Case Study Kaley O’Brien

David The patient is a 54 year old male who has had multiple contributing factors to increase his severe periodontal disease. Multiple previous conditions leading to multiple medication, deep pockets with progressive bone loss, and lack of knowledge have all lead to the severity of this patients condition. With a 5 sub rating, a case type IV, and 28 teeth this patient is ideal for my case study. The goal was to perform NSPT to arrest the disease and provide improvement to his periodontal condition. Initial Appointment: 1/15/15

Health History Age: 54 Last prophy: unknown Systemic diseases: High Blood Pressure, Type II Diabetes, stroke in 2001, and kidney removal in 2013. Medication: Omeprazole, Carvedilol, Amlodipine, Tamulosin, Hydrochlorothiazide, Simvastatin. Glipizide, Aspirin (.81 mg), and potassium. Dental Information: Gums bleed upon brushing, brushing 1x per day in AM with fluoride toothpaste

Vital Signs Date: Blood Pressure Repiration Pulse 1-8-15 141/93 14 76 1-21-5 154/94 16 67 1-28-15 151/94 70 1-29-15 139/88 72 2-6-15 139/86 18 65 2-13-15 149/96 74

IO/EO Findings Nothing abnormal Class I Occlusion Overjet 4mm Overbite 4mm

Dental Charting Existing Proposed 2-MO amalgam 3-DO amalgam 8-PFM 9-PFM, RCT 14-O amalgam, O amalgam 15-O amalgam, B amalgam 18-O amalgam, B amalgam 19-DO amalgam 29-DO amalgam 30-O amalgam 31-O amalgam

Periodontal Assessment Teeth Sites Bleeding 28 167 Suppuration 1 Furcations 8 20 Mobility 17 Pockets > 4 24 86 CAL 1-3 46 CAL 4-5 25 64 CAL +6 21 58

Microscope Evaluation Risk Factor C: TNC WBC’s, spirochetes, gliding and spinning rods All very motile

Intraoral Photos

Radiographic Findings Impacted third molars Generalized severe bone loss Calculus interproximal of almost every tooth.

Study Models

Dental Hygiene Diagnosis Case Type IV 2/5 calculus rating Gingival Description: Generalized severe papillary and marginal hyperemia Generalized severe papillary and marginal enlargement Generalized fibrotic Generalized spontaneous bleeding Generalized severe papillary and marginal inflammation

Dental Hygiene Diagnosis cont. Radiographs show generalized severe bone loss with generalized heavy interproximal calculus

Periodontal Risk Analysis LOW MODERATE HIGH Infectious diseases Irregular Dental Care Medications Systemic Diseases Existing Conditions

Caries Risk Analysis N/A LOW MODERATE HIGH Deep pits and fissures Visible carious/ white spots Root Exposure Visible dental biofilm Recently restored fillings Saliva Reducing Factors Frequent sugar exposure Appliances

Patient Goals Patient wants to get teeth cleaned, get rid of the bacteria seen on microscope slide, and do any restorations needed Interventions NSPT full dentition with aid of local anesthetic, teach good home care, gingival curettage, Arestin placement, and have the dentist diagnose any caries. Expected Outcomes NSPT will help reduce the bacteria and take away the environment in which they flourish. Proper home care will help to disrupt that bacteria and stop it from recolonizing. Restorations will be scheduled or referred out accordingly.

TREATMENT PLAN 1 -D0150- Comprehensive Oral Evaluation, -D0210-FMS, -D0330- Panoramic Image, -D1330-OHI, Oral B toothbrush, Impressions, Checkin 2 -D-4341 UR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage 3 -D-4341 LR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381-Arestin (5-8) 4 -D-4341 LL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381- Arestin (31B,30L, 27L) 5 -D-4341 UL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Laser Curettage, -D4381- Arestin (9,18,19), -D1206- Fluoride Varnish 6 -D0170- Re-Eval, -D1206- Fluoride Varnish, -D1330- OHI, -D4381-Arestin (27M and 11F)

