SENIOR CLINICAL

CASE STUDY
In Partial Completion of the Requirements for DHY: 405 & 406
By: Lucci McDaniel
PATIENT INFORMATION
PATIENT PROFILE
§ 35 year old male
§ 6’5, 280 lbs
§ Has been living in Seattle for 5 years,
previously from KC, MO
§ Hasn’t seen a dentist in over 8 years
§ Has never had a home dentist
§ Chief concern:
§ UL occasional temperature sensitivity and chewing
sensitivity
§ Curious if he has any cavities
§ Wanted a cleaning and to establish care

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MEDICAL CONDITIONS MEDICATIONS

§ ASA: II § Ibuprofen 600-800 mg (as needed for pain)

§ Vital signs at initial appt: 118/81 mmHg –HBP I § Recently prescribed Omeprazole by
§ Current tobacco user (chewing tobacco) – ½ primary care doctor, pt reported he has
can/daily not started to take this medication
§ Former cigarette smoker (5 years in remission)
§ Arthritis in the back
§ Adult stuttering
§ Psoriasis
§ GERD*
§ Primary hypertension*
§ Alcoholism in remission (5 years)
CLINICAL ASSESSMENT

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EXTRA-ORAL EXAMINATION

§ Generalized psoriasis throughout face and neck; currently inflamed

§ Swollen submandibular lymph nodes (bilateral, 2x1 inches; was noted by instructor that it can be common to have
enlarged lymph nodes during a flare up of psoriasis as it is an autoimmune disorder)
- recommended patient keeps an eye on this and check in with primary care doctor; monitor at each appt.
§ TMJ
§ Deviation to the right upon closing
§ Very strong masseter muscle upon clenching
§ Pt reports sometimes clenching his teeth throughout the day, increased with stress
 INTRA-ORAL EXAMINATION
§ Macroglossia, slight fissured tongue, and slight coated tongue
§ Left lateral side of tongue: possible leukoplakia; single, localized, well defined
boarders, 2x2mm, round, white, soft, smooth, no history, pt unaware, refer to oral
surgeon per DDS
§ Lower left vestibular area from #17-21: corrugated tissue, single/continuous,
round/oval, white mixed in with tissue color, rigid, smooth, pt unaware but reports
this is a common area where he places his chewing tobacco, refer to oral surgeon
per DDS
§ Left and right retromolar pads: hyperkeratosis like tissue, localized, single, right side:
5x3mm, left side: 3x3mm, oval, white, rigid, rough, pt unaware but reports that he
sometimes bites on his tissues back there when he is stuttering, refer to oral
surgeon per DDS

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GINGIVAL DESCRIPTION
MARGIN: GEN MOD ROLLED WITH
LOCALIZED SEVERE ON #24/25 BUCCAL,
FESTOONED ON #27/28 BUCCAL

COLOR: GEN MOD PINK WITH

LOCALIZED CYANOTIC ON THE UPPER
ANTERIOR LINGUAL AND BETWEEN #24/25
BUCCAL

PAPILLA: GEN SLIGHT-MOD BLUNTING

WITH LOCALIZED BULBOUS ON #21/22 &
#26/27

TEXTURE: GEN MOD SMOOTH

CONSISTENCY: GEN SLIGHT FIRM
WITH LOCALIZED FIBROTIC ON LR/LL BUCCAL RECESSION: GEN 2-3MM
 TOOTH CHART
o Existing:
• Occlusal Composite: #2
• Occlusal Amalgam: #15
o Treatment Planned:
• Recommended extraction of
#1, 16, 17, 32
OCCLUSION CLASSIFICATION
• Occlusion:
• Left & Right Molar: III
• Left & Right Canine: III
• Underjet:
• 6mm
• Open Bite:
• #3-13 with #18-31
• Occlusal Wear:
• Generalized severe erosion and attrition

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 RADIOGRAPHS

§ Findings:

§ Presence of all wisdom teeth

§ Moderate-Severe bone loss
around #1 and #16
§ Mod-Heavy calculus

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 PERIO CHART
(Initial)

Pockets: gen 3-5mm with loc 6-7 in

posteriors

Mobility: n/a

BOP: generalized

Furcation Involvement: Class II - #19 B,

#30 B/L and #31 L

WAG: lowers: gen 0-2

CAL: generalized clinical attachment loss of

2-4mm

Attrition: generalized mod

 CARIES RISK ASSESSMENT
§ HIGH Risk:
§ Current Oral Hygiene Habits:
§ Brushing at least 1x/daily
(usually in the morning)
§ Flossing occasionally
§ Fluoride in toothpaste and
tap water

§ Frequent consumption of
energy drinks and coffee
§ Exposed root surfaces
§ Plaque index score: 90%

