Running head: CAPSTONE PROJECT

Capstone Project

by

Katey Menke

Lake Washington Institute of Technology

In partial fulfillment

of the requirements for

DHYG 341, 342, 412, 422, 432, 438 - Professional Practicum,

Capstone, and Dental Hygiene Theory and Practice Series

Danette Lindeman, RDH, MEd

Spring Quarter 2019

May 7, 2019
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Assessments

Health History

The patient is a 62-year old female that presented with a blood pressure of 121/85 mmHg.

The blood pressure was taken on her right arm with a manual, adult sized cuff and had a pulse

rate of 77 BPM with a regular heartbeat. The dental history includes two previous root canal

therapies, five crowns and three composite fillings. The patient maintains on-time, 6-month

recall appointments at her current dentist. The patient is under the care of a primary physician,

Dr. Jill Enright at Overlake Internal Medicine for high blood pressure, Hepatitis-B and low

estrogen levels. The patient’s medications are: 25mg of Losartan, one time daily, to control

hypertension, a natural estrogen replacement hormone therapy, one time daily, to alleviate hot

flash symptoms of low estrogen, Centrum silver as a one-time daily multivitamin, and an

occasional aspirin for aches and pains, as needed. The patient reported to not have any recent

hospitalizations, no allergies to medications, is not a tobacco user and is of a high socioeconomic

class. The main systemic health concerns for the patient include hypertension, low estrogen

levels and hepatitis B.

Hypertension is a chronic medical condition that occurs when blood pressure in the

arteries is elevated. The American Heart Association defines normal blood pressure to be a

systolic reading of less than 120 mmHg and a diastolic reading of less than 80 mmHg. Elevated

blood pressure is 120-129 mm Hg / less than 80 mm Hg. Stage 1 hypertension is indicated to be

either 130-139 mm Hg / 80-89 mm Hg. Stage 2 hypertension is 140 mm Hg or higher / 90 mm

Hg or higher. A hypertensive crisis is a reading of any reading higher than180 mm / higher than

120 mm Hg. Systemic health concerns from hypertension include increased risk of a stroke,

vision loss, heart attack, heart failure, kidney disease or failure and sexual dysfunction
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(American Heart Association, 2018). Possible oral manifestations are gingival bleeding, gingival

inflammation, hypo salivation due to side effects of medication. Other possible manifestations

include lichen planus lesions, gingival enlargement when calcium channel blocker medication is

used to control the disease. (Kumar 2012). During the health history interview, the patient

reported she was recently diagnosed with high blood pressure 1-month prior to our first

appointment and she is following up with her PCP to ensure proper medication levels have been

achieved to control her blood pressure. Commonly prescribed medication for hypertension

include diuretics, Angiotensin-converting enzyme inhibitors, Angiotensin II receptor blockers,

calcium channel blockers, beta blockers, and renin inhibitors (MFMER, 2018). The patient is

currently taking an Angiotensin II receptor blocker called losartan (Cozaar).

Low estrogen levels are typical in postmenopausal women at the patients age of 62.

Systemic health concerns such as osteoporosis, hot flashes, night sweats, palpitations, headaches,

insomnia, fatigue, and neurological disorders. Possible oral manifestations are periodontitis,

lichen planus, alveolar bone resorption, xerostomia, sensation of painful mouth, and burning

mouth syndrome. Commonly prescribed medications are estrogen hormone replacement therapy;

however, this medication also includes serious side effects of increased endometrial or uterine

cancer risks. (Grover, 2014). The patient reported to experience hot flashes and has visited a

naturopathic doctor that prescribed a natural estrogen hormone replacement therapy, taken 1 time

a day. Patient reports that the hot flashes have been reduced since taking the medication.

Hepatitis is an inflammation of the liver. Hepatitis B is an infection caused by the

hepatitis B virus with symptoms that can last from a few weeks to lifelong. The patient does not

report any current symptoms but it should also be noted that carriers of the disease can appear

healthy and symptom-free and still spread the infection to others. Systemic health concerns are
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liver damage, cirrhosis, liver cancer and death. Possible oral manifestations are mucosal

membrane jaundice, bleeding disorders, petechiae, increased bruising vulnerability, gingivitis,

gingival bleeding, cheilitis, xerostomia, and bruxism. Commonly prescribed medications for

active chronic hepatitis B infections are antiviral medications, interferon injections and liver

transplant. Vaccinations for hepatitis also prevent the spread of the infection and the CDC

recommends dental personnel should follow standard precautions of PPE (C. N., 2018). The

patient reported that she found out that she had Hepatitis B 20-years ago when she was

attempting to donate blood at a blood bank. She did not know how or where she contracted the

disease and also does not report any symptoms associated with the disease.

Extra-oral Assessment

Notable deviations from normal include a papule that is 2 x 2 mm, round, sessile, well-

defined boarder, light pink, semi-firm, smooth, on lower right chin, pt. reported to be present for

5 years, non-tender, no apparent related history, no referral needed. Masseters appeared to be

slightly enlarged suggesting bruxism that is furthered confirm with attrition as noted on the tooth

chart. Submandibular lymph node enlargement of a 1x1mm round, movable, non-tender node.

Intra-oral Assessment

Notable deviations from normal are generally dry lips. A 1x1mm macule located on the

center of the lower lip that is round, flat, diffuse boarders, non-movable, smooth, present for

three years, non-tender, no apparent related history, suggested to refer to dermatologist for

evaluation. The patient reported that she regularly sees her dermatologist and the lesion was

previously biopsied and reported to be noncancerous. The right buccal mucosa presented

scattered petechiae due to patient reported check biting. Soft palate presented a 1x1mm
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erythematic right tonsil scaring. Velescope diagnostic test was preformed and the oral tissues

presented to be normal.

