CASE STUDY PRESENTATION:

ELAINE
JESSE GROSSMAN

DH 222
CLINICAL DENTAL HYGIENE

CASE STUDY: MEDICAL HISTORY

SUMMARY

Elaine is a 64 year old female with 24 permanent teeth.

Periodontal Case Type- III
Sub Calculus Evaluation- 3
ASA Class- II

CASE STUDY: MEDICAL HISTORY

Patient has type II diabetes. (Patient claimed it was well controlled due to lifestyle and

medication.)
A1C was 7.5 2 months before evaluation appointment. (Patient sees physician every 3

months.)
Patient has high cholesterol. (Controlled with medication.)

Patient takes Tylenol for arthritis pain 2 x per week.

Patient reports brushing 3 x per week at most.
At evaluation appointment it had been 18 months since last dental appointment.

Patient reports bleeding gums when brushing and flossing.

CASE STUDY: MEDICAL HISTORY

MEDICATIONS

Glipizide- Antidiabetic Agent (type II diabetes)

Considerations: Patient may experience stress-induced hypoglycemia during morning

appointments.
Trazadone- SSRI Antidepressant (sleep aid)
Considerations: Patient may experience xerostomia. Use vasoconstrictors with caution.

Atorvastatin- Antilipemic (high cholesterol)

Considerations: Patient may experience muscle weakness and may have trouble brushing.

Tylenol- Analgesic (joint pain)

Considerations: None

CASE STUDY: PERIO ASSESSMENT TOOLS

DENTAL CHART

CASE STUDY: PERIO ASSESSMENT TOOLS

PERIODONTAL ASSESSMENT

CASE STUDY: PERIO ASSESSMENT TOOLS

RADIOGRAPHS- SELECT PAS FOR RESTORATIVE TREATMENT

CASE STUDY: PERIO ASSESSMENT TOOLS

RADIOGRAPHS- BITEWINGS

Generalized moderate horizontal bone loss.

CASE STUDY: TREATMENT PLANNING

RESTORATIVE RECOMMENDATIONS
# 12 fractured
Recommended for full crown. *(MODBL composite with pins placed.)

# 28 fractured
Recommended for full crown. *(MODBL composite.)

# 18 recurrent decay on facial and mesial of crown

Recommended for mesial buccal composite.

# 13 recurrent decay
Recommended for MOD amalgam.

* Dentist ended up restoring #12 and #28 because patient said she would rather have them extracted
than pay for a crown because she could not afford it.

CASE STUDY: TREATMENT PLANNING

DENTAL HYGIENE DIAGNOSIS
Color- Generalized slight moderate hyperemia with severe on buccal of #8 and

lingual of #31.
Contour- Generalized slight moderate blunting of papilla.
Consistency- Generalized slight moderate edematous.
Bleeding- Generalized spontaneous upon probing. 24 teeth/144 sites
Clinical Assessment Markers- Furcations, mobility, recession, IAG.

Periodontal Case Type- III

Calculus Rating- 2.5/3

CASE STUDY: TREATMENT PLANNING

ORIGINAL TREATMENT PLAN

CASE STUDY: TREATMENT PLANNING

RISK ASSESSMENT
Systemic and Behavioral Factors:
Irregular dental care
Type II diabetes
Stress/anxiety
Arthritis

Caries Risk Factors:

Heavy plaque and calculus (2.5/3)
High sugar diet
Xerostomia

Removable appliance (flipper on # 6)

Periodontal Risk Factors:

Heavy plaque and calculus

Generalized spontaneous bleeding

Many restorations

Recession
Generalized moderate bone loss (Case type III)
Furcations
IAG

CASE STUDY: TREATMENT PLANNING

GOALS, INTERVENTIONS, & OUTCOMES
Goals:
Patient wants to keep all of her existing teeth. She does not want to lose all of them like her

husband.

Interventions:
Patient was educated on proper home care.
Patient will start brushing at least one time per day.
Patient will start scheduling regular dental visits. It is recommended once every 4 months.

Expected Outcomes:
Patient will develop the motivation to starting taking better care of her teeth.
Patient will hopefully start brushing daily and visiting the dentist regularly, as recommended.

CASE STUDY: INTRAORAL PHOTOS

Sub and Supra Calculus

CASE STUDY: INTRAORAL PHOTOS

Class II- 6mm Overjet with 5mm Overbite (100% overbite)

CASE STUDY: INTRAORAL PHOTOS

Restorative Recommendations

CASE STUDY: STUDY MODELS

Study Model OHI Demonstration:
I used the study model to show Elaine the

places she has been missing when brushing and

the places she gets the most build up.
I showed Elaine her fractured teeth on her

study model and explained the importance of

getting these teeth restored and considering
the possibility of getting full crowns down the
road as Dr. Wilson recommended.
I also showed Elaine her dental classification

(class II) and talked to her about her overbite

and overjet.

CASE STUDY: TREATMENT

02/11/16 OHI, comprehensive oral evaluation, four bitewings, 3 PAs, intraoral photos,

microscope, Oraqix
Patient was too sensitive to perio chart, even with the Oraqix, so we made the decision

to wait until she came in for quadrant scaling.

