1

Running head: CAPSTONE – Patient X

Capstone: Patient X

by

Ngan Tran #59

Lake Washington Institute of Technology

In partial fulfillment

of the requirements for

DHYG 438: Senior Capstone

Danette Lindeman, RDH, MEd

Spring quarter 2

April 25, 2019

CAPSTONE – Patient X 2

Assessments

Health History (Appendix 1)

The patient for this capstone project will be referred to as patient X. He is a 56-year-old male

who health alerts include heartburn, hay fever, type II diabetes, high blood pressure and high

cholesterol. Initial vital signs taken were 123/80 on his right arm using adult cuff, pulse was 68

bmp and normal. Patient is under care of Dr. Amanda Brender, his last physical exam was in July

of 2018. His last operation was umbilical hernia repair done on July 23 , 2018. Patient reported it
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was successful and no more symptoms occured. Patient did have a tetanus booster in around

2012. It was for preventative measures. First initial appointment, patient reported having taken

all his medications and did have a little breakfast that day. Orange juice was provided to him

upon his request for sugar need. This patient takes Metformin- a biguanides for diabetes mellitus

type II, Simvastatin- HMG-CoA reductase inhibitors for high cholesterol, Lisinopril-ACE

inhibitor for high blood pressure, Omeprazole -Proton-Pump inhibitor for heartburn,

Loratadine/Claritin for hay fever, Aspirin as an antiplatelet and multivitamins. Patient’s A1C was

6.8 taken on October 23 , 2018, blood sugar level was 130 within the month of October 2018.
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Patient has had cold sores/fever blisters in the past. Patient reported to be very compliant with

taking medications. Patient has hay fever listed on health history. He has no allergic reactions

reported to medicines. Patient is a never smoker.

This patient is a self-pay patient. He reported to have been seeing other dentists but

stopped going due to financial reasons since 2016. He didn’t remember his previous dentist’s

name. Patient came to Lake Washington and was screened for boards for Jun 2018, preliminary

AAP was IV/3/E. However, patient was busy at the time and did not go through with board

plans. This patient has no history of orthodontics or implants, nor a fearful patient. The only
CAPSTONE – Patient X 3

oral/facial surgery patient had in the past was to remove 3 of his wisdom teeth. Upon

interviewing, patient reported to have a high stress load due to working as an attorney of law. In

addition, his daughter has to live in a care facility far away due to medical conditions. Patient

generally does walking for exercising and described it as low to medium.

Upon research regarding periodontal diseases and diabetes type 2, in Current diabetes

review, evidence shows “a direct correlation between periodontal health and glycemic control in

type 2 diabetic patients. And that “patients with poorly controlled diabetes are at risk for severe

periodontitis. This results in the destruction of oral connective tissue and generalized bone loss,

leading ultimately to tooth loss.” The article also confirmed the “beneficial effect of periodontal

treatment on metabolic control of type 2 diabetic patients.”

Also regarding periodontitis and hypertension, current cardiology reviews provided

evidence on how the relationship between high blood pressure and periodontal disease. In

hypertension, “changes in microcirculation can cause ischemia in the periodontium, which favors

periodontal disease.” The article mentioned that periodontitis involved “inflammatory

immunological and humoral activities, which induce the production of proinflammatory

cytokines and the destruction of the epithelium.” This research articles have pointed out the

intertwined relationship between systemic disease and periodontitis.

Extra-oral Assessment

This patient has scattered sun spots on forehead and generalized skin tag size 1x1mm on

eyelids bilateral. Gen brown and black macules with sizes rang from 2x2mm to 3x3mm on his

forehead. No findings of crepitus, pain or subluxation. Generalized dryness on facial skin.

Patient’s vermillion border is obliterated. Checked with Velscope appeared an area endophytic

8x5mm loss of fluorescence. DHS to note and monitor for any future changes.
CAPSTONE – Patient X 4

Intraoral Assessment

Patient has slight linea alba on right vestibules. There was 1x1mm red petechie on the

left, a 5x7mm cluster of red spots, some are pus-filled. Patient report to have bitten his own

cheek recently. The was a scattered white patch on alveolar ridge between #29 & #31, appeared

to be extraction healing site. There was also large max exostoses bilateral posterior. Patient’s

tongue was slightly fissured along median sulcus. Tongue was heavily coated in white-ish yellow

coating. Tonsillar pillars were slight red and appear normal. Ventral tongue appeared lingual

varicosities which is one of variance of normal.

