Gingival Case Study

THE UNIVERSITY OF TEXAS DENTAL BRANCH THE SCHOOL OF DENTAL HYGIENE DHBS 320/DHCT 2201 - CLINICAL PRACTICE I SPRING SEMESTER 2009

STUDENT NAME Leslie Bebber

Patient Name Barbara Pendley EPR# 527608

Date of initial exam March 5, 2009 Date completed April 9, 2009

GINGIVAL CASE STUDY

ASSESSMENT Medical History: (systemic conditions, medication, and medical consultation if required) Medical consult received for bilateral knee replacement. Physician recommended Chephalexin 2000mg, 1hr prior to all dental appointments. Cephalexin prescription called was called in by Dr. Delattre. Additional medical consult requested due to elevated blood pressure readings of 182/100 upon first visit. Patient later started taking blood pressure medication, prescribed by doctor as a result.

Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint, present oral hygiene habits) Patient has had root canals, a bridge, crowns, filling and cleanings throughout her life and states that she has never had any complications with any prior dental treatment. Patient’s chief complaint is that she wants a good cleaning. Patient does not floss, use fluoride or antimicrobial mouth rinses. Patient’s regularly uses wooded toothpics, has poor dental I.Q. and is easily motivated and egar to learn. Oral Examination: (lesions noted, facial form, habits) Patient had labial petechiae, palatine torus, fissured tongue, and reduced salivary flow bilaterally in Stenson’s and Wharton’s ducts. Patient also had slightly swollen submandibular tonsils, bilaterally. Facial form was symmetrical, elevated mole 4x4x2 above left eyebrow, 4x4 flat brown patch on left cheek and a depigmented area 4x5 on right cheek. Dental Examination: (malrelations of groups of teeth, occlusion, abrasion, caries rate, radiographic findings) Radiographs: widening of the sinus mucosa bilaterally, radiopaque mass 6mm distal #18 with radiolucent border, caries as follows: 7M, 8D, 11M, 21M, 28MOD, bone loss is moderate, generalized, horizontal. Missing teeth: 1, 2, 4, 15, 16, 17, and 32. Dental charting: 27 and 22 and rotated distally and tilted mesially, creating a difficult area for patient to clean. Amalgam occlusal and buccal filling on 18, composites: 8D, 11M, 12MOD, 13MOD, 28MOD and 21MO, PFM crowns on 3, 5, 31, 29 and 19 with metal wore through occlusal on 3 and 5. Generalized tooth brush abrasion on facials. Periodontal Examination: Prophy Classification Q1 0 O’Leary Score

Q2 1 Q3 1 Q4 light 2

Periodontal Case Type slight/moderate perio

Appt 1 __x___ 2 ___FMS__ 3 _78%____ 4 __85%___ 5 __12%___

Phase Contrast Microscopy: Identify the microorganisms and the site from which the sample was taken (use the same site for both samples). Explain how you applied this information to your patient education sessions of the first and last appointments. Appt 1 Tooth # & Surface _27D_______ Last Appt Tooth # & Surface _27D_______ Cocci Yes _x__ No ___ Cocci Yes __x_ No ___ Filaments Yes _x__ No __ Filaments Yes __x_ No ___ Spirochetes Yes _x _ No ___ Spirochetes Yes ___ No __x_

Rods Vibrios WBCs

Yes _x__ No ___ Yes ___ No __x_ Yes ___ No __x_

Rods Vibrios WBCs

Yes __x_ No ___ Yes ___ No __x_ Yes ___ No __x_

GINGIVAL CASE STUDY - page 2 DHDx: Identify health behaviors or potential health problems in the form of “problem/cause” statements; focus on individual needs Patient exhibits xeriostomia as a result of taking Premarin medication and increased age. Erythmous and bulbous gingival tissue in lower canine areas as a result of mal-positioning of canines.

PLAN: Patient Goals – State a goal for each behavior needing modification. Interventions and expected outcomes should be included in each goal statement. Patient should use a daily rinse for xeristomia, such as Biotene and Prevident 5000 mixed with Crest ProHealth for additional fluoride and antibacterial action. Patient should also properly floss daily, concentrating on proper technique especially in the lower canine areas. Patient should exhibit reduced inflammation and bleeding upon proper home care and continued recare every three months.

