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Capstone Project

Kat Mundell

Dental Hygiene Practice VI

1/23/18
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Introduction:

When I first heard we had to do a “Capstone” patient, I was overwhelmed. I had no idea

where to find a “Capstone” patient. Luckily, I was talking with my roommate and he had

mentioned he had not been to a dentist or had his teeth cleaned in some time. I scheduled him

and while completing his assessment, learned he is a smoker, he has a systemic disease, he has

periodontal disease, and needs restorative work. I had found my Capstone!

Assessments:

• The patient’s chief concern and reason for coming to our clinic was he had a “filling that

cracked off.” He had not been to the dentist or a dental hygienist since 2012, about five years

ago. The patient is a 39 year old male.

• The patient’s blood pressure ranges from 116/81 to 146/56. The patient usually smokes right

before his appointments and rushes to arrive for his dental appointments, therefore his blood

pressure can be as high as 146/56.

• The patient is currently receiving Stelera (Ustekinumab) injections for his psoriasis. He

receives his injections every two months. He was diagnosed with psoriasis in 2009. His

psoriasis/arthritis is controlled and mild. When not controlled, his psoriasis can be severe. He

breaks out in red sores. He is under the care of Dr. Lars at Virginia Mason in Kirkland. He gets

blood tests done every time he gets his injections.

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• The patient has smoked on and off since 1996. Currently, he smokes about ten cigarettes a

day.

• The patient does not have any allergies.

• The patient is classified as ASA II because of his controlled psoriasis, medication, and

because he is a current smoker.

● The patient knows his dental health is important, but he does not have a dental home,

because he forgets to schedule his appointments. He has depended on other people to schedule

his appointments in the past. Nobody has scheduled his appointments since 2012, hence the lack

of dental appointments.

• The patient has a raised nevi on the left side of his neck, near the base of his neck. The nevi is

dark brown and 3x4 millimeter in size. The patient stated he has had it for a long time. The

patient has a 0.5x0.5 millimeter white lesion surrounded by redness on the buccal mucosa near

tooth 14. Patient states it does not hurt. The patient’s lateral border of his tongue is scalloped.

Dentinal pooling is present on tooth number 18.

• His gingiva is generalized slight erythematous with moderate erythematous tissue around

tooth number 27 and pressure with generalized rolling along the margins of the posterior teeth.

There is generalized blunted and bulbous papilla with generalized edematous consistency and

localized stippling is present on the maxillary and mandibular gingiva.

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• The patient has two existing root canals (tooth numbers 4 and 18), a MOBL composite on

number 19 and tooth number 18 has a porcelain fused to metal crown.

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• The patient has localized attrition on the mandibular anterior teeth and 10-11 and 28-29.

Tooth number 7 is rotated distally, tooth 9 has buccoversion, tooth number 25 is rotated mesially,

and the patient has had all of his third molars (1, 16, 17, 32) removed.

• The patient has Class I occlusion for both canine and molars on the left and right side and has

end-to end occlusion between teeth 10 and 21.

• The patient has generalized four millimeter pocket depths with localized five to six millimeter

pockets in his posterior teeth.

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• He has generalized bleeding especially in his posterior teeth. He has generalized one to two

millimeters of recession with localized three millimeters recession in quadrant one. The patient

presents with generalized class I and II furcations.

• He is open to new information and values prevention. He also wants product

recommendations.

• The patient has fluoridated water at home, but does not usually drink water.

● He has a high stress load.

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• The patient has a high sucrose/carbohydrate intake and drinks soda almost daily and eats fast

food frequently. The patient does not eat regularly; he frequently only eats one to two meals a

day. The patient understands he should eat more healthy meals and should drink more water

versus soda. On the other hand, the patient really enjoys his sodas and loves getting take-out. On

his daily food log, there are large blocks of time during the day when he does not eat. When he is

at work, he does not take a break to eat. He also rarely eats breakfast.

• The patient uses a power toothbrush one to two times a day and he uses flossers usually

one time a day.

• His plaque index, before his cleaning, has 57% with generalized plaque in every

interproximal surface.
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• The patient’s chief concern is getting his teeth cleaned and receiving necessary

restorative work.

• I took a full mouth series of radiographs because the patient had not been to a dentist

since 2012 and did not have radiographs on file.

