CASE STUDY 1

Case Study Paper

by

Rahel Mitiku

In partial fulfillment of the requirements for

Seattle Central College Dental Hygiene Program

DHY 402: Advanced Practicum in Dental Hygiene III

Mrs. Agatha Stavnesli, RDH, MSDH

Spring Quarter (Q8)

April 28, 2024

CASE STUDY 2

Case Study Paper

I Patient Information

Patient was 61 years old, female. She moved to the United States from Colombia a few

years ago. Patient reported no chief concern. The main reason for the visit was for initial

treatment and to establish care. Patients’ first language was Spanish, but we were able to

communicate in English throughout the treatment without an interpreter. Patient’s ASA

classification was class II due to the controlled medical conditions with medications. The most

current blood pressure was 116/72 mmHg, but it fluctuated between 116-128/72-80. Pulse was

83 bpm and respiration were 16 bpm. Patient weight was 180lb and her height was 5’2”. Body

mass index was 32.92.

Patients’ medical conditions were type 2 diabetes, hypertension, calculus of both

kidneys, small bowel obstruction, and incarcerated umbilical hernia. The most current HBA1C

was 6.6. Past medical history showed recurrent nephrolithiasis. Past surgical history was

appendectomy, bilateral breast implant, combined augmentation mammaplasty and

abdominoplasty, cystoscopy w/ureteroscopy w/lithotripsy, kidney stone surgery, lithotripsy,

ureteral stent placement. Family medical history include hypertension, Alzheimer’s disease,

melanoma, and colon cancer.

Current medications were atorvastatin (LIPITOR) 40mg tablet take 1 by mouth every

evening for high cholesterol, lisinopriL (PRINIVIL, ZESTRIL) 10mg tablet take 1 by mouth

once daily for high blood pressure, metFORMIN 500mg tablet take 1 by mouth two times a day

with meals for diabetes. Patients with type 2 diabetes and hypertension are at the higher risk for

periodontal disease and caries (Boyd et al., 2020). Type 2 diabetes can also cause poor wound
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healing after major periodontal treatment (Preshaw et al., 2012). The medications could also

cause xerostomia (Macedo et al., 2014).

Patient privacy and HIPAA compliance was maintained by making sure to close EPIC

chart note when a clinician was not in the operatory. All the intraoral photos were taken by only

capturing the oral cavity to ensure the privacy of the patient. I also did not discuss patients’

treatment plan with classmate or instructor unless it was intended for educational purposes or in

the best interest of the patient.

II Clinical Assessment

Patient reported her last dental exam was around five years ago. Snaking habit was

occasionally snack with chocolate and peanuts. Both right and left side occlusions for molar and

canine relations was class I. Overbite was 50% or moderate. Overjet was 6mm. No open bite and

no crossbite. Occlusal wear was localized moderate on the anterior. Overall assessment of dental

caries risk was moderate due to the presence of caries limited to enamel, interproximal

restoration more than one, presence of exposed root surfaces, visible plaque, snacking habit, and

restorations with poorly contoured margins.

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EO exam findings include bilateral submandibular lymph node and patient reported no

seasonal allergy and no pain, SCAR – 12x2mm located on the left side of the neck- patient

reported no pain and it is due to a surgical procedure that was done about 33 years ago, no

referral needed, and will monitor every visit. IO exam findings include short attachment of upper

labial frenum, scalloped tongue, slight bilateral linea alba, and tonsils are present. GD exam

findings were generalized unhealthy, generalized moderate pink color, localized slight

inflammation, and blunted papilla on the lower anterior, generalized slight rolled margins with

localized moderate rolled margins on sextant 5 buccal, generalized soft and spongy consistency,

localized slight stippling on anterior buccal, localized 1mm recession on molars and 2mm on #19

buccal.

