Running head: CAPSTONE PROJECT 1

Dental Hygiene Theory and Practice: Capstone Project

by

Maria Dela Cruz

Lake Washington Institute of Technology

In partial fulfillment

of the requirements for

DHYG 341: Professional Practicum

Danette Lindeman, RDH, MEd

Spring Quarter

November 14, 2018

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Assessments

Health History:

A patient presented to the Lake Washington Institute of Technology dental clinic for a

new patient examination. The patient is a 72-year-old female and was classified as III/2/D1-D2.

Her medical history, which was completed on October 10,2018, showed she has diabetes,

osteoporosis, rheumatoid arthritis, high blood pressure and high cholesterol, placing her in the

category of ASA-II. She’s under the care of a physician and has never been hospitalized for any

major diseases. She’s allergic to Lisinopril and is currently taking medications such as

Metformin, Insulin Glargine and Insulin Lispro for diabetes, Losartan and Metropolol for

hypertension, Atorvastatin for high cholesterol, Diclofenac as an analgesic for rheumatoid

arthritis, Montelukast for coughing, and Calcium and Vitamin D for osteoporosis. The patient

stated that she was seen by the doctor for her cough and found no significant findings on this

condition. Her vitals showed a blood pressure of 130/80 taken on her right arm with an adult

manual cuff and a pulse of 68 beats per minute. The patient is aware of her elevated blood

pressure and was recommended she monitor it. The patient is under a physician’s care and is

taking medications for her elevated blood pressure. Her A1C was 8.3 and blood glucose level

was 140. The patient ate lunch before coming to the office.

The patient is of Asian descent and a retired medical technologist who enjoys travelling

and taking care of her two grandchildren. Her diet consists of low carbohydrates and low sugar

content foods and beverages. She exercises every day and does not drink alcohol nor smokes

tobacco.
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The patient has type 2 diabetes which started in 1987. She is under her physician’s care and is

currently taking medications. The patient mentioned she developed the condition when she

became pregnant with her third child. The patient had gestational diabetes which developed into

type 2 diabetes.

Type 2 diabetes is the most common form of diabetes. If a person has type 2 diabetes, the

body does not use the insulin properly. The pancreas can make up for this but cannot do it for a

long period of time. The pancreas cannot make enough insulin to normalize blood glucose levels

(American Diabetes Association, 2018). A person with diabetes has a higher chance of getting

periodontal disease. It can also lead to pain and in time, can lead to tooth loss. Diabetes can slow

down healing which can interfere with periodontal disease treatment. Diabetes can contribute to

xerostomia or dry mouth which is a contributing factor to dental caries (NIDCR, 2018).

The patient has slight osteoporosis or thinning of bones which can result in fractures

especially on the spine, hips and wrist. Periodontitis and osteoporosis both progress with

advancing age, estrogen deficiency and family history. Current knowledge regarding the effects

of osteoporosis or osteopenia on periodontal disease and alveolar bone loss is inconclusive due to

differences in the alveolar bone structure and thickness. Individuals with high mineral levels in

the skeleton seem to retain their teeth with deep periodontal pockets more easily than those with

osteoporosis (Jonasson et.al., 2016).

The patient has an autoimmune disease Rheumatoid arthritis. The joints are involved and

result in inflammation which can cause pain and swelling. Recent scientific research is linking

the inflammation and bacteria found in periodontal disease to cardiovascular disease and

diabetes. It also links inflammation in patients with Rheumatoid arthritis (Hartwell, 2016).

Patients with Rheumatoid arthritis are at a higher risk of having periodontitis.

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The patient has hypertension and high blood pressure. Most medications have significant

effects in oral health such as xerostomia, dysgeusia or altered sense of taste, orthostatic

hypotension and gingival hyperplasia. Xerostomia may result in gingivitis, periodontal disease

erosion and loss of tooth structure. It can lower the pH within the oral cavity increasing plaque

formation and cavities (Mikaela, 2017). The use of anesthesia with epinephrine is part of the

treatment process. Risks include increased risk of acute hypertensive or hypotensive episodes,

angina pectoris, arrhythmias, and myocardial infarction. Caution is required for anesthesia with

epinephrine and impregnated with epinephrine retraction cord especially with uncontrolled

hypertension (Southerland et. al., 2016).

