Case Documentation Project

PATIENT “RICK KLEINER”

Christina Tulloch | DENH 437-447 | April 13th, 2020

Overview

The proportion of older individuals is rapidly growing in the US. In the face of the

expansion, both medical and dental providers must be prepared.[1] The older adult

population is more likely to possess qualities which will impact delivery of and the

demand for treatment. These patients are more likely to be medically compromised.

Aside from diabetes and heart disease, periodontitis has been found to be one of the

most prevalent medical conditions in the world, and the prevalence increases with age.[1]

In the VCU Dentalcare clinic, there is a large proportion of patients sixty years of age or

older. Anecdotally, many of these patients have periodontitis. The VCU Dentalcare

patient featured for case documentation, Rick Kleiner (pseudonym), consented to have

his dental treatment process documented and discussed.

Mr. Kleiner is 85 years old. He is retired. At his initial visits, he was the

predominant caretaker of his wife, who has dementia. He is prescribed medication for

the treatment of diabetes mellitus type II, hypertension, hypercholesterolemia, stable

angina, cataracts, and enlarged prostate (see: appendix, x). Overall, his health is good,

and he reports his medical conditions are well-controlled. His HbA1c within the last 6

months was 6.3%. His non-fasting blood glucose taken the day before treatment was

118-127 mg/dL. He had two total knee replacements which were placed in 2001 and

2011. The surgeon was not able to be consulted as the patient could not recall the

orthopedic surgeon’s information. After consulting with the attending dentists, and with

the input of the patient, the provider proceeded with assessments and treatment without

antibiotic prophylaxis. The decision is consistent with current AAOS and ADA guidelines.
[2, 3]
He formerly chewed tobacco for 33 years and quit in 1989. He had a history of

PAGE 1
coronary artery bypass procedure with stent placement in the 1980’s and 1990’s. He had

his nitroglycerin tablets with him at every appointment. He stated he last used a tab six

months prior after physical exertion, which is he identified as his only trigger. He stated

he has never needed one for dental treatment. He reported growing up without fluoride

in the water supply, and he experiences frequent xerostomia. He brushes twice per day

with a manual toothbrush. He uses prescription fluoride toothpaste daily. His role as a

caretaker often consumes much of his time and energy. Consequently, he often must

schedule his dental visits around his and his spouse’s medical appointments. When he

does have some free time, he states he likes to walk around his neighborhood, visit his

kids and grandkids, or read nonfiction books in his recliner.

At his initial visit with the provider, assessments were indicative of generalized

stage 3 grade B periodontitis (see: appendix, i). The patient’s gingival tissue was

generalized erythematous, generalized edematous, and the papillae were generally

blunted. The tissue surrounding #14DL was magenta in color. Periodontally, the pocket

depths were generalized 3-5 mm, with localized 6-7 mm readings. The gingival

recession was generalized 1-2 mm below the CEJ with localized 3-6 mm readings. His

deposits consisted of generalized heavy plaque and generalized moderate calculus. The

bleeding on probing was observed to be generalized and moderate. The OHI score was

1.1, and the PFS was 5% (see: appendix, xii and xiv). The patient is missing all 3rd

molars and all posterior teeth in quadrant 3. The patient’s existing hard tissue conditions

included several large amalgam and composite restorations, class V restorations,

several crowns, a 5-unit PFM bridge, and treated root canals (see: appendix, x). The

dentist performed an examination, and treatment was planned: D4341 scaling and root

planing 4+ teeth in quadrants 1, 2 and 4, prophylaxis in quadrant 3, #15 ML Decay, #2 M

decay (it had an MODB restoration existing), #3D restoration adjustment, and #29 DO

PAGE 2
had a defective restoration. The patient and provider discussed treatment options for his

periodontal disease and caries. A mutual agreement was made to proceed with

nonsurgical scaling and root planing (SCRP) and direct restorations as planned.