SCAR (arrow)

Current dental restorations are in a fair condition. Maxillary: #1 had an existing

occlusal composite restoration, #2 is missing, #3 had an existing RCT and MOBL composite

restoration – DDS recommended porcelain crown, #4 had an existing RCT and MOD composite

restoration – DDS found mesial defective margins and recommended porcelain crown, #5 had an

existing RCT and MOD composite restoration – DDS found distal defective margins and
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recommended porcelain crown, #6 had an existing lingual composite filling and porcelain labial

veneer, #7, 8, 9, and 10 had an existing porcelain labial veneer, #11 had an existing porcelain

retainer crown, #12 was extracted and had an existed porcelain pontic or dental bridge, #13 had

an existing RCT and porcelain retainer crown, #14 had an existing DOB porcelain onlay, #15

and 16 are missing.

Mandibular: #17 is missing, #18 had an existing MODB composite restoration and a

pulp cap, #19 had an existing MODB composite restoration – DDS found asymptomatic

periapical abscess and recommended endodontic therapy, #20 had an existing DOB composite

restoration, #21 had an existing OB composite restoration, #28 had an existing DOB composite

restoration - DDS distal defective margins and recommended DO composite filling, #29 had an

existing RCT and porcelain retainer crown – DDS found asymptomatic periapical abscess and

recommended retreatment of existing RCT, #30 was extracted and had an existed porcelain

pontic or dental bridge, #31 had an existing porcelain retainer crown, #32 is missing.

The radiographic exam shows that there is a clear evidence of the periapical abscess on

#19 and 29, defective marginal restoration on #4 and 5, localized slight-moderate horizontal
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bone loss around the premolar areas, localized moderate subgingival and supragingival calculus

on the posterior teeth, missing teeth, caries extend to enamel only, different restoration including

root canal treatment, porcelain pontic, retainer crown, onlay, veneer, and composite resin fillings.

Periodontal probing depth were generalized 2-3mm with localized 4-5mm on the

posterior. There was class I furcation involvement on #19 and 31 on both buccal and lingual. No

mobility but there was localized 1mm recession on #1, 3, 14, 18, 20, 21, 31 buccal, and 2mm

recession on #19 buccal. Localized slight BOP interproximally on the posterior teeth. There was

no crowding, drifting, super-eruption, or poor/loose contacts. #1 was slightly lingually verted so

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there was marginal discrepancy between #1 and 2. AAP classification for 1999 was stage III with

calculus code 2/D2 and 2017 was stage II grade B.

Current plaque index score is 75% located on all teeth interproximally, at the cervical

third of teeth surfaces. According to patient interview and oral plaque findings, patient’s oral risk

assessment shows moderate, and her oral health motivation was an average. Self-care routine

taken at the assessment was that patient brushes twice a day using manual toothbrush and flosses

once a day using floss picks. After reviewing patient’s oral risk assessment and plaque index

score, it clearly indicates that may be patient was not spending at least 2min when brushing and

patient might not be using the proper technique of flossing and brushing. After the

comprehensive assessment, the dentist made a referral to an endodontist for the periapical

abscesses found on #19 and 29.

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III Diagnosis and Planning

The reason why I selected this patient is because some of the medical conditions

include diabetes and hypertension, which evidence show that both conditions are related to

periodontal disease (Boyd et al., 2020). The patient also has so many different dental restorations

so I thought it would a great learning experience. Treatment goals/desired outcomes are to

reduce pocket depth and BOP, complete restorative treatment plan, increase homecare quality,

reduce unhealthy snacking, reduction of inflammation and biofilm accumulation, and prevent

progression of bone loss.

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After the assessment, it was determined that the patient needed therapeutic strategy of

receiving a non-surgical periodontal therapy due to the evidence of horizontal bone loss,

attachment loss, deep pocket depths with BOP, defective restorations, and localized moderate

sub and supra gingival calculus. Therefore, the first appointment was LL NSPT – HHx/VS,

EO/IO/GD, Local anesthesia (IABL left side using 4% Articaine 1:200k epi and 20% benzocaine

topical), Periodontal assessment on LL quad, Calculus detection, Pre-polish, Cavitron, Hand

scale, Floss, PE/OHI. For the patient education, educate the patient on the relationship of

diabetes and hypertension to periodontal disease. For oral hygiene instruction, introduce to the

patient the power toothbrush technique with toothbrush suggestions.

