Case study presentation

reyna Gutierrez
June 2023
Patient selection
• Rational • Treatment Dates
• Identified during Radiology Lab in 2022 • CMS
• Patient is in mid-30s and presented with heavy calculus and biofilm • January 19, 2022
buildup and horizontal bone loss. • Initial Appointment
• Patient Motivation • February 27, 2023
• Patient cannot remember the last time she went to the dentist. After • Second Appointment
discussing radiographs with patient, patient was interested in coming to • March 6, 2023:
Lane for therapy. • Third Appointment
• March 10, 2023
• Stage and Grade
• Forth Appointment
• Generalized Stage I, Grade B*
• March 13, 2023
• Calculus Evaluation • Re-Evaluation Appointment
• 3/4 • June 5, 2023
Pre-Treatment Assessment: Medical history
• Medical History • Dental Information
• Existing Care • Chief Concern
• Spleen removal in 1992 • Upper right sensitivity, thinks it’s due to a cavity
• Broken ankle requiring surgery 2020 • Last Dental Exam
• Last Medical X-Rays • Unknown
• Ankle, 2020 • Last Dental Cleaning/Treatment
• Medications • Unknown
• Daily multivitamin for general health • Last Dental X-Rays
• Allergies • CMS taken at LCC in 2022
• None
• Existing Conditions
• Migraines/Headaches associated with menstrual cycle
Pre-Treatment assessment –
Homecare and dietary routine
• Brushes 2X daily with a manual toothbrush and fluoride
toothpaste.
• Flosses 2X weekly using handheld flossers.
• Listerine mouthwash at night.
• Patient consumes healthy diet. Patient will consume food and
beverages high in sugar on rare occasions. Patient drinks coffee with
creamer in AM and water throughout day.
Initial clinical assessment
Extraoral/Intraoral Findings
Bilateral mandibular tori and large tonsils. Patient admits to breathing through mouth and snoring at night.
Dentist
recommended book, “Breath,” by James Nestor.

Occlusal Analysis
Angles Class I on R and L, 1mm Overbite, 2mm Overjet, 0mm midline deviation, molar pitting

Periodontal Examination
Generalized severe marginal and papillary inflammation
Intraoral Photographs
Plaque index

Plaque Index:
12% plaque free
Periodontal assessment
Generalized severe spontaneous bleeding
on probing

Measurements greater than 3mm – 75

Discussed measurements indicating health

and significance of measurements greater
than 3
Initial Clinical Assessment – Microscope
Evaluation
• Quality
• Spinning rods – greater than 25, gliding rods – greater
than 25, spirochetes – greater than 10, cocci, RBC 10.
• Mobility
• High
• Risk
•C
CMS taken: 1/19/22
Radiographic Examination
ONLY

Interpretation notes: #3MO

and Nasopalatine Cyst above
#8 and #9

Radiographic Tx and Referral

completed and delivered to
patient via mail
Bwx Images taken: 2/27/23

Restorative Needs/Recommendations: Watches on #3MO and #19D

Dentist’s Comments : Molar pitting on mandibular molars, if sensitivity occurs, composite fillings are an option in the future.
Sensitivity in upper right may be due to the amount of calculus present in dentition.
* Patient was charted for CRC
Dental chart
• No existing restorations to note
• Patient grew up in a city with fluoridated water
• Watches placed on #3MO and #19D
Risk Assessment
• Risk Factors
• Systemic and Behavior
• Irregular Dental Care
• Periodontal Due to data gathered during assessment procedures,
• Generalized Heavy biofilm patient is candidate for NSPT with local anesthesia.
• Generalized heavy Calculus
• Stage I, Grade B*
• Caries
Caries risk assessment indicated patient was at
• Irregular Dental Care
moderate risk for caries.
• Active Caries (1-2 lesions)
• Exposed root surfaces
• Dental/Orthodontic Appliances
Online Risk
assessment tool
http://www.philipscare.com/assess
Care plan centered goals and expected outcomes