Extraoral Assessment:

There are scattered macules on the patient’s face upon visual examination. The patient

stated they were age spots and freckles. The jaw presented lateral deviation to the right, and

presence of temporomandibular joint subluxation and crepitation when the patient opened her

mouth. No lymph nodes were noted.

Intraoral Assessment:

The presence of pigmentation on the vermilion zone was noted. The patient has bilateral

linea alba on the buccal mucosa with petechiae on the left buccal mucosa. The patient had a 2x2

mm non-tender brown macule on the left maxillary tuberosity, which the patient was not aware

of.
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Gingival Description:

The patient’s gingival margins presented with generalized slight erythema with localized

moderate erythema on the lingual surface of mandibular arch. Marginal contour was slightly

rolled and generalized blunted with localized slight to moderate gingival edema on the linguals

of mandibular teeth, and the gingiva is stippled.

Tooth Chart and Occlusion:

Tooth charting was completed on October 22, 2018. The patient has twenty-five teeth

present. She has an existing composite restoration on seven posterior teeth, and five anterior

teeth. Existing amalgam restoration on the cervical surfaces of three premolars teeth were noted.

She had root canal therapy on tooth number 19. She has three porcelain-fused-to-metal crowns

on teeth number 14 and 19 and a stainless-steel crown on tooth number 15. She has a composite

onlay restoration on tooth number 18, and attrition was noted on the incisal surfaces of teeth

number 6, 8,9, and 11.

The patient has open contacts between teeth 5-6, 11-12, 12-13, and 27-28. She has

marginal ridge discrepancies on teeth 12-13, 13-14, 19-20, and 20-21. A total of three teeth were

mesially rotated, and three teeth were linguoverted. The patient has 0mm WAG on her teeth

number 22, 29 and 30, and less than 2 mm on teeth number 3,5,6,19 and 20.

The doctor’s examination was conducted on October 22, 2018 and occlusion was

confirmed. The patient has class I Angle’s classification on both right and left molars and

canines. She has a slight overbite, 4mm overjet, no crossbite and no open bite.
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Periodontal Chart:

The patient’s periodontal chart showed generalized 3-4mm gingival pockets with

localized

5-6mm gingival pockets on the left maxillary and mandibular posterior teeth. She has

generalized 2-3mm recession. The patient has class1furcations on the maxillary and mandibular

posterior teeth. The patient had generalized slight to moderate bleeding upon probing.
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Risk Assessment:

The patient’s risk assessment showed clinical evidence of attrition, occlusal trauma, and

teeth mobility. The patient’s soft tissue showed clinically evident signs of xerostomia and

gingival recession. Dental history showed that the patient has a history of clenching and the

patient understands her oral status condition and values prevention. She wanted oral hygiene

product recommendations and is open to new information. The clinical and radiographic findings

indicated the patient has slight plaque accumulations and moderate subgingival calculus. She has

furcations and horizontal bone loss. The patient has a history of temporo-mandibular joint

subluxation and crepitus. The patient reported she goes to her annual physical exam, follows
CAPSTONE PROJECT 8

medical and dental advice. Her stress load is low, and her exercise level is in the medium

category. The risk assessment also showed the patient uses a medium bristle manual toothbrush,

tartar control toothpaste, and Listerine mouthwash. The patient brushes her teeth one to two

times a day and flosses two to three times a week. The importance of flossing every night was

reiterated to patient. Flossing does 40% of the work to remove interproximal bacteria or plaque.

The teeth have five surfaces and if we don’t floss we leave two surfaces unclean (Zamosky,

2018). The patient understood and intends to floss every night. Her plaque index has 22% of

plaque.
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Radiographs:

Because the patient’s full mouth radiograph was not current, a full mouth series of

radiograph were taken as required by Lake Washington Institute of Technology’s dental

department policy. The radiographic series was done on October 10, 2018 to aid the dentist in

proper diagnosis during the exam.