Presenting Concerns Identified

The patient informed the provider how he knew some of his teeth were

compromised. He communicated his desire to keep his remaining teeth for as long as

possible. The patient recalled his recent interactions with graduate periodontal residents

and a VCU AEGD prosthodontic provider. Due to the extensive amount of surgical

treatment which would be required to properly treat the periodontal defect on #14, and to

restore function to the LL, the patient decided he did not want to proceed with the

recommended procedures in these areas. The patient stated these areas do not greatly

bother him, and if they ever do, he will let his dental provider know. The patient was very

concerned with cost and with the number of visits which would be needed for all

proposed treatment. The patient valued the function his teeth served but did not equally

value oral hygiene. The patient possessed sparse knowledge of the oral cavity’s

connection with his overall health. The patient was unaware of the scientific linkage of

periodontal disease to his systemic conditions, namely cardiovascular disease [4, 5] and

diabetes. [5, 6]

Dental records documented Mr. Kleiner receiving regular supportive dental care.

However, barriers to maintaining oral health were identified. The patient had previous

nonsurgical periodontal treatment in the summer of 2018. He was last seen for

maintenance six months prior to initial case documentation assessments, although a

three- or four-month interval was most appropriate given his periodontal risk factors. The

provider asked the patient about his views on self-care and methods currently utilized.

PAGE 3
Loss of dexterity was observed. The provider empathized with the patient’s experiences

related to taking care of his wife. The patient explained the effort expended taking care

of his wife was “wiping him out”, and it prevented him from spending time taking care of

himself. The lack of adequate time spent on home plaque control combined with

dexterity and dental knowledge deficits were contributing factors which would need to be

addressed.

The patient was given multiple opportunities to fill out dietary analysis paperwork.

A self-addressed stamped envelope was provided at no charge to the patient. When

paperwork was returned uncompleted, he eventually admitted things were too stressful

at home. The provider proceeded to conduct a succinct verbal dietary analysis at every

dental hygiene appointment. The patient reported not knowing how much water he was

drinking daily. He stated he relies on frozen meals due to convenience. Many frozen

meals are high in saturated fat and sodium which have been linked to poor

cardiovascular health and poor glycemic control.[5] In addition, the patient reported daily

intake of retentive carbohydrates and sugars, which contributed to the patient’s caries

and periodontal disease risk. The patient’s hyposalivation was a significant contributor to

his oral disease. With the provider, the patient developed the following goals to improve

his odds of maintaining his current dentition and to lessen risk of tooth loss and dental

pain:

1. Improve oral health status, behavior, and literacy

2. Develop a routine which allows time for his own self-care

3. Increase nutrients from fresh sources and water intake

PAGE 4
Proposed Interventions and Modifications

Improve Oral Health Status, Behavior and Literacy

Mr. Kleiner was advised the best way to maintain his current dentition, barring

the surgical interventions which were recommended, was to proceed with nonsurgical

periodontal therapy, caries excavation and restoration, and to be placed on a three- to

four-month maintenance interval. The recommendation for periodontal therapy was

reinforced by systematic review and meta-analysis which finds an average improvement

in probing depths and CAL after therapy.[7] Using a motivational approach, the provider

emphasized fastidious home care as the single greatest tool for meeting his oral health

goals. The patient was shown in a mirror the areas where plaque accumulation,

periodontal pocketing, and gingival inflammation were greatest. He was shown areas

with furcation involvement, and he appreciated the susceptibility of these areas to caries

and further periodontal destruction.

The patient was given an Oral-B® Genius electric toothbrush. A study which

compared electric toothbrushing to manual toothbrushing showed significantly better

plaque control with an electric toothbrush. [8] He was shown how to operate the brush.

The patient was shown how the brush automatically turns off after two minutes. Proper

bristle angulation was demonstrated, i.e. modified Bass technique. The same

demonstration was repeated with an end-tuft brush in areas with furcation involvement,

crowding, and open contacts. The patient was introduced to several different interdental

cleaning aids, including reach flossers, conventional floss, superfloss, soft picks, and

proxabrushes. The patient stated he was able to dedicate two minutes in the morning

and evening to brushing. Similarly, he stated he would be able to clean interdentally at

least once per day with the item of his choice, superfloss and soft picks.

PAGE 5
 Mr. Kleiner was deemed to have CAMBRA extreme caries risk due to

hyposalivation, exposed root surfaces, and recent findings of active carious lesions. The

patient was advised to continue using prescription fluoride toothpaste daily, and

directions for usage were reviewed. The patient was notified of the substantivity,

bacteriostatic and remineralization properties of topical fluoride varnish at every

maintenance appointment.[1] The provider informed the patient how common

prescriptions for hypertension and diabetes can cause hyposalivation. He was advised

to not discontinue his medication, despite the increased risk of xerostomia. The patient

was given samples and instruction on how to use Biotene® products for daily xerostomia

relief.