Microscope showed risk factor C (a lot of WBCs, spirochetes, vibrios, and cocci).
Risk factors discussed- not brushing/flossing and visiting dentist regularly can lead to

increased bone loss.

OHI- brush at least one x per day (patient reports brushing every 3 days at most)

CASE STUDY: TREATMENT

02/18/16 Restorative treatment
Patient came in to have restorative work done on tooth #18 and during treatment

she had a diabetic incident. Dr. W and staff treated as though she had low blood sugar
(hypoglycemia), but it turned out that her blood sugar was very high. This was a great
learning experience because we learned that during diabetic incidents it is better to
assume that the person has low blood sugar because it will not harm a hyperglycemic
patient to give them more sugar, however if you fail to treat someone with low blood
sugar they can go into a diabetic coma.

CASE STUDY: TREATMENT

04/01/16 D4341 (UL), Perio scaling by quadrant

(Cavitron and hand scaling), LA, OHI

I was able to perio chart this quadrant at

this appointment and then did my sub comp

on this patient on the upper left quadrant.
Risk factors discussed- periodontal disease,

decay prevention, and irregular dental visits.

OHI- instructed patient to brush at least 1

x per day and purchase a water flosser.

04/20/16 D4341 (UR and LL), Perio scaling by

quadrant (Cavitron and hand scaling), LA,

OHI
Perio charted quads as I administered LA
Patient reports she is now using water flosser.

Risk factors discussed- periodontal disease

and risk of irregular dental care.

Homecare modification- instructed patient

she needs to spend more time in the

posterior.

CASE STUDY: TREATMENT

04/21/16 D4341 (LR), Perio scaling by quadrant (Cavitron and hand

scaling), LA, OHI, Arestin placed tooth #31

Perio charted final quad after patient was numb.
Risk factors discussed- periodontal disease and irregular dental

visits.
OHI- work longer in the posterior and angle water flosser

underneath/in between gums.

Recommendations- recommended patient for 3 month recall

with dentist of her choice.

*Restorative done on tooth #28 MODBL after my patient treatment
ended.

05/12/16 Restorative, LA
#12 MODBL with pins

placed (composite)
#13 MOD (amalgam)

*Restorative done by Dr.

CASE STUDY: RE-EVALUATION APPOINTMENT

05/18/16 Re-evaluation appointment, microscope, OHI, fluoride varnish, Oral-B toothbrush
Color- Generalized normal with localized slight hyperemia around #24 and #25.
Contour- Generalized normal with localized slight enlargement around #24 and #25.
Consistency- Generalized normal with localized edematous around #24 and #25.
Bleeding- Generalized slight delayed upon probing. 19 teeth/53 sites
Clinical Assessment Markers- Furcations, mobility, recession, IAG.

Periodontal Case Type- III

Calculus Rating- 1.5/1.5

Statement of Inflammation- Generalized normal with localized inflammation around #24 and #25
Microscope- risk factor B, spirochetes, vibrio, cocci (not too many to count).

CASE STUDY: PERIO ASSESSMENT TOOLS

PERIODONTAL ASSESSMENT- BEFORE AND AFTER

Before

After

CASE STUDY: INTRAORAL PHOTOS

Sub and Supra Calculus

CASE STUDY: INTRAORAL PHOTOS

Class II- 6mm Overjet with 5mm Overbite (100% overbite)

CASE STUDY: INTRAORAL PHOTOS

Restorative Recommendations

CASE STUDY: POST TREATMENT

RECOMMENDATIONS

CASE STUDY: PROFESSIONAL REFLECTIONS

When Elaine first came in it had been only 18 months since she had D4341quadrant scaling.

She had reported brushing 1-2 x per week at most. She saw an ad in the newspaper and knew
she should come into the clinic. Her motivation was the fact that her gums were bleeding
when brushing, her husband complaining of her bad breath, and the fact that her husband had
all of his teeth extracted a few years prior (which she was trying to avoid).
After treating Elaine, I realize that she is someone who loses her motivation quickly. I

recommended her to be seen for 3 month perio maintenance appointments with a dentist of
her choice. At this point, Elaine is doing a good job with home care and definitely has the tools
she needs to stay healthy, but it will ultimately be up to her.
Elaine is concerned with her type II diabetes and knows that having active periodontal disease

intensifies the systemic effects. She also knows the effects diabetes can have one her
periodontal disease and this was a big motivator for her.

CASE STUDY: PROFESSIONAL REFLECTIONS

What worked best for Elaine was coming in for quadrant scaling. I, of course, educated her like

crazy on OHI and she is now using an interproximal cleaner and electric toothbrush. Although
I explained to her what I learned in a textbook during my Periodontology class: The most
important thing she can possibly do would be to come into the dentist every 3 months or as
often as she can. My guess is that she is not someone who will ever be diligent about brushing
and flossing. If we can keep her coming back we can re-motivate her so she will keep up on her
daily home care and regular dental visits.
Periodontist consultation would be highly beneficial if patient was willing to go!
I feel like there is not a lot I would change with the treatment of this patient, however, I would

hope that she would find the internal motivation to make good choices for herself that will
sustain a healthy life.