CASE STUDY 1
Ulvie Shkolyar
Journal 2
Visit 1 G.S. 28 yr old male M/I
Dates of service 11/18/16, 12/1/16
Date posted on BB: 12/5/16
ASSESSMENT
- Patient helath history and vital signs, ASA.
Patient has nothing significant in medical history to report. His vital signs were 110/85 pulse 72. Patient is ASA I. No premedication required. Patient is currently not taking any prescription, medicinal herbs or over the counter medications.
- Oral pathology
Extra oral and intraoral findings were within normal limits. Patient had linea alba, slight ankyloglossia and hyperkeratinized coating on the tongue.
- Dentition
Patient presented with attrition on #8,9,11,21,22,27,28. Patient has a retained deciduous maxillary left canine. Several areas of diastema on maxillary and mandibular anteriors. Tooth #5 is fractured and is missing a distal portion of restoration. No active carious lesions were detected.
- Periodontal
Gingiva was pigmented, flaccid, edematous, stippled and blunted papilla in areas of diastema. Generalized moderate gingivitis was present. Patient is classified by as perio type I, 3-4mm probing depths, no furcations, no recession, moderate BOP, and no radiographic bone loss (confirmed during second visit). Based upon assessment, Arestin is not appropriate for this patient.
- Oral Hygiene
Patient is classified medium based on calculus present. I assessed this patient’s oral hygiene by interviewing him about his oral hygiene routine and using disclosing agent to obtain a plaque score. Patients plaque score was 0.8 and most of plaque was present interproximally. Patient was using a medium bristled brush, back and forth brushing method and did not floss. I demonstrated correct flossing technique on a typodont. Patient was struggling and unable to demonstrate it in his mouth. I decided to introduce Reach floss holder, which patient liked and was able to use correctly after demonstration.
- Radiographs
4 bitewings were exposed during second visit to evaluate the status of current restorations, bone levels and evaluate any interproximal caries. Panoramic radiograph was exposed to evaluate presence or absence of third molars. Bitewing radiographs confirmed periodontal type I – no radiographic bone loss was present; and revealed interproximal caries on #20D. Panoramic revealed no third molars present.
- Other Findings
Patient does not smoke and does not consume alcohol regularly. There were no other factors or significant findings in the assessment that would have affected patient’s optimal health.
TIME
Patient stated his last dental hygiene services were approximately three years ago. Three years is not an appropriate time interval between dental hygiene recare visits. This patient should be on a three months recall until his case value is light.
VISIT 1
During patients first visit I reviewed his medical history, took his vitals, did extra and intra oral exams, completed dental charting and periodontal charting, documented calculus deposits on accretions form. Then I used a disclosing agent to obtain a plaque score, which was 0.8, and taught patient how floss using a floss holder. After that I scaled URQ and ULQ with ultrasonic and hand instruments.
I taught patient flossing during the first visit to reduce generalized posteriorly 4mm pockets.
There were no medical, social, or psychological factors, which impacted the treatment.
Since patient always had trouble with using floss, I introduced Reach floss holder which patient liked and was able to use easily.
Patient was referred to DDS for evaluation of TMJ, replacement of fractured amalgam restoration on #5, and caries evaluation on #20.
VISIT 2
During the revisit, I reevaluated previously scaled areas, exposed 4 digital bitewings and panoramic radiograph, used a disclosing agent to obtain a plaque score, taught patient how to use a power toothbrush, scaled LRQ and LLQ, and applied 5% fluoride varnish.
Patient’s plaque score increased from 0.8 to 1.6. Patient stated he was very busy with his classes and work, and he knew he wasn’t brushing the way he usually does. There was generalized plaque presence on lingual surfaces of all teeth, and therefore I suggested to patient use of a power toothbrush. Also, most power brushes have a timer, which means patient is more likely to brush for two minutes, rather than with a manual toothbrush.
Patient responded positively to previously introduced flossing method, but hasn’t been brushing properly. During the revisit, most of his plaque was now on direct lingual surfaces. Patient knew he wasn’t brushing properly for the past week, but was surprised that his plaque score increased significantly. This motivated him to improve his plaque score. I explained to him that optimal oral health could only be achieved and maintained by following a home care routine, which should consist of brushing, flossing, and rinsing.
Patient’s tissue during revisit was still slightly bulbous, but firmer. There was also generalized biofilm present in previously scaled areas.
There were no additional interventions developed.
 Student Reflection
My clinical strength in the management of this patient was finding appropriate tools to help patient with his home care and time management. My weakness was the inability to detect residual calculus in UR quadrant, which could have been avoided by viewing radiographs before scaling rather than after. Also, I did not educate the patient during first visit on how important it is to follow a home care routine.
- During patients visit 6 months ago he reported discomfort in area of TMJ when chewing hard foods. I followed up on the issue during his recall visit, he stated he did not have it evaluated since but the issue was still present.
