Case Study #2

Profile

  • The patient is a 27 year old, Asian female.
  • Middle class, resides in New York with her family. The patient works as a patholoogist research assistant. The patient has insurance and she has a dental home that is walking distance from her office.
  • The patient reported she does not typically go to the dentist unless she is in pain and she reported scheduling hygiene appointments 1x/year.
  • The patient’s last dental exam, cleaning, and set of radiographs were in June 2016 and she had 4 bitewings exposed.
  • The patient reported brushing natural teeth 3x/day with a tapered end soft manual toothbrush with Colgate Total toothpaste. Patient was flossing only when food was stuck between her teeth, and using mouthwash occasionally.
  • The patient presented with multiple restorations and active carious lesions.

 

Health History Overview

  • BP: 124/78 ; Pulse: 80 ; ASA II
  • Pt. presents with Asthma and Hay Fever.
    • Pt. reports she uses takes antihistamines seasonally when allergies react to the pollen.
    • The patient reported to have asthma that was exercise induced and was not prescribed an inhaler.
    • Medications taken:
      • Birth Control
    • Vitamins
      • Vitamin D
      • Vitamin B12
      • Prenatal Vitamins
  • Allergy to Penicillin
  • The patient no history of drug, tobacco, or alcohol abuse

Summary of Clinical Findings

  • EO: bilateral clicking of TMJ. The patient reported she has experienced lock jaw at the dentist previously.  The patient reported grinding her teeth and presented with severe attrition. IO: The intraoral exam showed well-demarcated, white circular mucoceles about .5mm in diameter on the mandibular right retromolar pad. It was discussed with the patient that diet and toothpaste selection may be the cause of mucocele formation. The patient reported sensitivity on the lower left retromolar pad, and upon examination, there was palpable tenderness.
  • The patient presented with bilateral Class I of occlusion, 4mm overjet, and 30% overbite. Patient had teeth #5, 12, 21, and 28 extracted when she was 11 years old, as recommended by her orthodontist, before starting orthodontic treatment. The patient was in orthodontic treatment with traditional wires and brackets for about 1.5 years, and had a lingual bar on the mandibular teeth #22-27. Tooth #31 was fractured at the gumline and only the root remained. Tooth #3 had a large fracture and was missing the distolingual wall
  • Dental Assessment:
    • The patient had a crown on tooth #31, which exfoliated and was not recemented.
    • The fracture on tooth #3 occurred about a month after her crown fell out . The patient reports the occurrences happened about 1.5 years prior to treatment.
    • The patient has ceramic crowns on teeth #18 and #19.
    • Clinically and radiographically, the patient had normal tooth anatomy and no notable anomalies.
    • There was active decay on teeth #1 – #3, #14 – #17, and #30 – #32. The carious lesions were predominantly on the occlusal surfaces of the posterior teeth. The patient reported eating sugary, gummy candy and sleeping with it in her mouth. The patient was referred for a dental exam.
  • Deposits:
    • The initial plaque score was fair, 0.83, and her revisit plaque scores were consistent with the initial score.
    • Calculus was found subgingivally on the mesial and distal surfaces of the maxillary and mandibular right side. There was calculus present subgingivally on the distal surfaces of the maxillary and mandibular left side, but it was less significant than on the right side. The calculus formation on the right side may be due to the patient avoiding brushing in that area as she has exposed root surfaces on tooth #3 and #30. The patient had significant supragingival calculus on the lower anterior lingual aspect and maxillary left and right buccal surfaces.
  • Gingival Description and Periodontal Status:
    • The patient was classified as having Type I, localized Type II Periodontitis as she had generalized 4-5mm pocketing on the posterior teeth and class II furcation involvement on the mesial root of tooth #30 with 3mm of recession. The patient had generalized 2mm recession on the posterior teeth and 1mm clefting recession on teeth #22 – #27. She had generalized type I embrasure spaces, and a localized type II embrasure space between #22 and #23. The patient had moderate bleeding upon probing, especially in the maxillary left posterior teeth, and generalized marginal inflammation.
    • The attached gingiva appeared to be pink and was shiny in texture, exhibiting generalized inflammation and localized redness around the lower anterior lingual surfaces as there was heavy supragingival calculus.

 

Dental Hygiene Diagnosis

  • Patient is at a high risk for caries due to multiple risk factors and behavioral indicators that contribute to caries risk: sleeping with sugary candy in her mouth.
  • The patient had moderate visible plaque biofilm.
  • The patient presented with severe carious lesions on posterior teeth
  • Retained root tips
  • Type I, localized Type II active periodontitis due to 4-5mm pocket depths, moderate BOP, radiographic evidence of boneloss, and moderate recession.

 

Dental Hygiene Care Plan and Treatment

  • Preventative Services – periodontal maintenance
  • The patient was taught oral hygiene instructions, which included the Bass method of tooth brushing, flossing using the “C” shape technique, use of a floss threaders for interproximal areas near the lingual bar, use of soft picks, and incorporating fluoridated ACT mouthwash to her regimen.
  • After the CAMBRA assessment, the patient was instructed to use Crest Gum Detoxify toothpaste with 0.454% Stannous Fluoride in replacement of her current toothpaste 3x daily and to incorporate ACT anticavity mouthwash into her hygiene routine 2x daily
  • During the course of treatment, the patient’s gingiva appeared to decrease in flaccidity in the lower anterior teeth. The patient’s maxillary and mandibular left teeth were scaled to completion and the patient was polished using a fine abrasive. The patient was treated with 5% Sodium Fluoride varnish.
  • Referrals were given to the patient for restoration of multiple carious lesions and periodontal evaluation. The patient was also referred to her general dentist for 1.1% NaF anticavity toothpaste.
  • Debridement
    • Ultrasonic: used FSI-FLI-FG 100 & 1000, and THINSERT – FIT GRIP
    • These instruments allowed removal of subgingival calculus in areas the patient had 4+ mm pocket depths as well as on areas with moderate deposits.
    • After removal of calculus deposits, biofilm was removed using the THINSERT for deplaquing.
    • Hand Scalers: Anterior Sickle Scaler, Gracey 1& 2, 11/12, 13/14, SN 135
    • Applied advanced instrumentation by using alternative instrument cutting edges, especially at the line angles of the teeth.
    • Horizontal, vertical, and oblique debridement strokes were used for calculus removal.

The goal of hand scaling was to remove any residual soft biofilm not removed by Ultrasonic instrumentation and to remove supragingival and subginigval calculus formation. A night guard was recommended for the patient’s TMJ discomfort.