anesthetic to be administered as well as the use of
periofiles and langers due to the depth of pockets.
Patient education and Oral Hygiene instructions.
Patient was educated on their current state of health/ disease and why it is important to
routinely visit a primary dental provider for care as biofilm accumulates quickly. To further
assist with progressing to health, tobacco cessation was also recommended for the patient; the
ash line was declined, but it was recommended to slowly come off cigarettes by using less each
week, the first appointment the clinician recommended to reduce cigarette use to half a pack and
each week to progress less and less. Patient was then educated on using a water flosser which
was recommended to try and use at least 3 times a week or more at night. Additionally, the
patient was also educated on diluting mouth rinse in the water flosser to help irrigate with an
adjunctive chemotherapeutic aid inside the pockets to help lessen and control bacteria and
biofilm accumulation (Appendix J).

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After a few reoccurring appointments there was some acquired buildup of plaque
accumulation on teeth that were completed on the lingual surfaces. It was then recommended to
get an electric toothbrush and to spend a little more time on the lingual sides to lessen the plaque
accumulation.
Implementation of Treatment Plan
Dental hygiene treatment was performed on the patient which provided biofilm and
calculus removal (4341) on all four quadrants. This was developed as the correct treatment plan
due to the heavy calculus and bleeding sites within the quadrants. Utilizing irrigation and getting
an Rx for chlorhexidine was also utilized to help minimize bacteria and biofilm.
There was a total of 6 treatment appointments (Appendix J). At the first and second
appointment the patient was given a preprocedural rinse and precursory E/O I/O which had
shown no changes. The patient was then administered 2% Lidocaine with 1:100,000 epinephrine
to the right IA/L and buccal nerve. NSPT (4341) was performed on sextant 6 by first utilizing
periofiles to crush down binding calculus on two teeth. After exploring to find residual calculus
the clinician utilized the universal 4R/4L, and Gracey’s 5/6, 15/16, 17/18 to remove and disrupt
biofilm and calculus (Appendix J). Instrumenting proved to be a bit difficult due to the calculus
being in deep pockets and in the col area. Faculty helped to assist getting periofiles into the col
area to crush calculus and then going in with Graceys to help remove the calculus a horizontal
stroke interproximal proved to be useful to help remove the calculus that had developed a nidus
in concavities. At the end of the appointment the patient was then irrigated with chlorhexidine
rinse and given a bottle to take home to start using twice daily as an adjunctive therapy to help
lessen biofilm.
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At the next appointment, vitals, preprocedural rinse, and precursory E/O, I/O and a quick
reevaluation of sextant 6 was done again. E/O, I/O revealed that the patient’s Nicotinic stomatitis
and the leukoplakia area where the missing tooth was had lessen. The patient had disclosed that
they had now lessen cigarette use to ½ a pack a day. Additionally, sextant 6 was being
maintained properly and gingiva began to show signs of health as color began to become more of
a prominent pink and tissue was becoming firmer. The clinician then urged the patient to
continue keeping up with their self-care to maintain health (Appendix J). With both the molars
and premolars finished appointment three consisted of finishing quadrant 4. All of sextant 5
proved to be challenging to do the amount of calculus build up. The calculus consisted of
binding pieces from deep down in the pockets and was continuous up the enamel of the teeth.
After anesthesia administration, periofiles were used for the first hour- hour and a half of the
appointment to break down the walls of calculus. Once calculus was crushed down enough the
gracey 5/6 was used to clean up the area. The patient’s concavities on these teeth once again
proved to be challenging. To help reach these areas, mini graceys were used to access the thin
yet deep pockets in order to break and disrupt the calculus. Quadrant 4 was scaled to completion
and irrigate with chlorhexidine (9630) (Appendix J).
At the fourth appointment tobacco cessation was revisited, the patient stated they had
lessened cigarette use down to only 1-3 cigarettes a day. E/O, I/O exam correlated with the
cigarette use by displaying little presentation of nicotinic stomatitis. Upon reevaluating quadrant
4 the patient presented with a moderate accumulation of plaque it was then brought to the
patient’s attention and was suggested that they spend more time on the lingual parts of the teeth
to help combat biofilm accumulation in the areas (Appendix J). After pre procedural rinse and
administration of anesthetic (LIA/L LB) NSPT (4341) was performed on quadrant 3. Langers
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were better equipped to access deeper pocket and remove calculus and yielded great results
compared to gracey curettes and Montana jack as well as mini graceys helped to remove tough
small pieces of calculus that were deep in interproximal spaces. Overall, each tooth was
completed to completion and then irrigated in Quadrant 3 by the end of the appointment.
At appointment 5 vitals, preprocedural rinse, and precursors E/O, I/O was done. After
applying anesthesia (RPSA, RAMSA) NSPT (4341) was performed on quadrant 1. Periofiles
were used to crush down calculus then langers 17/18 and 5/6 were used to help instrument
(Appendix J). Periofiles had a difficult time entering furcations areas; due to the curvature of the
diamond files they allowed for ease of access to crush the calculus. With the assistance of
faculty, the calculus was crushed and removed. Montana jack was the used after instrumenting to
refine the areas. After completion of quadrant 1. The patient then received an electric toothbrush
and was then given OHI on how to use the toothbrush.
At our last treatment appointment quadrant 2 was completed on the patient. After
checking vitals and given preprocedural rinse and precursory e/o i/o the patient received
anesthesia (LPSA and LAMSA). NSPT (4341) was then performed on quadrant 2 (Appendix J).
Periofiles were used to crush calculus with the exception of tooth 15. A diamond file helped to
not only remove subgingival calculus pieces, but to also remove calculus within the furcations.
Langers 5/6 and 17/18 were used to remove calculus and a Montana jack and anterior scaler
helped to remove tedious interproximal calculus. Overall scaling was successfully completed on
each tooth. The patient was then polished with chlorhexidine rinse in order to avoid any irritants
accumulating in the sulcus. The patient was then given OHI about reevaluation visits and now
receiving additional supportive care appointments. All in all, the patient tolerated anesthesia and
treatment well and had no adverse reactions.

