CARIES CASE STUDY 1

Caries Case Study

Stephanie Gonzalez, DHS

Pima Medical Institute

RDH 240: Dental Hygiene Theory

Kathleen Pierce

July 20th, 2022

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Table of Contents

Title Page………………………………………………………………………………….............1

Table of Contents………………………………………………………………...………..............2

ASSESSMENT

Section I: Patient Information……………………………………………………………..3

Section II: Clinical Assessment…………………………………………………………...6

TREATMENT PLANNING

Section III: Treatment Planning …………………………………………………………10

IMPLEMENTATION

Section IV: Treatment Provided and Treatment Revisions …………………….……….11

PERIODONTAL RE-EVALUATION

Section V: Post-Treatment 4-6 week Re-evaluation……………………….…………….13

Section VI: Student Summative Evaluation of Therapeutic/ Preventative Outcomes…...16

References………………………………………………………………………………………..16
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ASSESSMENT

Section I: Patient Information

Patient X is a 58 year old Hispanic male, he was born in Mexico and moved to the US at

the age of 25. He now has three children and three grandchildren and enjoys traveling with his

family. Recently he retired from his job as a roofer due to an accidental fall and since then has

become more aware and concerned with his overall health. His main concern for seeking oral

care is that he hasn’t been to the dentist in a few years now and recently noticed his teeth have

become mobile and there’s an increase in space between his front teeth.

Discussing the patients’ health history, the patient discloses that he has had high blood

pressure for the past 6 years for which he is taking medication. The patient is also pre-diabetic

and has high cholesterol which he is managing with diet and exercise and is getting routine blood

work to monitor his sugar levels. He has a family history of stroke and high blood pressure on

his mothers side of the family and recently had surgery in 2020 on his femur and wrist due to a

fracture from an accidental fall at work. He is currently taking 81mg of Aspirin 1x a day for

heart attack prevention, 20 mg of Atorvastatin once a day for high cholesterol, 10mg of

Amlodipine once a day and 40mg of Lisinopril once a day for high blood pressure. The patient

also drinks on occasion over the weekend in social family events and exercises on occasion to

help strengthen his muscles after being on bed rest and crutches after his fall. The patient was

classified as ASA II due to his high blood pressure and was approved to continue treatment

without the need of a med consult.

The patients last dental visit was approximately 5 years ago for a routine checkup. He

presents with multiple missing teeth and mentions he has worn upper and lower partials for the

past 7 years. His x-rays show multiple restorations including fillings, root canals, crowns, and
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new signs of present decay. Also, after evaluating his x-rays evident severe bone loss is present

and classified as class IV bone loss. Overall, the patient presents with multiple factors that have

contributed to his oral health status. One of the main factors being culture as a barrier to care,

patient X was born and raised in Mexico where he mentions that his parents never put a high

importance to his teeth and was only taken to the dentist when he presented with pain. As a

result, his dental IQ regarding dental knowledge has always been low and over the years has had

little to no motivation when it comes to keeping up with his oral care.

It was asked of patient X to complete a three day nutrition log to see if his diet was

playing an active role in his caries progression. On all three days the patient ate cooked oatmeal

with milk and a cup of coffee for breakfast. On the first day for lunch the patient had chips and

salsa, a shrimp cocktail with saltine crackers, and a horchata drink. For dinner the patient had

chicken marinated in chili sauce with rice and a total of five tortillas, and an hour before bed the

patient had a cup of chamomile tea and a piece of Mexican sweet bread. The second day for

lunch the patient ate a turkey sub sandwich with veggies, a small bag of chips, and a 16oz. Coca

Cola. For dinner he had Lentil soup and two quesadillas followed by chamomile tea and

cinnamon cookies an hour before bed. On the last day he ate a homemade turkey sandwich with

an apple for lunch followed by 3 slices of peperoni pizza and a Pepsi for dinner. He also noted

drinking water continuously throughout the day. Overall, the patients nutritional log shows a

high consumption of fermentable carbohydrates and a moderate intake of acidic sugary drinks. I

explained to the patient the contribution that both carbohydrates and acidic drinks have on caries

and the demineralization process with hopes to decrease his intake and swap out some foods with

healthier choices.
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Patient X presents with both medical and dental indications that were taken into

consideration to proceed with their treatment and to help increase their oral and overall health

status. One being the proper type of anesthetic to use during the patient’s treatment. Since the

patient has high blood pressure it was evident that we had to use Articaine 4% with epinephrine

1:200,000 in order to avoid a medical emergency and be able to give him more anesthetic if

needed. As well, it was planned to perform multiple infiltrations due to multiple missing teeth.