IMPLEMENTATION: Therapeutic interventions, treatment sequencing; identify obstacles to care. This should not be worded in the past tense. It is treatment you plan on rendering. Appt 1 Upon the first visit I plan on completing the medical history. Depending upon antibiotic therapy which should be called in prior to the first visit, I will first attain the prophy class, which they were unable to do in assessment due to premed, I will also complete an extra/intra oral exam, obtain a microscope slide, do an O’Leary, gingival description, oral risk assessment and educated the patient accordingly. Appt 2 On the patient’s second visit I plan to take a FMS. If there is time remaining I would like to do an O’Leary, microscope, brief intra/extra oral for any changes, gingival description and reinforce proper home care with emphasis on the patient’s problem areas. Appt 3 On the third appointment I plan to complete a brief intra/extra oral exam for any changes, obtain another microscope slide, gingival description, O’Leary plaque score and educated the patient accordingly. I then plan to scale Q3 and Q4. Appt 4 Upon the patient’s 4th appointment I plan to scale Q1and Q2, spot prob and check for bleeding in Q3 and Q4. Depending upon the patient’s availability for another visit, I will polish and floss, continue OHI and see them back for one final appointment to revaluate the prob depths, bleeding and gingival description. Gingival Description - (include color, form, density, attachment, and bleeding) Appt 1 Marginal and papillary was coral, red in the lower anterior. Form was rounded/rolled on the marginal, blunted papilla and bulbous in the lower canine areas. The density of the marginal gingiva was resilient but smooth in the lower anterior region. The attached gingival was stippled in the maxillary anterior and smooth on the lower anterior facials.

Appt 2

We only took an FMS, no clinic time.

Appt 3 Note: Gingival description was not completed in EPR, patient will come back for additional visit in the summer upon which gingival description may be added to case study at that time, however I did make notes as follows: Patient only had slight bleeding upon probing and lower canine area had red marginal and papillary however less bulbous in form. Density was the same. GINGIVAL CASE STUDY - page 3 Appt 4 Note: Gingival description was not completed in EPR, patient will come back for additional visit in the summer upon which gingival description may be added to case study at that time, however I did make notes as follows: Patient had not bleeding upon probing and lower canine area was coral in the marginal and papillary with little to no bulbous form of papilla. Density was resilient, slightly smooth in the lower right canine area.

EVALUATION - (describe in detail the changes in patient's oral conditions as a result of the treatment and education you provided. Describe changes in bacterial flora) Patient exhibited great improvements in a short period of time. All pockets checked had reduced by 1mm, no bleeding upon probing and little to no erythmia/inflammation in lower canine area. Patient's bacteria flora exhibited cocci and only a few rods/filaments but no spirochetes. Patient's plaque score went from 85% to 12%. Patient was very egar to learn, applied proper Bass tooth brushing techniques and flossing. Patient was proud and excited to have such a big improvement in a short period of time. Recommendations regarding modification of care plan for re-treatment, referral, or maintenance. Patient was referred to private practice for restorative work. Patient is rescheduled in July for another prophy. Patient understood and had started a good home care plan which must be re-evaluated in July. Upon re-evaluation if the patient has continued the good job with home care I would recommend a 4 to 6month recare. Patient must also receive proper dental care for caries noted on radiographs. Charting: Dental/Perio Charted as usual – missing teeth, caries, restorations, overhangs, mobility, open contacts, food impaction sites, malrelations, attrition, abrasion, plaque, bleeding, probing depths, position of gingival margin, recession muscle pulls, furcation involvement; Perio Chart #2 (last appointment) open a “Limited/Problem-Focused Exam” perio chart to note plaque, changes in probe depths only, gingival margin on changes and bleeding points. Note: “Spot probing” and bleeding was noted on 4/9 in the perio chart, however it was not put in under “Limited/Problem-Focused Exam”. Please note due to medical issues, (pending eye surgery in one week, elevated blood pressure readings preventing treatment, and miscommunication in the amount of antibiotic to take prior to appointment thus delaying treatment, Patient stated she would be willing to come back in the summer, but due to eye surgery in one week was unable to come again. I did finish this patient but was rushed. Sorry. Treatment Notes - record in detail for each appointment the treatment provided i.e. oral hygiene education, patient response, complications, and improvements.