Preventative Strategies Patient Case Study
For this assignment we were split into groups and given a case study patient to collaboratively asses based on the information given. We were then asked to answer the following questions listed below. This assignment allowed me to listen to what others thought process may be when assessing a patient which then in return helped open my eyes to things that I may have missed or not considered.
- Assessment: Medical History
- What factors (i.e. access to care, systemic conditions, psychosocial influences, and/or medications) are present which must be considered during treatment?
-Obese: BMI , could have undiagnosed diabetes
-Medical/ dental anxiety pt reported
-High BP takes 2 hypertension meds and a cholesterol med
-Unemployed w/ child support: could make dental and med concerns not a top priority
-Smoker wants to quit could affect tissue health, delayed healing
-No insurance could increase the dental/medical anxiety
-Could have undiagnosed conditions b/c he doesn’t go regularly
-Recent extractions could be cause of tissue inflammation and smoking could cause delay of healing
- What alerts, if any, should be noted on the top of the HHx and brought to the RDH/DDS’attention?
-Seasonal allergies pt stated no meds taken for it
-High blood pressure taking 2 hypertensive meds (carvedilol, chlorthalidone), blood pressure remains elevated
-Obese possible ATC, because of comfort in chair
- What alerts, if any, should be added to Eaglesoft?
Cardiovascular- high blood pressure
- Should a referral to a physician recommended? Why or why not?
Yes, pt is taking two hypertensive meds and still has high BP. Pt would also need a med consult after second appt. where their BP was 140/90 per clinic rules. Obese could have undiagnosed diabetes.
- Do you feel that the medical history documentation was accurate and thorough? Why or why not?
Documentation seems accurate overall. Pt wasn’t able to say date of last physical examination or give any info other than the doctor’s name. Might be a sign that the patient hasn’t been in the last year.
- Assessment: Dental History
- What is the patient’s initial chief complaint?
Per medical history pt has sensitivity and needs an SRP. When asked about any complaints patient so none.
- What types of preventive and restorative treatment have been completed?
-Extractions/ missing teeth
– amalgams, composites, and crowns on 10 teeth total
- Do you feel that the documentation was accurate and thorough? Why or why not?
No, because the amalgams, composites, and crowns are not charted. Only missing teeth, retained roots and one caries charted.
- Assessment: Oral Examination
- Discuss abnormal findings on intra-oral and extra-oral exams, if any.
Obese
Nicotine stomatititis
Tobacco halitosis
Left TMJ popping but no discomfort
- What is the patient’s periodontal status (active or maintaining) and classification (HIP, HRP, GIP, Stage Grade etc)?
GRP
Stage IV b/c interdental CAL is 8mm, has at least class III furcations, flaring, VBL
Grade C b/c he smokes half a pack a day
- How do the gingival conditions support the periodontal status?
Inflammation (inflamm Gen 3), lots of edema, blueness (signs of chronic inflammation), whiteness, and bulbus
-surprised that the tissue wasn’t fibrotic since pt is smoking half a pack a day
- How do the indices (MPI and GBI) support the periodontal status?
GBI is low because pt is a smoker and decreases the blood flow and tissue healing. MPI is low but could be a thorough brusher that day.
- How does the periodontal charting support the periodontal status?
Patient has significant attachment loss, mobility, and generalized recession, which helps to determine the stage and grade.
- How do the radiographs support the periodontal status?
Able to see horizontal/vertical bone loss, retained roots (possibility that pt loss teeth to perio), and furcations are visible
- Describe the patient’s etiologic/initiating and local/systemic contributing factors to periodontal disease. Include deposit assessment and dentition assessment. Explain how they are related to this patient’s periodontal status.
