Patient Profile

  • Ms.B is a 52 year-old African American female.
  • Patient lives in Brooklyn with her husband. She currently have dental insurance and have access to dental clinic.
  • Her last dental exam was in May 2019 (Prophy) at NYCCT, Full mouth X-rays were taken in 2017 in a private dental clinic.
  • Patient states brushing twice a day with a soft toohtbrush, uses floss
    occasionally and uses mouth rinse once a week.

 

Chief Complaint

  • Patient states that “I’m here for my 6 months routine check up.”
  • Patient states she has pain on #32 that “comes and goes”
  • She is concerned about her exposed roots and recession, which causing her sensitivity.

 

Health History Overview

Blood Pressure:
1. BP 122/96 , Pulse 76,
2. BP 119/91 , Pulse 72
3. BP 115/93 , Pulse 71
ASA II

Medical Conditions:

  • Non smoker, non drinker
  • GERD (Diagnosed 7 years ago)
  • Hypertension (Referral given to patient for evaluations

Current Medications:

  • Primrose oil capsule once a day for symptoms of menopause
  • Omeprazole as needed to ease symptoms of heartburn (GERD)

 

Explanation of Condition(s)

  • Menopause
    • Occurs naturally when a woman’s ovaries run out of functioning eggs/ Aging
    • Signs and Symptoms : hot flashes, difficulty to sleep at night
  • GERD
    • Occurs when stomach acid frequently flows back to the esophagus
    • Signs and Symptoms : pain and burning sensation in throat
  • (Undiagnosed) Hypertension
    •  Abnormally high blood pressure
    •  Signs and Symptoms : BP above
      120/80, irregular heartbeat, chest
      pain

 

How condition is managed

  • Menopause
    • Suggested treatment :Hormone therapy. Estrogen therapy is the most effective treatment option for relieving menopausal hot flashes
    • Patient is currently taking Primrose daily at nighttime to treat menopause symptoms such as
      hot flashes
  • GERD
    • Suggested treatment : lifestyle modifications and over-the-counter medications. prescription
      medication or surgery if needed.
    • Patient is currently taking Omeprazole.

 

Dental Hygiene Management

  • No contraindications to dental hygiene care
  • Patient management strategy include treating patient in a semi supine position to prevent acid reflux for GERD.

 

Comprehensive assessments

  • Radiographs

Summary of Clinical Findings

  1. Extraoral/Intraoral Examination:
    • Extraoral: papule on the left side of the neck, bilateral TMJ clicking, pt says it causes discomfort sometimes when she eats. Linear alba on the right side.
    • Intraoral: Interdental papilla between #8 and #9 on the lingual is red, pt states the redness was
    • from drinking hot coffee
  2. Occlusion: Bilateral Class II- division I occlusion.
    • Overjet is 5mm, overbite is 50%. Abfraction on #4,#20,#21,#28,
  3. Deposits: Generalized moderate subgingival calculus, localized supragingival calulus on the lower anteriors ( lingual and facial)

 

Dental Charting

Findings:
• Class II amalgam restoration on #1,#2,#3,#4,#14
• Class I amalgam restoration on #15,#31,#32
• Class I composite restoration on #17
• Resin-based composite on root exposure on #20,#21,#28
• Pt report loss #18,#19,#29,#30 due to decay
• Porcelain-fused crown #5,#7,#8,#9,#10,#12,#13
• Suspected lesion #14-D, #16-O

*Changes that was unable to adjust on chart: #17-O does not have restoration, #31-O amalgam restoration has been replaced to a composite.

 

Caries Risk Assessment 

Carie Risk: HIGH

  • ADA CAMBRA Form was not
    complete.
  • Clinical findings:
    •  Decay noted on the distal #14 and the occlusal of #16.
    • Patient report loss of #18,#19,#29,#30 due to decay
    • No radiographic evidence of caries present.

 

Gingival Description & Periodontal Status

  • Generalized stippled pink gingiva, slight generalized inflammation. Localized rounded, enlarged shiny interdental papillae, localized moderate inflammation on the lower anteriors.

 

Periodontal Charting

  • Recession found on :#2,#4,#14,#15,#17,#2 0, #21, #28,#31#32
    • BOP was minimal
    • No mobility
    • Probing depth : 3-5mm
    • CAL: 5-8mm on molars and premolars.