Develop a Routine Which Allows Time for His Own Self-Care

Older adults with chronic medical conditions often prioritize medical care over

dental care.[1] Mr. Kleiner, who has multiple conditions, prioritized his and his wife’s

medical appointments over dental needs. It is common for the medically involved patient

to be non-compliant when there is no pain or immediate risk for complications.[9] He had

been a caretaker for his wife, who has dementia, for many years. The patient was

starting the process of moving his wife into an assisted living community. Social factors

have great bearing on dental health. It is important to consider the patient’s perspective

with regards to dental treatment. Treatment for Mr. Kleiner would not be complete

without addressing both the pathogenesis and salutogenesis of his periodontitis and

caries.

Treatment and realistic goals were fashioned following the findings of a

phenomenological study outlining a salutogenic approach to improving oral health

behavior.[9] The process of attaining goals for Mr. Kleiner was framed as a successive

process of increasing personal effort. The approach incorporated coordination with the

PAGE 6
patient’s team of providers and kin. Cleaning aids were introduced gradually to build

compliance. The provider acted as a motivating “supervisor” during the dental visits. The

frequency of visits helped to reinforce repeated oral hygiene routine and effective biofilm

removal. Building frequency and repetition is a crucial step toward automaticity of the

desired behavior. The patient was encouraged to participate. The desired behavior was

frequently reinforced with positive affirmations. Lastly, the feelings about the changes

were incorporated into the patient’s past, present, and future. He was remorseful for not

making these changes in the past. With the present conditions improving, the patient felt

a strong will to continue the positive gains in his future.

Increase nutrients from fresh sources and water intake

The patient agreed to conduct a dietary analysis by phone. The patient was

advised to be mindful of drinking at least eight glasses of water per day. He was given

recommendations for ways to increase nutrient content in meals by adding fresh or

frozen vegetables. The patient was advised to consult his primary care doctor before

making any drastic changes to diet. The patient was provided with a list of substitutions

which could help improve nutrients from food, which are important for oral health and

healing. He was advised to monitor added sodium and saturated fat from food. For

instance, the patient was taught how to read labels on frozen foods at the grocery store.

When eating out, the patient was encouraged to substitute steamed vegetables, salads,

or fruit for a side dish when compared to chips or fries. It was suggested the patient keep

a water bottle with markings on it to track daily water consumption. Adequate water

intake was emphasized as a method to decrease the effects of hyposalivation on caries

risk.

PAGE 7
Treatment and Process of Care

The dental hygiene provider spent several appointments observing and

assessing periodontal and hard tissue health. Assessments included recording

periodontal measurements, taking before and after photographs, fabricating before and

after study models, conducting nutritional and caries risk assessments, and recording

complete medical history reports. Gingival health and plaque control were gauged with

GI and PF scores. Most data collection was performed in-person, except for the dietary

counseling performed via phone call.

Before SCRP, the GI was 1.1, and the PFS was 5% (see: appendix, xii, xiv). The

patient tolerated SCRP well. After oral hygiene education and SCRP on one side, the GI

improved to 0.8 and the PFS to 54%. The PFS slightly decreased at the EIT and

periodontal maintenance appointments (45% and 44%, respectively), but the GI

improved to 0.45 at the same maintenance appointment. It has been proposed in

scientific literature the PFS can provide a “snapshot” of current plaque control, but GI

can be a more accurate indicator of long-term plaque accumulation and inflammation.[10]

The provider used disclosing solution and the PFS results to continually educate the

patient and reinforce positive changes. Again, salutogenic principles were used to turn

the positive gains into propulsive motivation for the patient.

Throughout treatment, collaboration was essential between the patient, dental

provider, and the patient’s medical team. The dental student revised areas of decay and

poor contact to give the patient improved hygienic surfaces. The patient continued to

follow up with his medical team to maintain glycemic control and target blood pressure

and blood lipid levels. The patient had a stent placed shortly after completion of SCRP,

but before EIT and maintenance. Interprofessional discussions about postponement and

antibiotic prophylaxis occurred, which was of great benefit to the patient.