Gingival Description

On the maxilla, this patient has generalized moderate erythematous, localized cyanotic in

the posterior. Margin contour was generalized rolled. Papilla contour was gen blunted, slight on

the anterior and moderate on the posterior and generalized bulbous. Margin consistency was

moderately edematous. Surface texture was smooth and glossy.

On the mandible, color of gingival margin was severe erythematous. Margin contour was

severely rolled. Papilla contour was generalized and moderately blunted. Consistency was

moderate to severe edematous. Surface texture was smooth and glossy.

Tooth Chart & Occlusion (TC Appendix 2)

The patient has twenty-six teeth present. With crown on tooth #19 has broken off. He only had

three wisdom teeth instead of four and they were extracted. Patient currently has 3 amalgam

fillings and 2 composite fillings. Patient also has porcelain fused metal crown on #14. This

patient has distal-version on canines # 22 and #27. There is generalized attrition on #5-13 and

#21,#22 and #28. Open contact was only recorded on mesial and distal side of broken crown.
CAPSTONE – Patient X 5

Patient has right and left molar class I and right and left canine also class I. Patient has no

overbite, no cross-bite, no open-bite, overjet is 3mm.

Periodontal Chart (Appendix 3)

Periodontal chart revealed generalized 3-5mm pockets with localized 6-8mm pockets in

the posterior molars. This patient has severe bone loss. There are generalized furcations class I

and II on both mandibular and maxillary molars. The patient has moderate to severe bleeding on

probing and exploring, especially on molars. The patient has generalized heavy plague and heavy

calculus sub-gingivally. Considering his radiograph together with periodontal chart findings and

amount of calculus, this patient is classified with Lake Washington Dental Hygiene program as

IV/3/E.

Radiographs (Appendix 4)

Due to no prior Xray, at initial assessment, October 2 , 2018, with the need to evaluate bone
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level as well as decay status, a full mouth x-ray with vertical bitewing instead of horizontal due

to bone loss level was taken on this patient. It was slightly complicated to take his Xray due to

his maxillary exostoses. Patient expressed discomfort with films in his maxilla.

Oral Hygiene

Patient uses a manual toothbrush medium soft twice a day, he uses soft pick to remove food

debris once a day. He doesn’t floss and uses no other aids. He does not currently use any mouth-

rinse. His toothpaste is Colgate or whatever that is good value at time of purchase.

Patient’s chief concern

This patient’s concern was to have a deep cleaning and have his broken crown fixed. He

is aware that he hasn’t had a cleaning for a period of time and would like to get back into teeth

cleaning routine. His broken crown also causes him to have pain/toothache.
CAPSTONE – Patient X 6

Dental Examination (Appendix 5)

Comprehensive doctor exam was performed October 3 , 2018 by Dr Richard Lowell. Dr

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Lowell confirmed white patch between #29 & #31 to be leukoplakia. Relayed to Dr Lowell about

obliterated vermilion border on lower lip and he found no suspicion. Upon comprehensive exam,

Dr Lowell found no new caries on this patient. He recommended for #19 that this patient do a

crown build up, crown prep and seat due to missing/broken crown. For #30, Dr Lowell

recommended Implant, abutment, prep and seat for the missing tooth. For #12, Dr Lowell also

recommended Implant, abutment, prep and seat for the missing tooth. Treatment plan can be

found below.

Plague Index (Appendix 8)

Plague index revealed a 50% rate meaning he at the moment has plague on half of all of

his teeth surfaces. In majority, his plague remaining areas include all interproximal surface on

anterior as well as posterior teeth.

Nutritional Analysis (Appendix 6)

Patient’s height if 5 feet 9.5 inches, current weight is 207 pounds. This is his normal

weight. He said his ideal weight would be less. But his weight has been stable and he has no

desire to lose or gain weight. Patient reported does not eat at regular times each day and usually

eats three times a day. He particularly likes burgers from the fast-food chains. When asked to

describe his feeling about food, love/like are the words he used. When patient is emotionally

upset, he eats irregularly, sometimes he would skip meals and sometime she would eat too much.

He does not drink alcohol on a daily basis. His exercise habit is light to moderate. He walks for

about 30 minutes a day, about 2 or 3 days a week.