Gingival Description

The patient’s gingiva presented initially differently between the maxillary and

mandibular arches. The maxillary gingiva was generalized: healthy coral pink color, knife edge

margin contour, pointed papilla contour, firm consistency and stippled surface texture. The

mandibular gingiva presented with generalized; slightly erythematous color, slightly rolled

margin contour, slightly bulbous papilla contour, slightly edematous consistency, and stippled

surface texture.

Tooth Chart

The tooth chart was completed by clinical evaluation and assessment of full mouth x-rays

taken on the day of the first appointment. The patient was found to have the third molars

extracted as well as the maxillary 2nd molars for orthodontics during adolescence; missing teeth

include 1, 4, 13, 16, 17 and 32. #2 has an occlusal composite filling that includes the mesial and

distal pits. #3 has had root canal therapy and a full noble metal gold crown. #6-11 incisal edges

present with attrition. #12 has a DO composite. #14 has had root canal therapy and a porcelain

fused to metal crown. #15 has an occlusal composite filling that extends to the mesial and distal

pits. #19 has a porcelain fused to metal crown. #20 is in buccal version, #21 is in lingual version.

A marginal discrepancy is between #20 and #21. Distal rotations are present on #22, 23, and 25.

Mesial rotations are present on #24, and #26. Attrition is present on #23 - #26. A porcelain fused

to metal crown is on #30 and there is a a full gold crown on #31. See Appendix A for the tooth

chart.

Occlusion
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The patient presented with right and left molar class II and canine class I. It should be

noted that the molar class II occlusion is partially due to the extracted 2nd premolars and the

patient does not exhibit facial characteristics of distal occlusion that include a posterior

positioning of the mandible to the maxilla.

Periodontal Chart

The patient presented with generalized 3-4mm pockets with localized 5mm pockets on

the distal buccal reading of #14 and 19 and the mesial lingual reading of #31. Localized 1 mm of

recession present on the buccal surface of #5 ,14 18, 29 and 31, and the lingual surface of #3, 14,

22, 26 and 31. Localized class I furcation are present on the distal root of #13 and 14, and the

palatal root of #14. The AAP classification and LWTECH calculus code is III/2/D1/D2. The

patient is classified as a D1 on the maxilla and a D2 on the mandible. See Appendix B for

periodontal chart.

Risk Assessment

Contributing factors to the patient’s caries risk level within the patients’ health history is

cardiovascular disease (hypertension) which the patient is taking medication (25 mg Losartain

q.d.), postmenopausal low estrogen levels, and previous hepatitis B infection. Hard tissue

findings show the patient the patient has clinically evident and is at risk for bone loss, attrition,

calculus and plaque, caries, and dentinal hypersensitivity. Additional clinically evident hard

tissue complications are misaligned teeth. Radiographs confirm moderate periodontal disease.

The patient does not have any dental history complications of anxiety, pain, sensitivity, soreness,

bad breath, grinding, use of night guard, difficulty swallowing or chewing, dry mouth clenching

or dexterity issues. The patient understands oral status, values prevention, wants oral hygiene

product recommendations and is open to new information. The patient drinks fluoridated water,
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participates in annual physicals, follows medical and dental advice has a medium stress load and

medium exercise frequency of bike riding, tennis and walking, does not use tobacco. Diet

consists of medium sucrose and carb intake including breads, pasta and crackers. Soft tissues are

at risk for xerostomia, gingival recession, gingivitis, lichen planus, and periodontal disease.

Clinically evident soft tissue complications are gingival recession, gingivitis and periodontal

disease. Behavior modification is not necessary for this patient. Alterations to care are based on

the patients age. The patient is a geriatric patient that would benefit from shorter appointment

lengths to reduce stress (American Dental Association, 2006)

Radiographs

A full mouth x-ray set was taken and included 20 films with horizontal bitewings. The x-

rays were taken to help identify current restorations for the tooth chart, examine bone for any

possible lesions, assess bone height levels to establish an AAP classification and to identify

caries. Clinically present radiograph findings include; existing restorations of crowns and

composite, isolated furcation’s, and horizontal bone loss of 25% or less. See Appendix C for full

mouth x-rays.

Plaque Index

The patient presented with a plaque index of 41%. There were 43 surfaces out of 104

tooth surfaces that disclosed plaque accumulations. Plaque was localized on the IP of molars,

facial surfaces of mandibular incisors, facial and lingual surfaces of the maxillary incisors and

buccal surfaces of the maxillary and mandibular molars. See Appendix D for plaque index.

Dental examination

The dental examination was completed on the second appointment with the patient. The patient

was clinically and radiographically examined by the attending dentist in the clinic. The dentist
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determined that the patient was healthy and there was no caries nor watches and no restorative

treatment was needed. Pretreatment photos:

Intraoral Photos

Pre-treatment and post-treatment photos were taken before and after treatment. Five

photos were taken on each set that included; direct facial, right facial, left facial, maxillary

occlusal, and mandibular occlusal. See Appendix E for pre-treatment photos and Appendix F for

post-treatment photos.

Nutritional Analysis

The patient completed a full 7-day nutritional analysis with an assessment log – the

patient used sparkpeople.com as a food logging tracker to be able to log her foods she consumed

for 7 days.

