1

Case Study: Spring Semester 2023

Myah Young
MCC Dental Hygiene Program
DHE 132: Dental Hygiene Theory I
Sheba Jones, RDH, MSDH, AP
April 17, 2023
2

Case Study: Spring Semester 2023

Case Report:
A 24-year-old male presented to the Arizona School of Dentistry and Oral Health clinic
for dental hygiene assessments and treatment. The patient’s chief concern was stated “My front
bottom teeth are yellowing” (see appendix A). After assessing the patient’s health history, it was
determined that the patient normally schedules six-month interval prophylaxis appointments but
is a little behind with the last dental visit being in June of 2022. By completing clinical
assessment forms at the beginning of the appointment, patient findings included no history of
tobacco use while the CAMBRA assessment form indicated moderate caries risk due to visible
plaque, exposed root surfaces, and medication that causes xerostomia (see appendix D). Overall,
the patient has moderate oral hygiene care with a routine of brushing twice a day and only
flossing every so often. This patient was chosen for this case study as his sequence of
appointments brought on many challenging and complex aspects which lead to several learning
experiences.

Medical History:
After reviewing the patient’s medical history, findings included having asthma as a child
and a severe tree nut allergy. The patient no longer carries an albuterol inhaler, as his asthma has
since dissipated. A red flag warning was placed on his chart for his tree nut allergy and included
a note stating that his allergic reaction causes the closing of the throat and as such an allergen
contact would be fatal. It was also noted that the patient does carry an epi pen, were a medical
emergency to occur. The only current medication the patient is taking is a daily dose of
doxycycline for the treatment of acne. Oral considerations for this prescription include the
occurrence of xerostomia, nasal congestion, sinusitis, and nasopharyngitis. After taking vitals
such as blood pressure, respirations, pulse, and blood glucose levels, the patient was found to be
in the normal range in all readings. The patient’s blood pressure read 115/75 mmHg with
respirations being 14 rpm and a pulse of 62 bpm. Lastly, the patient had a blood glucose level of
3

113 mg/dL. Because of the patient’s tree nut allergy, he was classified as an ASA II.
(see appendix A and B)

Dental History:
Patient presented with existing restorations on quadrant’s I and II consisting of a sealant
on #3 and lingual resin composite fillings on #7 and #10 (see appendix H). Patient had
orthodontics removed at 15 years old and has not experienced any shifting of his teeth as he
wears his upper and lower retainers regularly at night. The patient estimated having a wisdom
tooth extraction at around 17 years old, with all maxillary and mandibular third molars being
removed. On his health history form, the patient noted having periodical cold sensitivity on all
teeth, but predominately on his lower right teeth. As the patient recorded on his health history the
desire to have whiter teeth and the consistent use of white strips, this could be contributing to his
tooth sensitivity. The patient was educated on the effects whitening products have on causing
tooth sensitivity. When discussing oral hygiene care, the patient stated using a manual toothbrush
twice daily, flossing two to three times per week, and using a mouth rinse each morning.
Something noted was that the patient has never had fluoride varnish paste, and typically uses non
fluoridated toothpaste.

Nutritional Clinical Counseling:

Nutritional clinical counseling was provided for this patient, and any correlations
between his oral health and nutritional intake were discussed. After obtaining a three-day food
diary, it was found that this patient lacks in vitamin D, vitamin A, and calcium intake due to a
distaste for all dairy products (see appendix J). Because he currently has localized gingivitis, we
discussed the importance of vitamin A as an antioxidant in maintaining and protecting the
epithelial tissue by improving immune function in order to prevent gum infections. Next, it was
relayed how vitamin D and calcium play a huge role in tooth mineralization and alveolar bone
strength. As someone who has localized gum recession, cold sensitivity, attrition, bruxism, and
slight bone loss, maintaining strong calcified teeth and alveolar bone the best he can is of utmost
4

importance for this patient.