Patient is a smoker- systemic risk factor, smoking causes stain which is a local risk factor, smoking delays healing process, a person who smokes is 6x more likely to develop periodontal disease, smoking automatically puts people at a grade of at least B
Cardiovascular disease-(systemic risk factor) high blood pressure meds , taking 2 hypertensive meds but still presents with high BP, needs to see doctor
calc build-up and open contacts is a local risk factor
caries on M #12- local risk factor
no date for last medical visit (undiagnosed diabetes and BP)- leading to hyperinflammatory response
poorly contoured restorations on anterior teeth, missing teeth can lead to occlusal trauma or supraeruption
Missing many teeth a good chance this is due to perio problems because of apparent bone loss in those areas. Want to make sure to ask patient open ended questions about when teeth were taken out and why (lots of patients don’t always know why according to Mrs. Stover)
- Do you feel that the documentation was accurate and thorough? Why or why not?
Dentition assessment was not accurate or thorough because none of the restorations were charted.
They never followed up with last doctors visit or receive a med consult due to the high BP and taking to medications for BP.
Patient reported not wanting to quit smoking after initially saying they were very interested at the initial appointment. I think it would have been helpful for some follow up questions about what has changed their mind- did they try and it was awful, has a stressful situation come up?
- Assessment: Radiographic Findings
- Aside from periodontal findings, what significant findings exist on the radiographs?
Contour restoration on anterior tooth
Retained roots
Root absorption on lower anterior
Visible calc
Caries on mesial of #12
- Diagnosis and Treatment Plan
- Identify and explain any human needs deficits and the dental hygiene actions in the following table. Be sure to connect EVERY item on the treatment plan back to a human need deficit.
| Human Need | Deficit evidenced by… | Dental Hygiene Treatment Plan Items and actions |
| Health Risk | No date of Dr. appointment
Smoking High blood pressure Perio |
Med consult recommendation
Inquire about Dr. appointment Tobacco cessation counseling |
| Fear & Stress | Dental anxiety | LA may ease anxiety about treatment/ pain management
We could inquire about use of nitrous to help anxiety |
| Wholesome Facial Image | Tobacco halitosis
Missing teeth, visible calc and stain |
Tobacco cessation counseling
SRP, restorative referral, polishing |
| Skin/Mucous Membrane Integrity of H/N | Coated tongue
BOP, bleeding, inflam(gen 3), probing depths, attachment loss, generalized recession Bone loss |
Patient education- brushing tongue
Periodontal therapy-SRP MI, pt ed on homecare |
| Sound Functional Dentition | Missing teeth, caries, stain, restorations, calculus, occlusion, bone loss, how long has it been since last dental appointment | Restorative check, referrals, SRP |
| Conceptualization & Problem Solving | Prioritizing healthcare appointments, lack of understanding | Patient education, Motivational interviewing |
| Freedom from H/N Pain | Sensitivity to cold, cavity, pain with treatment | Healthy history, motivational interviewing, LA- make sure to ask pt how they are feeling, consider staggering timing of injections or being aware of where you start, fluoride varnish |
| Responsibility for Oral Health | Seems to lack motivation for homecare, not prioritizing health/dental appointments | Patient ed and motivational interviewing |
- What are your group’s overarching treatment/preventive strategies goals, and why?
Patient education on how systemic factors can link to oral health such as diabetes, cardiovascular problems, and smoking.
Education on homecare and fluoride as a preventative and managing technique.
We want to help this patient get to a biological equilibrium so that we can stop the progression of perio. We want to educate how the smoking, possibly undiagnosed diabetes, high blood pressure are all playing a role in how the patient can manage his perio problems. Educating the patient on the importance of regular health/ dental appointments, creating a homecare routine, want to see tissue response from SRP.
- What are your group’s priority patient education goals, and why?
Set goals on what teeth patient wants to keep
Continue to offer tobacco cessation counseling incase patient changes their mind
Reinforce homecare and use of parodontax, chlorhexidine, and tepe brushes.
Go over diet and setting up a doctors appointment so that any systemic problems could be diagnosed such as diabetes.
- Is your group’s approach the same as the approach in the Case Study? Why or why not?