The patient’s diet consistently lacked sufficient vitamin-D, calcium. Vitamin-D plays an

important role in the absorption of calcium, phosphorus and magnesium to allow for

mineralization of bones and teeth. Diets that lack vitamin D may have the oral manifestation of

enamel and dentin hypoplasia. Calcium is important in giving bones and teeth their compressive

strength by mineralizing the protein matrix with hydroxyapatite, furthermore, when calcium

levels are depleted, bones are weakened and teeth are more prone to dental decay and mobility

(Scheller 2018).

The patient is also consuming too many fats as the percentage of recommended daily

value should be around 30% fat in your diet, however the patient consumes about 40% fat in her

diet.

Plaque index scores of 41% is high due to the amount of carbohydrates the patient is

eating on a daily basis and also a lack of oral hygiene. The patient only currently brushes once a
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day and the plaque index would improve with a diet change of less carbohydrates and more fruits

and vegetables as well as an increase to brushing 2-times a day.

One dietary change commitment from patient is to eat more fatty fish such as tuna or

salmon to increase vitamin-D consumption. Another change commitment is to increase calcium

intake by making cheese, milk and yogurt apart of her daily diet.

Dental Hygiene Diagnosis

The significant findings of the dental hygiene diagnosis address the health history, dental

history, extra oral and intra oral exam, gingival description, oral hygiene, hard tissues,

periodontal status, and provided fluoride recommendations. Goals and interventions were

discussed with the patient and a hygiene treatment plan was made. The methods used to achieve

goals and outcomes was incorporating gold standards of dental hygiene care and current research

with the new patient assessments; medical history, extra-oral, intra-oral examinations, gingival

description, radiographs, tooth chart, periodontal chart and risk assessments See Appendix H for

the dental hygiene diagnosis.

The health history, which includes the patient reported hypertension, hepatitis B and low

estrogen. Hypertension is the most significant finding and due to family history of the disease.

The goal is to maintain a healthy blood pressure by continuing to take her prescribed medication

and monitor her blood pressure. The patient should maintain regular doctor visits with her

primary care provider to continue to monitor blood pressure.

The dental history shows that the patient goes routinely to the dentist every 6-months for

recall appointments. The patient goal is to continue to go every 6 months, the intervention is to

schedule her next recall appointment after initial therapy treatment.

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The extra-oral and intraoral examinations found a 2x2mm papule on the chin and a

1x1mm discoloration on the lips due to a previous biopsy, the patient goal is to wear sunscreen

Chapstick on her lips and maintain regular visits with her dermatologist. The intervention to

monitor and report any changes to the dermatologist, as needed.

Gingival description revealed maxillary gingival tissues were healthier than those of the

mandibular gingiva. The mandibular tissues were slightly erythematous, slightly rolled while the

maxillary tissues appeared to be coral pink and knife edge. The cause of the mandibular tissue

inflammation is due to lack of biofilm removal. The goal is to increase brushing and flossing in

order to sufficiently remove biofilm. The intervention is SRP therapy.

Oral hygiene habits include brushing once a day, plaque and calculus accumulation is

generalized light, interproximal due to a lack of removal of biofilm. The goal is to brush 2 times

a day with bass method and to floss once a day and introduce super floss to areas with crown

margins.

The hard tissues have brown staining on the premolars due to possible decay process. The

goal is to use the air polisher to remove staining, check with the doctor to verify staining is not

decay. The periodontal status includes generalized 3-4mm pockets, localized 5mm pockets,

slight BOP and class I furcation’s on 14 and 15. The etiology to increased pocket depths and

furcation’s on 14 are due to crown margins and the biofilm that is not being removed, the goal is

to use super floss and water pick to clean the crown margin, the intervention will be to demo

how to use super floss around a crown.

The patient fluoride sources are from the fluoridated city water she drinks, as well as, the

over the counter toothpaste she is currently using when brushing once a day. The goal for the

patient is to use fluoride toothpaste 2x a day and to continue to drink fluoridated water. The
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fluoride benefits will be to decrease bacterial load, demineralize decalcified enamel and to

occlude dentinal tubules to reduce sensitivity (Faller 2019).

Methods of evaluating success will be an updated periodontal chart during the tissue re-

evaluation phase. The periodontal chart should show demised bleeding upon probing, indicating

patient compliance in home care. An interview with the patient about brushing and flossing

frequency will also be performed with the goal of acknowledging successes and encouraging

further compliance.

Caries Risk Assessment

The cariogenic source for the patient comes from a high-carbohydrate diet with high

exposure to acid from the diet from drinks like coffee and wine. The recommendations are to

decrease coffee and wine consumption and eat less carbohydrates and eat more lean means like

fish, fruits, vegetables and milk consumption to increase calcium, vitamin D and to reduce acid

attacks on the teeth. A further recommendation is to prescribe fluoride toothpaste, such as

Clinpro to reduce bacteria and to strengthen enamel (Maguire, 2014).

Risk Assessment

Contributing factors to the patient’s caries risk level within the patients’ health history is

cardiovascular disease (hypertension) which the patient is taking medication (25 mg Losartain

q.d.), postmenopausal low estrogen levels, and previous hepatitis B infection. Hard tissue

findings show the patient the patient has clinically evident and is at risk for bone loss, attrition,

calculus and plaque, caries, and dentinal hypersensitivity. Additional clinically evident hard

tissue complications are misaligned teeth. Radiographs confirm moderate periodontal disease.