CAPSTONE – Patient X 7

Full 7-day diet log has been completed along with Assessment log. These show that

patient does not cook at home but rather opt for fast food options or TV meals majority of the

time. In addition, patient consumes a large amount of diet coke daily, in addition to soft sweets.

Through discussion, patient revealed to be very busy and does not want to spend a lot of money

and time on his meals. He goes through a lot of diet soda a day.

His diet is high in protein, unhealthy fats, red meat and acidic drinks. These foods largely

contribute to his high blood pressure, diabetics, tooth loss and broken crown. DHS reviewed with

patient the food log and discussed inadequate consumption of fruits and water. It was

recommended that he eats sweets more sparingly and increase water and fruit consumption. Also

discussed with patient about literature indicating diets with poor nutrition contribute to

periodontal status. Especially in patients with diabetes like in his case, nutrition affects greatly

oral health. General dentistry in 2017 revealed that “A lack of these nutrients affects nearly every

structure in the oral cavity, causing or contributing to …, poor mineralization, caries, … Damage

to the dentition can also be observed in individuals with unhealthy habits; for example, a diet

high in sugars will promote processes such as demineralization and caries.” Patient was

encouraged to read the labels when purchasing precooked meals and refrain from eating fast-

food daily due to high amount of fat and sodium.

Plague index score was also discussed with patient to inform where patient can improve

in removing biofilm. Decay process was explained to patient and encouraged interproximal

plague removal. Upon explaining to patient how biofilm and acidic attack contribute to tooth loss

caries, as well as systemically unhealthy, patient committed to drinking less diet soda and more

water throughout the day.

CAPSTONE – Patient X 8

Dental Hygiene Diagnosis (Appendix 7)

Patient’ health history includes type 2 diabetes, high cholesterol and high blood pressure.

Etiology could be patient’s nutritional intake, family history and exercise/lifestyle. Patient’s last

dental visit was in 2016. Lack of dental care visit is due to lack of insurance. EO/IO noted that

patient has scattered sun spots on forehead, vermillion border obliterated. Under Velscope, lower

lip appeared red, loss in fluorescent green. This is possibly due to sun exposure and lack of sun

screen use. This was discussed with patient and it was recommended he uses sunscreen daily and

moisturize his lips for protection.

Patient’s gingival margin were generalized red and rolled, localized cyanotic. His

papillary were edematous and blunted generally. This could be contributed to by poor brushing

technique, inadequate biofilm removal and lack of mechanical removal of calculus. Patient’s oral

hygiene include brushing 2 to 3 times a day with a manual medium soft tooth brush. Soft pick is

used once daily. Plague and calculus level were heavy. This is also due to lack of mechanical

removal of calculus, ineffectiveness of biofilm removal and improvable brushing technique.

Hard tissues include 1-7 fillings include amalgam and composites and crowns and a broken

crown. This is caused by lack of oral health awareness and lack of fluoride as well as poor OH

habits. Periodontal status can be summarized as generalized 3-5mm, localized 6-8mm,

generalized furcation cl I and II, generalized recessions 1-2mm, loc mobility class I. BOP was

heavy. Periodontal status is due to poor OH habits and existing periodontitis status.

DHS carefully reviewed with patient about goals of monitoring his A1C and blood

glucose level for diabetes, also encouraged to continue annual exams so the physician can

monitor his disease status. It was discussed that after periodontal scaling and root planning, he

will be on a periodontal maintenance every 3 months. And it’s substantial that he keeps his dental
CAPSTONE – Patient X 9

appointments to arrest /halt periodontal disease. Patient was shown modified bass technique to

remove bacteria from the gum-line. Pt was also shown to properly use soft-picks in deep pockets

to remove bacteria. Flossers were introduced to patient for easier access knowing traditional

string floss would be gold standards. Patient education will include how flossing will effectively

remove interproximal biofilm, this will improve PI score if patient persists using it daily.

Samples of flossers were given at assessments. Patient will be informed of new recent literature

on how an electronic toothbrush along with flossing can really be much more beneficial than just

using a manual toothbrush. The Journal of Clinical dentistry came to a conclusion that “an oral

hygiene routine with an oscillating-rotating electric toothbrush, stannous fluoride dentifrice, and

floss significantly improved gingivitis compared to regular hygiene with a manual toothbrush

and an anti-cavity sodium fluoride dentifrice.” Along with flossing, patient will also be

encouraged to start using clinPRO 5000 to prevent new cavities from forming and prevent

sensitivity on recessions. Patient is instructed to use it twice a day.

