Periodontal

Patient
Case Study
Presented by Colleen LeBlanc
 Meet My Patient!
My case study patient is a 31-year-old woman who recently relocated to the United States
from Oaxaca Mexico after discovering she was born in San Diego. Accompanied by her
estranged partner, she sought shelter with a kind Samaritan, amid suspicions of intimate
partner violence. Her two children, aged 12 and 14, remain in Mexico under their
grandparents’ care.

Despite uncertainties, Erika does her best to take care of her oral health, including regular
cleanings in Mexico, though comprehensive radiographs were not part of her prior dental
care.

This initial dental encounter in the U.S. presents an opportunity to establish a dental home,
marking the beginning of her oral health journey in her new home!
 Medical History

The patient has been in the US for two Categ

months and is beginning to establish Medication
ory
Dose Note

her healthcare.
Severe depression 2 mg
Prazosin is used to treat high blood
Prazosin Alpha pressure. It works by relaxing and
Suicidal ideations (MINIPRESS) Blocker
capsule
widening blood vessels so blood can
1x daily
Hepatitis B antibody core positive flow more easily.

Irregular menstrual cycle

treats depression, panic attacks, OCD,
10 mg
According to the patient’s records, she is FLUoxetine
SSRI capsule
bulimia, and severe PMS. It's a selective
(PROZAC) serotonin reuptake inhibitor (SSRI) that
currently working with her healthcare 1x daily
restores serotonin balance in the brain.
team to monitor and care for her mental
health.
Medical & Dental Indications
Depression can impact oral health in various ways:
Neglect of oral hygiene: Depression may lead to neglect of
oral hygiene, increasing the risk of cavities and gum disease.
Bruxism: Stress-related bruxism can cause tooth wear and
jaw pain. Pt had very stron masseters
Dry mouth: Some depression medications can cause dry
mouth, raising the risk of tooth decay and gum disease.
Poor diet: Changes in diet associated with depression can
contribute to tooth decay and erosion.
Avoidance of dental care: Individuals with depression may
avoid seeking dental treatment, allowing dental problems to
worsen.
 Initial Summary of Dental History
Assessment &
Dental Findings

Progress Note The patient states that when she lived in

Oaxaca, she received dental cleanings at least
once a year
The patient stated that she had “never had this
many x-rays” when the FMX was being
performed. She stated “They only did x-rays if
there was a problem with the tooth”
History of occlusal sealants placed on #18,19
No need to refer to specialist
Summary of Risk Assessments

The patient is at moderate risk for caries due to her

02/14/2024
medication, FLUoxetine (PROZAC) which puts her at risk
for xerostomia, diagnosed depression, and heavy levels
of calculus
The patient states that she does not typically snack
between meals and does not consume coffee, juice or
sodas
Strong masseters and malocclusion present the risk of
attrition
Patient brushes her teeth 2x daily and tries to floss daily
 Perio: Gen 3-4 mm pockets with localized 5
mm pockets on her posterior teeth
Summary of Class I furcation present #2,30 buccal and
Clinical #1 ML
Assessments All 32 teeth are present. #1,16,17& 32 are
partially erupted
Monitor placed on #3 and 30 for
noncarious enamel staining
 The patient presents bilateral subluxation, left side deviation, and
very strong masseter muscles. The patient states that she does
not feel pain with her TMJ.
Extra Oral
Examination OHI: I informed the patient on how strong masseters can lead to

Findings increased occlusion forces, potentially resulting in significant

tooth wear and other oral issues

Bilateral moderate linea alba

Small brown lesions on tongue &soft palate
Intra Oral DDx Hyperpigmented fungiform papilla
Slight mandibular tori contralateral to #21 and #27
Examination Slight exotosis #6-11
Findings Possible chromogenic staining present
Severe attrition present in sextant 5
Light attrition present sextant 2
 Generalized unhealthy, generalized medium pink
with generalized slight melanated pigmentation,
generalized full papilla with localized blunting
Gingival #23/24, generalized moderate rolling, generalized
Description smooth and shiny, generalized slight stippling,
generalized soft texture
 Periodontal Chart
&
Tooth Chat
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Radiographs