- Calculus was mostly present on facial and lingual surfaces of mandibular anterior teeth and buccal surfaces of maxillary posterior teeth.
- Patient didn’t have a dental cleaning is 3 years due to lack of dental insurance and could not afford to pay out of pocket. I placed him on a 3m recall because I would like to evaluate his progress, and if he is successful with home care, then place him on a 6 m recall.
- I recommended Listerine Antiseptic mouth rinse to reduce inflammation.
CASE STUDY 2
Ulvie Shkolyar
Journal 1
Visit1 S.P. 27 year old male H/II
Date of service 10/13/16, 11/15/16
Date posted: 11/19/16
ASSESSMENT
Patient health history and vital signs, ASA
Patient does not have any allergies or systemic conditions that require premedication. Vital signs were 120/84 pulse 80. Patient does not currently take any medicinal herbs, prescription or OTC medications. Patient is ASA I – healthy.
Oral Pathology
Patient had several petechiae on left mucobuccal fold; patient reported biting his cheek recently. Petichiae were healed upon reevaluation during revisit. 2x3mm fibroma was located adjacent to tooth #31.
Dentition
Patient had 90% overbite, 4mm overjet and occlusion class II. Attrition was present on teeth 6-11, 22-27. Teeth #14,16,30 are missing. Tooth # 6 is buccally verted. Tooth #11 is fractured at incisal edge. Suspicious lesions detected on #1 O, #3L, #5D, #15DO.
Periodontal
Patient’s gingiva was pink, edematous, and easily retractable. Bulbous interdental papilla localized anteriorly.
Type II: 4-5mm probing depths, moderate BOP. No recession present. Slight periodontitis. Arestin is not appropriate treatment for this patient. Arestin is indicated for patients with 5-7mm pocket depths, which did not respond to scaling and root planing and improved home care.
Oral Hygiene
Based on calculus present, patient is identified as heavy case. Most of calculus was present on lingual surfaces of mandibular teeth.
Patients plaque score was determined using disclosing agent and was 1.3 during his first visit. Plaque was mostly on cervical thirds of buccal and lingual surfaces of posterior teeth.
Radiographs
FMS was exposed due to several suspicious lesions, need to evaluate radiographic bone loss and to evaluate status of current restorations.
Radiographs revealed impacted #16 and localized bone loss near areas of missing #14 and 30. No radiographic decay was detected.
Other Findings
Patient doesn’t smoke or consumes alcohol on a regular basis.
Patient moved to United States very recently. According to my conversation with the patient, oral hygiene care, and dental care in general, in his country is significantly different than in US. Since there is no such profession as dental hygienist, dental cleanings are usually performed by the dentist. My patient didn’t know what floss is and he never used a mouth rinse before. He also didn’t know how to brush correctly.
TIME
Patient stated that his last dental hygiene services were in summer of 2015, which is not an appropriate amount of time between dental hygiene services. He is heavy type II, which indicates his recare interval should be every 3 months.
TREATMENT MANAGEMENT
VISIT 1
During the first visit medical and dental history data were collected, all assessments were completed, teeth #25-27 were scaled and full mouth series exposed.
Fluoride rinse and 5% fluoride varnish were recommended to the patient due to caries activity. Power brush was recommended to remove biofilm effectively. Flossing twice daily to remove interproximal biofilm.
Patient responded to recommended physiotherapeutic aid well. On his second appointment, plaque score improved from 1.3 to 1. He’s been using a power toothbrush for the past week and was excited to see the improvement and to continue improving his home care even more. Patient was referred to DDS for evaluation of several suspicious carious lesions and evaluation of fibroma near #31.
VISIT 2 (11/15/2016)
Patient responded to previous interventions well. He was excited to learn new techniques to improve and maintain his oral health. He’s already lost two teeth due to lack of proper home and professional care, and subsequent decay, and wants to make sure to keep his oral cavity healthy.
Upon reevaluation of previously scaled area I noticed more firmness and resilience, no edema, and no bleeding was present.
There were no additional interventions developed.
During second visit I reevaluated previously scaled area, used disclosing agent to obtain and record a plaque score, reviewed correct brushing technique with a power brush and taught patient how to floss. I also scaled all four quadrants using ultrasonic and hand instruments, engine polished and applied 5% fluoride varnish.
REFLECTION
My clinical strength with this patient was time management and improvement in his home care. Seeing improvement in his home care made me more confident in my skills and knowledge. This patient reminded me of myself several years ago, when I immigrated to United States. My oral health back then also needed a lot of improvement, which I was able accomplish with the help of my dental hygienist and desire to change my habits. I shared my story with the patient and hope it will inspire him to start new healthy habits such as flossing, brushing and rinsing twice daily, and also keep his regular dental hygiene appointments.
