1. Candice Richins, SDH Mesa Community College

2. PATIENT PROFILE 40 year old Caucasian male presented to clinic in September of 2015, for a routine exam. Cattle rancher. Over 13 years since last dental appointment. The pt reported that the last time he saw a dentist was for pain at #1, #16, #17, and #32. The dentist was going to charge $300 for extraction, pt determined that was too expensive and he would rather deal with the pain. Pt also reported that at the same dental appointment, the RDH told him that his “gums were in too bad of shape and she wouldn’t clean them”. Pt reports taking his daughters to the dentist/hygienist every 6 months, if not more. Last physician visit, September of 2014, routine check up. Pt presents in good general health. Generalized Active Case Type II, Early Periodontal Disease. Level II calculus pt.

3. CHIEF CONCERN “My wisdom teeth hurt, especially the upper left one.”

4. HUMAN NEEDS THEORY #3 Freedom from Pain in Head in Neck (pain at #1, #16, #17, and #32). #4 Wholesome Facial Image (“my teeth are so bad”) #5 Skin and Mucous Membrane Integrity of the Head and Neck (fibrotic tissue at buccal mucosa, due to chewing tobacco). #6 Biologically Sound and Functional Dentition (Pain at #16 so severe, pt chews predominantly on right side). #8 Responsibility for Oral Health (Pt doesn’t keep regular dental appointments, but does keep regular medical appointments. Pt keeps regular dental appointments for his children. Pt has no desire to quit sipping sodas all day or quit using tobacco).

5. MEDICAL HISTORY Pt reports no existing medical conditions. Last physician visit, September of 2014. Pt presents in good general health.

6. ALLERGIES Penicillin (hives). Seasonal allergies (itchy nose, runny eyes).

7. VITALS Blood Pressure: 128/88 mmHG (Pre-hypertensive) Pulse: 68 BPM (within normal range) Respirations: 18 RPM (within normal range) ASA I

8. ASSESSMENTS CAMBRA- Indicated high risk. Pt reported sipping on soda through out the day. Tobacco Use Assessment- Pt reported using chewing tobacco for the last 25 years. Starts using within 30 minutes of waking up, and constantly has it in his mouth until he goes to bed. Has tried to quit in the past and was not successful. No desire to quit right now.

9. ASSESSMENTS (cont.) EO/IO- -Pt reported being out in the sun a lot and not using SPF protection, urged pt to begin using SPF and to see a dermatologist once a year and if he sees any dermatologic changes. -Lesion found on buccal mucosa adjacent to #16 & #17, well circumscribed, red in color with white center, 5mm x 2mm. Pt reports biting his cheek. Had DDS confirm. -Buccal mucosa adjacent to mandibular molars and premolars appears fibrotic. Pt confirmed these are the areas where he packs chewing tobacco. -Lower lip had two palpable nodules, adjacent to central incisors. Pt confirms it was a scar due to a childhood injury. -Nearly half of the crown of #16 broken off due to decay. Gingivial Description- Generalized coral pink in color, generalized fibrotic tissue, generalized bulbous interdental papilla, with normal contour. Occlusion- Bilateral class I. 2mm overjet. Normal overbite. No fremitus. No mobility. Radiographs- RX for 20-series FMS and 1 panoramic given by Dr. Lazore. Exposed by Candice Richins using digital sensor (KV63, MA8, d0.08). Developed by Karaynn Cannan. Probing- Full probing chart