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Evaluation of Treatment
The patient returned three weeks later for a reevaluation appointment (D0170) (Appendix
K). Health history was reviewed, and vitals (Bp and glucose) were retaken at the reevaluation.
The patients' vitals read as 130/80 mmHg (stage 1) and a glucose at 128 mg/dL when they ate
around 11 o’clock (within normal limits). Although blood pressure was high it was in the
patient's average limit at prior appointments. Tobacco cessation was reevaluated as well, the
patient still continued to use 1-3 cigarettes a week. However, patient is still currently looking for
a dental home.
After procedural start the patient received a preprocedural rinse and E/O, I/O exam was
performed. E/O exam reported no significant changes, and I/O exam showed that the patient's
nicotinic stomatitis had gone away and a new 1x1 erythmatic lesion indicative of a cheek bite
was present on the left buccal mucosa.
Gingival description had shown signs of change that were in favor towards health. The
patient presented with gingiva that was generally pink and firm with stippling and localized
blunting of papilla and slightly red gingiva in sextant 5 (Appendix K, M). Additionally, perio
charting was done and had also shown signs towards health as well. Periodontal probing
displayed pocket reduction from 34% to 20% with a generalize reduction in all pockets
(Appendix N). One pocket had an overall reduction of 3mm (7mm to 4mm). Furthermore,
bleeding upon probing had also lessened to localized areas from 30% to 15%. Although the
reduction in bleeding showed success the distal of tooth 19 presented with a 5mm pocket with
bleeding indicating an active disease sight (Appendix N).