The patient does not have any dental history complications of anxiety, pain, sensitivity, soreness,

bad breath, grinding, use of night guard, difficulty swallowing or chewing, dry mouth clenching
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or dexterity issues. The patient understands oral status, values prevention, wants oral hygiene

product recommendations and is open to new information. The patient drinks fluoridated water.

Participates in annual physicals, follows medical and dental advice has a medium stress load and

medium exercise frequency of bike riding, tennis and walking, does not use tobacco. Diet

consists of medium sucrose and carb intake including breads, pasta and crackers. Soft tissues are

at risk for xerostomia, gingival recession, gingivitis, lichen planus, and periodontal disease.

Clinically evident soft tissue complications are gingival recession, gingivitis and

periodontal disease. Behavior modification is not necessary for this patient. Alterations to care

are based on the patients age. The patient is a geriatric patient that would benefit from shorter

appointment lengths to reduce stress (American Dental Association, 2006)

Planning

The patient hygiene treatment plan includes four additional appointments after the new

patients assessments are completed; one appointment for each quadrant. Each appointment will

have a different education and motivational intervention, as well as, oral hygiene instruction. Our

first SRP appointment will be a 4341 on the upper right and we will focus on learning about the

decay processes, we will also review the bass method of brushing to remove more biofilm near

the gingiva. The SRP is coded to be 4341 due to the generalized 4mm pocketing as seen on the

periodontal chart (American Dental Association, 2006). Our second appointment will be an SRP

on the lower right quadrant and we will talk about the importance removing biofilm and plaque

under crown margins and demo super floss technique, the third appointment will be for the upper

left quadrant and the educational intervention will be about furcation care. The oral hygiene

instruction will be based on using the rubber tip stimulator. The fourth appointment will review

the importance of maintaining regular recall appointments and the goal will be to schedule the
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next appointment at the tissue re-evaluation appointment where we will evaluate how well the

SRP worked and determine the suggested recall frequency. The patient was informed of the

recommended treatment, why it was recommended and signed an informed consent.

Justification of the SRP is due to the 4 or more, 4mm or greater pockets in the quadrant

and the moderate level of interproximal calculus. Also, the patient’s active periodontal disease

was taken in consideration for the therapeutic treatment of billing code 4341, SRP (Delta Dental

2018).

Goals and expected outcomes are decreased bleeding on probing, a decrease in

inflammation and pocket depths as well as an increase in the healthy appearance of gingival

tissues. The goal for the patient compliance is to increase brushing to twice a day, using bass

method, morning and night. Use floss once a day in a c-shape method and to use superfloss

around crown margins 1x a day. An additional patient home care technique is using the rubber

tip stimulator in furcation areas. It is shown that the rubber tip stimulator is useful in

interproximal plaque control and firming tissue of the gingiva (Freeman, 2019).

Therapeutic intervention included possible use of Arestin in periodontal pockets that do

not respond to SRP treatment, as evaluated during the tissue re-evaluation. The indication would

be a 5mm or greater pocket with moderate to severe bleeding on probing 4-6 weeks post SRP

treatment. Arestin is a sub gingival antibiotic medication, minocycline hydrochloride that is

shown to reduce pocket depths in patients with adult periodontitis (RxList, 2017).

Additional therapeutic intervention included recommending the doctor prescribe

prescription fluoride toothpaste. Our clinic has clinpro 5000 1.1% sodium fluoride for our

patients with moderate to high caries risk. This dentifrice has added tri-calcium phosphate and is

a 5,000-ppm fluoride toothpaste that delivers fluoride calcium and phosphate to the teeth. The
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benefits from this toothpaste include remineralization of enamel, reduction of sensitivity and

reduction of bacterial load intraorally (Doyle, D. 2012)

No restorative treatment is needed.

Implementation

The implementation of the dental hygiene treatment plan was planned to be completed in

7 appointments but was completed in 6. I had planned to do 1 quad per appointment but it turned

out the upper quads were light enough to be completed together during the same appointment.

The first two appointments were for new patient assessments, the third appointment was SRP on

the lower right, the fourth appointment was for SRP on the lower left, the fifth appointment was

SRP on the upper arch and the final appointment was the tissue re-evaluation.

The instrumentation strategy included the use of the Cavitron with FSI-1000 triple bend

tip on moderate power and hand scaling instruments; Gracey curettes, universal curettes and

sickle scalers. The benefits of ultrasonic scaling with the Cavitron are increased patient comfort

as compared to just manual methods of calculus debridement. A further benefit of use of the

cavitron is the removal of supra and sub gingival biofilm (Drisko, et. al. 2000). The gracey

curettes were used for their ideal capability of subgingival calculus removal due to their specific

design to work in specific areas. The 11/12 was used for mesial surfaces and the 13/14 was used

for distal surfaces of posterior molars. The universal curettes used were the Barnheart 5/6 and the

4R4L curettes and they were used to fine tune and remove small to medium sized calculus

deposits from mesial, distal, buccal and lingual surfaces (Kamath & Umesh, 2013). These

instruments were used due to the patients’ needs of biofilm removal, subgingival interproximal

calculus removal and mandibular anterior supra calculus removal. The clinician skill was

acceptable in removing calculus removal effectively.

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The additional dental hygiene services provided; blood pressure and vitals, head and neck

exams with oral cancer screenings, Velscope oral cancer screening, intra oral photos before and

after SRP treatment, periodontal chart before and after SRP treatment, dental hygiene diagnosis,

oral health education, fluoride varnish, and polishing.

Patient participation varied throughout the process during the various appointments, as

patient motivation changed. Patient motivation increased when the patient was taught to use

superfloss under crown margins with a demonstration and guided instruction. Patient motivation

also increased when she noticed how her mandibular anterior lingual felt clean after the cleaning.

