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DH 151
April ,2016
a. Age :48
b. Sex : Female
c.Race : Hispanic
d. Occupation :Telemarketing
e. Marital Status : Married
f. weight :195 pounds
g. height : 56
i. Chief complaint : My gums bleed and I feel my mouth a little dry, and sometimes my teeth
are sensitive
Past Medical History : 2006 - Diagnosed with cervix cancer
Treatment:Received radiotherapy for a few weeks
Had a hysterectomy
uterus.ovaries and fallopian tubes removed
2008 - Acquired fungus infection on feet
Treatment: Antifungal medication.
Hospitalizations :
2006 - Hysterectomy, hospitalized for 4 days.
No complications after surgery

Past medication or drug use: Cancer treatment: Patient doesn't remember the name of
the medications.
Fungal infection: Doctor recommended Lamisil ,patient was
allergic, physician change medication, patient doesn't
remember the name.
Family History : Mothers Mother: Died of stomach cancer on 1991.
Mothers Brother: Died of prostate cancer on 2007.
Mothers Niece: Died of breast cancer on 2010.
Review of systems: Patient denied any neurological, psychological, functional,
respiratory, cardiovascular, dermatological, gastrointestinal,
sexual, hematological and, immunological conditions.
The endocrine system was affected because of the
hysterectomy surgery on 2008, patient stated, after the surgery, I
eat sweets more than used I to. In addition, the psychological
system was affected since the patient was observed expressing how
the cancer surgery changed her life since she did not have any kids
and felt frustration and desire to become a mother.

Current Medication: None

Vital Signs: a. P : 64
b. BP :120/80 mm Hg
c. R : 16
ASA Classification: Patient is allergic to Lamisil (antifungal),according to the ASA
classification, allergies to a medication classifies the patient as
Past history of dental exam, treatment and hygiene visits
a. Last FMX : December 2014
b. Last dental exam : December 2015
c. Last dental treatment :Prophylaxis December 2015
d. Dental hygiene frequency :Once a year
e. Scaling Root Planning :
f. Existing restorations:June 2010
g. Periodontal Maintenance : Patient states nobody told me about it , just I have to come
back for cleaning once or twice year
h. Periodontal surgery : None
i. Restorations: - Amalgam restorations: 1O,3O,12DO,15O,
-Composite restorations :2B,3OB,4MO.5DO ,14B,15B
-PFM crown :13 done in 2005.
-Partial removable denture: Patient states started to used it on December
2015, but she lost it, patient also mentioned that when she was wearing the
partial lower denture she felt more even bite and less pressure on the front
Extra Oral Examination:WNL
Occlusion, TMJ and oral habits:
a) Arch relationship classification
Right Molar : Unclassifiable
Left Molar : Unclassifiable
Right Canine : Class I
Left Canine : Class I
Overjet :3mm
Maximum Opening :45mm
Open bite: none
Patient profile: Mesognathic
b) TMJ :
None deviation,clicking or popping.
c) Oral habits :
Signs of attrition on mandibular & maxillary anterior
teeth,abfraction 21
Intraoral examination: WNL.

Patient present a grayish flat lesion of a size 3x3 mm, around the
buccal and palatal gingival tissue of tooth 13,where she presents a
PFM crown,patient states had an extensive amalgam filling
previously to the crown. To my opinion the lesion maybe be an
amalgam tattoo based on the characteristics and antecedents of
the lesion, but I would like to mention that any oral lesion the only
way to give an accurate diagnostic is through a histological study;
which I don't consider is necessary on this case since patients
states is being on her mouth for more than 20 years with no
changes .
Also during the salivary glands assessment it was noticed a very
low salivary flow,and patient statesI often feel my mouth dry,and
this got worse after the radiotherapy on 2008.
5.Caries and Dental Examination
a. Identification of decalcification, possible caries, and defective restorations
Most of the present restoration (amalgam and composites)
-Abfraction on buccal of # 20
- Amalgam restorations: 1O,3O,12DO,15O,
-Composite restorations :2B,3OB,4MO.5DO ,14B,15B, have open
b. Caries location and type evaluated
None clinical cavity observe,FMX is not available to give a more accurate
c. Caries Index (DMFT) recorded and evaluated
a.D= 9 ,M=6 ,F=0
6.Periodontal Evaluation
Gingival description:
a.Maxillary Free Gingiva: reddish, blunted, rolled, smooth.
b.Maxillary Attached Gingiva : pink, smooth, shiny, stippled.
c.Mandibular Free Gingiva: rolled, blunted, edematous, shiny,
d.Mandibular Attached Gingiva:reddish, shiny, smooth, edematous, lack of
Full mouth: BOP, Probing, Recession, Furcation and Mobility Assessments
a. Baseline :23 sites
b. Final : 13 sites
Probing depths :
Baseline (03/04/16): Generalized 4 mms and 5 mms pocket depths
with localized 6 mm on #2D,3D.
On mandibular anterior teeth probing was not done due the
presence of supragingival calculus; a gross debridement would be
necessary for a more accurate measurement of the periodontal pockets.