PAGE 8
Response to Interventions

At the conclusion of the case documentation project, Mr. Kleiner was successful

at achieving the goals he set at the start of the experience. By the end of the project, the

patient reported he was more purposeful in his actions. At his maintenance appointment,

he reported he was drinking more water and eating healthier. With his wife now living in

a skilled care facility, he was able to adjust his routine to allow more time for his own

self-care. Mr. Kleiner reported spending more time on oral hygiene, meal preparation,

and stress-reducing hobbies, such as reading in his recliner.

The measurements of periodontal pockets and inflammation (GI, BOP) were

observed to improve with the implementation of periodontal therapy and home oral

hygiene modifications. Most periodontal pockets resolved by 1-2 mm. The provider was

unable to detect the full extent of the known periodontal defect on #14 upon initial

assessments (see appendix, xiii). The provider suspected the defect was difficult to

access due to deposit accumulation and inflammation. Once the patient returned for the

periodontal maintenance, the narrow defect was clinically detectable as a 10 mm pocket

depth on the ML aspect of #14 with class I tooth mobility (see appendix, xxxiv). The

defect was previously captured on CBCT and the patient was made aware of the

severity via periodontal specialist consult. When discussing treatment options during the

case documentation process, the patient decided to proceed with nonsurgical therapy.

The patient knew more invasive treatment would be needed to remove all infection in the

area. Much like periodontal disease, treatment decisions are influenced by a multitude of

factors. For Mr. Kleiner’s treatment, all treating providers involved were bound to abide

by the patient’s autonomy. It was the patient’s desire to avoid costly, long-duration dental

PAGE 9
appointments unless necessary to alleviate pain or abscess. Mr. Kleiner’s sentiments

were found in research to be characteristic of his age group.[1]

Provider Reflection

The treatment of periodontal disease in older adults is a worthwhile process

which can be complicated by unique age-related factors. As the provider embarked on

her capstone project, she was unfamiliar with the realities of living with multiple chronic

health conditions, caring for a spouse with declining health, or making decisions based

on a fixed income. She was unaware of the multifaceted interplay between social factors

and oral health in the older adult population. The provider spent many hours collecting

the necessary data to make conclusions about the patient’s current status, progress, and

expectations for improvement. She was diligent about communicating with other medical

and dental providers regarding treatment clearance and progress.

Non-surgical periodontal therapy has been proven to be an effective treatment

for periodontal disease, but limited literature exists documenting the effects of age on

response to periodontal treatment.[1] In the case of Mr. Kleiner, treatment was

successful, as most sites exceeded the average 0.5mm CAL improvement found in a

recent meta-analysis.[7] The provider was especially interested in the detection of a 10

mm pocket depth at the maintenance appointment. The area was not detected as an

issue at EIT. The dental hygiene provider discussed the findings with the attending

faculty, the student who performed the EIT, and the patient. It can be surmised the

pocket was difficult to detect before SCRP. As the inflammation in the area subsided,

and skill of the dental hygiene provider became more advanced, the narrow pocket was

detected. The dental hygiene provider learned the importance of utilizing existing data

with repeated examination to form her evaluation of therapy. The tooth will be an

PAGE 10
ongoing area of periodontal infection, which the patient is aware may lead to pain,

further infection, or tooth loss. The patient was made aware of the research available,

which links tooth mobility to increased risk of tooth loss.[10]

The dental providers involved made many treatment decisions based on clinical

guidelines for antibiotic prophylaxis. A survey conducted of dental providers shows there

is inconsistency regarding familiarity and application of current AAOS and ADA

guidelines for antibiotic prophylaxis in patients with prosthetic joints.[11] The VCU faculty

were in the majority of providers who follow current guidelines. In Mr. Kleiner’s case,

antibiotic prophylaxis was not indicated. The dental hygiene provider established a firm

understanding of these guidelines through completing the capstone project. Mr. Kleiner

returned to the clinic in October and January for EIT and maintenance, respectively. One

month before the EIT, he had a drug-eluting stent placed. Before January, no dental or

medical provider had discussed post-angioplasty dental precautions as it related to the

healing stent. The dental hygiene provider was grateful she protected the patient by

conducting thorough health history assessments. She called the cardiologist and

explained the patient was scheduled for periodontal maintenance. Ashe explained the

treatment is elective, but invasive in nature and can lead to bacteremia. The doctor gave

medical clearance to proceed with treatment, as did the attending dentist, and the

discussion was documented in the patient note and followed with a faxed consult. Often,

these patients are instructed to avoid elective treatment for several weeks or months.