TREATMENT PLAN 1 -D0150- Comprehensive Oral Evaluation, -D0210-FMS, -D0330- Panoramic Image, -D1330-OHI, Oral B toothbrush, Impressions, Checkin 2 -D-4341 UR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage 3 -D-4341 LR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381-Arestin (5-8) 4 -D-4341 LL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381- Arestin (31B,30L, 27L) 5 -D-4341 UL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Laser Curettage, -D4381- Arestin (9,18,19), -D1206- Fluoride Varnish 6 -D0170- Re-Eval, -D1206- Fluoride Varnish, -D1330- OHI, -D4381-Arestin (27M and 11F)

Treatment Plan Rationale Based on the severity of the patients periodontal disease, the patient was needing to undergo NSPT. With pockets being this deep and the patient being so infected there was no way this could be performed without aesthetic. In hopes to help progress the healing of the tissue curettage was performed on every quadrant and Arestin was placed in any pockets that were still not showing signs of progress at the subsequent appointment.

OHI Initial Recommendations: Compliance: Modifications Brush with new Oral B toothbrush with Bass method for 2 full minute twice daily, flossing with “c” shape, use of perio aid to clean deep pockets, talked about possibility of waterpik, and brushing tongue as well. Patient advised at initial appointment to focus on brushing twice daily for 2 full minutes Compliance: Great effort, but patient still not consistently brushing twice per day. Patient also found perio aid difficult to manipulate Modifications Brought up possibility of waterpik again and talked to patient again about importance of brushing more. Compliance to modifications By the re-evaluation appointment I could see great improvement in David’s brushing compliance and that David had invested in a Waterpik.

Motivation Strategies Intrinsic Proper OHI to “get rid” of all the bacteria Brushing to reduce patients discomfort in mouth Extrinsic Arresting periodontal disease in order to avoid toothloss. Proper OHI to decrease negative appearance of mouth OHI utilization I was able to use the microscope, intraoral photos, and the discomfort to help motivated the patient to have great home care compliance.

Re-Evaluation Appointment Date: 4/7/15 2/2 Case Type III with Localized Case Type IV Microscope Risk Factor B OHI Compliance: great compliance with water pik, but patient still working on brushing morning and night Gingival Description: Generalized moderate papillary and marginal hyperemia with localized severe on 3-4, 13-14, 24-25, and the maxillary anterior Generalized moderate papillary and marginal enlargement with localized severe on on 3-4, 13-14, 24-25, and the maxillary anterior Generalized moderate papillary and marginal inflammation with localized severe on on 3-4, 13-14, 24-25, and the maxillary anterior

Re-Evaluation Appointment cont. Patient motivation is still the same and is what is helping him maintain progress. The expected outcomes were reached as far as removing all of the calculus and teaching proper home care techniques. Patient still needs to have routine cleanings and have restorative work completed.

Periodontal Assessment Teeth Sites Bleeding 23 80 Suppuration 2 Furcations 8 20 Mobility 12 Pockets > 4 58 CAL 1-3 22 73 CAL 4-5 60 CAL +6 14 35

Intraoral Photos

TREATMENT PLAN 1 -D0150- Comprehensive Oral Evaluation, -D0210-FMS, -D0330- Panoramic Image, -D1330-OHI, Oral B toothbrush, Impressions, Checkin 2 -D-4341 UR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage 3 -D-4341 LR, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381-Arestin (5-8) 4 -D-4341 LL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Gingival Curettage, -D4381- Arestin (31B,30L, 27L) 5 -D-4341 UL, D9215 Local Anesthetic, -D1330-OHI, -D4999- Laser Curettage, -D4381- Arestin (9,18,19), -D1206- Fluoride Varnish 6 -D0170- Re-Eval, -D1206- Fluoride Varnish, -D1330- OHI, -D4381-Arestin (27M and 11F)

Comparison 1/15/15 4/17/15 Calculus Deposit 2/5 2/2.5 Case Type IV III localized IV Microscope Risk Factor C Risk Factor B

Reflection I thought that overall my case study was an amazing patient. I do however wish that he would have been more dedicated to his oral health. It seemed that he would do really good for a while, but then he would revert back to old habits and only brush once per day. There was some dexterity restrictions with David, but this was not to the degree that would prevent him from performing any of the things I instructed him on. I feel that it was more of a laziness factor when it came to David! I would have like to have been able to accomplish more as far as motivating him to want to brush twice a day, but I exerted all capabilities that I had. This was an awesome learning experience and made my overall oral hygiene education better!