CASE STUDY

PRESENTATION

BY: BETHANY MONIZ DH2

Rationale for Patient Selection

Perio Case Type III, with Loc IV

Generalized 1-2mm CAL, with Loc 3-4mm

Deposit Evaluation: 3 / 3.5 Sub

Ideal patient to improve or stabilize his existing condition

26 Teeth Present

MEDICAL HISTORY

HIV

Hepatitis C

High Blood Pressure

Kidney Stones Patient working with Physician

Nervousness and Anxiety

Gums Bleed when Brushing

Patient stated that he quit smoking in August 2014

Current Lab Results:

CD4: 470

VL: < 20

Pretreatment Assessment
VITALS:

BP: 137 / 85

RESP: 14

PULSE: 89

IO/EO Exam: No significant findings

Dental Charting: Missing teeth # 1, 3, 16, 17, 19, 32
Microscope: Risk Factor C.

Cocci, Spirochetes, Gliding Rods present. Bacteria

were TNC, with high mobility. WBC less than 10 per
field of view.

Perio Assessment

Bleeding: Loc Sl Spontaneous upon probing

CAL:

Furcation Involvement: # 2 - Class II,

Mobility: # 4 & 8 Class I, # 9 Class II

Gen Sl 1-2 mm recession

with Loc 3-4mm

# 14, 18, & 31 Class I

RADIOGRAPHS

STUDY MODEL

STUDY MODEL Home Care

Occlusion: Class II, Division I

Mandible is retruded and maxillary incisors are protruded

To Demonstrate OHI:

Point out areas of heavy plaque around molar teeth

and interproximal areas

Accessing mandibular lingual anterior teeth

where calculus built up the fastest.

DENTAL HYGIENE DIAGNOSIS

Perio Case Type III, Generalized moderate Periodontitis

Gingival Description:

Color: Gen Sev Hyperemia

Contour: Gen Mod Enlarged

Consistency: Gen Mod Fibrotic

Radiographic Findings that Support Diagnosis:

Generalized Moderate Horizontal Bone Loss

Localized Vertical Bone Loss:

Mesial # 2
Distal # 31

RISK ASSESSMENTS

Periodontal Risk Factors: Recent tobacco use, irregular dental care

Caries Risk Factors: Patient drinks sugary energy drinks and

vitamin water throughout each day. Patient brushes 1x/day.

Dental Exam revealed decay # 20 DO, # 21 DO

Patient Goals: Maintain oral health through nutrition, smoking

cessation, and regular dental visits.

Interventions: Regular perio maintenance visits every 3 months,

complete caries prevention & remineralization and 3-day diet
tracking.

Expected Outcomes: Arrest disease progression, reduce pocket

depths, inflammation, calculus, and plaque.

TREATMENT PLAN and RATIONALE

Treatment Plan:

3 Appointments for NSPT

Comp Oral Eval

FMS

OHI

Periodontal Scaling per quadrant

Local Anesthesia

Topical Fluoride Varnish

Rationale for several appointments based on the fact that it had been
3+ years since his last cleaning, as well as NSPT because he is a Perio
Case Type III.

TREATMENT PROGRESS NOTES

Evaluation appointment: 11.13.14
Initial appointment: 11.14.14
Continuing Care appointment: 11.18.14
Caries remineralization appointments:

11.18.14, 11.24.14, 12.2.14, 12.5.14

DHR appointment: 11.26.14

Completion of NSPT: 1.26.15
Recall/Continuing Care appointment: 4.20.15

ORAL HYGIENE INSTRUCTION

Initial appointment: Sulcular brushing 2x/day, c-shape floss technique
1x/day, and use of fluoride mouth rinse for remineralization and
sensitivity.
Patient Compliance: Poor patient only brushing 1x/day, not flossing.
Mod-Heavy Plaque present.
Modifications to OHI: Referred a mechanical toothbrush to help
reduce plaque, Prevident and Chlorhexidine were prescribed at this
appointment. Also referred Xylitol chewing gum as we were starting
his Caries Remineralization treatment.
Patient Compliance to Modifications:
Poor still Mod-Heavy Plaque present, however,
patient was using the Prevident and Chlorhexidine.