 

Dental Hygiene Diagnosis

  • Patient at a high risk for caries due to her claiming tooth loss of #18,#19,#29,#30 due to decay.
  • Patient has a suspected decay on #15-O.
  • Type II active periodontitis due to generalized 3-5 mm probe depths, minimal BOP, extensive recession and radiographic evidence of slight bone loss.

 

Dental Hygiene Care Plan

Plaque Index was conducted and patient had a score of 1.0, which is fair. PI reflect plaque retention on interproximal areas. Oral hygiene instruction was given to patient to do C-shape flossing once a day. Patient was also given a floss reacher to floss posterior teeth.

Horizontal bitewings were recommended to evaluate suspected decay, persistent tooth pain(#32) and possible bone loss due to clinical findings of extensive recession.

Patient stated she has sensitive teeth and requested for localized pain management. Topical was used for probing. Full mouth debridement with ultrasonic and handscalers. Oraqix was used during full mouth debridement. Ultrasonic power was adjusted to blue zone (comfort zone) to increase patient
confirm. Patient has tight pockets. Thin insert was used for debridement. Patient tolerated well during treatment.

Engine polish was performed and 5% NaFl Varnish was applied.

 

Consent for Treatment/treatment plan

 

Implementation –Treatment

  • Medical history was reviewed. Blood pressure was taken. Referral was given to patient due to HBP
    readings.
  • Patient is currently taking two supplements (Primrose and Omeprazole). Researched the two medications and found no counter interactions or adverse effect with dental tx.
  • Extra oral and intraoral examination were performed. Periodontal examination and dental charting were performed.
  • Plaque index was conducted. Oral Self-care Instructions: C-shaped flossing due to disclosing solution retention were all interproximal. Introduced patient the Floss Reacher to reach posterior molars. Advised patient to use Fluoridated mouthrinse due to high risk caries status.
  • Full mouth debridement with Handscalers, ultrasonic and engine polishing.
  • Upon debridement, topical was used and patient expressed sensitivity. To increase patient comfort, oraqix was then implemented into the treatment.

 

Evaluation of Care – Outcome of Care -Prognosis

  • Patient is motivated to follow oral hygiene instruction to reduce plaque retention. Patient shows interest in improving overall health.
  • Patient should return in 6 months with less inflammation in the gingiva and less plaque retention in the interproximal areas.
  • Patient is motivated to return for recare appointment.
  • Patient will show improvement on plaque index when return for recare.

Referrals

  • Medical referral
    • BP was taken three times and the measurements were all persistent to be 120/80
    • Patient was referred to her general doctor to evaluate her blood pressure.
  • Dental referral
    • Patient was referred to her general dentist to evaluate #15-O for suspected caries (seen clinically) and #32 due to persistent pain.

 

Continued Care Recommendations

  •  Patient will return in 6 months for recare.
  • Patient is compliant and probing depth had reduced since last
    dental visit, which shows pateint has a good home care regimen.
  • Patient will follow oral hygiene instruction to continue her home care routine.

 

Final Reflection

Due to patient sensitivity, I believe I made the right decision to use Oraqix instead of topical anesthesia to increase patient comfort. I believe I had the correct instrument selection of using the thin insert since patient have very tight gingiva.

Radiograph was unable to reveal decay on #14D due to horizontal overlap. It would be ideal if the radiographs were retaken in order to evaluate #14D.

 

References
  • Nikparvar, M., Farshidi, H., Madani, A., Ezatirad, R., Azad, M., Eftekhaari, T. E., … Kassem, H. H. (2019). Prevalence, Awareness, Treatment, and Control of Hypertension in Hormozgan Province, Iran. International Cardiovascular Research Journal, 13(3), 91–95. Retrieved from http://search.ebscohost.com.citytech.ezproxy.cuny.edu/login.aspx?direct=true&db= ccm&AN=138632864&site=ehost-live&scope=site
  • Ozcan, H. (2019). Healthy Life Style Behaviors and Quality of Life at Menopause. International Journal of Caring Sciences, 12(1), 492–500. Retrieved from http://search.ebscohost.com.citytech.ezproxy.cuny.edu/login.aspx?direct=true&db= ccm&AN=136698218&site=ehost-live&scope=site
  • Commisso, A., & Lim, F. (2019). Lifestyle Modifications in Adults and Older Adults With Chronic Gastroesophageal Reflux Disease (GERD). Critical Care Nursing Quarterly, 42(1), 64–74. https://doiorg. citytech.ezproxy.cuny.edu/10.1097/CNQ.0000000000000239