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The patient was then retreated on the distal of tooth 19 as NSPT (4342) and the rest of the
mouth was perio maintenance (4910) (Appendix K, L). Most sights showed mild-moderate
plaque accumulation which was disrupted with a universal 4R/4L. Horizontal strokes showed
great success at achieving greater surface area and disrupting biofilm. Supragingival calculus
build up was present on sextant 5 and was removed using an anterior gracey (5/6) and an anterior
sickle scaler. After successful removal of biofilm, the patient was then polished with CPR polish
and flossed. After flossing arrestin (4381) was applied to the distal of tooth 19 to help aide in
bacterial control. It was explained to the patient that arrestin was a small dose of antibiotics that
is put into the gums to help control the number of bacteria and not to floss or water floss the area
for 10-14 days after in order for the best results (Appendix K, L). After arrestin was applied the
patient then received fluoride varnish. Overall treatment was successful and yielded great results
for the patient. The human needs were also reassessed for the patient (Appendix K). Protection
from health risks was partially met due to the patient still having one or two cigarettes a week.
Freedom from fear and stress need is met, the patient did not have any issues of fear or stress at
the dental appointments. Freedom from head and neck pain was partially met. The patient still
has some signs of discomfort when probing but did not need anesthesia nor had issues when
instrumenting. Wholesome Facial Image need was met, patient did not have any complaints
about appearance or halitosis. Skin and mucous membrane integrity of the head and neck need
was partially met. Patient still presented with BOP and some pocketing; however, it showed
some signs of improvement. Biologically sound and functional dentition need is not met. The
patient still has not found a dental home and shows some signs of mobility. Conceptualization
and problem-solving need is partially met. The patient has a better understanding of the disease
process but does not fully understand techniques to disrupt and remove biofilm (charter
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technique due to missed areas on the linguals of teeth). Responsibility for oral health was
partially met. The patient is taking more responsibility for oral health but continues to smoke and
has not found a dental home. Overall, the patient presented with a therapeutic endpoint and will
have a 3–4-month supportive care appointment.
Reflective conclusion
Overall, my first appointment with a high-level patient was a great and rewarding learning
experience. As part of my research, I was interested to explore the link between malocclusion
and periodontal diseases. Much research goes back and forth on whether or not malocclusion
actually affects oral health. However according to a study on malocclusion patients from Saudi
Journal of Medicine and Medical Sciences, “In the present study, most of the patients in all types
of malocclusion classes had PI and GI of score 2. This finding is comparable with the results of
studies on the interaction between malocclusion and gingivitis that have found greater levels of
gingivitis in individuals with malocclusion compared with those without malocclusion, thereby
suggesting a link between increased plaque accumulation in patients with malaligned dentition
(Javali et al 2020).” This explains that misalignment of teeth due to malocclusion is what makes
plaque retention higher in malocclusion individuals; due to the misalignment and crowding of
teeth can make difficulty to uphold selfcare in patients. This is further proved later on in the
journal when Javali states “However, factors that favor the retention of deposits, such as
irregularity of tooth position and overhanging/ill-fitting dental restorations, could lead to
periodontal compromise. Studies have shown that irregularities in the position of teeth and
crowding increase the rate and accumulation of bacterial plaque. Clinical analysis has shown that
crowding of teeth makes removal of plaque difficult, predisposing to gingival inflammation and
periodontal destruction (Javali et al, 2020).” This is important as hygienists to be mindful of

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malocclusions as it plays a huge part in incorporating customized self-care instructions to our
patients to be able to better remove plaque accumulation. Additionally, it allows hygienists to
determine if appropriate referrals are needed to help the patient in correcting their bite in order to
upkeep oral health.
I had learned many technical aspects of instrumenting with this patient. During previous
experience with a heavy calculus and perio 2 patient I had hard times removing calculus with just
bite stroke and debridement techniques. However, the introduction of Periofiles showed me how
to lessen the working strength and work more efficiently. Being able to start with Periofiles and
then work into using instruments made great results in calculus removal. Furthermore, the use of
aesthetics presented a great way to demonstrate pain control with not only this patient but other
patients in clinic. It provides a less stressful environment and allowed for me to perform better
instrumentation without having to worry as much about the patient’s comfort. Langers also
became one of my favorite instruments due to the the double cutting edges, which allowed me to
only switch instruments every so often, it helped me to work more efficiently with my patient
rather than having to constantly go and pick up a new instrument with graceys.
Many challenges also presented themselves during treatment. When first instrumenting it was
challenging being able to get instruments, especially Periofiles deep into the pocket areas. With
some assistance from faculty, it allowed me to first use an explorer to gauge where the calculus
was and being able to then go in with instruments to remove it. Additionally, having furcations
with calculus proved to be the most difficult and frustrating part of calculus removal since the
Periofiles could not access them. Utilizing diamond files for furcations proved to be useful and
was a great skill to learn to better enhance my knowledge on instruments. Having a sequence and
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learning instruments allowed me to understand morphology of col spaces with advanced
periodontal diseases better. Overall, this helped to develop skills I can apply in the future.
My greatest successes with my patient were firstly to discussing the disease process to my
patient. It allowed to showcase what I learned throughout my schooling and apply it to patient
care. Additionally, as time went on my technical skills had developed immensely and treatment
started to come easier with time. It allowed me to use these skills later with patients and have
success with them later on.
When looking at fulfilling the patient’s needs, I felt as though I did a great job in fulfilling
most of their needs. I did this by implementing great OHI techniques to help guide and aide the
patient into the correct path to oral health. At first it was a little difficult to explain the process of
NSPT and why things should be done to progress through health, but as time went on it became
easier and more natural to explain why we floss, and why it would be good to incorporate mouth
rinse with a waterflosser. Some areas I do feel as though I was not able to fulfill the patient’s
needs. I realize that some OHI I could have talked about such as Biotene use or using better
visual aids by using a typodont could have better helped the patient understand their oral self-
care. However, there is always room for improvement and with time I will be able to incorporate
more OHI in the future to better assist my patients. With this in mind, I will continue to apply
new ways to assist my patients in the future and research new products to help allow my
application of education grow in the future.
My intentions and expectations were met by being able to understand and practice the
instruments that were new to use. It allowed me to develop better skills to help with future
patients and to eventually pass my mini mock board on another difficult patient.
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During the course of the treatment my patient had experience some behavioral changes. The
patient was attentive and understanding on what it meant to upkeep their oral health. My patient
developed a more positive attitude towards their oral health, and it showed during the
reevaluation.
All in all, the patient allowed me to carry on an abundant of skills to apply in the future. For
next semester I will apply my use of Periofiles in order to break up calculus easier as well as
having a better understanding of accessing deeper pockets with instruments. Not only will my
technical skills be put to use, but I will apply my patient care skills to better communicate and
educate my patients better to prep them for success in the future.