The patient felt discouraged when her plaque index was the same pre and post SRP treatment.

The patient had a high pain tolerance and did not express any pain or discomfort during any

appointment. During SRP the patient’s pain was controlled by local anesthetic. 2% lidocaine

with1:100,00 epi was used on nerve blocks for each quadrant during the quadrant’s scaling.

Daily biofilm was controlled by brushing one time a day. The patient was advised to

brush 2 times a day to remove more daily biofilm but the patient did not comply and maintained

her once a day brushing. The patient was advised to complete interproximal care once a day;

wish super floss under crown margins, proxy brush in large embrasure spaces and floss in tight

contacts. The patient reported that she was able to incorporate interproximal care 3 times a week.

The patient’s plaque accumulation reduced from generalized moderate interproximal plaque to

generalized slight interproximal plaque.

Evaluation

Notable changes in the evaluation processes in the implementation phase of treatment

include changes in the periodontal chart and in gingival appearance. The post treatment

periodontal chart changes included a reduction of the bleeding points. The initial periodontal
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chart had 13 BOP areas, where as the post SRP periodontal chart only had 7 bleeding points. The

reduction of bleeding on probing areas indicated that the SRP treatment was successful in

increasing the oral health (Berakdar, et. al, 2012). There was a decrease of 1mm in a few of the

deepest pockets; a 5mm went to a 4mm and a 4mm went to a 3mm. The areas of recession and

furcation’s saw no changes. The gingival appearance improved from initial assessment of having

generalized slightly erythematous color, slightly rolled margins, pointed papilla shape and

slightly edematous consistency to an improved gingival description of: generalized coral pink

color, knife edge contour, pointed papilla, and firm consistency. The patient was happy to see

and hear that her gums appeared to be healthier. See Appendix B for post SRP periodontal chart.

Post treatment intraoral photos were taking during the tissue re-evaluation. See Appendix F. for

post treatment intraoral photos. The patient remained motivated and open to oral hygiene

instruction for daily biofilm control but the patient was not able to incorporate additional

brushing in her daily habits. The patient reported to maintain the once a day brushing despite

understanding the benefits of twice a day brushing. The patient reported an increase in

interproximal care but did not accomplish the daily interproximal care goal by completing

interproximal care only three times a week. Additional therapeutic interventions needed included

prescribing the patient Clinpro toothpaste. Arestin treatment was not indicated for use as the

pocketing depths decreased to 4mm and the BOP had significantly improved (Orapharma 2016).

No referrals to specialists were needed. The patient’s maintenance interval is 4 month recalls.

Documentation

All aspects of documentation were completed, a chart audit was completed. I was able to

maintain accurate documentation during the treatment process. During the assessment phase the

comprehensive medical history was completed and signed by the patient, instructor and doctor.
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Vitas signs were recorded at each visit. Extra and intra oral findings were recorded at each visit.

The tooth chart was updated with current restorations, missing teeth, WAG, malposition’s,

rotations, marginal ridge discrepancies, open contacts, attrition and abfractions, as needed. The

periodontal charts recorded bleeding on probing, furcation’s, mobility, recession, CAL,

suppuration, as needed. A full mouth radiograph series was taken, mounted and dated within the

patients file. Patient homecare behaviors were assessed, recorded and updated at each visit. The

ASA was put in the patient alert box and in the medical history. The AAP is in both the edit

patient box and in the chart notes. The risk assessment is scanned into smart docs. The patient

had a dental exam, no medical consults or referrals were needed. Hygiene and restorative

treatment plans are signed and scanned into smart docs. The patient signed the consent form

prior to treatment. The patient also signed HIPPA forms and they are scanned into the file. The

patient received appropriate care for her needs. The hygiene treatment is complete and the

appropriate recall interval is established and recorded into chart notes and edit patient areas.

Goals and therapy outcomes are documented during the tissue re-evaluation. Pain management

and post-operative instructions are appropriate for patient care and are documented accurately.

Reflective Conclusion

The theory learned in my dental hygiene education was applied thought the patient

treatment process. The new patient assessments required knowledge of head and neck anatomy

for the extra oral exam; it is necessary to understand muscles and normal tissue anatomy to

differentiate deviations from the norm. The intraoral examination requires knowledge of oral

pathology to be able to identify normal or not normal tissues that would possibly require follow

up or referrals. Instrumentation competency and understanding of dental anatomy is necessary to

complete the periodontal chart and SRP cleanings. Restorative knowledge and understanding of
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radiology x-ray reading is necessary to complete the tooth chart with existing restorations.

Critical thinking and a knowledge of available oral hygiene products is necessary to provide a

personalized dental hygiene treatment plan with goals to improve the patient’s oral health.

The professional growth I recognized by providing care to the capstone patient was

becoming more time efficient, incorporating my technical knowledge and instrumentation

technique, as well as, using critical thinking skills. I became more time efficient by completing

new patient assessments and SPR cleanings at a quicker speed. I used my technical knowledge to

understand the patient’s medically compromised condition and correlate systemic health with

oral health. I used my instrumentation technique to properly remove calculus and used critical

thinking skills to provide customized care to address the patient’s needs.