Panoramic Radiograph taken 02/14/2024

Radiographs

Full Mouth Series taken 02/14/2024

Pre-Treatment Photos
 Patient Selection
Selected for case study due to:
Need for 4 quadrants of Non-Surgical
Periodontal Therapy (NSPT)
Diagnosis of Major Depressive Disorder (MDD)
Exhibits signs of:
Bruxism
Treatment Goals and Approach:
Severe attrition Over 4 quadrant NSPT visits, we aim to:
Class 1 furcations Provide comprehensive debridement & oral hygiene
instruction
Improve home care skills & compliance
Disrupt recurrent calculus formation cycle
Offer education & motivational support for positive habit
Empathetic approach for the 31-year-old patient with
depression, bruxism, attrition & furcation involvements
Set solid foundation for future periodontal health
Treatment Plan, HIPPA/Confidentiality
& Consent

Privacy was maintained by:

Maintaining strict confidentiality during patient discussions.

Using secure electronic records and logging out when not in use.
Limiting access to patient information on a need-to-know basis.
All photos that were taken did not include the patients face or any identifying fea
Dental Hygiene Diagnosis
II
Dental Hygiene Diagnosis
Chart Notes
 Treatment Revisions
The patient completed 3 out of 4 quadrants of comprehensive
non-surgical periodontal therapy (NSPT). Despite multiple
attempts to reschedule, she cancelled her final appointment
twice and did not respond to follow-up efforts.

Although significant progress was made in improving her oral

hygiene skills and disrupting the calculus formation cycle, the
incomplete treatment poses a risk for disease recurrence and
compromised long-term periodontal stability.
 Post Treatment Evalulation
Throughout the treatment process,
several significant improvements were
observed in the patient's oral health
and overall confidence:
Gingival Health:
Reduced swelling
Firmer and tighter gingiva
Oral Hygiene:
Less biofilm present
Cleaner tongue with less coating
Reduced interproximal debris
Patient Confidence:
More talkative and engaged
during visits
Excited about completing
treatment
Reports regular flossing practices
For her final appointment I will
conduct a tissue reeval and thorough
patient interview.
To do this I will:
Complete a full mouth post
treatment PC. Indications of
improvement:
Lowering the 5 and 6mm pocket
readings to healthy levels
Reduced BOP
Assess all tooth surfaces,
especially those with bleeding
points, using a periodontal
explorer for residual calculus
deposits
Assess plaque index after soft
tissue visual inspection to avoid
disclosing solution interference
Patient Interview:
Evaluate patient's self-care
routine's impact on periodontal
health.
Identify areas where patient needs
additional aids for oral care.
Questions I would ask:
What is something that you learned
while in my care?
Now that you have had treatment,
how motivated are you to make
improvements with your homecare?
Do you see yourself coming in every 4
months for cleanings?
Post Treatment Photos

Quadrant IV 2 weeks post treatment

If the patient returns for her final appointment, full
mouth IO photos will be taken
 References
Ada caries risk assessment form completion instructions. (n.d.). https://www.ada.org/-/media/project/ada-
organization/ada/ada-org/files/resources/public-programs/give-kids-a-smile/gkas_caries_risk_assessment_forms.pdf

Brooke Sergent, R. (2023, February 5). Dental stain: Hygienists can ascertain source, help increase dental patient
confidence. Today’s RDH. https://www.todaysrdh.com/dental-stain-hygienists-can-ascertain-source-help-increase-
dental-patient-confidence/

Hunter KD, Wilson WS. The effects of antidepressant drugs on salivary flow and content of sodium and potassium ions in
human parotid saliva. Arch Oral Biol. 1995 Nov;40(11):983-9. doi: 10.1016/0003-9969(95)00079-5. PMID: 8670028.

Mayo Foundation for Medical Education and Research. (2023, December 19). Dry mouth. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/dry-mouth/symptoms-causes/syc-20356048