Care Plan centered Goals

Dental hygiene diagnosis/planning/case presentation
• Treatment Plan
• Priority: Generalized heavy calculus and gingival inflammation in every quadrant. Priority was mandible, where there
was tissue detachment.
• NSPT (SRP) treatment consent form read and signed by patient
• Patient consented to be case study patient
• Patient understands completion of NSPT treatment is important for her oral and systemic health, as well as to stop
progression of bone loss. Patient took days off work and scheduled all appointments in advance.
Initial treatment plan
Oral Hygiene Instruction
• Patient demonstrated circular brushing strokes on crown only.
• Introduced 45 degree angle
• Discussed benefits of an electric toothbrush, patient purchased oral-b electric
toothbrush from clinic.
• Demonstrated correct brushing technique with electric toothbrush
• Demonstrated GENTLE brushing with an extra soft toothbrush for sensitive areas.
• Demonstrated proper C-Shaped Flossing.
• Role of patient: maintain health of oral cavity at home! Team effort!
Appointment #2 No change in medical history
Vitals: BP 119/82 Pulse: 70 Resp 16

Treatment Completed: NSPT UR, OHI, 1PA, limited

exam, traditional gingival curettage #6-8 (B and L)
Pt Compliance: Reduction in biofilm levels due to use
of oral-b toothbrush. Patient is brushing 2X daily
and flossing. Patient cannot floss mandibular
anteriors due to calculus.
Additional pa taken: 3/6/23
• Rational: Radiographic diagnosis of nasopalatine cyst during CMS in 2022.
No treatment was sought out by patient.
• Diagnosis: Nasopalatine Cyst apical to #8 and #9
• Dentist Comments: According to our doctor, literature says to remove NP
cysts; However, when consulting with doctors at OHSU, they said to watch
it and our doctor agreed. Dr. wants a PA taken of the area each year to
monitor the cyst and informed patient if she experiences any numbness,
tingling, or tooth displacement in the area, to come in for an exam.
Appointment 2 Continued
• CRC was completed on UR quadrant
• Ultrasonic and hanscaled UR to completion
• Local Anesthesia: Right PSA, MSA, AMSA, SP #8
• 20% Topical Benzocaine, 1 ½ cartridges of 4% Articaine 1:100,000
• Patient achieved profound anesthesia
• Gen heavy spontaneous bleeding, 2X2 with chlorhexidine used to
readapt tissue while scaling
• Gingival Curettage #6-8 (B and L)
• Completed due to inflammation and boggy tissue
• Advised patient of post-op instructions, including warm salt water
rinse
Appointment #3 No change in medical history
Vitals: BP 123/83 Pulse: 73 Resp 16

• Treatment Completed: NSPT LL, OHI, Laser Curettage #22-27 (B and L)

• Pt Compliance: “Patient is doing great with OHI.” Suggested continuing
warm salt-water rinses for sensitivity.
• Previously debrided Areas: Slight interproximal plaque, localized slight
spontaneous bleeding, deposit remaining on #8M. Generalized slight
marginal inflammation, localized slight papillary.
Appointment #3 continued
• Techniques Used: Ultrasonic and handscaled entire
LL to completion. Ultrasonic and handscaled #25-
#27 to completion.
• Local Anesthesia: Left GG, SP #24, #25, #27
• 20% Topical Benzocaine, 1 ¾ cartridge of 2%
Lidocaine 1:100,000 used
• Profound anesthesia achieved
• Laser Curettage #22-#27 with classmate and
instructor.
• RGutierrezDH2 completed #22-24 B and L
• Another DH2 student completed #25-#27 B and L
• Written consent obtained
• Patient provided written POST-OP instructions
 Laser curettage #22-27

Appointment #3: 3/10/23

Appointment #1: 2/27/23 Appointment #4: 3/13/23
Laser Post-Procedural Photo
Appointment #4 No change in medical history
Vitals: BP 121/77 Pulse 77 Resp 16

