Case Study II

 

• Demographics

K.M., 22 years old, Medium/Type 1.

• Assessment

1. Medical history – WNL. BP: 127/79 P: 81
2. Nonsmoker
3. No premedication needed
4. No systemic diseases/conditions present
5. No medication

• Oral Pathology

1. EO: WNL. Right side TMJ popping. No pain associated. IO: WNL. Tonsils were removed. Hyperkeratinized bilateral surfaces of the tongue. Bilateral mandibular tori present.

• Dentition

1. Bilateral Class I Occlusion. Overjet: 4mm. Overbite: 60%
2. No tooth abnormalities. Patient is missing tooth #5, 12, 28 & 21. Recession on facial surface of teeth present on #3, 5, 11, 13, 14, 20, 22, 27, 29, 30 and lingual surfaces of 22 & 27. There is also attrition on #22-27.
3. Possible caries are generally present and active on posterior teeth of maxillary and mandibular arches specifically on #14, 15, 19 & 18.

• Periodontal

1. Medium Perio Type I. Generalized 3-4 mm pocket depth with moderate bup.
2. Gingival exam showed generalized pigmented, soft gingiva with knife edged papilla on localized anteriors. Generalized interdental papilla was slightly red with mild inflammation. The cervical one third of molars, #3, 4, 14, 15, 18, 19, 30 & 1 had marginal red mild inflammation.

• Oral Hygiene

1. Initial plaque score – 0.83 Fair. Revisit plaque score – 0.83 Fair (no change).
2. Supragingival and subgingival calculus was present on lower anteriors, #22-27. Subgingival calculus was also present on surfaces of posterior teeth, #1-4, 13-16, 30-32 & 17-19.
3. For oral hygiene instruction, the modified bass toothbrushing technique was introduced and taught because patient presented generalized marginal plaque. Due to recession, patient was taught to brush gently with extra soft toothbrush.

• Radiographs

1. Yes bitewing radiographs were required to verify and detect possible caries.
2. During data collection, radiographs were taken by me but unfortunately they were undiagnostic because I made a processing error.
3. Radiographs were unable to reveal any conditions.

• Treatment Management

1. Visit 1: Reviewed medical and dental history. Performed EO/IO exam. Completed dental and periodontal charting. Completed calculus detection. Proposed a treatment plan.

Visit 2: Reviewed medical history. Reviewed EO/IO exam. Performed plaque index with disclosing solution and explained findings to patient. Introduced oral hygiene instruction; modified bass toothbrushing technique. Physically taught patient how to brush and allowed patient to independently brush. Completely hand scaled LR & UR quadrant. Patient was referred out for possible suspicious caries.

Visit 3:  Reviewed medical history for any new significant findings. Reviewed EO/IO exam. Obtained a new gingival description on previously scaled area. Performed new plaque index with disclosing solution. Reviewed previous taught OHI; modified bass toothbrushing technique and introduced flossing. Res-evaluated UR & LR quadrant for residual calculus. Completely hand scaled UL & LL quadrant. Performed engine polishing and fluoride treatment.

1. 1. No medical, social or psychological factors affected treatment.
   2. On the second visit, the modified tooth brushing technique was introduced as the first oral hygiene therapy. This technique was introduced due to the patient’s present marginal plaque during plaque index assessment. The patient responded to the OHI with enthusiasm. She enjoyed the idea of circular motion and downward stroke. My patient felt that this brushing method would be successful for her. No change had occurred in the new performed plaque index. In our next session, flossing was introduced to the patient for interproximal plaque removal. Patient was referred to DDS for suspicious caries possibly present on  #14, 15, 18 & 19. I believe my treatment plan was well planned and I would not change anything.

• Evaluation

1. My patient felt that the interventions introduced and taught had helped her gain knowledge about her oral health. She already was into good oral hygiene because she had stated to me that she has orthodontic treatment in the past and stated she learned how to take care of her teeth from her orthodontist.
2. As treatment progressed my patient was very enthusiastic to come back and get the full cleaning done. She stated that her gingiva looked healthier and her teeth seemed cleaner after I cleaned the UR & LR quadrant.
3. During the initial visit the patient’s tissue was generalized pigmented, stippled and non resilient with mild inflammation. Localized interdental papilla filled interproximal spaces of tooth #6-11 & 22-27. Blunted papilla was present on all posterior teeth, #1-5, 12-16, 17-21 & 28-32. In the second visit, the patient’s gingival exam showed a decrease in inflammation on anterior teeth #6-8, 24-27 and marginal gingiva of #3, 4, 14, 15, 18, 19, 30 and 1 showed no clinical signs of redness on the area previously scaled.
4. The additional intervention developed with my patient as treatment progressed was implementing my patient the importance of the taking the referral we have given her during clinic for caries evaluation. I had expressed to my patient that allowing the decay to progress may result in worst circumstances such as increasing side effects of pain. I also explained to her that it may progress to the conditions of a root canal and explained to her what that meant.

 

• Reflection

1. I believe that I have accomplished everything I planned throughout treatment both educational and mechanical. I was able to teach my patient OHI and give her the basics of why it is so important to keep up with brushing and flossing. This was my first completed patient and I felt very rewarded when I was able to satisfy my patient by giving her a healthy and clean smile. I was able to mechanically hand scale all four quadrants, while trying to keep my patient comfortable each visit. It made me feel like a true hygienist in the making.
2. A positive experience I had during clinical treatment with my patient was when I was able to completely remove calculus all on my own from the UR quadrant without having to rescale. I was really proud of myself and felt like I am continuing to progress with using my instruments correctly. Hearing from my instructor that I had done a good job made me feel extremely joyful.
3. A clinical weakness I had during patient treatment was during my last visit. In the last visit, I was hand scaling the UL quadrant and was using my posterior gracey’s and could not remove subgingival calculus on the mesial of tooth# 16 and 17. I took a lot of time and force trying to remove this calculus. I then started to realize that it was my incorrect angulation so I began to practice insertion and angulation and was then able to successfully remove the calculus. With this experience, I now practice more on having the correct angulation which is 70 degrees when the lower shank is parallel to the long axis of the tooth.