CARIES REMINERALIZATION
CRT RESULTS: Mutans Streptococci < 10 (5)
Lactobacilli < 10 (5)
Appointment 1: Plaque Free 68%
Appointment 2: Plaque Free 72%
Appointment 3: Plaque Free 63%
Appointment 4: Plaque Free 49%

MORE OHI MODIFICATIONS

* Learning moment for Clinican and Patient
At the 4th Caries Remineralization appointment I showed patient
the plaque index chart, and how the Plaque Free % was decreasing
(instead of increasing).

2 minute timer given to patient

2-3x/day

To be successful with our treatment plan of arresting the disease

progression, thorough homecare, plaque removal, and disrupting
bacteria is necessary on his part.

Interdental brushes

NUTRITIONAL COUNSELING: 3DAY DIET TRACKING

Patient only eats 2 meals/day.

Due to health conditions he doesnt feel well in the mornings, limits

appetite

He recently changed his diet to more whole foods Diet tracking

included fruits, vegetables, grains, and meat.

No dairy products because patient is lactose intolerant.

Drinks several energy drinks throughout the day we discussed that

most energy drinks contain 1.5 times more sugar than a regular
soda.

DHR Appointment

# 20 DO Amalgam

Fall Term Restorative Class

MOTIVATIONAL STRATEGIES
Intrinsic:

Patient shows internal motivation to

achieve oral health

Extrinsic:

Reduce inflammation

Stain removal

Reduce sensitivity

Prevident prescribed to reduce decay

Chlorhexidine for bacterial reduction

Final NSPT Appointment

Patient presented with a skin condition on face and neck.
(Extraoral photos were approved by patient to document).
Atopic Dermatitis Swollen, white-yellow lesions, extremely itchy

Patient uses a Topical Corticosteroid

Cream to treat

Dry skin and Immune System Dysfunction can be

factors of a break out.

Usually clears up in 1-2 weeks

Arestin placed on the Distal # 30 8mm pocket

FINAL NSPT APPOINTMENT

Continued

PA of # 31 To confirm complete removal of calculus because

pocket depth on distal was 11mm

Arestin placed on # 30 Distal 8 mm pocket

Homecare compliance: Good. Improvement on visible plaque

from previous appointments.

CONTINUING CARE APPOINTMENT

Date of Visit: 4.20.15
Deposit Evaluation: 1 / 1.5
Inflammation: Slight-Moderate papillary and marginal
MicroscInflammationope: Risk Factor B. Significant reduction in
microorganisms Few spinning rods, few gliding rods, few WBCs.
OHI Compliance: Very Good Significant reduction in plaque,
calculus and inflammation
Treatment Plan: 1 Perio Maintenance Visit
Patient motiviation factors have not changed
Outcome from NSPT were overall met, except in 2 localized areas Distal
# 30 8mm pocket, Distal # 31 10mm pocket. Both areas were
unresponsive and deep pockets remain.

COMPARISON: NSPT to
CONTINUING CARE
INITIAL APPOINTMENT

RECALL APPOINTMENT

Deposit Evaluation

3 / 3.5

1 / 1.5

Probing Depths above 3 mm

55 areas

26 areas

Bleeding

BOP 15

BOP 6

Scaling: Moderate

Scaling: Slight - Moderate

Microscope

Risk Factor C Risk Factor B

POST TREATMENT
RECOMMENDATIONS

Regular 3-month Perio Maintenance visits

Referred patient to a Periodontist for consultation because recall

appointment did not show healing/improvement from NSPT
treatment on # 30 Distal and 31 Distal.

Pocket Depths: # 30 Distal 8mm, # 31 Distal 10mm

PROFESSIONAL REFLECTION
Treatment Plan changed to add appointments for restorative and
caries management.
One thing I would have changed would be to spend more time
reviewing home care using intraoral photos and radiographs as a
motivational tool.
My greatest learning moment was during the caries remineralization
appointments and disclosing for plaque index. The plaque free
areas were decreasing at each appointment. I knew I needed to
change my approach in communication (expressing his role at home
and instructing

THE END
I appreciate the opportunity to work with this patient.
I learned a lot about working as a co-therapist and
as a clinician.