10. KERATOTIC PATCH (bilateral)

11. SEVERE & VISABLE DECAY

12. DENTITION CHART

13. RADIOGRAPHS- fmx

14. RADIOGRAPHS- panoramic

15. PROBE CHART

16. TREATMENT Generalized active case type II, early periodontitis. Due to improper biofilm removal. Level II calculus pt. Patient consented to and received the following tx: -Prophylaxis tx of QI. Anterior & posterior sickle scalers, universal curette. -NSPT, 4342 (#13), QII. Anterior & posterior sickle scalers, distal & mesial gracies, universal curette. -NSPT, 4342 (#18, #19, #21), QIII. Anterior & posterior sickle scalers, distal & mesial gracies, universal curette. -NSPT, 4342 (#31), QIV. Anterior & posterior sickle scalers, distal & mesial gracies, universal curette. -Polishing of entire dentition using fine prophy paste. -Flossing of entire dentition using Glide floss. -DDS limited oral exam. -CHX rx given. -Irrigation of entire dentition using iodine/water solution. -Application of 5% sodium fluoride varnish to entire dentition. -4 week re-evaluation appointment. OHI- Pt reported using a manual toothbrush QD and never flossing. Educated pt on importance of at-home care, pt committed to brushing BID with an electric toothbrush and flossing QD with a waterpik. POST OP- May feel tenderness for a few days, call me if you are in pain. Nothing hot or crunchy for 4 hours. Use CHX rinse as directed on bottle, discontinue use after 2 weeks. DDS LIMITED ORAL EXAM- Carious lesions detected and extraction recommended at #1, #16, #17, and #32. Carious lesions and restoration recommended at #10-L and #31-O. Pt referred to outside general dentist.

17. CARE PLAN

18. CARE PLAN (cont.)

19. RE-EVALUATION 4 weeks later, pt returned for re-evaluation. No changes in HHX. Vitals: -BP 130/84 mmHG (pre-hypertensive) -Pulse 60 bpm -Respirations 18 rpm ASA I EO/IO: Fibrotic tissue at buccal mucosa, adjacent to mandibular molars and premolars, due to chewing tobacco habit. Gingival Description: coral pink in color, generalized blunted interdental papilla. Probing Chart: (next slide) Generalized Case Type II, early periodontal disease. Localized Case Type IV, severe periodontal disease. Hard Tissue Findings: Pt reported that he would make a dental appointment the following week. Re-care: Pt was urged to come back for a re-care appointment in 4 months time. In hindsight, I should have made that 2-3 months.

20. RE-EVALUATION PROBING CHART

21. FEEDBACK Faculty Feedback: - If a pt’s health history presents with no significant findings, make sure to ask when their last physician visit was. If their last physician visit was ten years ago, NSF may not be true. - Make sure to roll your instrument and stay adapted to the tooth as to not cause soft tissue trauma. - 3 rd molar probing depth was not accurate at initial assessment appointment. Patient Feedback: - Pt reported feeling comfortable with me, that I had “good chair-side mannerism”. - Pt reported feeling comfortable enough to be honest with me, instead of fibbing and telling me what I wanted to hear. - Pt reported feeling very little discomfort, despite having NSPT tx in three quadrants without any anesthesia. This could possibly be due to vasoconstriction in oral cavity due to tobacco use.

22. SELF EVALUATION OF TX How I could have improved management of this patient: I should have referred the pt to his physician to have his kerototic patch biopsied. I should have put the pt on a 2-3 month re-care instead of 4 months.

23. SELF EVALUATION OF TX (cont.) My Greatest Success: This was my first experience with an upper level calculus patient. I considered it a great success to fully debride his entire dentition of heavy calculus. My Frustrations: I found it extremely difficult to remove this type of calculus with hand instruments alone. Most Valuable Learning Moment: I had the opportunity to use extraoral fulcrums and I also had the opportunity to use finger assisted lateral pressure combined with the toe-down technique.

24. SELF EVALUATION OF TX (cont.) My Greatest Area of Improvement: By the time I finished tx on this patient, my hand scaling skills were significantly improved as well as my confidence in my abilities. Areas Needing Continued Focus: Instrument adaptation at line angles. I tend to cause soft tissue trauma in these areas.

25. SELF EVALUATION (cont.) My Intentions for Next Semester: Continue to work on instrument adaptation. I believe my largest area of concern is causing soft tissue trauma to my patients. Continue to work on time management. Although I have improved significantly in this department, I still need to work on this. Continue to work on detection of suspicious radiographic areas. I understand this will make me a more valuable team member when looking for employment. Work on my computer skills. Dexis/Dentrix shortcuts. Personal Reflection: I believe I have come a long way this semester. I am faster, more accurate, comfortable with anesthesia, my hand scaling skills have greatly advanced and improved, and lastly, I feel comfortable using a cavitron. I am happy that I still have one more semester left of school to further improve my skills as well as advance myself in time management techniques.