Clinical Case

Study
Lillie C. Jones
Department of Allied Health,
Missouri Southern State University
DH 295: Seminar in Dental Hygiene
Mrs. Merritt
November 24, 2023
Section I: Basic Information
Patient Profile and Social History
 Juliet Higgins
 Patient ID: 13940
 58-year-old, Caucasian/White, Female
 Chief complaint:
 My patient states that #23-24 are very sensitive and painful
when eating, drinking, and brushing. She would also like to
preserve the teeth she has left and not have to get dentures like
her siblings have done.
 Ms. Higgins is a widow of 15 years who has a 35-year-old
daughter and a 32-year-old son.
 Occupation:
 Part-time substitute/student teacher
 Education achieved:
 Associate in Physical Education
 Currently a Junior in college
 Completed 129 credit hours while pursuing her Bachelor’s in
Physical Education
Dental History
 Symptoms:
 #2, 4-5, 13-14, 17-18, 20-21, 30, & 32 have been
extracted throughout the years due to caries and
abscesses
 #23-24 are sensitive/painful when eating or drinking
 Dry mouth and infrequent bad breath from medications
and mouth breathing
 Last dental visit:
 On 04/29/2019 at Dr. Stephen E. Stidham, DDS at 502 E
Bond Street, Monett, MO 65708 to have a composite
placed on the occlusal of #14 and to have #21 extracted
due to it being broken at the gum line because of caries
 No radiographs were completed at this visit
 Last cleaning was, at least, 10 years ago, but the patient
doesn’t remember the exact date
 Routine oral hygiene:
 Irregular dental visits
 Brushes 2x daily with Pro Namel Sensodyne toothpaste
 Doesn’t floss
 Picks teeth with fingernails
Economic Influences

 Socioeconomic status:
 Lower class based on socioeconomic factors evaluated during casual conversations at each appointment
 Factors include:
 Education: Associate in Physical Education and is working towards a Bachelor’s in Physical Education
 Occupation: Part-time substitute/student teacher
 Income: Low financial income due to only working when openings appear, no spouse/partner to provide
financial support, no benefits offered by her employer, and only uses government-provided insurance
(Medicare) since it is free
 The patient has often mentioned how money is tight and how it has been hard to find a good
substitute position lately.
 Residence: Lives alone in a functioning, but worn-down trailer
 Uses Medicare, but it doesn’t cover dental work
 Patient’s attitude/behavior:
 She talked about how her family has a long history of prematurely losing teeth due to decay, infection,
and spontaneous pulp death. The patient showed great concern for her current dental health and was
willing to do anything to improve it. She took all the advice and education I offered about her oral and
nutritional health seriously. She was very accepting of the treatment plan we discussed and was eager to
start.
Section II: Objective Data
Health History
Anemia:
• Diagnosed in August of 2020 by
Dr. Hamlin; Bruises easily due to
anemia; Manages it with OTC
ferrous sulfate
Arthritis:
• Only in the knees due to not
having any articular cartilage to
cushion knee joints; Aches when
she walks or runs; Diagnosed in
2003, but doesn’t remember the
doctor who diagnosed her
Bruises easily: Cold sores/fever blisters:
• Due to anemia • Occurs during winter and when
she is stressed; Last occurrence
on 11/07/2023 when at her
MSSU dental appointment

Epilepsy or seizures: High blood pressure: High cholesterol: Liver disease:

• First occurred in 1989; Last
occurrence in 2011; Idiopathic
cause; Only occurs at night while
she is sleeping; Wakes up with
headaches the next morning
• Diagnosed in 2021 by Dr. Hamlin; • Diagnosed in August of 2023 by • Fatty liver diagnosed in August of
Controlled through OTC odorless Dr. Hamlin; Lowers cholesterol 2020 by Dr. Hamlin; The patient
garlic levels through diet seems to be less concerned about
it since she can get crowns out on

Stomach/intestinal disease:
• Gastritis has been present since she
was born; Causes dehydration and
upset stomach; Patient continuously
drinks water to counteract adverse
effects
 Vital Signs

Initial Appointment 10/31/2023

Temperature 97.2, temporal
Pulse 64 bpm, regular, full-and-strong,
right wrist
Respirations 14 rpm, normal depth, regular, easy,
no noise, no odor
MIL 180 mmHg
Blood Pressure 124/82 mmHG, right arm
Tobacco Status No past or present use
ASA Classification ASA II
Medical History

Hospitalizations/surgeries:
• Extraction of #2, 4-5. 13-14, 17-18, 20-21, 30, & 32; No specific date on removal since they were done over
multiple years
• Tubal ligation performed in 1998; General anesthesia used with no adverse effects; Patient doesn’t remember
where it was done or who performed the procedure