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Appendix
Appendix A
SUBJECTIVE
50 yr. old male presents to clinic for hygiene services
CC: None at this time
MED HX:
-patient presents with type 2 diabetes, diagnosed 10 years ago.
-Patient states most updated HBA1C is 6.3 that was taken 9/11/23
-patient experiences high blood pressure.
-Patient has had a left shoulder full replacement(2019). Experiences chronic pain. Discussed with
Dr.Greene, Dr. Greene stated no premed is needed since it has been over two years.
-patient takes phentermine (2 years)
-Patient smokes cigarettes on off, one pack a day. Patient does not remember how long they have
been smoking, interested in smoking cessation.
-patient experiences dry mouth.
-Patient experiences GERD.

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DENTAL HX:
-patient has tooth sensitivity to cold and experiences dry mouth.
-last dental visit was 5-6 years ago.
-patient has had past dental work done( root canal, restorations, and tooth extractions).
ALLERGIES:
-seasonal
MEDICATIONS: (mg., dosage, side effects)
Diabetes:
-Trulicity: 3mg(.5mL) injected once weekly
-Jardiance: 25mg TAB PO QD, may cause orthostatic hypotension/ dizziness.
-pioglitazone HCL: 30mg TAB PO QD: caution with stress-induced hypoglycemia.
Weight loss:
-phentermine: 37.5mg TAB PO QD, caution with vasoconstrictors constriction and monitor blood
pressure.
-Topiramate: 100mg TAB PO twice daily: may cause dysgeusia, Xerostomia, and gingival
hemorrhage.
-hydrochlorothiazide: 12.5mg TAB PO QD, helps with water retention, may cause orthostatic
hypotension.
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Acid reflux:
-Omeprazole DR: 20mg 1 TAB PO QD: may cause taste perversion, dry mouth, esophageal
candidiasis, stomatitis, and mucosal atrophy.
Cholesterol:
-atorvastatin: 10mg TAB PO QD, may cause myopathy and muscle weakness, making it difficult to
brush.
Sleep:
-Doxepin: 10mg TAB PO QD: (TCA)caution with vasoconstrictors, may cause Xerostomia, unpleasant
taste, apthous stomatitis.
Other medications:
-Aspirin: 81mg TAB PO QD- Patient stated it was recommended to take as preventative for heart due
to medications and known history of high BP.
-Centrum silver: OTC multi vitamin, 1 TAB PO QD
-magnesium: 400mg 1TAB PO QD for muscle pain.
__________________________________________________________________________
OBJECTIVE
(8/31)
Vitals: BP 120/78 mm Hg (slightly elevated), Pulse: 88bpm, Respirations: 20 rpm
Glucose:130 mg/dL before 9 this morning

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(9/14)
Bp: 120/78 mm Hg, glucose: 135 mg/dL ate last night.
(9/19)
BP: 130/80mm/Hg (Stage 1) Glucose: 109 mg/dL ate at 9 this morning
(9/21)
BP: 125/80 mmgHg (Stage 1) Glucose: 154 mg/dL ate around 1 oclock
(9/25)
BP: 130/80 (Stage 1) Glucose: 128mg/dL ate around 1 o'clock
(10/3)
BP: 130/80 (stage 1)
Glucose: 140 mg/dL ate around 11 am
(10/5)
BP: 130/80mmHg (stage 1)
Glucose: ate at 10:30 am, 133 mg dL
(10/10)
BP: 120/78 mmHg (elevated)
Glucose: ate at 4pm, 154mg/dL
(10/30)
BP: 130/80mmHG (stage 1)