Recession :
# 1B: 3 mm #2B:5 mm #3B: 4 mm #14B: 4 mm #15B: 3 mm #16B: 2 mm #16 P:
6 mm #15P: 6 mm #14P: 5 mm #3P: 2 mm #21B: 2 mm #22B: 2 mm #20L: 2 mm
#21L: 2 mm
Furcation :
#2: Class II #14: Class II #15: Class III #16: Class II
+1 : teeth # 8,9,23,24,25,26,2,3,16
+ : teeth # 7,10
CAL: Recession + pocket depth:
Buccal #1-8mm,2- 8mm,3- 7mm,14- 9mm,15- 8mm,
16- 7mm,20-5mm, 21-5mm,22-5mm
# 3-7mm,14-10mm,15-11mm,16-11mm
Tooth Extrusion:
Due of the missing posterior teeth on the mandibular arch.
# 3,4,14,15
Primary Etiology:
Plaque biofilm
Chronic Periodontitis is considered a multifactorial disease,where the biofilm plays the
main etiologic role for the developed and progression of the periodontal disease destroying
supporting structures of the tooth such as bone.
Periodontal Perpetuating (Contributing) factors:
Some factors contributing to the development of the periodontal disease were:
-The missing of most of mandibular posterior teeth contributed to the decrease of
the vertical dimension, adding pressure to the anterior teeth during
mastication,causing mobility on maxillary and mandibular anterior teeth,(+1 on
8,9,23,24,25,26, and + on 9,10).because all the front teeth have to do a chewing
function which is designed to be performed by molars.
-Another factor, the poorly contoured composites restorations on the buccal of
maxillary molars (2,3,14,15) are causing plaque traps,leading to increase of
gingival inflammation .
-The PFM on #13 it's causing biofilm accumulation due the open margins and
also when it was prepared the biological width wasn't preserved, the inflammation
can be observed around the tooth and patient bleed easily with light probing.
-The patient suffered from xerostomia which decreased the oral ph, contributing
to the accumulation of biofilm and the possibilities to develop dental caries,
because many of the bacterias related to periodontal disease and dental caries
proliferate faster in an acidic environment.
FMX and Panoramic image:
None available
AAP Classification & Rationale:

Generalized Severe Chronic Periodontitis

Due the generalized pockets depths of 4 mms and 5s mm, recession
between 4 mm-6 mm, CAL 6 mm-10 mm meaning a severe bone loss , also
this process was developed throughout a long time period.
7.Oral Hygiene Evaluation
Plaque control record ,index recorded and evaluated:
03/04/16 Baseline PFI 10%
03/29/16 Final PFI 40%
The second appointment was on 03/11/16, the patient received a comprehensive oral
hygiene education that included: brushing and flossing technique, dental aids information,
recommendations of use of mouthwash, prescribed toothpaste, nutritional analysis and
recommendations based on the results.
Patient seemed very interested and motivated to learn more about oral health, and even though
this project allows only to do an assessment and preventive dental treatment as education and
fluoride varnish application, it was great to observe a good improvement in dental plaque
control, which will be more beneficial for the patient after she has done a dental prophylaxis or
SRP depending on her needs.
Assessed patients dental home care and skill:
Patient plaque removal skill
Patient was using a circular back and forward motion, which is
inadequate, patient missed all the gingival margin area,the mandibular lingual
anterior teeth and all the maxillary palatal area. Patient stated she did not use
dental floss regularly just when she felt food between her teeth. She also had
never received an oral hygiene education from a dentist or dental hygienist on her
visits to her previous dental appointments.
Patients knowledge and awareness of dental and periodontal diseases:
Patient had a minimal knowledge about what is periodontal disease and
their etiological factors.Patient described gum disease ,When the gums bleed
1. Carbohydrate intake :
Pt. carbohydrate intake increased:
a.First 3 days diet journal
(03/11/16-03/13/16) 233.33 minutes of exposure
b.Second 3 days diet journal (03/25/16-03/27/16) 253.33 minutes of exposure
2. Analyze BMI
a.Pt weight: 190 pounds
b.Pt height: 56
c.BMI: 31.5, OBESITY
3. Activity Analysis
a.Activities :