Areas I excelled in were patient comfort, pain control and periodontal charting. Areas I

look to continue to improve upon is instrumentation to provide the most efficient calculus

removal strokes, sharpening instruments when they become dull, even during treatment and also

providing motivational education to my patients to increase patient compliance to home care

instructions.
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Reference:

American Dental Association (2006). Top 10 claim concerns: ADA, NADP share views on

dentists’ concerns. Retrieved from: https://success.ada.org/en/dental-

benefits/~/media/26642C1F55B14CB4B2FEFA1962B212DE.pdf

American Heart Association. (2018). Health Threats From High Blood Pressure. Retrieved

November 17, 2018, from http://www.heart.org/en/health-topics/high-blood-

pressure/health-threats-from-high-blood-pressure

Berakdar, M., Callaway, A., Eddin, M. F., Ross, A., & Willershausen, B. (2012). Comparison

between scaling-root-planing (SRP) and SRP/photodynamic therapy: six-month study.

Head & face medicine, 8, 12. doi:10.1186/1746-160X-8-12

C. N. (2018, May 22). Viral Hepatitis. Retrieved November 17, 2018, from

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Delta Dental. (2018, January 29) Prophylaxis, Scaling and Root Planing Codes and Billing

Guidelines. Retrieved from https://www.deltadentalin.com/getmedia/a24627db-9ebb-

4bcd-b076-d13f0b98730e/FLI-6396-Provider-Prophylaxis-and-Root-Planing-Code-and-

Billing-Guidelines.aspx

Doyle, D. J. (2012, September). Motivating Patients To Use Prescription Toothpaste. Retrieved

from: https://www.rdhmag.com/articles/print/volume-32/issue-9/features/motivating-

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periodontics. J Periodontol. 2000;71:1792-1801.

Erica L. Scheller, Charles Hildebolt and Roberto Civitelli, Oral Manifestations of Metabolic
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Bone Diseases, Primer on the Metabolic Bone Diseases and Disorders of Mineral

Metabolism, (941-948), (2018).

Freeman, A. (2019). Gum Stimulator: What Is It And How Do I Use It?. Retrieved from:

https://www.colgate.com/en-us/oral-health/life-stages/adult-oral-care/gum-stimulator--

what-is-it-and-how-do-i-use-it--

Faller, R. V. (2019) Fundamentals of Dentifrice: Oral Health Benefits in a Tube. Retrieved from

https://www.dentalcare.com/en-us/professional-education/ce-courses/ce410/fluoride-s-

mechanism-of-action

Grover, C. M., More, V. P., Singh, N., & Grover, S. (2014). Crosstalk between hormones and

oral health in the mid-life of women: A comprehensive review. Journal of International

Society of Preventive & Community Dentistry, 4(Suppl 1), S5-S10.

Kamath, D. G., & Umesh Nayak, S. (2013). Detection, removal and prevention of calculus:

Literature Review. The Saudi dental journal, 26(1), 7–13.

doi:10.1016/j.sdentj.2013.12.003

Kumar, P., Mastan, K., Chowdhary, R., & Shanmugam, K. (2012). Oral manifestations in

hypertensive patients: A clinical study. Journal of Oral and Maxillofacial Pathology :

JOMFP, 16(2), 215-221. doi:http://lmcproxy.lwtech.edu:2091/10.4103/0973-029X.99069

Maguire, A. (2014, June 27) ADA clinical recommendations on topical fluoride for caries

prevention. Retrieved from https://doi.org/10.1038/sj.ebd.6401019

Malamaed, S. F. (2010) Knowing your patients. American Dental Association JADA. Vol. 141.

Pp 1-4. Retreived from: https://jada.ada.org/article/S0002-8177(14)63472-3/pdf

Mayo Foundation for Medical Education and Research (MFMER). (2016, July 06). Choosing
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blood pressure medications: Know your options. Retrieved from

https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-

blood-pressure-medication/art-20046280

Orapharma. (2016) Why Arrestin? Retrieved April 8, 2019 from:

https://www.arestinprofessional.com/why-arestin

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health-menopause-online/changes-at-midlife/changes-in-hormone-levels

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Sheetal, A., Hiremath, V. K., Patil, A. G., Sajjansetty, S., & Kumar, S. R. (2013). Malnutrition

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Appendix A: Tooth Chart
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Apendix B: Periodontal Chart

Periodontal Chart, Pre-SRP

Periodontal Chart, Post-SRP

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Appendix C: Full Mouth X-Rays

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Appendix D: Plaque Indicies

Plaque Index Pre-Treatment

Plaque Index Post-Treatment

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Appendix E: Pre Treatment Photos
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Appendix F: Post Treatment Photos
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Appendix G: 7-Day Dietary and Assessment Log