Caries Risk Assessment

During assessments, it was clinically evident this patient has missing teeth, mal-aligned teeth,

broken crown, gingivitis, heavy bleeding on probing, severe bone loss and generalized

recessions. With these presented evidence, this patient presents periodontal disease.

Contributing factors to his periodontal disease status include non-fluoridated water usage and

poor biofilm control. Cariogenic source includes his diet high in acidic drink throughout the day

with no water consumption to balance out pH. Recommendations to address caries risk include

lowering his diet coke consumption and replace it with water. Water consumption should follow

diet coke to decrease acidity. Also, like mentioned above, he should use fluoridated toothpaste

twice a day to remineralize enamel after acid attacks. DHS will present with patient about a case
CAPSTONE – Patient X 10

study published by Zhejiang University, this study is a perfect example to show patient how

harmful soda is to teeth and what future will hold if he continues to put his teeth under acid

attacks. The potential result is rampant decay. This case study concluded that “excessive intake

of soft drinks could cause complex dental consequences including dental erosion and caries.”

This study also provided really helpful recommendations for patients that are excessively

consuming soda “Considering that excessive intake of soft drink and poor oral hygiene pattern

are likely etiologic factors, we recommended the patient to reduce soft drink intake and contact

time of acids, not to hold drinks in the mouth, and to use fluoride or re-mineralizing toothpaste to

brush the teeth at least twice a day, but avoid tooth brushing immediately after soft drink intake”

Risk Assessment (Appendix 8)

Patient’s current health history include these conditions that patient is taking medications

for: heartburn, diabetes mellitus type two, high blood pressure and high cholesterol. Clinically,

patient is found to have leukoplakia between #29 &#31. Radiographically, patient has under

seven existing fillings include composite and amalgams and one crown and one broken crown.

Periodontum status revealed plague was heavy and moderate calculus, slight mobility, moderate

BOP. Patient has 25-50 % horizontal bone loss. Prevention survey reveals patient has pain on the

broken crown, patient has sore, bleeding gums sometimes when flossing. Patient understands

oral status, values prevention, wants OH/product recommendation and is open to new

information. OH habits include brushing 2 times a day with a manual tooth brush and use of soft

pick once daily. The goal we have discussed for him to switch to an electronic toothbrush and

use fluoridated toothpaste and start to floss to remove biofilm interproximal. Initial plague index

indicated 50% plague, patient was disclosed and shown to have all interproximal surfaces as
CAPSTONE – Patient X 11

having plague. This means half of his teeth surfaces are covered in plague and it means his

manual brushing doesn’t reach interproximal.

Fluoride benefits were discussed with patient and patient was encourage to start using

Fluoridated toothpaste, as well as drinking tap water that has Fluoride in it. Fluoride is a natural

mineral that exists in drinking water and have effects to prevent demineralization on teeth as well

as helping remineralizing enamel and antibacterial. These great effects were explained carefully

to patient and patient seemed to be open to using Fluoride and receiving Fluoride at tissue

reevaluation visit.

Based on health and dental history findings, DHS will make alterations to care. DHS will

make sure to ask all questions related to diabetes prior to each appointment such as whether

patient had a meal prior, if patient has taken his medication, his most recent A1C level and Blood

glucose level to ensure it’s safe to provide treatment. Blood pressure and pulse will always be

taken to assess and monitor his high blood pressure disease. If BP is high, retake the BP and refer

patient to his physician if needed. Also patient will be informed to let clinician know if he needs

sugar intake and provide as needed.

Indian Journal of dental research has published “Influence of diabetes mellitus on

periodontal disease” in 1993. Their study came to a conclusion that “salivary calcium level was

significantly higher in uncontrolled diabetics which helps in calculus formation and hence

increases severity of periodontal disease” This will be good information to educate patient on

keeping on monitoring well his diabetes status and continue to take his medications regularly.