• Treatment Completed: NSPT UL and LR, OHI, 5% NaF Varnish

• Pt Compliance: ”Patient is doing great with homecare.” Currently using
electric toothbrush everywhere except areas healing from curettage.
Previously debrided areas: No remaining deposits. Localized slight
spontaneous bleeding. Localized slight biofilm along gingival margins.
• OHI modifications – Introduced perio-aid and demonstrated tracing along
margins of teeth #22-27.
Appointment #4 Continued
• Techniques Used: Ultrasonic and handscaled UL and LR • Sent patient home with treatment form. No referrals
to completion. are indicated at this time.
• Generalized severe spontaneous bleeding • Took post-procedural intraoral photos. Showed pre
• Local Anesthesia: Right IA and LB, Left PSA and AMSA and post NSPT photos with patient.
• 20% Benzocaine Topical • Patient was very happy with results.
• 1 cartridge of 2% Lidocaine 1:100,000 for IA and LB • Discussed re-evaluation appointment in the spring
• 1 cartridge of 4% Articaine 1:100,000 for PSA and and need for 3-month recall going forward.
AMSA
Medicaments: 5% NaF Varnish
Intraoral photos

Photos taken during the Initial Appointment: 2/27/23 Photos taken during at conclusion of NSPT: 3/13/23
Reappointment/reevaluation
• Exactly 12 weeks since conclusion of NSPT
treatment
• Chief Complaint - None
• Compliance with homecare
• 2X daily with Oral-B electric toothbrush
• Patient is not flossing regularly. WHY?
Reevaluation Assessments No change in medical history
Vitals: BP 126/91, Second Take 122/84 Pulse 82 Resp 16

- Current Homecare Habits: Brushing with electric toothbrush 2X

per day, tries to floss 1X a day.
- Periodontal Assessment
- Significant reduction in BOP and measurements above 3mm
- Color: Generalized moderate hyperemic
- Contour: Generalized moderate enlarged
- Consistency: Generalized moderate edematous
- Generalized moderate marginal and papillary inflammation
- Calculus deposit: 1.5/2
microscope
- Microscope evaluation
- Quality and Quantity: Spinning rods TNC, Gliding rods TNC, Cocci TNC
Spirochetes 10-20, RBC 10-50, WBC 10
- Mobility: High
- Risk Factor: C
- Discussed role of biofilm and inflammatory response

- Due to increased visibility of bacteria (system update?)

Re-Evaluation Photos – pre-procedural and disclosing
Treatment plan
• Caries Risk: • Goals: Patient will find a dentist that accepts her insurance
• Patient is still moderate risk so she can continue regular dental care. Patient will
• Two incipient lesions continue to brush 2X daily and floss 1X daily.
• Infrequent dental care
• Interventions: OHI – including CocoFloss where ortho bracket
• Ortho appliance
is located, correct brushing technique with electric
• Treatment Plan toothbrush. Discuss etiology of periodontitis and role of
• Oral facial images, re-evaluation appointment, topical biofilm.
application of fluoride varnish, OHI, caries risk assessment –
moderate risk • Expected Outcomes: Reduction in bleeding and
inflammation. Decrease in inflammation from moderate to
slight.
Modifications to Homecare
• Cocofloss - “CocoPlush Threaders” – demonstrated c-shaped
flossing
• Tepe Brushes – Size pink
• Chlorhexidine rinse
• Sent home with patient to use everyday for two weeks
• Instructions provided to patient
Treatment
• Implementation of care
• Techniques used: Ultrasonic and handscaled entire dentition to completion, polished
for remaining stain and biofilm
• Hard/Soft Deposits: Gen slight interproximal hard deposits, Gen slight interproximal
soft deposits
• Bleeding: Gen moderate spontaneous bleeding
• Medicaments: 5% NaF Varnish, 2X2 with Chlorhexidine for tissue readaptation
• Recare: 3-month Recall; Reminded patient about nasopalatine cyst
Post-Procedural re-evaluation photos
 If patient improves her homecare routine and attends 3-month interval
maintenance appointments, I believe she has a fair prognosis and that she can
slow the progression of bone loss. Based on our conversations, I am unsure
whether she has the motivation to follow-up with a dentist for 3-month
Professional intervals. I plan on following up with her in the future.

judgement and Reflection: I would have preferred to have her back between 4-6 weeks to
reflection see how her tissue responded to treatment. The soonest I could get her back
in was at the 12-week mark and by this point we were already at her
maintenance interval. I also wish I would have introduced tepe interproximal
aids at the conclusion of NSPT.
Learning Moment: How quickly tissue heals!