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DIAGNOSIS AND PLANNING

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AAP CLASSIFICATION

1999: Case Type IV/2/D3

2017: Stage III Grade C
§ Supporting Evidence:
§ Current bone loss levels
§ Age
§ CAL/WAG
§ Tobacco user
Treatment Plan:
§ NSPT of all 4 quads
§ 3 month perio-
maintenance following
NSPT

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 DENTAL
HYGIENE
DIAGNOSIS
§Goals:

§Complete recommended treatment plan / referral

§Increase home care routine quality and quantity
§Reduce inflammation, biofilm, calculus, pocket depths,
and BOP
§Tobacco cessation
§Prevent progression of bone loss/stabilize
periodontium
§Get patient on an appropriate recall routine for perio-
maintenance
§Control GERD and acidic diet

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IMPLEMENTATION

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Treatment Plan:
HHx/VS, EO/IO/GD, LA (with 4% Articaine 1:200k), Calc Detect, Spot Probe, Pre-Polish,
Cavitron, Handscale, Floss, PE/OHI
Visit 2 3 4 5
Type of NSPT 1 - LR NSPT 2 - UR NSPT 3 - LL NSPT 4 – UL/tissue re-eval
Appointment
Date 11/17/23 12/1/23 12/1/23 1/12/24
Vital Signs 120/70 123/79 118/75 116/70

Type of Right IABL Right PSA, MSA, ASA, GP, NP Left IABL Left PSA, IO, GP, NP
Injection

PE/OHI Importance of finishing NSPT, the healing
process, and how tobacco can affect the
healing process. Also talked about making
it a habit to brush 2x/daily
Other Warm salt water rinses encouraged and
ibuprofen as needed for any discomfort
Post-op instructions for Arestin Used disclosing solution today and
evaluated plaque levels, went over
Rubber Tip Stimulator with patient for
plaque removal and increase blood
flow circulation (pt liked the rubber tip)
Arestin placement on #3 mesial Arestin placement on #18 distal –
appropriate post-op instructions given
Importance of staying of 3 month
periomaintence recall and maintaining
proper home care
Arestin placement on #14 M/D and #15 M
5% Fl- Varnish
Tissue Re-evaluation (LL)

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EVALUATION

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 TISSUE RE-EVALUATION
§ Gingival Description: generalized unhealthy, generalized moderate
pink with localized white around the margin of #19, generalized slight
to moderate blunting, generalized slight rolled margins, generalized
slight soft, generalized smooth, generalized 1-3mm of recession.
§ Change from before treatment: cyanotic tissue was resolved
(interproximally), margins went from moderately rolled to
slightly rolled w/ loc mod on #22/23 , plaque index was only
present on occlusal pits compared to interproximally and on
gingival thirds
§ Periodontal Chart: the probing depths revealed 3mm pocketing with
localized 4-5mm pocketing on #17 and #18. There was also a major
improvement in BOP – localized on #17 and #18.
§ Before treatment: generalized 4-5mm pocketing with localized
6mm on #17
§ Calculus Levels:
§ Localized roughness interproximally on lower anteriors
§ Clickable on #17 and #18

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Before & After

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STUDENT SUMMATIVE EVALUATION
§ The case study project allowed me to see a patient from their initial appointment to their last
recommended cleaning appointment and follow through on a treatment plan that I created for them.

§ I was able to see first hand how quick tissue healing can happen, how important patient education is, and
also learned how to use critical thinking throughout each appointment.

§ Doing this case study early on allowed me to learn how important it is to utilize all resources at each
appt; periodontal chart, radiographs, recognize areas of inflammation, etc.

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 REFERENCES
Carramolino-Cuéllar, E., Tomás, I., & Jiménez-Soriano, Y. (2014). Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome. Medicina
oral, patologia oral y cirugia bucal, 19(3), e289.

Chakraborty, A., & Anjankar, A. P. (2022). Association of gastroesophageal reflux disease with dental erosion. Cureus, 14(10).

Fowler, E. B., Breault, L. G., & Cuenin, M. F. (2001). Periodontal disease and its association with systemic disease. Military medicine, 166(1), 85-89.

Lindhe, J., Westfelt, E., Nyman, S., Socransky, S. S., Heijl, L., & Bratthall, G. (1982). Healing following surgical non‐surgical treatment of periodontal disease: A clinical
study. Journal of clinical periodontology, 9(2), 115-128.

Preshaw, P. M., Dunn, I., Milward, M. R., & Roberts, A. (2023, April 5). Assessing periodontal health and the British Society of Periodontology Implementation of the new
classification of Periodontal Diseases 2017. Dental Update. https://www.dental-update.co.uk/content/periodontics/assessing-periodontal-health-and-the-british-society-of-
periodontology-implementation-of-the-new-classification-of-periodontal-diseases-2017/

Winn, D. M. (2001). Tobacco use and oral disease. Journal of dental education, 65(4), 306-312.

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