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The second appointment was planned for LR NSPT – HHx/VS, EO/IO/GD, Local

anesthesia (IABL right side using 4% Articaine 1:200k epi and 20% benzocaine topical),

Periodontal assessment on LR quad, Calculus detection, Pre-polish, Cavitron, Hand scale, Floss,

PE/OHI. For the patient education, educate the patient on caries formation and importance of

interproximal cleaning. For oral hygiene instruction, introduce to the patient the C-shape flossing

technique with floss type suggestions.

The third appointment was planned for UL NSPT – HHx/VS, EO/IO/GD, Local

anesthesia (PSA and IO left side using 4% Articaine 1:200k epi and 20% benzocaine topical),

Periodontal assessment on UL quad, Calculus detection, Pre-polish, Cavitron, Hand scale, Floss,

PE/OHI. For the patient education, provide some nutritional counseling to address the patients

habit of snacking. For oral hygiene instruction, review homecare techniques and replace snack

with healthy once. Discuss drinking water after sugary snacking and consider introducing a water

flosser.

The fourth appointment was planned for UR NSPT – HHx/VS, EO/IO/GD, Local

anesthesia (PSA and IO right side using 4% Articaine 1:200k epi and 20% benzocaine topical),

Periodontal assessment on UR quad, Calculus detection, Pre-polish, Cavitron, Hand scale, Floss,

FlV, PE/OHI. For the patient education, educate the patient on risk and management of defective

restorations. For oral hygiene instruction, fluoride toothpaste discussion and apply fluoride

varnish to exposed root surfaces and all restorative margins.

The fifth appointment was planned for 4 weeks tissue re-evaluation – HHx/VS,

EO/IO/GD, Periodontal assessment on LL quad, Calculus detection, Pre-polish, Cavitron, Hand

scale, Floss, PE/OHI. For the patient education, educate patient on xerostomia effect and
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management. For oral hygiene instruction, discuss water hydration and introduce xylitol products

if needed in the future.

The last appointment was planned for 4-month periodontal maintenance recall –

HHx/VS, EO/IO/GD, FMPC, Calculus detection, Pre-polish, Cavitron, Hand scale, Floss, FlV,

PE/OHI. For the patient education, check on homecare quality and techniques. For oral hygiene

instruction, review homecare techniques based on findings and patient interview.

The main discussion with the patient was to complete the planned hygiene treatment

and restorative treatment. The dentist referred the patient to an endodontist to treat the periapical

abscess on #19 and 29 and stressed completing the restorative treatments for the defective

margins on the existing fillings. We also discussed the consequences of no treatment was that the

periodontal disease would progress so increased bone loss, pocket depth, inflammation, caries,

attachment loss, and eventually tooth loss.

IV Treatment Provided

The overall treatment was completed in a total of five appointments. The first

appointment was on 1/18/2024 for initial assessment; where HHx/VS, EO/IO/prelimGD, IO

Photo, PANO, FMX, FMPC/PSR, Tooth Chart, Occlusal Assessment, DHD/CP, PE/OHI, DDS

Exam, and Informed Consent was completed. On this appointment, increasing flossing and
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brushing frequency was discussed. Spending at least two minutes when brushing was also

discussed.

The second appointment was on 1/25/2024 for initial quad treatment on LL; where

HHx/VS, EO/IO/GD, Topical (20% benzocaine), LA (IABL using 4% Articaine 1: 200k epi),

PC, Calculus Detection, Pre-polish, Cavitron, Hand Scale, Floss, and PE/OHI was completed.

On this appointment, relationship of diabetes and hypertension to periodontal disease was

discussed. Power toothbrush technique was provided with power toothbrush suggestions.

The third appointment was on 2/16/2024 for second quad treatment on LR; where

HHx/VS, EO/IO/GD, Topical (20% benzocaine), LA (IABL using 4% Articaine 1: 200k epi),

PC, Calculus Detection, Pre-polish, Cavitron, Hand Scale, Floss, and PE/OHI was completed.

On this appointment, caries formation and importance of interproximal cleaning was discussed.

C-shape flossing technique was provided with floss type suggestions.