Since if his diabetes is uncontrolled, it also affects his periodontal disease negatively.
CAPSTONE – Patient X 12

Planning (Appendix 9 for hygiene and 5 for restorative)

Hygiene treatment plan was generated to address his active periodontal disease, this

patient will be cleaned in sextant, his AAP is IV, calculus code at LW Tech is 3/E. Patient will

need six appointments of scaling and root planning with local anesthesia. At each visit, sub-

gingival irrigation with chlorhexidine will be used, along with Arestin as needed for bactericidal

effects. Patient will be shown bacterial movement on a microscope from his deep pockets. This is

used to explain decay process as well as helping him understand his periodontal disease status.

Microscope demonstration will be used to aid in patient compliance and motivation.

Additionally, brushing, flossing and soft pick demonstration will be completed. DHS will

discuss with patient about literature on how power driven tooth brush are much more effective

than manual. Journal of periodontology from the year of 2002 has provided evidence that

concluded that “The use of PDT, especially counter-rotational and oscillating-rotating brushes,

can be beneficial in reducing the levels of gingival bleeding or inflammation.” In 2008, Journal

of Clinical Industry also confirmed that a Sonicare “was significantly more effective than MTB

in the reduction of plaque after two and four weeks of product use, and significantly more

effective in the reduction of gingivitis and bleeding sites than MTB after four weeks.” These can

also be presented to patient to encourage switching to a power vs manual tooth brush.

At the last appointment, Fluoride varnish will be applied. After the last cleaning, he will

be scheduled back for a tissue reevaluation in 4 to 6 weeks to assess success of therapeutic

therapy. Hopeful outcome will be reduced pocket depths, reduced BOP, reduced inflammation,

change in gingival margin description, reduced bulbous papilla and lower score on plague index.

He will also be put on a three-month periodontal maintenance after last cleaning to retain
CAPSTONE – Patient X 13

periodontal therapy success. Restorative treatment plan includes crown build up, prep and seat

for #19; implant is recommended for #12 and #31 preceding abutment, prep and seat.

Implementation

A treatment plan was created with four appointments planned which changed to six due

to Lake Washington’s policy to clean patient per sextant instead of quadrant. Full mouth scaling

and root planning therapy was completed in Fall quarter. Tissue re-evaluation was done in Winter

quarter as well as the three-month recall perio maintenance. This patient’s treatment was

provided by two dental hygiene students due to patient sharing to help with another student’s

requirement.

At the first cleaning appointment, lower left sextant, sextant four was scaled. Patient

reported he had taken medication for diabetes as well as other medications for high blood

pressure. His A1C was 7 since April 2018, his blood sugar level was 130 within the month of

October. Student noticed erythematous scratches on patient’s lower cheek and right hand. Patient

reported his daughter threw a tantrum and those were the results. His daughter had to live in a

care facility due to her health status. This was one of the stress source for patient. Also at this

appointment, leukoplakia noticed between #29 & #31 likely an extraction scar. For this

appointment, Anesthetics was utilized for patient comfort. Lidocaine 2% with epi 1:100,000 was

used. Total amount for left IA was one carpules and no reactions. Patient however, did report that

it was painful when needle went through IA nerve. Student withdrew at first penetration and

changed point of insertion to a higher spot, patient satisfied with second penetration. Ultrasonic

with blue tip was used followed by hand scaling. Graceys were heavily utilized, especially

Gracey 11/12 and Gracey 13/14. Files were also used to break off pieces. Mini Graceys were also
CAPSTONE – Patient X 14

used to access deep pockets for posterior tips. A 204s was utilized for subgingival calculus on

premolars. Anterior teeth were scaled by Nevi and off set sickle.

It was observed that patient had moderate plague, moderate calculus and some pieces

were tenacious. Patient had moderate stain and moderate heme on scaling. Student reiterated

importance of flossing to remove sub biofilm in addition to supra by using soft pik. This

appointment goal was to increase flossing for biofilm control.

At the second appointment, sextant three was scaled. This sextant was scaled utilizing

similar instrumentation as sextant four, with ultrasonic scaler and hand instruments such as

graceys 11/12, 13/14, nevi, sickle scalers and files. Anesthetics was given with no reactions. Left

PSA, Left MSA were given with 1 and ⅔ carpules of Lidocaine 2% with epi 1: 100,000 with

Benzocaine 20% as topical. No reactions.

This appointment was 8 days after the first scaling appointment. It was observed that

patient had light plague this day. Moderate stain, heavy bleeding on scaling, calculus was

tenacious interproximally. Student demoed c shaped flossing technique, reiterated biofilm

removal importance.