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Oral Hygiene/Patient’s Chief Concern/Plaque Index:

The patient was alternating between and electric and manual medium bristle toothbrush

twice daily during our first two appointments. She was flossing two to three times a week using

waxed floss and Listerine mouthwash. She was not using any other oral hygiene aids. By the

third appointment, the patient switched to a soft bristled toothbrush and started flossing every

night. The patient’s chief concern was to have her teeth cleaned, because she was overdue for her

dental appointment. Her plaque index was calculated at 22%.

Dental Examination:

The doctor’s exam was done on October 22, 2018 by Dr, Gandhi. There were no cavities

diagnosed and there were no signs of incipient caries. The patient mentioned she is experiencing

sensitivity on tooth number 20 when she brushes her teeth. The doctor recommended to use a

soft bristle toothbrush and to brush gently. No other treatment was proposed.
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Pre-treatment Intra-Oral Photographs:

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Study Models:
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Nutritional Analysis/Caries Risk Assessment:

The patient’s food intake record revealed the patient planned out her meals. She stated

she eats accordingly to her condition. As stated in choosemyplate.gov, for women 51 years old

and above, the daily recommended amount for fruits is 1 ½ cup, vegetables is 2 cups, grains is 5

oz. with a minimum of 3 oz., protein is 5 oz., dairy is 3 cups, and oils is 5 teaspoon

(choosemyplate.gov, 2018). The dietary assessment log based on the choosemyplate.gov,

showed the patient had adequate amounts of vegetables, grains and water in her diet. However,

the patient didn’t have adequate daily recommendations for fruits, dairy and protein. The log also

indicated the patient needs to eat less of fats and sweets. The assessment log tallied the patient’s

total acid exposure, and the result was eighty minutes per day. Reviewed the result with the

patient and addressed history of caries formations and oral manifestations with diet involving

fats, sweets, and fermentable liquids and solid and hard food. Informed the patient that one of the

most common and prevalent dental infectious diseases is dental caries. Caries is caused by the

dissolution of the teeth by acid produced by the metabolism of dietary carbohydrates by oral

bacteria (Touger-Decker & van Loveren, 2003). A discussion was done with the patient about

the effects of food with high acid content in connection with xerostomia and how it can affect

caries formation and periodontal condition, especially due to her caries risk level being

moderate. Upon review with the patient, she committed to lessen her fermentable liquids and

sticky retentive foods in a day.

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Dental Hygiene Diagnosis

The patient was classified as III/2/D1-D2. Significant findings on the dental hygiene

diagnosis health history is medications for her diabetes, high cholesterol, high blood pressure and

rheumatoid arthritis. The proposed goal is for the patient to continue with her medications and

schedule regular medical check-ups.

The dental history showed the patient’s last continuing care was in January due to time

limitations. The proposed goal is for the patient to keep up with regular dental check-ups. The

extraoral/intraoral portion of the dental hygiene diagnosis showed no significant lesions noted.

However, a 2x2 macule was noted on the left maxillary tuberosity, and is proposed to be

monitored for any changes.

The gingival description showed generalized slight erythema with localized slight to

moderate edematous gingiva on the lingual of the mandibular teeth. The gingival condition

possibly could be due to the patient’s systemic disease which causes xerostomia. The proposed

goal is to recommend Biotene for xerostomia. It contains a mouth-moisturizing agent to provide

soothing, lubricating relief and its gentle, alcohol-free formula refreshes your mouth, while
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helping to keep it clean and maintain a healthy mouth (Biotene, 2018). Another proposed goal is

the use of the modified Bass toothbrushing technique and flossing every night.

The oral hygiene section showed the patient brushes her teeth one to two times a day and

flosses two to three times a week. The patient has moderate calculus build up. The proposed goal

is to brush at least two times a day and floss at least every night. Patient uses a combination of

manual and Sonicare electric toothbrush. The patient was informed that Sonicare removes up to

7x more plaque than a manual toothbrush. Manual toothbrush makes at least 300 brush strokes

per minute compared to Sonicare which makes 31,000 brush strokes per minute. Sonicare makes

it easier to keep hard-to-access areas of the mouth clean (Philips Sonicare, 2018).

The hard tissue section of the dental hygiene diagnosis showed no present cavities noted;

history of porcelain fused to metal crowns, root canal therapy and signs of attrition. The hard

tissue conditions are related to history of carious lesion and attrition. The proposed goal is for

night guard and good oral home care to promote optimal oral health.