The situation highlights the inconsistency within medical and dental providers. The

encounter underscored the need to always collect and document recent changes to the

medical history form. The dental hygiene provider came to understand how decisions to

use prophylactic medication or postpone elective treatment is based on a provider’s

interpretation of guidelines.

PAGE 11
 The provider enjoyed the experience of building a professional relationship with

Mr. Kleiner. It was rewarding to be able to follow the patient through the phases of his

treatment. Through the course of her research, the provider discovered many sources

which reinforced her assumptions and previous knowledge regarding treating older

adults. The frequent assessment of oral hygiene helped the provider become more

comfortable with measuring the PFS and GI score. Interestingly, recent research

suggests QLF-D technology may one day be used as an alternative to PFS and GI

measurements, which have clinical shortcomings.[12] The case documentation project

was an invaluable opportunity for the provider to develop her abilities. She identified

patient concerns, implemented treatment and set the groundwork for behavioral

modifications. She evaluated her interventions based on previous assessments. Due to

the COVID-19 pandemic, Mr. Kleiner’s next maintenance appointment was indefinitely

cancelled. The provider is confident she would have seen further improvement in

inflammation and plaque control at the patient’s April periodontal maintenance

appointment.

Resources
[1] Renvert S, Persson G. Treatment of periodontal disease in older adults.
Periodontol 2000. 2016;72(1):108–19.

[2] Quinn R, Murray J, Pezold R, Sevarino K. The American Academy of Orthopaedic

Surgeons Appropriate Use Criteria for the Management of Patients with
Orthopaedic Implants Undergoing Dental Procedures. Journal Bone Joint Surg
Am. 2017;99(2):161–3.

[3] Sollecito T, Abt E, Lockhart P, Truelove E, Paumier T, Tracy S, et al. The use of
prophylactic antibiotics prior to dental procedures in patients with prosthetic
joints. J Am Dent Assoc. 2015;146(1):11-6.

PAGE 12
[4] Ziebolz D, Jahn C, Pegel J, Semper-Pinnecke E, Mausberg R, Waldmann-
Beushausen R, et al. Periodontal bacteria DNA findings in human cardiac tissue -
Is there a link of periodontitis to heart valve disease? Int J Cardiol. 2018;251:74-
9.

[5] Liccardo D, Cannavo A, Spagnuolo G, Ferrara N, Cittadini A, Rengo C, et al.

Periodontal Disease: A Risk Factor for Diabetes and Cardiovascular Disease. Int
J Mol Sci. 2019;20(6):1414.

[6] Teshome A, Yitayeh A. The effect of periodontal therapy on glycemic control and
fasting plasma glucose level in type 2 diabetic patients: systematic review and
meta-analysis. BMC Oral Health. 2016;17(1).

[7] Smiley C, Tracy S, Abt E, Michalowicz B, John M, Gunsolley J, et al. Systematic

review and meta-analysis on the nonsurgical treatment of chronic periodontitis by
means of scaling and root planing with or without adjuncts. J Am Dent Assoc.
2015;146(7):508-24.

[8] Kulkarni P, Singh D, Jalaluddin M. Comparison of Efficacy of Manual and Powered

Toothbrushes in Plaque Control and Gingival Inflammation: A Clinical Study
among the Population of East Indian Region. J Int Soc Prev Community
Dent. 2017;7(4):168–174.

[9] Östergård G, Englander M, Axtelius B. A salutogenic patient-centred perspective of

improved oral health behaviour - a descriptive phenomenological interview study.
Int J Dent Hygiene. 2016;14(2):142–50.

[10] Hassel A, Safaltin V, Grill S, Schröder J, Wahl H, Klotz A, et al. Risk factors for tooth
loss in middle and older age after up to 10 years: An observational cohort study.
Arch Oral Biol. 2018;86:7–12.

[11] Teixeira E, Warren J, McKernan S, McQuistan M, Qian F. Prescribing practices for

antibiotic prophylaxis in patients with prosthetic joints. Spec Care Dentist.
2020;40:198–205.

[12] Lee J-B, Choi D-H, Mah Y-J, Pang E-K. Validity assessment of quantitative light-
induced fluorescence-digital (QLF-D) for the dental plaque scoring system: a
cross-sectional study. BMC Oral Health. 2018;18(1).

PAGE 13