Also, microscope was utilized to educate patient on the types of bacteria that exist under

the gingiva. A sample from #15 Buccal was taken, pocket depth was 7mm. Patient was shown

motile bacteria activity and it was discussed with patient that these organisms negatively impact

the bone and the teeth on oral cavity as well as systemically. The patient did not seem to be

surprised or showed any emotions with the microscope demonstration.

Third scaling appointment was scheduled to be 7 days after second scaling day but

patient could not come till later in the appointment. So student took the opportunity to take his

impressions for diagnostic cast.

CAPSTONE – Patient X 15

Sextant one was done at third scaling appointment. Instrumentation utilized were piezo

scaler and hand instruments. Anesthetic was also used. At this appointment, student utilized

Chlorohexidine as subgingival irrigation. Journal of periodontology has provided evidence that

using Chlorohexidine rinse followed by scaling and root planning significantly reduced pocket

depth and gingival index. (Jolkovsky, 1990) This benefit was also communicated to patient.

Upon checking pocket depths of scaled quads, #14 Distolingual reading was still #7mm (same as

original reading at intake), so Arestin was placed to encourage bactericidal effects and reduce

pocket depth. Patient was instructed to not floss at this area for one week so the Arestin has

enough time to provide beneficial effects.

Scaling appointment was a success with less visible bleeding on scaling. Patient was

asked to show his flossing technique and was encouraged to increase biofilm removal as a part of

controlling his periodontal status, feedback on flossing was also given.

Fourth scaling appointment was done a day after third scaling appointment. At this

appointment, an ulcer was found on maxillary exostosis by tooth #5, endophytic 3x4mm, round

shape, off white color bone like. Pt reported no pain. Student and clinicians to monitor when

patient comes back. This day, sextant 2 was scaled utilizing Piezo and hand instruments.

Anesthetics were utilized, Right and left ASA and Nasopalatine were given with 1 and ⅔

carpules of Lidocaine 2% with epi 1: 100,000. No reactions. After scaling, subgingival irrigation

was provided and arestin was placed again to help reduce bacteria.

After fourth scaling appointment, patient was transferred to another student to complete

sextant #4 and #5. Two weeks after fourth scaling appointment, patient came back for the fifth

scaling appointment. Ulcer recorded at fourth appointment was still present. Dr. Lowell
CAPSTONE – Patient X 16

examined lesion and referred patient to Knoff & Fettig Oral Surgeons for further examinations.

Intra oral photos were also taken and posted on patient’s chart. (Appendix 11)

At this appointment, sextant six was scaled. Piezo and hand instruments were utilized

after patient was anesthetized with Lidocaine 2% with epi 1:100,000 1 carpules, no reactions.

Another student recorded generalized moderate plague and calculus, heavy bleeding on scaling.

The goal was to brush for full two minutes and increase biofilm removal.

At the sixth scaling appointment, which was a day after the fifth appointment, patient

came back to have the last sextant scaled, sextant five. Ulcer was still present. Student

anesthetized patient with left infiltrations from tooth 22 to 27, also right and left mental was

given with Septocaine 4% with epi 1: 100,000 total 1 and 1.5 carpules. Ro reactions recorded.

At this appointment, the ultrasonic scaler and hand instruments were utilized, sub

gingival irrigation were provided with Chlorohexidine.

Evaluation

At the tissue reevaluation, a full new perio chart was recorded. Post treatment revealed

patient had generalized 3-5mm pockets with localized 6-7mm pockets. The number of deep

pockets had decreased and bleeding on probing decreased less than 50 percent. Areas of

recessions did not significantly change. The ulcer to be followed up from last scaling

appointment had healed on its own. Patient did not need to go see a specialist.

On the maxillary, color of gingival margin has changed from generalized moderate

erythematous to generalized light erythematous, margin contour changed from generalized

blunted and bulbous to generalized less bulbous on the anterior, although still moderately

bulbous on posterior. Surface texture stayed the same: smooth and glossy before and after

procedure.
CAPSTONE – Patient X 17

On the mandible, color of gingival margin changed from severe erythematous to

generalized light erythematous. Margin contour changed from severely rolled to generalized

rolled. Consistency changed from severely edematous to moderately edematous. Surface texture

changed slightly from smooth and glossy

The difference was noticeable but not significant. The reason being that patient did not

improve home care and no flossing was done at home, patient was still drinking about 8 diet

cokes a day, no changes compared to prior treatment. His diet remained high in carb and sugar

and home care unchanged. The patient was praised for keeping all his appointment, and came

back for perio maintenance, and reminded to brush and increase biofilm removal. He maintained

high caries risk.