The periodontal section showed generalized 4mm with localized 5-6mm pocket depths,

furcations and generalized 2-3mm recession which attribute to biofilm formation. The proposed

goal is to educate the patient about the importance of good oral home care and to maintain

regular continuing dental hygiene care. Due to the patient’s recession, I proposed the use of

prescription Fluoride toothpaste due to root exposure. The root surfaces of teeth are not as hard

as the enamel and can get caries easily. It can also cause thermal sensitivity and sensitivity to

sweets. Fluoride in toothpaste is absorbed directly by dental plaque and demineralized enamel

and increases the concentration of fluoride in saliva one hundred to a thousand-fold (ADA,

2017). The American Dental Association recommends the use of fluoride containing toothpaste.

Patient was using mouthwash and asked what the difference is between prescription fluoride
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toothpaste and a fluoride rinse. Informed the patient that ACT fluoride rinse is approved to

prevent caries, while prescription fluoride such as Prevident prevents caries and prescribed for

sensitive teeth (Treato, 2018).

The dental hygiene diagnosis also showed that the patient has temporo-mandibular joint

subluxation and crepitation on the right side when she opens her mouth, which was related to

bruxism and clenching. The proposed goal is to recommend a night guard.

The methods used to achieve goals and outcomes is to keep track of the patient’s oral

home care and determine whether the proposed therapy and intervention is attainable by the

patient. The patient is aware of her periodontium and is willing to work towards the betterment

of her oral health.

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Planning

The proposed dental hygiene treatment plan based on the patient’s gingival recession,

furcation and pocket depths, consisted of three quadrants of 4342 and one quadrant of 4341

scaling and root planing and was signed by the patient. Because the patient has a 5-6mm gingival

pocket depth, I planned on placing Arestin in the 6mm gingival pocket depth and subgingival

irrigating the remaining 5mm gingival pockets. The goal of this treatment is to reduce

inflammation and reduce the bacterial load which may have caused the gingival pocket

formation. The goal is to inform the patient that scaling and root planing may not be enough to

decrease the bacterial load. The baseline levels of bacteria might return in just a few days.

Antibiotics such as Arestin can help reduce the prevalence and severity of periodontal disease. It

is orally administered and concentrated in the gingival crevicular fluid of the periodontal

pockets. This in turn will be useful as an adjunct in the treatment of periodontitis (Arestin

professional, 2018). The aim is to reduce the gingival pocket depth by removing the biofilm that
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causes inflammation and bleeding. Because of the presence of a macule on the right maxillary

tuberosity, I plan to use the Velscope to check for abnormalities. The presence of 5-6 mm

gingival pockets led me to plan on showing the bacteria found in these pockets using the

microscope. Because of root exposure due to recession, I plan to recommend prescription

fluoride toothpaste as an adjunct to her regular toothpaste. I plan to teach her and recommend the

use of periodontal aids for the furcations on posterior teeth. The patient has considerable

amounts of spacing in between her teeth, so I plan on recommending the use of a proxibrush. It is

my plan to bring the patient’s gingival condition to its normal healthy state and to prevent caries

formation. I also plan on educating the patient about the importance of oral home care to

promote optimal health. I plan to demonstrate proper and correct tooth brushing and flossing

techniques and recommend a soft bristle toothbrush. I plan of having her back for tissue re-

evaluation with fluoride application appointment 4-6 weeks after the last quadrant of scaling and

root planing. I planned an appointment for her continuing care three months after the initial

dental hygiene therapy. I plan to reiterate the importance of having good oral hygiene and

regular visits to the dentist to promote optimal oral health.

Implementation

The number of dental hygiene appointments planned was seven. The new patient

assessments were completed in October 10, 2018, and doctor’s exam was done in October 22,

2018. No restorative treatment diagnosed during the doctor’s exam. Patient’s A1C level, blood

glucose level and blood pressure were monitored every appointment visit. Health history and

medications were reviewed every appointment visit as well.

During the first appointment for dental hygiene treatment, scaling of the lower right was

completed. The patient requested not to have anesthesia for this appointment. And since this
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quadrant is III/2/D1, we opted to use Oraqix (lidocaine and prilocaine) 2.5/2.5 , 1/2 carp with no

reactions. The patient didn’t feel any discomfort during the procedure.