Suffered a broken back from a car accident in 2002, but was not hospitalized or had any
surgery performed
Physician’s care:
• Dr. Justin Hamlin at Royce Clinic at 1407 Miner Street, Sarcoxie, MO 64862; Phone #: 417-548-3334
Medications:
• Rx diazepam (Valium): 0.5 mg taken 3x daily for seizure prevention
• Rx hydrocodone and acetaminophen (Vicodin): 135 mg taken when needed for back pain caused by broken back
• OTC ferrous sulfate (Iron): 45 mg taken 1x daily for anemia
• OTC odorless garlic: 1500 mg taken 1-2x daily for high blood pressure
Medical History Continued

Allergies:
• Codeine makes the patient feel nauseous and gives her an upset stomach; Last used on 09/08/2023 in
combination with hydrocodone to relieve back pain

Tobacco status:
• No past or present use

Alcohol use:
• No past or present use

ASA classification:
• ASA II
Medical History Form
Medical History Form
EOIO: History and General Tab

 History tab:
 Oral surgery: #2, 4-5, 13-14, 17-18, 20-
21, 30, & 32 have been extracted
throughout the years due to caries and
abscesses
 General tab:
 How often do you brush?
 2x daily
 How often do you floss?
 Never, but does use her fingernails to
clean in between teeth
 Toothpaste:
 Pro Namel Sensodyne
 Mouthwash:
 Listerine
 Emotional motivators:
 Wants to have healthy teeth
 Emotional concerns:
 Doesn’t want to lose any more teeth
EOIO: Habits Tab
 Habits tab:
 Grinds teeth at night
 Intervention: Use stress toys, chew sugar free
gum, eat healthy snacks or drink water, or use a
mouthguard when sleeping
 Accidentally bites cheeks when eating
 Intervention: Eat slowly and cut food into small
pieces
 Breathes through mouth
 Intervention: Drink lots of water to keep oral
cavity wet, use artificial saliva when sleeping,
chew sugar free gum to stimulate salivary flow, or
eat healthy and chewy foods that stimulate
salivary flow
 Eats candy 1x daily
 Intervention: Reduce sweets intake, swish with
water or brush teeth after eating sweets, eat
healthy sweets instead, and try to eat sugar free
options
 Drinks artificially sweetened smoothies 1x daily
 Reduce sweetened beverage intake, swish with
water or brush teeth after drinking, try to use
natural sweeteners like Stevia, and make sure to
EOIO: Head Tab
 Head tab:
 3X3 mm raised, skin-colored mole on right
cheek by right nostril
 Lymph nodes are non-mobile, non-
palpable, and non-tender
 Upper and lower lips are slightly dry
 Left ear pierced, but as healed and closed
 Palatal tori
 Yellow film on tongue
 2X2 mm bite mark on left cheek near
occlusal of #19
 Petechiae on buccal mucosa near #31
 Abrasion on buccal mucosa of right cheek
near #31
 Scarring on lower lip making lip appear
pale
 Bilateral Fordyce granules near labial
commissures
 Mucogingival involvement of #25
EOIO: Cosmetic Tab

 Cosmetic tab:
 Anterior crossbite with #22, 23, 10, & 11
 3 mm diastema between #24 & 25
 2 mm diastema between #22 & 23
 1 mm diastema between #8 & 9
 Moderate incisal attrition of maxillary and
mandibular anteriors
 Generalized moderate, intrinsic yellow
staining with generalized moderate,
extrinsic yellow to light brown staining at
the interproximals
 Generalized white spots are also present
(most likely due to decalcification).
EOIO: Occlusion, TMJ, &
Perio Tab
 Occlusion tab:
 Maximum opening unassisted is 3 fingers
 Edge to edge bite from #24-25
 Diastema between #24 & 25
 No overjet due to edge-to-edge bite
 Anterior crossbite with #22, 23, 10, & 11
 Molar relation left and right side are NA due to missing first molar
 Cuspid relation left and right side are Class 3
 Midline is deviated to the left by 7 mm
 TMJ tab:
 No pain, crepitus, popping, or sliding
 Perio tab:
 Consistency is firm
 Hygiene is fair
 Plaque buildup is moderate
 Inflammation is moderate
 Margins are swollen
 Blood is present during palpitation
 Attached gingiva is pink and glossy
 Papillae are blunted, red, and boggy
 Generalized moderate, marginal inflammation with #25 in
mucogingival involvement and generalized, heavy BOP.