Throughout the program, patient came back 6 times for scaling and root planning and for

tissue reevaluation. He was put on a three-month recall due to high caries risk patient. This recall

is to ensure periodontal health until homecare is better achieved. This decision was based on a

journal published in 2015. Journal of evidence based dental practice found weak evidence in a

specific interval such as three or four month. Instead, risk based interval recommendations are

better than fixed interval recall. (Farooqia, 2016)

Periodontal Maintenance

At the three-month recall, patient came back on time for his first perio maintenance. His

gingival description was generalized fibrotic and erythematous on the lingual posteriors, papilla

blunted, smooth and glossy texture. His pocket readings were generalized 3-5mm with localized

5-8mm, generalized recessions, furcation involvement and generalized moderate bleeding on

probing. His home care was brushing two to three times a day as reported by patient, using a

manual soft tooth brush. He also reported that he flossed 2-3 times a week. He also used a soft
CAPSTONE – Patient X 18

pik to remove food debris. My goal for him was to brush at least two minutes each time, and use

modified bass technique to remove biofilm 1-2mm subgingival. Fluoride varnish treatment was

provided. Air polisher was utilized to remove isolated stains on posterior teeth. Patient has been

reclassified to IV/PM/D1 and did not need re-treatment after three months, which was a very

positive sign. Patient is put on a three-month recall.

Reflective conclusion

This project gave me an opportunity to put everything I have learned didactically and

clinically together to provide comprehensive treatment to my patient. Via didactic classes, I have

learned how and why periodontal disease works and I was able to explain and educate that to my

patient. I was able to show him microscope slides with bacteria and explained how they can

harm his gingiva and alveolar bone. At the same time, I was able to give him nutritional

counseling advice on which food/drink to avoid to prevent caries. I had also studied instruments

and was able to put them to work by choosing the right instruments for the right areas in the

mouth that will best benefit my patient. This patient was very compliant and came to all of his

appointment including tissue reevaluation and perio maintenance. Even though he did not reduce

soda intake or carb intake and did not increase brushing and flossing frequency, it was the first

step for him to improve his oral care by showing up and committing to making those

appointments despite of his busy schedule.

Professionally, I grew tremendously throughout working with this patient. My new

patient assessments used to take at least two appointments. My first scaling appointment required

the whole clinic time which was 2.5 hrs. to finish it. But by the fourth scaling appointment, I was

able to clean him in one hour. I grew from being very nervous when giving anesthetic to being

very comfortable giving injections. By applying what I learned didactically, I was able to utilize
CAPSTONE – Patient X 19

motivational interviewing, was able to educate home care, disease process and had grown with

him.

The areas I excelled in were instrumentations. From requiring 2.5 hrs. to finish one

sextant, I became more familiar with them and scaled him efficiently. Local anesthetic was also

an area I excelled in since I found that my patient was comfortable and did not react to

anesthetics going in. I made sure to give it slowly to best provide patient comfort. Areas I need to

improve is finding what was most important to him. I could do better in motivating him to brush

and floss better, as well as adjusting his diet. Using the right vocabulary and sending the right

message will be key in proving the best care possible to my patients.

CAPSTONE – Patient X 20

Documentation

Throughout the capstone project, all aspects of documentation were completed. Patient did get a

comprehensive Dr Exam within twelve months at Lake Washington Dental Clinic. Health history

was signed by all. Patient signed all HIPPA and consent forms. All treatment provided and what

wasn’t provided was referred out (Appendix 10, Referral for Oral lesion). Fluoride treatment was

provided to patient at tissue reevaluation appointments. All signatures have been obtained.

Nutritional diary was obtained by student calling and obtaining due to patient’s busy schedule.

This flexibility allowed all aspects of documentations obtained as expected.

 CAPSTONE – Patient X 21

Bibliography

Chavada, M. G., Shah, H. M., & Jethal, B. S. (1993). Influence of diabetes mellitus on periodontal

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