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BPM:86
RPM: 18
Glucose: 128mg/dL last ate around 11o'clock
ASA Classification:
ASA 2
PROCEDURAL START: A Saban,RDH
PARQ: Patient’s questions have been addressed; patient consents to Radiographs, Panoramic, and
limited eval.
(9/14)
Patient consents to NSPT 4341 all quads, irrigation, and chlorhexidine rinse.
EOIO EXAMINATION: (ABCDT format) and Sleep Apnea assessment
(done on 8/31)
E/O:
-4x7 bilateral brown patch lesion posterior to ears. Patient was unaware, will continue to monitor.
- 1x1 scattered brown papule lesions on lower neck indicative of a skin tags. Patient is aware of
lesions.
I/O:
-1x1 hard pale pink papule lesion on gingiva below central incisors.
-Nicotine stomatitis on hard palate
-coated tongue
-1x1 scattered areas of flat erythema lesion on left buccal mucosa indicative of cheek biting.
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-Leukoplakia between 3 and 5.
(10/5)
-2x3 leukoplakia well demarcated on Right bucal mucosa indicative of a cheek bite. Pt stated to have
bitten his cheek on monday.
-Leukoplakia between tooth 3 and 5 has gone down.
(10/10)
-lesion on the right buccal mucosa has gone away.
Follow up EOIO EXAMINATION: (10/30)
-Nicotonic stomatitis has decreased significantly.
-1x1 well circumscribed ulcerated erythema indicative of a cheek bite.
MALLAMPATI SCORE:
-Patient presented with a malampati score of 3.
GINGIVAL DESCRIPTION:
-Gingiva is generally pale pink and red and has a spongy and shiny texture. Margins are slightly rolled
and edematous in sextant 5. Papilla is generally blunted.
(10/30)
patients gingiva was generally pink and firm with stippling and localized blunting of papilla and
slightly red gingiva in sextant 5.

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Gingival biotype and Mucogingival conditions
Gingival biotype: Thick
Vestibular height: Normal
Mucogingival conditions: N/A
Aberrant frenum attachments: N/A
HARD TISSUE FINDINGS:
NSF
OCCLUSION:
-Bilateral class I with edge to edge bite.
-Overjet is not in normal limits (4mm)
-fremitus on 7,9, and 10
RADIOGRAPHS:
Rx by: Dr .Greene
Processed by: Jacob de Werd
Type/Number of Images: 23
63 KvP 0.8 mA 0.8 Seconds
Pano
70 KvP 10 mA 9.0 Seconds
(9/14/23)
Type/Number of Images: 1 BWX and 3 PA retakes were done

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DENTIST EXAM: Dentist exam completed by Dr. Huffman, Dr. Huffman stated NSF.
__________________________________________________________________________
RISKS ASSESSEMENTS
HEALTH HISTORY:
-Smoke 1 pack of cigarettes a day.
-type 2 diabetic
CARIES:
CAMBRA risk assessment indicated patient is high risk for caries.
-recommended biotene or all day spray to help with xerostomia
PERIODONTAL SUMMARY STATEMENT:
-patient presented with Periodontitis Stage III with generalized distribution of Grade C with a rapid
rate of progression.
DENTAL HYGIENE DIAGNOSIS:
-Patient presents with BOP due to biofilm and calculus accumulation
CALCULUS:
-Patient presents with generalized moderate calculus with localized heavy in sextant 5 (60%).
BIOFILM:
-patient presented with heavy biofilm accumulation (80%)
HUMAN NEEDS: Needs (met/notmet/partial)why?
Protection from Health Risks- partially met. Patient still has one or two cigarettes a week.
Freedom from Fear and Stress- Need is met

25
Freedom from Head and Neck Pain- Patient is partially met. Patient still has some signs of
discomfort when probing.
Wholesome Facial Image- need is met.
Skin and Mucous Membrane Integrity of the Head and Neck-
Need was partially met. Patient presented with BOP and some pocketing.
Biologically Sound and Functional Dentition- Need is not met. Patient still has not found a dental
home and shows some signs of mobility.
Conceptualization and Problem Solving- Need is partially met. Patient has a better understanding of
the disease process, but does not fully understand techniques to disrupt and remove biofilm (charter
technique and missed areas on the linguals of teeth)
Responsibility for Oral Health- Patient has partially met. Patient is taking more responsibility for oral
health, but still continues to smoke and has not found a dental home.
__________________________________________________________________________
PROCEDURES
PERIODONTAL EVALUATION:
Full probing in patients chart.
(10/30)
updated probe readings: patient has generalized gains and reduced pocketing.
DENTAL HYGIENE TX:
Reevaluated patients health with probing and gingival description. Patient presented with a more
stable periodontium with the exception of the distal of tooth 19. Retreatment was done on tooth 19
and arrestin (1mg) was applied to the active site (19D)
All teeth treated to completion. Using universal curette, anterior Gracey, and anterior sickle scaler
polished with CPR prophy paste.