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• At the doctor’s exam, Dr. Lowell discussed with the patient the need for a composite

DOBL on tooth number two. He also needs a root canal with a porcelain-fused to metal crown on

tooth number four. There is a radiolucency near the apices of number eighteen which prompted

the doctor to discuss either having tooth number eighteen removed or retreated. Tooth number

nineteen needs a mesialbuccal cusp composite because of tooth decay and tooth number

twenty-seven needs to be monitored due to incipient decay.

Dental Hygiene Diagnosis:

• The patient had generalized gingival erythematous with generalized rolling of the

gingival margins. His papilla were blunted and bulbous with edematous consistency. This may

be caused by lack of efficient home care. To remedy this, I will go over flossing and brushing

techniques. I will emphasizing the importance of interproximal cleaning. I will review the
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modified bass tooth brushing method and demonstrate the ‘C’ flossing technique. I will use the

plaque index to demonstrate what areas he is missing in his home care.

• The patient has generalized interproximal plaque and calculus and calculus as well as

calculus along the gingival margins. He has moderate generalized staining on the lingual

surfaces. To reduce bleeding and pocket depths, I will recommend other dental hygiene aids,

such as soft picks. The patient has a wall of calculus on the lingual of sextant five and after

calculus removal the embrasure space will be larger therefore a proxy brush may be appropriate

to clean these large embrasures.

• He has active decay, a broken filling and a periapical abscess. I will be scheduling

restorative work on the dental hygiene side and on the restorative side with a DDS.

• The patient presents with generalized 1-3 millimeter recession, 3-4 millimeter pockets

with localized 5 and 6 millimeter pockets and generalized bleeding upon probing. To reduce

bleeding and pocket depths the recommendation of alternative dental hygiene aids, such as soft

picks and a proxy brush will be discussed.

• The patient has a high sucrose diet so we talked about rinsing his mouth out with water

after he drinks soda. We also discussed how it is better to drink soda quicly, rather than sipping it

throughout the entire day. We discussed how sucrose causes an acid attack because of the

bacteria in his mouth.

Daily Food Log:

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● The patient smokes about ten cigarettes a day. Therefore, I will provide the five steps of

smoking cessation.

• He is at a high risk for dental caries and periodontal disease because of his history of caries,

lack of proper home care technique, and diet. I will suggest the patient use a Rx toothpaste and
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demonstrate proper home care techniques to help improve the patient’s ability to reduce the risk

of disease.

• After the doctor’s exam, the patient purchased Clinpro, but did not seem enthusiastic

about leaving the toothpaste on and not rinsing it out so I suggested trying it right before bed.

Clinpro will increase the amount of fluoride in his oral cavity, with the goal of reducing his risk

for caries.

• When I discussed the importance of dental care with the patient, he joked, “I will loose

all my teeth and then I will just get implants!” After several conversations about dental health, I

hope he understands the importance of dental heath. He has little motivation to make dental

appointments, but once they are scheduled, the patient is motivated to make it to all of his

appointments. He is glad he is finally getting his teeth “taken care of” and is relieved that our

facility can take care of all his dental needs. My hope is for our clinic to become his dental home

so he can continue receiving dental hygiene treatments on time.

● The patient was classified as AAP IV because he had generalized moderate to severe

bone loss. The patient had enough calculus in his posterior teeth to be classified as a D2. He was

classified as IV/2/D2. After cleaning two quadrants, the patient was reclassified as AAP III

because he did not have as much bone loss as previously thought.

• At the doctor’s exam, Dr. Lowell discussed with the patient he needs a composite DOBL

on tooth number two. He also needs a root canal with a porcelain-fused to metal crown. There is

an abscess near the root of number 18. The doctor discussed with him that he can have tooth

number eighteen removed or retreat the root canal. Tooth number nineteen needs a mesialbuccal
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cusp composite because of tooth decay. Tooth number twenty-seven needs to be watched in his

future appointments because he may have incipient decay.

● I will complete four quadrants of 4341 scaling and root planing (SRP) with local

anesthetic. The patient has indicated he is fearful of needles, therefore I will use nitrous oxide

while I give him injections for his first SRP. If the patient does well, I will not use nitrous for the

other quadrants.

• I will measure the success of the patient by completing another Plaque index and

periodontal chart at his tissue reevaluation. The goal is for decreased pocket depths and

decreased bleeding points. The PI will help me determine if the patient has improved with his

home care. I will also compare his initial gingival description and the gingival description at his

tissue reevaluation.