Clinical Assessments:
After performing an extraoral and intraoral examination on the patient, there were several
significant findings (see appendix A and B). Extraorally the patient presented with a moveable
nodule measuring 6mm on the right side of the jaw under the patient’s chin. While this nodule
was challenging to feel, with help from faculty, a tactic was shown how to effectively feel for
nodules by using a scoop method under the patient’s chin when undergoing an extraoral
examination. Intraorally, the patient presented with a burn on the right side of his hard palate.
After discussing this finding with the patient, it was concluded that it may have occurred by
drinking hot coffee. The patient presented with bilateral linea alba and slight mandibular tori on
the ride side of his mouth (see appendix A). Faculty aided in pointing out a small tissue tag on
the patient’s upper labial frenum attachment. Lastly, the patient presented with a well
circumscribed leukoplakic papule measuring 2x2 mm on the distal interdental papilla of #27. An
intraoral photo was taken for documentation purposes (see appendix F). Because the patient was
seen in one week, the recommendation was made to visit his regular dentist if the lesion did not
dissipate in two weeks. It was determined that the patient has a mallampati score of III, which
explains his struggle with snoring. After reviewing occlusion, it was confirmed that the patient
has bilateral class I malocclusion and an anterior edge to edge bite. During this examination,
attrition on his lower anterior teeth was also noted (see appendix F). While the patient does wear
a nightguard at night, the possibility of clenching and grinding throughout the day was also
discussed. To prevent further attrition, wearing his nightguard during the day when he notices an
increase in bruxism was recommended.

Periodontal Examination:
The patient presented with generalized coral pink marginal gingiva that tapered slightly
coronal to the CEJ. There was some localized areas of apical migration of the marginal gingiva,
contributing to recession. The attached gingiva was generalized firm and stippled, and the
5

interdental papilla showed generalized signs of health as they were pointed and filled the
embrasure spaces (see appendix A). Periodontal charting was completed on all quadrants (see
appendix G). The patient presented with generalized 1-3mm periodontal pocket depths with
localized 4mm readings, bleeding upon probing, and 1-3mm recession readings on almost all
buccal surfaces of the patient’s molars and premolars. Because of all the exposed dentin from the
areas of recession, it was discussed with the patient how this may be contributing to his tooth
sensitivity and how fluoride varnish may help in mineralizing these areas in order to reduce the
sensitivity. While there was no mobility present, faculty helped in identifying a class I furcation
on the buccal surface of #19. (see appendix G)

Radiographic Examination and Screening Exam:

In the process of completing treatment, Dr. Huffman came in for a screening exam and
started with a radiographic examination of the patient’s full mouth series of radiographs and
panoramic that were taken at the first appointment of this sequence of appointments (see
appendix E). Hard tissue findings were communicated to the dentist such as a small chip on the
mesial incisal surface of #8 and staining on the distal of #2, and occlusal staining on the occlusal
surfaces of #14 and #15. Also, bone loss was pointed out on the radiographic images of the
mandibular anterior teeth and was concluded to be due to attrition and bruxism. By reviewing the
radiographs, Dr. Huffman diagnosed caries on #14 OL, #20 OL, #3 OL, #15 OL, and #18 O and
filled out a referral form for the patient to take to his regular dentist to have the decay restored. In
response to the patient’s recession on #28 and #29, Dr. Huffman recommended class 5 facial
fillings on the buccal surfaces of both teeth and wrote that on the referral form as well. He also
recommended the use of a desensitizing product to be placed on #28 and #29 when scaling in
future appointments. Since treatment was already completed on this quadrant, a note was made
to apply such as product in future appointments. Lastly, Dr. Huffman put a watch on a
radiolucent region on the mesial of #21. (see appendix E and H)
6

Oral Hygiene Examination:

As part of the sequence of assessments, the oral hygiene assessments of biofilm and
calculus detection were performed (see appendix I). The disclosing solution Hurriview 2 was
used on all quadrants in order to assess the areas of the teeth that had biofilm accumulation. After
making the appropriate calculations, it was determined that the patient had an O’Leary plaque
score of 20%. Because there was a moderate amount of biofilm accumulation, the results were
discussed and viewed using a mirror with the patient in order to educate him on areas he is
missing the most with his toothbrush and the proper oral hygiene care to prevent it. In his care
plan, a goal was made to reduce the percentage to 10% (see appendix B). Then, an explorer
instrument was used in order to detect areas of calculus present in all quadrants. The patient was
concluded to be a Level 1(see appendix C), as localized areas of roughness were detected and
there was moderate calculus buildup on the lingual surfaces of sextant #5. (see appendix I)

Dental Hygiene Diagnosis and Treatment Plan:

After all assessments were completed, the information accumulated was used to create a
proper care plan specific to the patient’s needs (see appendix B). The periodontal summary
statement concluded to be localized gingivitis case infection on reduced periodontium. The
dental hygiene diagnosis stated that the patient presents with localized gingival bleeding upon
probing due to biofilm and calculus accumulation. The treatment plan for this patient consisted
of an adult prophylaxis in order to remove biofilm and calculus. Treatment was to be started on
quadrants #1 and #4, and then move unto quadrants #2 and #3. The anticipated outcome for this
treatment plan was the reduction of gingival inflammation through the removal of biofilm and
calculus in order to obtain healthy 1-3mm probe depths and reduced bleeding upon probing. The
universal curette, Gracey curettes, explorer, and sickle scalers were planned to be used in order
to remove biofilm and calculus. To conclude the treatment plan would be polishing and flossing.
Fluoride varnish was also added to the treatment plan to help with tooth sensitivity and
mineralization since this patient is susceptible to caries. After going over the treatment plan, and
reasonings behind it, the patient gave consent with a signature. (see appendix B)
7

