Prepared by: Catherine DellaMaggiora

Patient Selection I chose this patient because of her willingness to receive treatment and the motivation she seemed to display. She is very motivated by her appearance and wants her smile to be healthy and friendly.

 Medical History: - 38 year old female - Patient smokes a half pack of cigarettes daily, and has been for about 20 years. Has tried quitting and been unsuccessful. - Does not take medications. - Has not had a dental cleaning in 20 years. - Brushes with fluoride toothpaste one time a day

 Intra Oral/ Extra Oral No significant findings Vitals

Dental Chart

Periodontal Assessment

Periodontal Assessment - Periodontal Case type III - Color: Generalized moderate marginal and papillary hyperemic - Contour: Generalized moderate marginal and papillary enlarged - Consistency: Generalized moderate marginal and papillary fibrotic - Bleeding: Generalized moderate spontaneous - Assessment Markers: Recession, furcations, IAG - Statement of Inflammation: Generalized moderate marginal and papillary inflammation. - Deposit Rating: 2.5/3, Microscope Risk Factor: C

Treatment planning - Appointment 1, 1/29/15: OHI, Comprehensive Exam, D4341 NSPT LR, Local Anesthesia - Appointment 2, 2/615: OHI, D4341 NSPT UR, D4341 NSPT UL, Local Anesthesia - Appointment 3, 2/12/15: OHI, D4341 NSPT LL, Local Anesthesia, Fluoride Varnish - Re-evaluation, 4/8/15: OHI, Localized Delivery of Antimicrobial Agents on #3-MB, Localized Delivery of Antimicrobial Agents #14-DL, Fluoride Varnish - Post treatment: 3 month recall with regular dentist.

Radiographs - Case Type III, caries are present

Intraoral photos Before Treatment

Study Models - Angle’s Classification: Class II - Overjet: 6mm - Over Bite: 3mm - Midline: 2mm left - I was able to use the study models to show the patient where food is becoming caught and how to brush with the Bass Method. She could also see why orthodontics would be beneficial by seeing her overbite and overjet.

Treatment - I use the Cavitron and hand scaled the entire dentition, and polished. - At each appointment, I saw significant changes in inflammation in areas that had been subgingivally debrided. At the 3 rd appointment, the patient’s inflammation was slight marginal and papillary with no bleeding. - The patient’s homecare significantly improved at each appointment as well. She started using a manual toothbrush with no flossing, and ended using an electric toothbrush and a water flosser daily. - I placed Arestin® at the Re-eval appointment on #3-MB, #14-DL due to inflammation and increased pocketing on these surfaces.

Oral Hygiene Instruction - I recommended she brushes 2 times a day with the bass method, uses an electric toothbrush, uses xylitol products for caries, uses an interproximal brush or water flosser for interproximal cleaning, quits smoking, has her restorative recommendations completed, and has a 3 month recall with a regular dentist for periodontal maintenance. - I explained to her how daily plaque removal and quitting smoking will help keep extrinsic stain to a minimal and keep her future restorations white. Smoking can severely discolor composite restorations.

Additional Therapy Interventions - Smoking Cessation: I discussed with the patient all of the benefits of quitting. I also told her that she can contact me anytime she is thinking about quitting or has decided to quit. After saying this she explained how she felt supported by someone and wants to quit soon. She had already established the quit date of 3/1/15 and wants to follow through with it. - Caries management: I explained how the combination of sugar, periodontal disease, and smoking are contributing to her caries risk. She likes to chew gum so I recommended xylitol products and xylitol gum. I also asked her to cut back on soda and sweets.

OHI Results She followed all of my instruction adequately. She purchased an electric toothbrush and water flosser because she knew it was beneficial. She also began completing her restorative work and scheduled a consultation for orthodontics. Finally, she decided to quit smoking and established a quit date: 3/1/15 Plaque after initial instruction was localized, extremely slight interproximal on #24 and #25. No further oral hygiene instruction was given.

Continuing Care Evaluation

-The patient is still doing a great job with home care. She has quit smoking almost completely. She still has 1 cigarette a week and plans on cutting that out of her routine. All of her restorative work had ben completed and orthodontics have been placed on her teeth by Dr.Wilkinson. Her inflammation is generalized normal, and localized moderate marginal and papillary inflammation on #3-MB and #14-DL (these areas were then treated with Arestin®). There is slight bleeding on buccal surfaces of #3. Deposit rating at this appointment was 1/1. I hand scaled and polished entire dentition and a fluoride varnish was placed to prevent future decay. Generalized normal, Microscope risk factor B, Deposit rating 1/1.

Intraoral Photos After Treatment

Professional Reflections of Treatment Performed - I selected this patient because of her periodontal condition and her willingness to become peridontally stable. She showed such enthusiasm in achieving oral health, I thought she would be great to work with. - My treatment planned changed at the re-eval appointment, because I decided the patient would benefit from Arestin ® placement in the areas with inflammation/increased pocketing.

- One thing I would/could have done different to impact the oral health of this patient would have been to recommend sipping on water all day for dry mouth. She said she had dry mouth occasionally but that it was nothing to worry about. I wish I had still given her options. - My greatest learning moment with this patient happened when I was giving this patient local anesthesia. I had never encountered a patient that required extra anesthesia before. I ended up giving her 3 carpules before she was numb. She had had this issue in the past and I should have asked her about it before I began the injections.