Copy of Dental Hygiene Diagnosis:

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Planning

The patient was treatment planned for 4341 scaling and root planing. The justification for

classifying the patient for 4341 is due to his four or larger millimeter pockets in all of his

posterior teeth. Our goal is to have generalized 2-3 millimeter pockets. The patient and I plan on

achieving this improvement by having him brush his teeth two times a day with complete
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interdental cleaning one time daily. The patient is establishing a dental home at LWTech, and

therefore will, hopefully, continue regular cleanings. During his appointments, I will review

brushing techniques to ensure he is cleaning the gingival margin and I will also review how

caries develop. I will also review how calculus and plaque can cause recession and bone loss.

Increasing oral health knowledge of the patient will help motivate him to continue his home care

routine and regular dental appointments. After each SRP treatment I will provide subgingival

irrigation with chlorhexadine to help reduce bacterial load and encourage the use of Clinpro

5000. After scaling and root planing, I will apply fluoride varnish at the patient’s tissue

reevaluation appointment.

Implementation:

I planned on cleaning one quadrant per appointment. I started with the upper left, then at

his next appointment I cleaned the upper right. When I started SRP, my skill level was lower

than it is now, so I planned on cleaning one quadrant or sextant per appointment. By the time I

finished his SRP, my skills had improved so I cleaned two quadrants in one appointment.

Unfortunately, because of my lack of experience I had the whole mandible to clean (versus the

right side or left side), and because I cannot anesthetize both the left and right side due to safety

reasons, I had to split the cleaning into two appointments. The maxilla had more calculus than

the mandible. The patient was classified as AAP III-IV, therefore I had to use my Graceys for

calculus removal. For the mandible, most of the heavy pieces of calculus were in the anterior. I
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used my sickle and 4R/4L to remove the ledges, which were easily removed. I used perio files to

remove the ledges in sextant five.

At his appointments, we talked about tobacco cessation and went over the five R’s, but he

was not ready to quit smoking. The patient knows the short term and long term risks of smoking.

He is worried about affecting the health of people surrounding him. The rewards of him quitting

would be he would not have to worry about smelling like cigarettes. Some roadblocks he faces

and prevents him from quitting is his anxiety which he uses smoking as a reliever. When he says

he is going to quit, people are not supportive and do not believe he is going to quit. Also, the

only time he gets a break from work is when he takes a smoke break. At a later appointment we

repeated the five R’s and the patient informed me he had cut down the number of cigarettes he

smoked from ten to seven. He still faces the same roadblocks of using smoking as an anxiety

reliever. He still only takes a break when he takes a smoke break.

The patient started using Clinpro 5000 toothpaste. He was more motivated to floss, and

started flossing daily. He is very interested in getting his restorative needs done at our clinic. His

diet continues to include soda, Slurpees and fast food, but he has starting drinking more water.

There was a large gap in time between when I finished the maxilla and started the mandible and

by the time I cleaned the mandible, there was only a light plaque build up. What a difference

since the beginning of treatment! The lack of plaque shows he has improved his toothbrushing

and interproximal cleaning with floss. He brushes his teeth two times a day and he flosses once a

day.

Evaluation
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To evaluate the patient’s progress, I performed a tissue re-evaluation. I preformed 4341

scaling and root planing (SRP) on his maxilla during the fall quarter and completed his tissue

re-evaluation for those quadrants before the quarter ended. I completed 4341 SRP on his

mandible during winter quarter and completed the tissue re-evaluation for those quadrants at the

end of the quarter. The last tissue re-evaluation, was a great opportunity to summarize the

treatment and education he had during his treatment.

Post-Gingival Description

During new patient assessments, the patient had generalized erythematous gingiva. There

was moderate erythematous tissue around tooth number 27. There was generalized moderate

gingival rolling, especially in the posterior teeth with the papilla was blunted and bulbous

generalized edematous consistency. There was generalized stippling present. At the tissue

re-evaluation of the maxilla, the gingiva was generalized medium pink. There was slight

erythematous on the buccal of five through six, ten through twelve, and lingual of two through

three. There was moderate erythematous tissue around tooth number 27. There were rolled

margins on the buccal of two through four, eleven through twelve, fourteen, and lingual of three

and fourteen. There was generalized rolling on the mandible. The papilla was blunted in the

posteriors. The gingiva was ‘fibro-edematous’ (both fibrotic and edematous). At the tissue

re-evaluation for the mandible, he continued to have generalized medium pink gingiva. There

was slight erythematous tissue lingual of five through eleven and buccal of twenty-two. There
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was slight rolling on twenty-two, twenty-six through twenty-eight, five, eleven through twelve

and lingual of five and twenty-two. The papilla was pointed except for sextants two and five. The

gingiva was firm.