Cleans house once a week

No walking
b.Activity level : Sedentary

4.Nutritional Counseling
a. Patient mets 90 % of target
b. Pt. not deficient in macronutrients

c. Pt. deficient in : Ca,K,Fe,Mg,Vit A,k,D and Choline

d. Advised patient to :
Increase H2O intake to 2000 g/day (8 cups)
Obtain Ca from Cheese,Milk,sunflower seeds,soybeans
Obtain Potassium from potatoes,beets,squash.
Obtain Iron from meat,beans,nut,sunflowers seeds.
Obtain Magnesium from Green leafy vegetables, such as spinach,
and whole grains .
Obtain Vitamin A from sweet potatoes,carrots,dark leaf.
Obtain Vitamin K from frozen kale/spinach
Obtain Vitamin D from 15 min sun exposure daily and fatty fish.
Obtain Vitamin Choline from cereal,eggs,garlic.
9.Fluoride Analysis
a.Current Use : Crest Whitening plus Scope anticavity 0.243% NaF 2x/day
b.Water Fluoridation :0.6 ppm
Increase Topical fluoride use ,based on the CAMBRA results which
determined the patient has a HIGH-CARIES RISK .
10.Caries Risk Assessment
a.CAMBRA assessment:patient was determined to be a HIGH RISK for
b .Recommendation :
-Continue using Crest whitening plus scope anticavity 0.243%NaF at
morning,and start using before bedtime Prevident 5000 ppm to help to
remineralize the teeth and also decrease the sensitivity the patient has with all
the several root exposure(recommending to patient do not remove completely
the paste,to increase the benefits through the night) .
-Start using Listerine zero ,which does not have any alcohol(patient has
xerostomia ,avoid any product with alcohol)
- Chew Xylitol gum 5 min after snacks 3-5/day , for dry mouth.
- 5% NaF Varnish (at the last dental appt of SRP)
Education on Caries Control
Patient was educated on the etiology and progression of dental caries,and how
important it is to:
-Decrease the fermentable carbohydrates from the diet.
-The bacteria in biofilm or plaque present in the patients mouth, consume
sugars and products acids which destroy the tooth structure of susceptible
tooth,reason why is important to have plaque control.
-Understand the importance of fluorides ability to remineralize teeth in order to
reduce the risk of caries.

-Original Overall Prognosis:

Poor, due patients diet,(high in fermentable carbohydrates ) lack of appropriate
brushing and flossing technique, lack of fluoride mouthwash,the severe root
exposure increasing the accumulation of biofilm.
The proposed patients caries prevention plan is very different to the current oral patients
care, because the new recommendation included the use of Prevident 5000 toothpaste,
mouthwash without alcohol, xylitol chewing gum, in office NaF 5% varnish at every
appointment and also to reduce the intake of fermentable carbohydrates. If the patient follows all
the recommendations the prognosis will be improve.
11.Oral Hygiene Instruction and Treatment Plan
Goals: To be achieved in 3 weeks period between initial appointment and
a.Improve PFI by minimum 20%
b.Decrease BOP sites by 40%
c. Decrease PD by 1-2 mm (Could be more after pt has done the SRP)
a.Current regimen : manual toothbrush, 0.243 NaF Crest toothpaste,circular,
back and forward motion twice a day.
b.Recommendation:Demonstrated modified bass technique, with manual
brush and suggested electric toothbrush,continue toothpaste twice a day
adding Prevident 5000 toothpaste ,Mouthwash (alcohol-free),Xylitol chewing
Current regimen:None
Recommendation:twice per day,seesaw with c-shaped technique.Pt was
showed and practice how to use it,advised to spend enough time during
Current regimen::None
Recommendation:ACT Anticavity 0.05 NaF (alcohol-free)
13.Post Instructions Status
a.E / I :No Changes
b.Gingival Tissues:
-.Maxillary Free Gingiva: pink,blunted,rolled,smooth.
-.Maxillary Attached Gingiva : pink,smooth,shiny ,stippled.
-.Mandibular Free Gingiva: rolled,blunted,edematous,shiny,
-.Mandibular Attached Gingiva:reddish,shiny,smooth,edematous,lack of
Periodontal Re-evalution :03/29/16
a. Probing : Most of periodontal pockets were reduced at least 1mm or maintain
the same.
b. Recession,Mobility,Furcation : No Changes
c. PFI : 40% (30% improvement)

d. OHI Compliance : Pt claims to have followed all the instructions, and seems
happy to feel and see the difference on her gums, even without the SRP, Pt.started
using an electrical toothbrush and flossing everyday at least once per day.
e. Nutrition Compliance: Pt carbohydrate liquid exposures decreases from 100
minutes to 53.33 daily, mainly soda intake, but the solid exposure increased from
133.33 to 153.33
Proposal Dental Treatment
Full Mouth Scaling and Root Planing (Four appointments )
Due the amount of tedious calculus the patient present I will recommend one
quadrant of Scaling Root Planing (one hour per appointment).
First appointment
-Record of vital signs
-Extraoral and Intraoral Examination
-Periodontal Examination (with all records of gingival description , probing
depth, calculus code,BOP,CAL,recession ,furcation).
-Scaling Root Planing UR ( one hour per quadrant) with the proper anesthesia
given to patient to make the treatment more comfortable.
-Comprehensive Oral Hygiene education
-Toothbrush method recommended:Modified Bass due the several recession and
also for the plaque control.
-Toothbrush recommended :Soft, small, tufted also give the option for an electric
-Education about how use dental flossing,interproximal toothbrushes,etc
-Recommended a NaF 1.1% toothpaste twice a day, to help to remineralize all the
teeth especially the multiples root exposure due gum recession and reduce the
sensitivity patient feels.
-Recommended the use of oral mouthwash without alcohol, because of patients
-Recommended use of xylitol gum after eating snacks 3-4 x / day (diet analysis
revealed patient eats snack frequently),also the xylitol will help with xerostomia
the patient presents.
-Next appointment to continue SRP for LR quadrant asap or according patients
Second appointment
-Record of vital signs
-Extraoral and Intraoral Examination
-Periodontal Examination (with all records of gingival description , probing
depth, calculus code, BOP, CAL, recession, furcation).
-Scaling Root Planing LR ( one hour per quadrant) with the proper anesthesia
given to patient to make the treatment more comfortable.
-Re evaluate OHI intraorally and also with patient ,in case is necessary reinforce.
-Next appointment to continue SRP for UL quadrant asap or according patients
Third appointment
-Record of vital signs
-Extraoral and Intraoral Examination