26
OHI:
-explained to patient the importance of continuing self care and 3 month recare appointments.
-explained arrestin and the effects it has on the bacteria.
__________________________________________________________________________
PLANS
POST OP:
- No flossing/ water flossing in the area arrestin was applied for 7-10 days.
NV:
-3 month recare appointment

27
Appendix B
28
Appendix C
29
Appendix D
30
Appendix E
Appendix F
31
32
Appendix F-2
33
Appendix F-3
Upper left molars

34
Appendix F-4
35
Appendix G
36
Appendix H
37
Appendix I
38
Appendix J
39
Appendix K
SUBJECTIVE
50 yr. old male presents to clinic for hygiene services
CC: None at this time
MED HX:
-patient presents with type 2 diabetes, diagnosed 10 years ago.
-Patient states most updated HBA1C is 6.3 that was taken 9/11/23
-patient experiences high blood pressure.
-Patient has had a left shoulder full replacement(2019). Experiences chronic pain. Discussed with
Dr.Greene, Dr. Greene stated no premed is needed since it has been over two years.
-patient takes phentermine (2 years)
-Patient smokes cigarettes on off, one pack a day. Patient does not remember how long they have
been smoking, interested in smoking cessation.
-patient experiences dry mouth.
-Patient experiences GERD.

40
DENTAL HX:
-patient has tooth sensitivity to cold and experiences dry mouth.
-last dental visit was 5-6 years ago.
-patient has had past dental work done( root canal, restorations, and tooth extractions).
ALLERGIES:
-seasonal
MEDICATIONS: (mg., dosage, side effects)
Diabetes:
-Trulicity: 3mg(.5mL) injected once weekly
-Jardiance: 25mg TAB PO QD, may cause orthostatic hypotension/ dizziness.
-pioglitazone HCL: 30mg TAB PO QD: caution with stress-induced hypoglycemia.
Weight loss:
-phentermine: 37.5mg TAB PO QD, caution with vasoconstrictors constriction and monitor blood
pressure.
-Topiramate: 100mg TAB PO twice daily: may cause dysgeusia, Xerostomia, and gingival
hemorrhage.
-hydrochlorothiazide: 12.5mg TAB PO QD, helps with water retention, may cause orthostatic
hypotension.
41
Acid reflux:
-Omeprazole DR: 20mg 1 TAB PO QD: may cause taste perversion, dry mouth, esophageal
candidiasis, stomatitis, and mucosal atrophy.
Cholesterol:
-atorvastatin: 10mg TAB PO QD, may cause myopathy and muscle weakness, making it difficult to
brush.
Sleep:
-Doxepin: 10mg TAB PO QD: (TCA)caution with vasoconstrictors, may cause Xerostomia, unpleasant
taste, apthous stomatitis.
Other medications:
-Aspirin: 81mg TAB PO QD- Patient stated it was recommended to take as preventative for heart due
to medications and known history of high BP.
-Centrum silver: OTC multi vitamin, 1 TAB PO QD
-magnesium: 400mg 1TAB PO QD for muscle pain.
__________________________________________________________________________
OBJECTIVE
(8/31)
Vitals: BP 120/78 mm Hg (slightly elevated), Pulse: 88bpm, Respirations: 20 rpm
Glucose:130 mg/dL before 9 this morning

42
(9/14)
Bp: 120/78 mm Hg, glucose: 135 mg/dL ate last night.
(9/19)
BP: 130/80mm/Hg (Stage 1) Glucose: 109 mg/dL ate at 9 this morning
(9/21)
BP: 125/80 mmgHg (Stage 1) Glucose: 154 mg/dL ate around 1 oclock
(9/25)
BP: 130/80 (Stage 1) Glucose: 128mg/dL ate around 1 o'clock
(10/3)
BP: 130/80 (stage 1)
Glucose: 140 mg/dL ate around 11 am
(10/5)
BP: 130/80mmHg (stage 1)
Glucose: ate at 10:30 am, 133 mg dL
(10/10)
BP: 120/78 mmHg (elevated)
Glucose: ate at 4pm, 154mg/dL
(10/30)
BP: 130/80mmHG (stage 1)