An ultrasonic scaler was used initially to remove calculus, followed by hand

instrumentation. Universal and Gracey curettes were utilized to remove the residual subgingival

calculus. An anterior and posterior sickle scaler were used on the anterior and posterior

supragingival calculus. Instrumentation of the quadrant was successful, and patient’s calculus

and plaque level were non-tenacious and easy to remove.

During this appointment, I discussed with the patient about her gingival recession and

root exposure. Recommended Clinpro 5000 to prevent cavity formation especially on the root

surfaces and use of perio aid to clean the furcation areas.

The second dental hygiene appointment was done on the lower left quadrant. And since

this is a D2 quadrant, the instructor discussed with patient that we need to numb the area, so the

patient would feel comfortable, to which the patient agreed. One capsule of 2% Lidocaine with

1:100,000 epinephrene was administered. 20% Benzocaine topical anesthesia was used without

any complications. Ultrasonic scaler and hand scaler were used for this appointment. Reiterated

the use of a proxy brush on the spaces between the mandibular anterior teeth. Use of an end tuft

brush was also discussed for brushing the distal portion of the terminal molars.

A bacterial sample from tooth number 18 mesial was taken and placed under a

microscope to show the bacteria present in his oral cavity. The patient was told that the motile

organisms are negatively impacting her oral health, increasing periodontal disease. The patient

was aware of the different bacteria that she saw under the microscope due to her line of work.
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Subgingival irrigation with 0.12% CHX Gluconate was administered after the scaling and

root planing. Chlorhexidine has powerful antibacterial properties and can be especially helpful in

maintaining a healthy mouth after a teeth deep-cleaning procedure such as tooth scaling and root

planing (Procter and Gamble, 2019). Arestin Minocycline HCL 1mg was placed in teeth number

18 mesial and 19 buccal to improve the 6mm deep pockets.

The third dental hygiene appointment was done on the upper right and upper left

quadrant. The patient requested not to use anesthesia this time again. And because these

quadrants were D1, we used Oraqix (lidocaine and prilocaine) 2.5/2.5, 1/2 carp with no

reactions. The patient didn’t feel any discomfort during the procedure.

I used the cavitron ultrasonic scaler with the help of the universal and Gracey curette. I

used Graceys 11/12 and 13/14 for the subgingival calculus on the posterior teeth, and universal

curette for the anterior and posterior teeth. The anterior teeth was accessed with an offset sickle

and a nevi scaler.

We did the Velscope cancer screening today due to macule on the left maxillary

tuberosity. The patient mentioned that she was not aware of the macule and was not bothering

her. The Velscope technology stimulates epithelial cells and stroma by a blue light (400-460

nm). It is the self-fluorescence of the tissues that allows detection of changes morphology and

composition of the tissues in a non-evasive manner. However, this additional examination does

not replace the oral examination and scalpel biopsy, which remains the golden standard of

diagnosis (Videira & Araújo, 2019). Velscope screening resulted to WNL and recommended to

watch the area.

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Evaluation

During the tissue re-evaluation phase of treatment, it was discovered that the initial

therapy was successful. The post treatment periodontal chart revealed the area that had Arestin

improved by 1 mm. There was still generalized slight bleeding on probing. Generalized decrease

of pocket depths by 1 mm.The areas of recession and furcations remained the same. The plaque

index showed an increase in the plaque formation which could be due to xerostomia. Patient

mentioned that she keeps forgetting to use the Biotene that we recommended. Recommended ice

chips with xylitol this time. Discussed with patient that the xylitol and ice chips website reported

that they are safe to use for diabetics. Ice chips uses xylitol which is a polyol, a sugar alcohol. It

is all natural, safe for diabetics and has many health benefits. It is mostly made from birch bark

and is non-GMO (Ice Chips, 2019). Patient’s flossing increased to every night and modified Bass

tooth brushing technique was being practiced.