Studies from the National Institute of Health show that pre-diabetic patients have a slower

healing process and are at an increased risk of infection. This made it priority to arrest current

decay and stop the periodontal disease progression by performing non-surgical periodontal

therapy and maintain frequent recall intervals followed with an extensive home care routine.
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Section II: Clinical Assessment

When asked about the patients current home care regimen he disclosed that he wasn’t

taking care of his oral health as well as he should be. His current regimen was only brushing

once a day at night and not flossing or using any other type of interproximal aid. As a result, his

plaque index score placed at 19%. When performing the clinical assessments, we started by

performing an extraoral and intraoral exam. Findings included scattered brown macules on the

face and neck ranging from .5mm-8mm and bilateral movable nontender submandibular lymph

nodes. The right submandibular node measured at 5mm x 8mm and the left measuring at 1cm x

1cm. Also present was a left supraclavicular movable nontender lymph node measuring 1cm x

5mm. Intraorally, the following was seen: red and inflamed vestibules, enlarged tonsils, signs of

stomatitis possibly due from the patient’s partial denture and a white coated, geographic,

enlarged tongue. The patient’s gingival description was described as generalized moderate red,

enlarged, edemic margins with blunted papilla’s and localized severe red, smooth shiny, boggy,
CARIES CASE STUDY 7

and eroded margins on the lingual surfaces. With the use of a complete full mouth series,

panoramic film, and a clinical assessment the patient showed multiple hard tissue findings. This

included multiple missing teeth with only thirteen remaining which showed various existing

restorations such as composite fillings, root canals, and porcelain crowns. The patient’s occlusal

classification showed an anterior end to end bite which validated the wear on the patients upper

and lower anteriors. After evaluating the patients’ risk assessment, he fell under a moderate risk

for caries and new findings found caries on the distal surface of seven and distal, incisal, facial,

lingual caries on number 25. Along with a thorough periodontal exam the patient’s status

included generalized bleeding with 4-5mm probing depths and localized 8-9mm pockets on the

lingual surfaces of the lower anteriors. As well as class I and II mobility, slight recission, and

MAG on the lower anteriors. Based on the severity of the patient’s disease and the complexity of

his disease as well as the rate of progression the patient was classified as stage IV grade B. The

amount of calculus present categorized the patient as an LG IV which determined the need for

nonsurgical periodontal therapy with no referrals needed. Multiple contributing factors helped

come to a conclusion regarding the patient’s classification. This included his systemic factors

such as high blood pressure, high cholesterol, pre-diabetic, a family history of diabetes and a

history of sleep apnea. The patient’s oral behavior also played a contribution due to his high

intake in fermentable carbohydrates and sugar, not removing his partials, infrequent oral care,

and a poor home care regimen. And lastly, the root of the problem were his psychosocial factors

such as culture as a barrier to care, English as a second language, and lack of motivation which

resulted in a low value placed on his oral health.

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TREATMENT PLANNING

Section III: Treatment Planning

When I came across this patient, I took into consideration all of the risk factors that they

presented. These risk factors included a high risk for caries and periodontal disease, contributing

systemic factors, recurrent caries, and evidence of grinding and xerostomia. These factors made

this patient an excellent candidate for this specific case, as well as being a reliable source. My

goals for this particular patient were to establish a dental home of record in order to maintain

regular dental visits. Another main goal was to increase the patient’s homecare regimen in order

to reduce any inflammation and help reduce the patient’s stomatitis caused by his partial denture.

My therapeutic strategy for this patient was to perform full mouth periodontal therapy with the

use of local anesthetic and antimicrobials. I also planned on performing soft-tissue curettage to

help the tissue heal quicker and remove any eroded tissue. I anticipated to perform therapy using

my files on the lower anteriors to break down tenacious pieces of calculus as well as the

extended Gracey’s and the right and left slimline due to the degree of bone loss. In order to

maintain the treatment performed I wanted to educate my patient on the disease progression and

how working together can help him prevent further decay and bone loss. My plan was to help the

patient start by understanding the basic technique of how to brush properly. I believed that the

modified bass technique would fit his situation to help lower the amount of plaque accumulated

at the gum line. I also believed that the rubber tip would help lower the inflammation and remove

plaque from hard to reach areas. When discussing my plan to the patient I discussed his current

oral status and how arresting his decay and providing periodontal therapy was important in order

to preserve his teeth and stop further disease progression. I also talked about the possible

increase in sensitivity after periodontal therapy and the benefits of salivary substitutes and
CARIES CASE STUDY 11

fluoride therapy. Before proceeding with treatment, I answered any questions the patient had and

obtained a signed informed consent from the patient.

IMPLENTATION

Section IV: Treatment Provided and Treatment Revisions

Patient X was seen for a total of 5 times to complete both his periodontal therapy and his

restorative treatment. On February 14th he came in for his initial assessment where his health

history was thoroughly evaluated and questioned to better understand his health status. We

continued by taking a panoramic film and nine periapical images to see any signs of caries and

evaluate his bone levels. A thorough intraoral and extraoral examination was performed along

with an occlusal classification and gingival description. Various measurements and presentations

were recorded such as probing depths, gingival recession, furcations, mobility, and bleeding to

properly classify this patient and have a baseline of his current health status. Taking everything

that was noted we were able to create a dental hygiene care plan and asses the patients risk based

on his findings. On March 14th, the patient had a doctor exam where two caries were found, #25-