43
BPM:86
RPM: 18
Glucose: 128mg/dL last ate around 11o'clock
ASA Classification:
ASA 2
PROCEDURAL START: A Saban,RDH
PARQ: Patient’s questions have been addressed; patient consents to Radiographs, Panoramic, and
limited eval.
(9/14)
Patient consents to NSPT 4341 all quads, irrigation, and chlorhexidine rinse.
EOIO EXAMINATION: (ABCDT format) and Sleep Apnea assessment
(done on 8/31)
E/O:
-4x7 bilateral brown patch lesion posterior to ears. Patient was unaware, will continue to monitor.
- 1x1 scattered brown papule lesions on lower neck indicative of a skin tags. Patient is aware of
lesions.
I/O:
-1x1 hard pale pink papule lesion on gingiva below central incisors.
-Nicotine stomatitis on hard palate
-coated tongue
-1x1 scattered areas of flat erythema lesion on left buccal mucosa indicative of cheek biting.
44
-Leukoplakia between 3 and 5.
(10/5)
-2x3 leukoplakia well demarcated on Right bucal mucosa indicative of a cheek bite. Pt stated to have
bitten his cheek on monday.
-Leukoplakia between tooth 3 and 5 has gone down.
(10/10)
-lesion on the right buccal mucosa has gone away.
Follow up EOIO EXAMINATION: (10/30)
-Nicotonic stomatitis has decreased significantly.
-1x1 well circumscribed ulcerated erythema indicative of a cheek bite.
MALLAMPATI SCORE:
-Patient presented with a malampati score of 3.
GINGIVAL DESCRIPTION:
-Gingiva is generally pale pink and red and has a spongy and shiny texture. Margins are slightly rolled
and edematous in sextant 5. Papilla is generally blunted.
(10/30)
patients gingiva was generally pink and firm with stippling and localized blunting of papilla and
slightly red gingiva in sextant 5.

45
Gingival biotype and Mucogingival conditions
Gingival biotype: Thick
Vestibular height: Normal
Mucogingival conditions: N/A
Aberrant frenum attachments: N/A
HARD TISSUE FINDINGS:
NSF
OCCLUSION:
-Bilateral class I with edge to edge bite.
-Overjet is not in normal limits (4mm)
-fremitus on 7,9, and 10
RADIOGRAPHS:
Rx by: Dr .Greene
Processed by: Jacob de Werd
Type/Number of Images: 23
Pano
70 KvP 10 mA 9.0 Seconds
(9/14/23)
Type/Number of Images: 1 BWX and 3 PA retakes were done

46
DENTIST EXAM: Dentist exam completed by Dr. Huffman, Dr. Huffman stated NSF.
__________________________________________________________________________
RISKS ASSESSEMENTS
HEALTH HISTORY:
-Smoke 1 pack of cigarettes a day.
-type 2 diabetic
CARIES:
CAMBRA risk assessment indicated patient is high risk for caries.
-recommended biotene or all day spray to help with xerostomia
PERIODONTAL SUMMARY STATEMENT:
-patient presented with Periodontitis Stage III with generalized distribution of Grade C with a rapid
rate of progression.
DENTAL HYGIENE DIAGNOSIS:
-Patient presents with BOP due to biofilm and calculus accumulation
CALCULUS:
-Patient presents with generalized moderate calculus with localized heavy in sextant 5 (60%).
BIOFILM:
-patient presented with heavy biofilm accumulation (80%)
HUMAN NEEDS: Needs (met/notmet/partial)why?
Protection from Health Risks- partially met. Patient still has one or two cigarettes a week.
Freedom from Fear and Stress- Need is met

47
Freedom from Head and Neck Pain- Patient is partially met. Patient still has some signs of
discomfort when probing.
Wholesome Facial Image- need is met.
Skin and Mucous Membrane Integrity of the Head and Neck-
Need was partially met. Patient presented with BOP and some pocketing.
Biologically Sound and Functional Dentition- Need is not met. Patient still has not found a dental
home and shows some signs of mobility.
Conceptualization and Problem Solving- Need is partially met. Patient has a better understanding of
the disease process, but does not fully understand techniques to disrupt and remove biofilm (charter
technique and missed areas on the linguals of teeth)
Responsibility for Oral Health- Patient has partially met. Patient is taking more responsibility for oral
health, but still continues to smoke and has not found a dental home.
__________________________________________________________________________
PROCEDURES
PERIODONTAL EVALUATION:
Full probing in patients chart.
(10/30)
updated probe readings: patient has generalized gains and reduced pocketing.
DENTAL HYGIENE TX:
Reevaluated patients health with probing and gingival description. Patient presented with a more
stable periodontium with the exception of the distal of tooth 19. Retreatment was done on tooth 19
and arrestin (1mg) was applied to the active site (19D)
All teeth treated to completion. Using universal curette, anterior Gracey, and anterior sickle scaler
polished with CPR prophy paste.

