Case Studies

PERIODONTAL CHALLENGE
One of my most challenging patient cases was in my 3rd semester of dental hygiene school. The patient was a 33 year old male that complained of sensitivity on his lower back teeth and occasional bleeding when he brushed. He reported normal health but had a blood pressure reading of 127/92 corresponding to stage 2 hypertension declaring him ASA 2. He had not been to a physician in over 11 years and had not been to the dentist in 4 years. He reported that medical & dental appointments made him a little anxious. I therefore knew that I had to be aware of that and try my best to keep him calm and comfortable during the appointment. I made sure to explain everything and let the patient know that if anything made him uncomfortable he could let me know. Assessments revealed probing depths of generally 2-5mm and localized 6mm probing depths posteriorly with moderate bleeding upon probing. The gingiva was pink with melanin pigmentation and an inflamed spongy texture The interdental papillae were bulbous and red. There was also generalized supragingival and subgingival calculus which was a challenge for me because up until this point I had not had a patient with supragingival calculus. Due to the amount of time that had passed from his last dental appointment, I exposed an FMS to evaluate the entire mouth. The FMS revealed generalized radiographic calculus, horizontal bone loss of up to 30% and a radiolucent carious lesion on #9-F. The patient was diagnosed with stage 2 grade B periodontitis, a heavy case value and a high caries risk. A treatment plan was created for 3 total visits but as it was a challenging case, I took an extra visit to complete the treatment.

I recommended an antiseptic mouthrinse for the AM and a fluoridated mouthrinse for the PM as home care instructions to reduce the inflammation and caries risk. There were a lot of deposits to be removed so I had my instructor administer local anesthesia for each quadrant. This was the first patient of mine that needed local anesthesia so it was a good experience working with it because it also reduced the bleeding. Hand-scaling everything was definitely challenging. The calculus was tenacious and at the beginning of subsequent appointments, there were always rescales that needed to be done as the tissue was shrinking and healing. I taught the modified bass method, flossing and reinforced with each visit to try and encourage change in the patients homecare. I also recommended Sensodyne to remedy the sensitivity he mentioned in the initial visit. We concluded the treatment with engine polishing and the 2% neutral sodium fluoride gel.
Although the treatment took longer than anticipated, I was proud that I was able to fully handscale a patient that had tenacious calculus and manage their anxiety effectively.

ARESTIN
I had the wonderful opportunity of placing Arestin on a patient. This patient was 31 years old, new to our school clinic and had not been to the dentist in over 4 years. Her chief complaint was bleeding gums and bad breath. She was in good health and had a normal blood pressure reading of 118/64 but presented with allergies making her an ASA 2. However, it was an interesting experience because when I asked what allergies she had, she provided a list of 17 things. The list included things such as abietic alcohol, disproportionated rosin and EINECS 215-786-2. My first question to the patient was, “how do you know you are allergic to these things?” because it was quite an interesting list and I was concerned she would possibly have an allergic reaction during the appointment. It turns out that she took an allergy test and was basically allergic to contact lens cleaning solution, bacitracin & pine nuts.

Assessments revealed generalized probing depths of 1-5mm with localized 6-8mm probing depths posteriorly and severe bleeding. The gingiva was generally pink & spongy with bulbous red interproximal papillae. She had generalized heavy subgingival calculus and an FMS was exposed to make a proper diagnosis. The radiographs revealed generalized horizontal bone loss of up to 30%, generalized radiographic calculus deposits and a 0.5cm diameter idiopathic osteitis. As a result she was diagnosed with Stage 2 grade B periodontitis and a heavy case value. She had a low caries risk because she had no restorations or caries. The treatment plan was developed which encompassed 3 total visits where the second visit was reserved for scaling the right side & the last visit was to scale the left side, apply arestin in the previously scaled areas & engine polish as well as apply 2% neutral sodium fluoride gel.
Scaling was a challenge due to the heavy bleeding, deep pockets and heavy deposits. The ultrasonic was utilized, primarily the powerline insert, in addition to hand instruments to complete the treatment. Applying the arestin was a great experience as the probing depths were very deep. As I retook the probing depths in the last visit prior to placing the arestin, I noticed that the probing depths were even deeper. Usually we expect a reduction in these readings because of tissue healing but I realized that because my patient had such heavy deposits, the probing depths from the initial visit were not accurate. However, I was glad to have the opportunity to place the Arestin on this patient because I anticipated an improvement in her periodontal health.

I applied the Arestin to a total of 7 sites. It was satisfying to see the product fill the pockets especially in the areas where I did it from both the buccal and lingual aspects.
We ended the treatment with engine polishing and the 2% neutral sodium fluoride treatment. The patient and I were excited to see the results of the treatment and she came back in 6 weeks for re-evaluation. Instantly the gingiva looked a lot better than it initially did and I was happy for the patient because she wasn’t experiencing any more bleeding or bad breath. When I took the probing depths again I was happy that they did in fact reduce in 5 out of the 7 areas. The patient was very satisfied with the treatment and grateful to learn that the probing depths reduced. Below are the results of the Arestin treatment:
#3ML: 6mm to 4mm
#4MB:5mm to 4mm
#4ML:6mm to 5mm
#4DL:6mm to 6mm
#5DB:5mm to 4mm
#5DL:5mm to 4mm
#29ML:5mm to 5mm