After the scaling and root planning, the patients erythematic and bulbous tissue had

improved. Instead of red and rolled margins, the patient had generalized smooth margins. The

papilla was as bulbous. Removing the calculus and improving home care helped improve the

health of the gingival tissue and this was seen in the gingival descriptions.
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Perio Chart

At the tissue re-evaluations, I completed a perio chart to assess how his tissue responded

to treatment. During new patient assessments, the patient had generalized three to four millimeter

pockets with generalized five and six millimeter pockets. There was generalized one to two

millimeters of recession with localized four millimeter recession. There was generalized

bleeding. At the tissue re-evaluation for the maxilla, I only perio charted the maxilla. There were

generalized four to six millimeter pockets on the lingual aspect. On the buccal aspect, there were

generalize one to three millimeter pockets with localized four millimeter pockets. There was

generalized bleeding. Recession had stayed the same. At the tissue re-evaluation for the

mandible, I perio charted the whole mouth. There were localized 4 and five millimeter pockets.
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There were generalized one to three millimeter pockets. There was localized bleeding. In

conclusion, his pocket depths had improved after treatment. The patient had less bleeding.
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Biofilm Removal

During the patient’s scaling and root planing appointment of his mandible, I noticed the

absence of plaque. From his first appointment when there was heavy generalized plaque, to his

tissue re-evaluation, there was a remarkable reduction in plaque. This is seen in the plaque

indices. During his new patient assessments, his plaque index was 57 percent. For the first half of

his tissue-re-evaluation, his index was 46 percent. At his last tissue re-evaluation, the patient’s

index was only 24 percent! He had plaque localized inter-proximally. As a result, we reviewed

‘C’ shaped flossing. The patient stated he had started flossing while he was watching television,

versus in front of a mirror. We discussed how it would be beneficial to use a mirror to get the

correct technique.

Tissue Re-evaluation

As a learning tool, we utilized the microscope during his appointment. He had a five

millimeter pocket in the upper right quadrant. I took a sample from inside the pocket and put it

on a slide for the patient to see. On the slide, I pointed out objects moving, rods, cocci, and white

blood cells. I explained cocci and some rods are okay and are examples of bacteria in healthy and

normal gingiva. We do not want to see a lot of rods. I explained the ‘bad’ bacteria live under the
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gum line and have to be cleaned out. The bacteria act like a wound; our body responses by

getting inflamed and bleeding. The patient was very responsive and interested in the slide.

At his tissue re-evaluations, we reviewed his diet and daily habits that may affect his oral

health. During the new patient assessments, the patient stated he ate a lot of fast food and loved

drinking soda daily. He never drank water. By the tissue re-evaluation, the patient had started to

increase his water intake. He also became more motivated to eat healthier and make prepared

meals at home versus eating fast food. Hopefully, he stays motivated and continues a healthier

lifestyle. The patient still smokes about a pack of cigarettes a day. He wants to quit, but not in the

next month or anytime soon.

Therapeutic Interventions

Originally, the patient was classified as AAP IV because the patient had moderate to

severe bone loss. At a later appointment, the AAP code was changed to III because it was

decided the patient had more moderate bone loss rather than severe. This did not change the

planned hygiene treatment. The patient had scheduled to get the root canal on number 18

retreated, but at the appointment the DDS decided the tooth was too loose and changed the

treatment to extraction. She also added 31 OL composite on the treatment plan. The patient

wants to get the treatment completed.

Maintenance Interval
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During the tissue re-evaluation, I removed localized inter-proximal roughness caused by

calculus. Localized calculus removal was needed. Even though the patient had localized

roughness and had improved their plaque removal, I felt he needed professional cleanings and

review of home care frequently. As a result, I decided his appointment frequency should be

every three months. If during his future appointments he maintains a healthy and static state, his

frequency can be changed to every four months. At his first maintenance appointment, I will

complete a perio chart and a plaque index. Using the information I gathered from assessments, I

will review home care. I will also cavitron and hand scale to remove plaque and calculus.