Patient Education and Oral Hygiene Instructions:

Due to high amounts of biofilm and calculus buildup as well as gingival inflammation,
proper and efficient methods of oral hygiene care were discussed with the patient. The use of a
electronic toothbrush such as a Philips Sonicare was highly recommended in order to best
remove biofilm buildup as well as the use of a Waterpik which will help to better clean the
interproximal spaces that are harder to reach for this patient. These methods will aid the patient
in a reduced accumulation of calculus formation throughout their oral cavity. It was also
discussed with the patient the importance of keeping a 6 month recall prophylaxis appointment
with their dental office in order to prevent the prolonged accumulation of biofilm and calculus,
which can contribute to acquiring gingivitis and caries. Lastly, the many benefits of fluoride
were discussed with the patient, especially in the treatment of tooth sensitivity and prevention of
future areas of decay.

Implementation of Treatment Plan:

Starting on quadrant #1, an adult prophylaxis was performed using all instruments
discussed in the treatment plan. The posterior sickle scaler was found very effective and useful in
removing the more tenacious calculus from the distals of the second molars. Because it was very
difficult for this patient to keep his mouth open, faculty recommended the use of a bite block in
order to provide relief for both the patient and clinician. While it was an adjustment learning how
to provide treatment on a patient that struggles with keeping their mouth open, the use of a bite
block was found to be extremely beneficial. Both the debridement stroke and the calculus
removal stroke were used during the prophylaxis, and while two nights of treatment were
originally in the treatment plan, all four quadrants were completed in one night. The explorer
was used throughout this process in order to confirm that the calculus was being removed.
Polishing, flossing, and application of fluoride varnish concluded the appointment sequence.
(see appendix B)
8

Evaluation of Treatment:
With completion of treatment and the confirmation from faculty that all calculus and
biofilm was removed, the patient was very pleased to have his whole cleaning completed in one
night. While removing the subgingival calculus was a challenge, because of the use of proper
angulation and instrumentation, no burnishing of calculus or tissue trauma occurred. All aspects
of the standard of care were followed throughout his appointments, and as such the patient felt
comfortable and confident in the abilities of the clinician. Although the longer appointments and
having to keep his mouth open for long periods of time was challenging for the patient, the use
of a bite block and intermediate breaks provided ease and relief at all times. With the removal of
biofilm and calculus and education on proper oral hygiene habits, it is hoped that the patient will
notice a reduction in gingival inflammation in the near future. From the nutritional counseling to
the diagnosis of caries, the patient gained a better understanding of all the factors that contribute
to the maintenance of his oral health.

Reflective Conclusion:
Writing this case study reminded me of when I wrote my first case study, just one
semester ago! Yet within that short period of time, my skills and abilities as a clinician have
grown immensely. While I have had to push myself through many challenges along the way, it
has provided me with so many learning experiences. Each of which have made me a better
clinician. I chose to write my case study on this patient because around the time I was seeing him
in clinic, I was struggling with confidence and doubting my skills both in time management and
calculus removal. As this sequence of appointments was right in the middle of the semester, I
was really hoping to see improvement in completing my patients at a quicker pace. Because this
patient had a short attention span and the habit of closing his mouth in the middle of treatment,
being able to meet my goals seemed nearly impossible. But, instead of seeing these challenges as
a negative thing, I decided to use it as motivation to complete this patient as efficiently as my
abilities would allow both for his case and mine. And low and behold, with encouragement from
faculty and remaining focused with the task in front of me, I was able to complete treatment on
9

all four quadrants in one night. Not only did I improve my time management, but I learned how
to be more flexible and adaptable with my patient’s needs, which I know will serve me greatly in
the future. While time management and flexibility were a strength of mine, I also had many
moments of learning from my mistakes. One that stood out to me was missing several areas on
his teeth when charting for recession. Fortunately, with guidance from faculty I learned methods
to more accurately examine for recession such as using my explorer to feel for the location of the
CEJ. Overall, I obtained many new skills and learning experiences while providing dental
hygiene care to this patient. In my time at clinic this semester, I gained the hindsight that every
patient will present their own specific needs and a different status in their oral health, which will
only further grow me in my path to becoming a dental hygienist in the upcoming semesters.