-Periodontal Examination (with all records of gingival description , probing

depth, calculus code,BOP,CAL,recession ,furcation).
-Scaling Root Planing UL ( one hour per quadrant) with the proper anesthesia
given to patient to make the treatment more comfortable.
-Next appointment to continue SRP for LL quadrant asap or according patients
Fourth appointment
-Record of vital signs
-Extraoral and Intraoral Examination
-Periodontal Examination (with all records of gingival description , probing
depth, calculus code,BOP,CAL,recession ,furcation).
-Scaling Root Planing LL(one hour per quadrant), with the proper anesthesia
given to patient to make the treatment more comfortable.
-Re-evaluate if the patient is following all the previous recommendations about
oral health, and if there is anything the patient is missing or doesn't understand
completely reinforce.
-NaF 5% Varnish application at the end of treatment
-Schedule a follow up appointment in 4-6 weeks.
-Next appointment 4-6 weeks to re evaluate .
-If the dental treatment it was successful schedule the patient for a periodontal
maintenance in 3 months ,if not will be necessary to re evaluate to find out, where
it was the failure and corrected it (maybe misunderstanding of patient how to
maintain good oral hygiene,will be necessary to reinforce.)
-In case there is still calculus redo the SRP on the areas where be necessary.
--Selective Coronal Polishing: It is prefered to do it at this appointment, because,
the tissue will be less tender, sore and inflamed.
-Refer the patient with the general dentist:
-For a comprehensive oral evaluation, taking of FMX to evaluate the
possible replacement of some fillings and the PFM on #13
-Patient is interesting to get a new lower partial denture and obtain some
information regarding dental implants.
-Patient will be refer with the Periodontist for a complete periodontal assessment
to discussed the possibility to place some implants on the mandibular posterior
14. Discussions
Overall, the patient met the goals set on the first appointment.The Plaque Free Index was
improved by 30% (goal was 20%), the BOP sites decreased by 55%, most of pockets depth were
decreased at least by 1mm. Also her consumption of carbohydrates decreased by

The patient understood the oral hygiene education and the importance to maintain a healthy
mouth, and all the factors that contributed to obtain it.The patient had several problems on her
oral mouth through the years, such early loss of teeth due economic issues which didn't let her to
get them fixed,ending with extracting affected teeth, causing also extrusion of the opposing teeth
and loss of the vertical dimension and interocclusal space, making more difficult to rehabilitate
due of the lack of appropriate interocclusal space, adding extra pressure to the anterior front teeth
during the mastication forces due the lack of most mandibular posterior teeth. Making all these
factors even worse after, the radiotherapy she had on 2006, according to the patient caused
xerostomia increasing the risk of cavities.
The patient made a comment about her previous dentist.The patient expressed her desire to do
something about to rehabilitate her mouth, but unfortunately the dentist told her, You would
have to invest thousands of dollars in order to restore your mouth, because, it has a lot problems,
and also you have medi-cal, which mainly will cover tooth extractions, reason why it's better for
you, just keep your mouth as currently it is,and just come to do prophylaxis every 6-12 months.
The clinician could not believe what the patient told her about this dentist, it was very
unprofessional, disrespectful, and irresponsible. The patient mentioned, after she talked to this
dentist she felt very sad and hopeless about to rehabilitate her mouth.The clinician explained to
the patient, that the bad experience she had with that dentist should not stop her desire to
improve her oral health,and that is the reason why it is so important to have a good oral health
by controlling the dental plaque accumulation and also having a low carb diet to decrease the
risk of tooth decay, if she can establish a good management of all these factors it would help her
to have a good periodontal foundation necessary to rehabilitate and maintain her oral mouth.

At the CAMBRA and nutritional assessment, it was given to the patient an Oral B Electric
Toothbrush,and some Glide dental floss, the patient seemed very interested and motivated about
everything that was explained on the appointment.
At the last appointment the patient expressed how happy she was about the electric
toothbrush,that her teeth felt smooth and clean, and her gums were not bleeding as much and also
that she started chewing the xylitol gum ,and how she was putting more attention about the type
of food she ate and if the food was sticky she brushed her teeth after.
The clinician felt excited about the overall improvement of the patient came through the
process, and how effective can a good and motivational oral education for patients be, and how
clinicians should never assume that an economic situation will put a patient away have a good
dental treatment .The oral care professionals have a responsibility to educate and offer all the
options available to the patient, leaving an impact on patients as part of the process, and, after
receiving all necessary information, patients will be able to make the best decisions according to
their personal situations.
15. Conclusions
The overall Oral health of the patient was poor,due to many factors such as lack of
knowledge, proper professional information, economic issues, but it was proved through the
project the patients improvement and motivation to recover a good oral health.
One of the major problem the patient had and contributed to the accelerated progress of the
periodontal disease, was the lack of most of posterior teeth, which had caused a severe loss of the
vertical dimension and the interocclusal space, making more difficult to rehabilitate with partial
lower denture,bridge or implants, and also was causing an occlusion trauma to the patients