Conclusion

Documentation

I completed this patient’s new patient assessments including full mouth x-rays, intra oral

exams, gingival description, periodontal chart, tooth chart, risk assessment, and dental hygiene

diagnosis. This is included in his electronic chart and submitted in previous assignments. In

addition to new patient assessments, I completed pre- intra oral photos, diagnostic casts, and a

Velscope examination. During his 4341 scaling and root planing appointments, he had a doctor

exam, tobacco cessation counseling, home care instructions, and diet counseling. The

documentation for this information is included in his chart or in previous assignments. During

his tissue re-evaluations, I completed a periodontal chart, plaque index, post-intra oral photos,

and residual calculus was removed. We also discussed his diet and reviewed oral hygiene home
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care techniques such as flossing technique. The importance of home care and professional

cleanings was reinforced by taking a sample from one of his deep pockets and viewing it on the

microscope. This is documented in his chart. I completed his maxillary tissue re-evaluation

during fall quarter and his mandibular tissue re-evaluation during winter quarter. At his first

tissue re-evaluation, I only periodontal charted his maxillary arch, therefore, his mandibular arch

does not have periodontal documentation at this appointment.

Dental Hygiene Education

After completing this patient’s new patient assessments, I knew he would benefit from a

well-rounded education about his health, with a focus on oral health. I was able to use the skills

and knowledge I have learned in my didactic and clinical courses to educate and treat the patient.

For example, the patient does not have an ideal diet and this is easily seen in his oral health. The

patient had erosion pits from the soda he drinks every day. Using the information from my

didactic classes about nutrition and diet analysis, I was able to have conversations with my

patient about how his diet was not only affecting his overall health, but also his oral health. We

were also able to discuss how his smoking affects his gingival health which then influences his

bone health. We reviewed his home care routine and we discussed how the plaque and calculus

present, was creating an inflammatory response. The body’s response to plaque and calculus is

the gingiva moves away from the cause of the inflammation. As a result, the bone follows. I

learned information in my didactic classes to understand detailed information influencing a

patient’s oral health and overall health. In clinic, I have learned how to communicate to patients
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this information in a way they can understand and in a way that motivates them to care about

their health. This was seen in my capstone project.

Professional Growth & Strengths and Weaknesses

As a dental hygienist, this capstone patient has helped me grow professionally. For

example, when I started his scaling, I had time to scale only one quadrant per appointment. By

his third and fourth quadrant I could have easily completed two quadrants in one appointment.

Unfortunately, I could not anesthetize him bilaterally, therefore I continued scaling one quadrant

per appointment. Another skill I gained through this project was discussing personal topics with

patients. When I was first seeing patient’s it was difficult for me to extract personal information

from patients. For my capstone patient, I had to delve into his lifestyle. We discussed health

history, his diet, his nightly/morning routine, smoking habits, eating habits, and other health

habits. Now, when I need to gather information from patients, I know how to be delicate and

sensitive to patients, but collect the necessary information.

Patient Results

Overall, the patient showed improvement in his oral health. This is apparent by his

periodontal chart, gingival description, plaque indices, and bleeding. During the patient’s new

patient assessments, his plaque index was 57%. During his last tissue re-evaluation, the plaque

index was 25%! This shows his home care has improved. He is effectively removing 75% of the
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plaque on his teeth. Before treatment, the patient had generalized erythematous gingiva. He had

generalized moderate rolled gingival margins with generalized bulbous papilla. At his tissue

re-evaluation, he had generalized medium pink gingiva with localized slight erythematous tissue

and rolling, localized to the anteriors. He had generalized pointed papilla, except in sextants two

and five. After treatment, his gingival description demonstrated healthier gingiva. The patient’s

periodontal chart showed symptoms of disease. He had generalized four to six millimeter

pockets, generalized bleeding, and generalized one to four millimeters of recession. At his tissue

re-evaluation, he had one to three millimeter generalized pocket depths. He had localized four

and five millimeter pockets, with localized bleeding, and recession remained generalized one to

three millimeters.

Using new patient assessments such as radiographs, periodontal charting, and plaque

indices, I was able to form a dental hygiene diagnosis. I completed four quadrants of 4341

scaling and root planing. At his tissue reevaluations, I used assessments, such as a periodontal

charting and bleeding, to conclude if the therapy was successful.