48
OHI:
-explained to patient the importance of continuing self care and 3 month recare appointments.
-explained arrestin and the effects it has on the bacteria.
__________________________________________________________________________
PLANS
POST OP:
- No flossing/ water flossing in the area arrestin was applied for 7-10 days.
NV:
-3 month recare appointment
Jde Werd/SDH
49
Appendix L
50
Appendix M
51
52
Appendix N
53
References
Javali, M. A., Betsy, J., Al Thobaiti, R. S. S., Alshahrani, R. A., & AlQahtani, H. A. H. (2020).
Relationship between Malocclusion and Periodontal Disease in Patients Seeking
Orthodontic Treatment in Southwestern Saudi Arabia. Saudi journal of medicine &
medical sciences, 8(2), 133–139. https://doi.org/10.4103/sjmms.sjmms_135_19

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1

Case study- Fall semester 2023

Case study- Fall semester 2023

Mesa Community College Dental Hygiene Program

Department of dental hygiene, Mesa Community College

DHE 212: Theory II

Professor Dawn Brause

November 12, 2023

phentermine, topiramate, hydrocholorothiazide. For acidreflux/GERD the patient was taking

mm Hg (slightly elevated), Pulse: 88bpm, Respirations: 20 rpm. Glucose:130 mg/dL before 9

and being under the care of a physician (Appendix A).

root canal therapy on teeth 12 and 19 (Appendix A, B, E).

the lesions were monitored and had lessen or resolved.

thick bio type with a normal vestibular height.

presented with signs of fremitus on teeth 7, 9, and 10 (Appendix A, F).

Radiographic examination was completed by Dr. Huffman examined radiographs and no

of horizontal bone loss (20%). Additionally, radiographs confirmed restorations to be porcelain

Oral hygiene examination

pertaining to sextant 5 and lower quadrants. (Appendix H, F-4).

Human needs Theory

Dental Hygiene Diagnosis and Treatment Plan

level 3 alternative. It was recommended anesthetic to be administered as well as the use of

periofiles and langers due to the depth of pockets.

Patient education and Oral Hygiene instructions.

biofilm accumulation (Appendix J).

Implementation of Treatment Plan

and irrigate with chlorhexidine (9630) (Appendix J).

and was then given OHI on how to use the toothbrush.

treatment well and had no adverse reactions.

was present on the left buccal mucosa.

bleeding indicating an active disease sight (Appendix N).

have a 3–4-month supportive care appointment.

irregularity of tooth position and overhanging/ill-fitting dental restorations, could lead to

periodontal destruction (Javali et al, 2020).” This is important as hygienists to be mindful of

patients to be able to better remove plaque accumulation. Additionally, it allows hygienists to

upkeep oral health.

success with them later on.

application of education grow in the future.

educate my patients better to prep them for success in the future.

50 yr. old male presents to clinic for hygiene services

CC: None at this time

-patient presents with type 2 diabetes, diagnosed 10 years ago.

-patient experiences high blood pressure.

-patient takes phentermine (2 years)

been smoking, interested in smoking cessation.

-patient experiences dry mouth.

-Patient experiences GERD.

-patient has tooth sensitivity to cold and experiences dry mouth.

-last dental visit was 5-6 years ago.

MEDICATIONS: (mg., dosage, side effects)

-Trulicity: 3mg(.5mL) injected once weekly

-Jardiance: 25mg TAB PO QD, may cause orthostatic hypotension/ dizziness.

-pioglitazone HCL: 30mg TAB PO QD: caution with stress-induced hypoglycemia.

candidiasis, stomatitis, and mucosal atrophy.

taste, apthous stomatitis.

to medications and known history of high BP.

-Centrum silver: OTC multi vitamin, 1 TAB PO QD

-magnesium: 400mg 1TAB PO QD for muscle pain.

Vitals: BP 120/78 mm Hg (slightly elevated), Pulse: 88bpm, Respirations: 20 rpm