mouth, because, all the mastication forces are directed to anterior, reasons why it was important
to create an even mastication forces for the patients mouth.
It has been reported through studies, that occlusal trauma can affect the periodontium
negatively in the presence presence of plaque and calculus by accelerating the progression of
periodontal disease.The purpose of this study to investigate the effects of the occlusal trauma on
periodontal destruction,particularly loss of attachment.
The conclusion of the study was,
When inflammation was combined with occlusal trauma, immune complexes
were confirmed in more expanding areas than in the area of the I group without occlusal
trauma, and loss of attachment at the onset of experimental periodontitis was increased.
Damage of collagen fibers by occlusal trauma may elevate the permeability of the antigen
through the tissue and result in expansion of the area of immune-complex formation and
accelerating inflammatory reaction. The periodontal tissue destruction was thus greater in
the T+I group than in the I group. (Nakatsu, S., Yoshinaga, Y., Kuramoto, A., Nagano,
F., Ichimura, I., Oshino, K.Hara, Y. 2013)
There has been many studies about the importance to replace missing teeth, trying to improve the
health.This study was done about the prosthetic replacement of missing teeth:
Prosthetic replacement of missing teeth aims to improve health. This can be
achieved by improving the patient's well-being and quality of life and by restoring the
biological balance in terms of occlusal and mandibular stability in the occlusal and the
orofacial system. In occlusal systems with a complete anterior region and 'satisfactory'
premolar and molar regions, prosthetic replacement of missing teeth is not indicated
generally. In case of a restricted number of missing teeth in the anterior region and/or a

not 'satisfactory' premolar region, fixed dental prostheses may be indicated. In case of an
incomplete anterior region and no 'satisfactory premolar as well as molar regions,
removable dental prostheses are usually indicated. These guidelines are presented in the
absence of sufficient scientific evidence. Therefore, in clinical decision making, the
question whether prosthetic replacement of missing teeth is sensible, and if so, by which
type of dental prosthesis, can only be answered after a dialogue with mutual respect
between care provider and patient (Ned Tijdschr Tandheelkd. 2014)
In Conclusion, this project shows how periodontal disease is given and all factors involved
and for their progress. Also shows as oral care health providers we have the responsibility,to
acquire the professional knowledge, to able to educate the patients and guide them to obtain and,
maintain a good oral health and the importance of the prevention in the process of Health.
During the project, I did challenge myself in two important aspects: The ability to motivate the
patient about the importance to maintain a good oral hygiene, and also the skill to develop an
efficient time management during patients treatment. I felt very pleased that I was able to give
the correct oral hygiene instructions to the patient and, the patient understood it and practiced
resulting and a considerable decrease of the dental plaque, decreasing the inflammation and gum
redness, even without performing a dental treatment. My learning is how powerful is the dental
hygienists role to educate our patients and to help them to achieve a good oral health. We have
a big responsibility to obtain all the latest knowledge about brushing techniques, types of dental
aids, types dental brushes, types of different toothpastes, etc. in order to recommended the
appropriate dental tools for each patient and his /her specific needs, with the ultimate goal to help
to have and maintain a healthy oral cavity.

Nakatsu, S., Yoshinaga, Y., Kuramoto, A., Nagano, F., Ichimura, I., Oshino, K., . . . Hara, Y.
(2013). Occlusal trauma accelerates attachment loss at the onset of experimental
periodontitis in rats. Journal of Periodontal Research J Periodont Res, 49(3), 314-322.
Ned Tijdschr Tandheelkd.(2014).Prosthetic replacement of missing teeth. Indications for fixed
and removable dental prostheses.121(1):45-56.
Xerostomia. (n.d.). Retrieved May 28, 2016, from
Zanardi, P. R., Santos, M. S., Stegun, R. C., Sesma, N., Costa, B., & Lagan, D. C. (2015).
Restoration of the Occlusal Vertical Dimension with an Overlay Removable Partial
Denture: A Clinical Report. Journal of Prosthodontics. doi:10.1111/jopr.12351