DIFL and #7-D. There has been evidence that shows a correlation in an increased risk of caries

seen in patients who use acrylic resin dentures (Tejaswi, 2022). Based on his recurrent caries

rate and 19% plaque index, the patient was walked through the benefits of using a perio-aid to

better clean localized areas of concern. An informed consent was signed, and we continued by

provided full mouth periodontal therapy with the use of anesthetic. Due to the patients’ high

blood pressure, we proceeded using Articaine 1:200,000 with epinephrine. In localized areas of

inflammation, soft tissue curettage was also performed to help lower the inflammation and

remove any necrotic tissue in conjunction with oral irrigation using chlorhexidine. On April 1 st

the patient came in to start his restorative appointments and arrest the decay present on #25-
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DIFL. The clinician continued by administering the same type of anesthetic and used a rubber

dam for isolation purposes. Pre-photos and post photos were taken to show the patient the results

of his tooth and post-op instructions were given. Weeks later on April 29th the patient came in for

his last restorative filling, #7-D. Articaine was used again, and the clinician also took various

photos of how the tooth presented with decay, after removal of decay, and the final restoration.

The patient was seen a final time on May 2nd for his 4-6 week periodontal re-evaluation. The

patient appeared with slight improvement when probing depths were reassessed however, there

was an increase in his plaque index. When questioning the patient there were no concerns of

post-op sensitivity or pain, he did however notice a slight increase in the comfort of his gums

with a slight decrease in bleeding. When home care regimen was questioned the patient did not

present with an increase in motivation to better his oral health and continued to only brush once a

day. We proceeded by providing a full mouth debridement using cetacaine for comfort and the

Right and Left Slimline’s to better clean areas where furcations were present. When reviewing

health care aids a rubber tip stimulator was introduced to help minimize the localized areas of

inflammation as well as help remove plaque biofilm from difficult areas. Intraoral photos were

taken and the use of a medium grit prophy paste was used to polish coronal surfaces followed by

the application of 5% NaFL varnish.

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PERIODONTAL RE-EVALUATION

Section V: Post-Treatment 4-6 week Re-evaluation

The patient presented for his 4-6 week periodontal re-evaluation with no changes

regarding his medical history and current medication list. The patient mentioned he still noticed

mobility on his lower anteriors but did notice that his gums weren’t bleeding as much and

weren’t as painful. When re-observing his intraoral and extraoral exams no new lesions were

found and previous macules and papules remained the same dimensions. A new periodontal chart

was taken and compared to the initial measurements the patient presented with. Overall, there

was improvement seen in probing depth with stable areas of recession and furcations. However,

new findings of suppuration were seen in the lingual surfaces of the lower anteriors. A new

gingival description was noted and remained similar to the initial description with a slight

reduction in redness and a plaque index increase by 37%. Despite a lack of motivation to

increase the patients home care regimen, the patient did begin to use an electric toothbrush and a

water flosser. The patient now has a better understanding about the need to remove his partials
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nightly and is trying to change his habits and removing them on most nights. In summary, there

was a generalized effective pocket reduction seen with periodontal therapy and arrest of decay

from further expanding and compromising the tooth. It was then discussed with the patient the

importance of maintaining regular care in order to reduce the disease progression as well as the

importance of doing his part by keeping up with his home care regimen. I also described

potential complications of not receiving care resulting in needing full dentures in the near future.

As well as, non-compliance with recall intervals not being met resulting in a possible referral to a

periodontist. I recommended to the patient to continue on a 3 month periodontal maintenance

recall with fluoride applications to help prevent further decay and help watch for signs of

remission as well as the application of Arestin to help combat areas that are difficult to treat.

Studies show the benefits of fluoride to help prevent dental caries by inhibiting demineralization

and enhancing remineralization (Chopra, 2022). A year from now I hope to see my patient with

as many of his natural teeth as possible to be able to maintain functional speech and masticatory

functions. When comparing my original treatment goals and desired outcomes there was both a

positive and a negative result. One of my goals was to arrest my patients decay from further

expanding, I was successfully able to explain to my patient the importance of arresting the decay

sooner rather than later and was able to motivate him to get it taken care of. My second goal

consisted of hoping to increase my patients home care regimen to brushing twice a day and

flossing 2-3 times a week. My patients home care was not increased in the end however, he did

implement switching from a manual toothbrush to an electric toothbrush as well as integrating

the use of a water flosser.

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Section VI: Student Summative Evaluation of Therapeutic and Preventative Outcomes

As a result, this case helped me as a clinician to better understand how host response

varies from patient to patient and how to proceed with treatment in such cases. This makes it

very important to be able to recognize and modify treatment according to the patients’ needs and

functions. When looking at the overall case some modifications that could have been made to

enhance the treatment outcomes would have been to perform the patients’ needs in a timely

manner. I believe this would have helped avoid the progression of decay and the possibility of

remission. I also believe that it played a factor in not maintaining proper motivation for my

patient versus how the outcome would have been if the patient was consistently motivated to

improve his overall oral health.

REFERENCES

Chopra, S. (2022). Diagnosis and prevention strategies for dental caries. Journal of Advanced

Medical and Dental Sciences Research, 10(5), 43-45.

Tejaswi, S., & Ambikathanaya, U. K. (2022). Dental caries in relation to removable acrylic

partial denture - A review. Journal of Advanced Medical and Dental Sciences

Research, 10(8), 1-3.