Our approach is similar but would want to incorporate more motivational interviewing. We want to have a more individualized approach to understand what the patient is going through and how that could be affecting smoking amount and anxiety about dental/ medical care. It would be important to approach the subject of nutrition because the patient is obese according to BMI and that could also be linked to undiagnosed diabetes. Uncontrolled diabetes is a risk factor for periodontal disease.
- Implementation
- What would be an appropriate instrumentation approach, and why?
Monitor patient’s toleration with an US. IF patient tolerates well we would begin with the universal tip to get off supracalculus. Then we would reexplore with explorer and move subg, L/R tip for furcations, then slim lines for smaller subg calc. Reevalutate with explorer and use HS when necessary.
- Monitoring preventive strategies and goal progress: Using recorded assessment data (photos for example) and quotes from T&P note entries (PSTA and PT ED for example), explain progress or lack of progress seen clinically.
-based on notes from 4/4/19 slight progress but due to smoking habits lower right was healing slowly.
-photos from 4/23/19 indicate patient has inadequate homecare due to supracalc buildup and bulbousness of gingiva.
- What, if any, changes were made to home care over the course of treatment? Did the behavior changes make a difference clinically? What data support that?
Patient was told they were doing a good job brushing on 3/28 and given Parodontax and 12% CHX.
Based on notes between 3/28 and 4/4 patients homecare improved but between 4/4 and 4/23 homecare maybe wasn’t as much of a priority anymore because based on photos inadequate homecare allow for supracalc buildup.
- Describe the gingival conditions and inflammation in detail (including histology) at the final appointment. What gingival changes (if any) did you see at the end of treatment? What data support that (notes and photos for example)?
Stagnation of blood flow cause of blueness for the tissue color based on intraoral photos in IO photos on 3/26 and 4/23
More plasma leakage causing edema so when we saw a decrease there is vasoconstriction which results in tissue looking less bulbous.
Patient went from a state of chronic inflammation to an acute inflammation over the course of the treatment.
- What do you think accounts for the changes (or lack thereof): treatment, behavior changes, a combination, or something else? Why?
Removal of calculus during instrumentation, homecare with the use of Parodontax and CHX. Overall, the change is a combination of the instrumentation with the new homecare routine. The calculus is a local contributing factor that helps decrease inflammation by controlling the biofilm formation.
- Maintenance
- What periodontal maintenance interval was suggested? Why?
Every 3 months because that is the time it takes for the bacteria to become virulent. This patient also created a lot of calculus and has active periodontitis.
- Was a referral for additional procedures recommended? Why or why not?
A referral was recommended for a periodontist and retained root needs to be addressed. Patient has active periodontitis.
- How thorough and helpful was the completion of the TSR form? What would your group change if you could write it over again?
TSR form was complete but not very helpful. More instruction was needed so that the patient has more guidance and understanding of what they can do to help with the health of their mouth. The way the TSR was filled out seems negligent when the clinician is saying the patient is doing great when the patient went from poor oral health to moderate/fair at best. We want to encourage but want to be realistic of what is going on in the patient’s mouth.
- Evaluation
- Do you feel the patient will follow through with recommended homecare, periodontal maintenance interval, and referred dental care? Why or why not?
No, because of the financial stress and inconsistency in seeking healthcare.
- Is there anything your group would do differently regarding the care of this patient that has not already been addressed? Why or why not?
Yes, we would be more objective while still be encouraging toward the patient. We would really want to figure out what would motivate the patient to make healthy changes and seek professional help when needed.
- What have you learned from this case study?
How important it is to individualize patient care. It was really interesting to compare progress of the patient.
Competency
After spending the last two years in the dental hygiene program all of us students have continuously implemented the dental hygiene process of care. The dental hygiene process of care involves assessing, diagnosing, planning, implementing, evaluating, as well as documenting treatment. The PSP project seen above helped us to improve on how we individualize treatment and care for patients based on their specific needs. By seeing patients from all different walks of lives and being able to implement the dental hygiene process of care for each and every one of them I feel as though I am competent in this area of dental hygiene.