DATE MEA FOOD Ca F Carb Pr Cho So Pot Vit Vi Vi Ca I Fi

L lor a ohyd ot lest diu assi am ta ta lci r be
ies t rates ei erol m, um, in mi mi um o r,
n Na K A, n n , n to
IU C D Ca , ta
F l
e di
et
ar
y
10/22/2 breakf Cottage Cheese, 19 6 8 27 23 74 190 4 0 0 16 2 0
018 ast 2% Milkfat, 1 cup 4 6
(not packed)
10/22/2 breakf Pineapple, canned, 14 0 39 1 0 2 304 2 39 0 3 4 2
018 ast 1 cup, crushed, 9
sliced, or chunks
10/22/2 breakf coffee with 40 2 7 0 0 0 0 0 0 0 0 0 0
018 ast creamers n sugars,
1 cup
10/22/2 lunch Butter, salted, 2 72 8 0 0 22 58 2 5 0 1 0 0 0
018 pat (1in. sq, 1/3in.
high)
10/22/2 lunch Safeway Select 22 0 48 8 0 0 0 0 0 0 0 0 2
018 French Bread, 2 0
serving
10/22/2 lunch Soup - Butternut 19 3 43 4 8 41 117 57 10 1 17 1 12
018 Squash Soup, 2 0 6 6 3 4
cup
10/22/2 dinner Beef, round steak, 11 3 0 19 48 44 326 0 0 0 0 1 0
018 3 oz 2 0
10/22/2 dinner Red Wine, 2 glass 17 0 5 0 0 7 258 0 0 0 1 5 0
018 (3.5 fl oz) 5
10/22/2 dinner Rice a Roni Long 24 7 43 5 0 76 0 6 2 0 15 1 1
018 Grain and Wild 0 0 5
Rice-1 cup, 1
serving
10/22/2 dinner Home-Fried 26 1 38 5 0 60 0 0 0 0 0 0 4
018 Potatoes (1 2 1 1
potato), 1 serving
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10/22/2 snack Crackers, regular, 20 1 2 0 0 34 5 0 0 0 0 1 0

018 1 cracker,
rectangular
10/22/2 snack Cheddar Cheese, 26 2 1 17 70 41 65 14 0 2 47 3 0
018 0.5 cup, diced 5 2 0
10/23/2 breakf Light Cream 88 9 2 1 30 18 55 6 1 0 4 0 0
018 ast (coffee cream or
table cream), 3
tbsp
10/23/2 breakf Quaker Instant 16 2 32 4 0 26 180 20 0 0 8 1 3
018 ast Oatmeal, with 0 0 0
maple and brown
sugar, prepared
with water, 1
packet, prepared
10/23/2 breakf coffee, Folgers 0 0 0 0 0 0 0 0 0 0 0 0 0
018 ast drip made at
home, 1 serving
10/23/2 lunch Sun Chips Harvest 21 1 29 3 0 31 105 2 0 0 0 2 4
018 Cheddar, 1.5 oz 0 0 0
10/23/2 lunch lemon aid 8 oz., 1 11 0 0 0 0 0 0 0 0 0 0 0 0
018 serving 0
10/23/2 lunch Subway Deli Tuna 32 1 36 13 26 83 0 8 20 0 15 2 3
018 Sandwich, 1 5 6 0 0
serving
10/23/2 dinner Fig Newtons, Fat 18 0 44 2 0 25 130 0 0 0 4 8 2
018 Free 2 cookies, 2 0 0
serving
10/23/2 dinner Pork Chops (pork 16 8 0 23 67 56 308 0 1 0 2 5 0
018 loin), roasted, 3 oz 9
10/23/2 dinner White Wine, 1 70 0 1 0 0 5 82 0 0 0 1 2 0
018 glass (3.5 fl oz)
10/23/2 dinner Ellie Krieger's 22 5 40 3 0 0 0 0 0 0 0 0 5
018 Honey Roasted 3
Sweet Potatoes, 1
cup
10/23/2 dinner Cesar Salad Mix - 30 2 16 4 20 74 0 16 60 0 12 1 4
018 Fresh Express, 2 0 6 0 0 2
serving
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10/24/2 breakf Cinnamon Raisin 13 1 27 5 0 17 99 0 0 0 8 8 2

018 ast English Muffin, 1 7 0
muffin
10/24/2 breakf Starbucks Grande 25 6 37 12 25 0 0 10 2 0 40 0 0
018 ast Vanilla Latte, 1 0 15
serving
10/24/2 breakf Butter, salted, 2 72 8 0 0 22 58 2 5 0 1 0 0 0
018 ast pat (1in. sq, 1/3in.
high)
10/24/2 lunch Soup - Butternut 95 2 22 2 4 21 588 28 52 0 9 7 6
018 Squash Soup, 1 8
cup
10/24/2 lunch Dippin Stix Sliced 30 2 24 10 0 19 0 0 0 8 0 0 6
018 Apples and Peanut 0 2 0
Butter, 2 serving
10/24/2 dinner Green Giant 80 1 16 2 0 33 0 2 4 0 0 2 2
018 Valley Fresh 0
Steamers Roasted
Red Potatoes,
Green Beens &
Rosemary Butter
Sauce, 1 serving
10/24/2 dinner macadamia 42 3 14 24 0 0 0 0 0 0 0 0 2
018 crusted Halibut, 1 5 1
serving
10/24/2 dinner White Wine, 2 14 0 2 0 0 10 165 0 0 0 2 4 0
018 glass (3.5 fl oz) 0
10/24/2 dinner Safeway Select 22 0 48 8 0 0 0 0 0 0 0 0 2
018 French Bread, 2 0
serving
10/24/2 snack Pin Wheels (1 16 5 13 4 2 50 0 11 54 0 6 6 2
018 whole tortilla 1 1
rolled with
chili's,olives,crea
m cheese &
pimentos), 1
serving
10/25/2 breakf Cottage Cheese, 19 6 8 27 23 74 190 4 0 0 16 2 0
018 ast 2% Milkfat, 1 cup 4 6
(not packed)
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10/25/2 breakf Pineapple, canned, 14 0 39 1 0 2 304 2 39 0 3 4 2