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Post-Treatment Intra-Oral Photographs:

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Reflection

In treating a medically compromised patient, it is necessary to use all the information

given to us during our education. The knowledge that I gained about drug interactions and side

effects made me competent and efficient in doing the treatment plan, advise the patient about

oral hygiene and encourage the patient in her overall oral health. I was able to connect the effects

of her medications to the erythematous gingiva and moderate interproximal calculus. If I could

improve on one thing is to take photographs and measurement of the intraoral macules on the

palate to be able to determine the condition in the future. I believe that I grew as a clinician

especially developing my critical thinking abilities and thoroughly explaining to the patient ways

on how to achieve optimal dental and medical care.

Documentation

The patient presented as a new patient and all documentations were completed. The

patient filled out the privacy consent, HIPAA and extensive health history at the front desk. The

health history was reviewed and expanded upon chair side with patient. The patient signed all

necessary documents, including the dental hygiene treatment plan. The patient didn’t have any

restorations that needed to be done. There was no issue with the documentation throughout the

treatment, and all treatment was understood and consented to by the patient.
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References

Choose MyPlate. (n.d.). Retrieved October 30, 2018, from https://www.choosemyplate.gov/

Compare act fluoride rinse vs prevident - comprehensive analysis by treato. (n.d.). Retrieved

November 6, 2018, from https://treato.com/ACT+Fluoride+Rinse,Prevident/?a=s

D, H. (2016, December 15). Rheumatoid arthritis and oral health. Retrieved November 10, 2018,

from https://hartwelldentistry.com.au/oral-health/rheumatoid-arthritis-oral-health/

Diabetes. (2018, July). Retrieved October 30, 2018, from https://www.nidcr.nih.gov/health-

info/diabetes/more-info#overview

Dry mouth oral rinse. (n.d.). Retrieved November 10, 2018, from https://www.biotene.com/dry-

mouth-

products/mouthwash/?gclid=EAIaIQobChMIwPu5t4qs3AIVAQAAAB0BAAAAEAAY

ACAAEgJVzfD_BwE&gclsrc=aw.ds

Fluoride: topical and systemic supplements. (n.d.). Retrieved November 1, 2018, from

https://www.ada.org/en/member-center/oral-health-topics/fluoride-topical-and-systemic-

supplements

High blood pressure - oral health implications. (2011, September 17). Retrieved November 10,

2018, from http://claredental.com/high-blood-pressure-oral-health-implications/

Is chlorhexidine mouthwash right for you? (n.d.). Retrieved March 24, 2019, from

https://oralb.com/en-us/oral-health/solutions/mouthwash/chlorhexidine-mouthwash-pros-

and-cons
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Jonasson, G., & Rythén, M. (2016, July 13). Alveolar bone loss in osteoporosis: a loaded and

cellular affair? https://doi.org/10.2147/CCIDE.S92774

Manual vs. Electric. (n.d.). Retrieved November 5, 2018, from https://www.usa.philips.com/c-m-

pe/oral-health-care/information/manual-vs-electric Patient periodontal infection education

and guidelines. (n.d.). Retrieved November 6, 2018, from

http://www.arestinprofessional.com/Patient-education-guidelines

Southerland, J. H., Gill, D. G., Gangula, P. R., Halpern, L. R., Cardona, C. Y., & Mouton, C. P.

(2016). Dental management in patients with hypertension: challenges and solutions.

Clinical, cosmetic and investigational dentistry, 8, 111-120. doi:10.2147/CCIDE.S99446

Touger-Decker, R., & van Loveren, C. (2003). Sugars and dental caries. The American Journal

of Clinical Nutrition, 78(4), 881S–892S. https://doi.org/10.1093/ajcn/78.4.881S

Type 2. (2018). Retrieved October 30, 2018, from http://www.diabetes.org/diabetes-basics/type-

2/?loc=hottopics

VELscope is a non-invasive oral cancer-screening device. (n.d.). Retrieved March 24, 2019,

from https://www.dentistryiq.com/articles/2012/07/velscope-is-a-non-invasive-oral-

cancer-screening-device.html

What is Xylitol? (n.d.). Retrieved March 24, 2019, from https://www.icechips.com/about-xylitol-

benefits-and-more
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Zamosky, L. (n.d.). More reasons why you should floss. Retrieved November 6, 2018, from

https://www.webmd.com/oral-health/features/still-not-flossing-more-reasons-why-you-

should-floss