The fourth appointment was on 02/23/2024 for the third quad treatment on UL; where

HHx/VS, EO/IO/GD, Topical (20% benzocaine), LA (PSA and IO using 4% Articaine 1: 200k

epi), PC, Calculus Detection, Pre-polish, Cavitron, Hand Scale, Floss, and PE/OHI was

completed. On this appointment, some nutritional counseling to address the patient’s habit of

snacking was provided. Replacing snack with healthy ones and drinking water after sugary

snacking was discussed. Patient was also introduced to a water flosser.

On this same appointment, tissue re-evaluation was also completed on LL quad; where

GD, PC, Calculus Detection, Pre-polish, Cavitron, Hand Scale, Floss, and PE/OHI was

completed. During the tissue re-evaluation, generalized light supragingival plaque, light heme,

light stain, and reduced pocket depth with 1mm was noted. Compared to the initial periodontal
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findings, the tissue re-eval showed good and expected improvement. For patient education and

oral hygiene instruction, biofilm index and homecare technique were reviewed.

The fifth and final appointment was on 03/04/2024 for the last quad treatment on UR;

where HHx/VS, EO/IO/GD, Topical (20% benzocaine), LA (PSA and IO using 4% Articaine 1:

200k epi), PC, Calculus Detection, Cavitron, Hand Scale, Polish, Floss, FlV, Intraoral Photos,

and PE/OHI was completed. On this appointment, risk and management of defective restorations

was discussed. Fluoride varnish application and post-op instructions was provided.

V Post-Treatment Evaluation

Post-treatment intraoral photos were taken with disclosing agent applied and without

the disclosing solution. Summary of gingival description, plaque index score, probing depth,

bleeding upon probing, and patient at home oral care compliance was compared to the initial

periodontal findings and significant improvement was shown. Patient was provided with the

importance of maintaining regular four-month interval periodontal maintenance treatments.

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The original discussion with the patient was to complete the planned hygiene treatment

and restorative treatment. The dentist referred the patient to an endodontist to treat the periapical

abscess on #19 and 29 and stressed completing the restorative treatments for the defective

margins on the existing fillings. The patient reported that she would follow up with the

restorative treatment plan once she travels back to Colombia because patient expressed that the

restorative treatment in Colombia is more financially suitable for her compared to the states.

We originally discussed the consequences of no treatment as well, which was that the

periodontal disease would progress so increased bone loss, pocket depth, inflammation, caries,

attachment loss, and eventually tooth loss could happened if treatment was not completed. The

patient followed up with each treatment plan and was able to complete all the hygiene treatment.

The patient was also compliance with all the oral hygiene instructions provided to her and

improved in her at home oral care.

VI Student Summative Evaluation

I learned so much form completing this case including management of patients with

diabetes and hypertensions. I learned what treatment plan accommodation needed for this

patient, such as best appointment time, acceptable HbA1c level, blood glucose level, blood

pressure categories, medication contraindications with local anesthesia, oral hygiene appliances

most appropriate for the patient.

Some of the modifications that enhanced the treatment outcome include morning

appointments and making sure patient took their medication and ate some food to avoid

hypoglycemic shock in the dental chair. Have the patient sit up on the dental chair for at least

two minutes before dismissing to avoid orthostatic hypotension. In addition to providing

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instruction on different techniques of regular brushing and flossing, educate the patient on cause,

dental effect, and management of xerostomia.

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Reference

Boyd, L. D., Mallonee, L. F., Wyche, C. J., & Halaris, J. F. (2020). Chapter 2 – Evidence-Based

Dental Hygiene Practice. Wilkins’ Clinical Practice of The Dental Hygienist. Burlington,

MA. Jones & Bartlett Learning.

Macedo Paizan, M. L., & Vilela-Martin, J. F. (2014). Is There an Association Between

Periodontitis and Hypertension?. Current Cardiology Reviews, 10(4), 355–361. doi:

10.2174/1573403x10666140416094901

Preshaw, P. M., Alba, A. L., Herrera, D., Jepsen, S., Konstantinidis, A., Makrilakis, K., &

Taylor, R. (2012). Periodontitis and Diabetes: A Two-way

Relationship. Diabetologia, 55(1), 21–31. doi: 10.1007/s00125-011-2342-y