018 ast 1 cup, crushed, 9
sliced, or chunks
10/25/2 breakf Orange Juice, 1 11 1 25 2 0 2 473 4 13 0 2 2 1
018 ast cup 0 7
10/25/2 lunch White Wine, 2 14 0 2 0 0 10 165 0 0 0 2 4 0
018 glass (3.5 fl oz) 0
10/25/2 lunch Olive Garden, 61 1 100 0 0 17 0 0 0 0 0 0 10
018 Bruschetta, 1 0 3 60
serving
10/25/2 dinner Green Giant 100% 20 2 42 6 0 60 102 4 20 0 4 8 6
018 Natural Valley 0 0 0
Fresh Steamers -
Roasted Red
Potatoes, Green
Beans &
Rosemary Butter,
2 serving
10/25/2 dinner Chocolate Wafer 78 3 13 1 0 10 38 0 0 0 1 4 1
018 Cookies, 3 wafer 4
10/25/2 dinner Starbucks Grande 25 6 37 12 25 0 0 10 2 0 40 0 0
018 Vanilla Latte, 1 0 15
serving
10/25/2 dinner salad - cesar salad 90 6 8 2 10 33 0 0 0 0 0 0 2
018 kit, 100 gram(s) 0
10/25/2 dinner Chicken, cornish 27 8 0 48 217 16 643 4 2 0 3 1 0
018 hens, 1 bird whole 7 3 0
10/26/2 breakf Quaker Instant 16 2 32 4 0 26 180 20 0 0 8 1 3
018 ast Oatmeal, with 0 0 0
maple and brown
sugar, prepared
with water, 1
packet, prepared
10/26/2 breakf Starbucks Grande 25 6 37 12 25 0 0 10 2 0 40 0 0
018 ast Vanilla Latte, 1 0 15
serving
10/26/2 lunch Tim Horton's BLT 45 1 53 18 30 85 0 4 15 0 2 3 2
018 Sandwich , 1 0 8 0 0
serving
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10/26/2 lunch Apple 14 7 20 0 0 15 85 0 30 0 0 0 2

018 Chips Golden 0
Delicious ( 1oz
bag), 1 serving
10/26/2 lunch Chocolate Wafer 52 2 9 1 0 70 25 0 0 0 0 3 0
018 Cookies, 2 wafer
10/26/2 dinner Cheesecake 91 2 8 0 0 53 0 0 0 0 0 0 0
018 Factory, Herb 9 8 8
Crusted Filet of
Salmon, 1 serving
10/26/2 dinner glass white wine 19 0 2 0 0 14 0 0 0 0 0 0 0
018 (general), 10 oz 3
10/27/2 breakf Ham and Cheese 38 1 0 24 260 99 25 12 0 0 22 4 0
018 ast Omlet (3 Egg), 1 0 5 5
serving
10/27/2 breakf Orange Juice, 1 11 1 25 2 0 2 473 4 13 0 2 2 1
018 ast cup 0 7
10/27/2 lunch Sandwich: Grilled 48 3 37 22 0 0 0 0 0 0 0 0 0
018 Tomato/Cheese 3 2
(1T lite mayo,
tomatoes, 2 slice
cheese, 1T becel),
1 serving
10/27/2 lunch Red Lobster, 12 0 7 0 0 20 0 0 0 0 0 0 0
018 White Wine - 0
Glass, 1 serving
10/27/2 dinner Cesar Salad Mix - 30 2 16 4 20 74 0 16 60 0 12 1 4
018 Fresh Express, 2 0 6 0 0 2
serving
10/27/2 dinner Chocolate Wafer 52 2 9 1 0 70 25 0 0 0 0 3 0
018 Cookies, 2 wafer
10/27/2 dinner Rice Bowl, Spicy 37 5 62 21 25 15 0 6 40 0 4 1 1
018 Beef & Broccoli, 0 50 0
Uncle Ben's, 1
serving
10/27/2 dinner Red Wine, 3 glass 26 0 8 0 0 10 388 0 0 0 2 7 0
018 (3.5 fl oz) 2
10/27/2 dinner Chicken Breast, 13 5 1 19 53 45 153 1 0 0 1 4 0
018 with skin, fried, 1 1
unit (yield from 1
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lb ready-to-cook
chicken)
10/27/2 snack Fig Newtons, Fat 18 0 44 2 0 25 130 0 0 0 4 8 2
018 Free 2 cookies, 2 0 0
serving
10/28/2 breakf Eggs - Scrambled 14 9 2 12 430 13 0 12 0 0 4 8 0
018 ast - 1 Large Egg, 2 0 0
serving
10/28/2 breakf French Toast with 54 7 71 15 71 13 0 0 0 0 0 0 5
018 ast Maple Syrup (3 0 5
pieces), 1 serving
10/28/2 breakf Florida's Natural, 11 0 26 2 0 0 450 0 12 0 0 0 0
018 ast orange juice, 0 0
original premium,
not from
concentrate, no
pulp, pasteurized,
8 oz
10/28/2 lunch chicken cesar 23 1 8 16 50 98 0 0 0 0 0 0 1
018 salad-store 0 6 0
bought, 1 serving
10/28/2 dinner Cesar Salad Mix - 30 2 16 4 20 74 0 16 60 0 12 1 4
018 Fresh Express, 2 0 6 0 0 2
serving
10/28/2 dinner Hamburger 28 1 27 19 55 86 370 4 4 0 0 1 0
018 Helper- Lasagna, 0 1 0 0
1 cup
10/28/2 dinner Safeway Select 22 0 48 8 0 0 0 0 0 0 0 0 2
018 French Bread, 2 0
serving
10/28/2 dinner Red Wine, 1 glass 87 0 3 0 0 3 129 0 0 0 1 2 0
018 (3.5 fl oz)
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Appendix H: Dental Hygiene Diagnosis

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Appendix I: Dental Hygiene Treatment Plan