Case Study

PROJECT
Edith Gonzalez-Rodriguez, 2024
 table of
CONTENTS
01 Patient informtion

02 Clinical Assessment

03 Dental Hygiene Diagnosis, Tx Plan and Rationale

04 Tx Provided and tx revisions

05 Post-tx evaluation

06 Student summative evaluation of therapeutic

and preventive outcomes
 Assessment
SECTION I:
PATIENT INFORMATION
 Introduction:
My patient for this project is J - he is 26 years old, born and raised in
Reno, NV. However, he now currently lives in Lakewood, WA with his
roommate.

J has a twin brother, but both were adopted into a family with other
adopted and foster children. J’s adopted father and mother divorced
when he was in elementary school.

J’s roommate motivated him to seek oral care at NeighborCare after

seeing a Reddit post about our hygiene facility.
 Health
HISTORY
JACOB’S CHEIF
ASA CLASSIFICATION: VITAL SIGNS:
CONCERN (CC):
BP: 113/71
II Adult Dental Examination -
Pulse: 80
February 26th 2024:
Respiration: 20

CC: “Pt is here for an overall

AAP CLASS/CODE: PHSYICAL CHARACTERISTICS:
evaluation of his oral health -
1999: II2/D2 Height: 6' 1" he is currently experiencing
pain on the last molars in the
2017: IB Weight: 182 lb UR + UL and experiences
sensitivity in the top and
bottom front teeth”
 Health History
MEDICAL HISTORY:
December of 2023 J presented to the emergency department for
evaluation of suicidal ideation: “Intake assessment.”

J endorsed experiencing emotional dysregulation, symptoms of depression

and anxiety, and auditory hallucinations which he referred to as “head-
mates.”

At the time of his visit, J referred to himself as “we” and shared names of his
head-mates: “Jake, Ash, Aubrey, Jade.”

Towards the end of December, J was admitted to “5WB - SW Psych

Services” for psychiatric evaluation and tx.
 Health History
PHARMACOLOGIC HISTORY:
GABAPENTIN
(NEURONTIN)
600 mf tablet
J is instructed to take 1 tablet by
mouth 3x a day for anxiety
.Dental interactions of concern to
dentistry:
None reported at this time, but
because of CNS side effects are
common, the use of anxiolytic
sedative drugs may potentially
increase the CNS side effects.
MIRTAZAPINE
7.5 mg tablet
J is instructed to take 1 tablet
by mouth daily in the evening
for depression + anxiety.
Dental interactions of concern
to dentistry:
Xerostomia
RISPERIDONE
(RISPERDAL)
0.25 mg tablet
J is instructed to take 1 tablet by
mouth every evening for mood.
Dental interactions of concern to
dentistry:
Increased excretion: chronic use
of carbamazepine
Increased sedation: other CNS
depressants, alcohol, barbiturate
Additive photosensitization
tetracyclines
 Medical or Dental
INDICATIONS:
When discussing substance use, J described drinking most mornings (tall
bottles of Mike’s Hard Lemonade) and stated he is a strong cannabis user
(using dabs) and smoking hourly.

J stated he smokes nicotine daily and used to engage in self-punishment

via inhaling cigarette smoke and holding his inhalations to a point of
feeling lightheaded.

Overall, the patient was interested in bettering his mental, emotional and
oral health. J stated he will be speaking to his primary care physician in
regards to possible rx drugs that may help him quit.
Patient Privacy:
 Assessment
SECTION II:
CLINICAL ASSESSMENT
 Exam
FINDINGS:

EO IO GD
EXAM EXAM EXAM
1) TMJ - bi lateral 1) Mod bi lateral linea Gen UN - Gen red with
crepitus and deviation alba 2) Narrow palate 3) bright red margins, gen
on the L upon closing (pt White hairy, coated mod enlarged, gen mod
reported no tongue, 4) Ankyloglossia, rolling, gen soft/spongy
pain/tenderness.) 5) Tonsils present 6) for consistency, gen
2) R submandibular Keratinized tissue on the smooth/shiny for texture,
lymph node: 4x4mm, retromolar pads recession - severe/mod
firm, movable, pt reports (bilaterally) gingival inflammation
to pain upon palpation (loc 1mm)
 Current
DENTAL CONDITIONS:

ANGLES’OVERALL CLASSIFCATION:
MOLARS: CANINES:
R - CLASS I. R - CLASS I.
L - CLASS I. L - CLASS II, DIVISION 2
 At the new patient assessment, Dr. J treatment planned the following teeth for composite
restorations: #2 O, #4 MOD, #5 D, #8 DF, #9 DF, #10 MDF, #15 O, #20 DO, #29 DO.

J does not have any existing restorations, but he does have localized, heavy, sub and supra
calculus present on sext five. In regards to his missing teeth on the mandibular arch, J stated he
had both of his lower second molars removed approximately five years ago due to those teeth
having severe infection.
Radiographic
EXAM
Radiographic
EXAM

Overall, J does not have any bone

loss present. So Dr. J found it most
appropriate for the patient to
return for restorative work and a
prophy (Scaling presence gen
mod/sev gingival inflammation
[D4346]).
Periodontal
EXAM:
 Plaque
INDEX SCORE:
J presented to his initial appointment with
generalized, heavy plaque.

Current self-care routine (at assessment,

NOT post treatment):
J stated he brushes at least 3-4x a week
He currently does not use any interdental
cleaning products to clean in between his
teeth
Patient was unaware if his toothpaste
had fluoride - “I’ve never heard of
fluoride... What is that?”
Oral Risk
ASSESSMENT:
 Psychosocial
OBSERVATIONS:
J was very quiet and kept a lot to him at his initial assessment. However, after
being his primary clinician for all of his cleanings I got the opportunity to
genuinely get to know him.

He slowly began to open up to me and looked forward to coming to each

hygiene appointment.

The only time I truly noticed a big change towards J’s attitude was when I
explained to him that it would be best to complete his “full mouth cleaning” in
quadrants with local anesthetic.
 Referrals:
NO REFERRALS ARE NEEDED
AT THE MOMENT.
Diagnosis & Planning
SECTION III:
DENTAL HYGIENE DIAGNOSIS, TX
PLAN & RATIONALE
Diagnosis &
Planning:
 Discussion points with Jacob:
POSSIBLE THERAPEUTIC
ALTERNATIVES:

No treatment: Expected results: Jacob’s responsibility in

Development of
generalized supra and sub
calculus, infection, future
bone loss, and the
potential losing teeth.
Short term tx:
IT Prophy divided in Inflammation of the gums
quadrants with local will decrease: gums will
anesthetic + completion of return to their natural pink
composition restorations color
A decrease in teeth
sensitivity
Prevention of future decay
Proper removal of plaque +
calculus
tx outcomes:
Brushing x2 day with a mTB
C-Shape flossing 1-2x a day
Following through
recommended hygiene care
plan
Stop using cannabis +
nicotine products to prevent
advanced periodontal issues
Consent
FORMS:
Implementation
SECTION IV:
TX PROVIDED & TX REVISIONS
 Treatment Provided:
D4346 - Q4: D4346 - Q3: D4346 - Tissue
02/29/2024 03/08/2024 Maxillary arch: Evaluation:
Reviewed CC, Reviewed CC, 04/01/2024 04/01/2024
HHx/VS, HHx/VS, Reviewed CC, GD, PC, calculus
EO/IO/GD,LA, Calc EO/IO/GD,LA, Calc HHx/VS, EO/IO/GD, detection, cacluclus
detect, ultrasonic, detect, ultrasonic, Calc detect, removal *cavitron +
hand scale, polish, hand scale, polish, ultrasonic, hand manual scaling*,
PE/OHI PE/OHI scale, polish, PE/OHI biofilm removal
 Component 3: Implementation
Patient care:
How did J respond to care?
Is J more or less motivated?
Did J evaluate or notice their own progress +
healing?
Did J experience having postoperative pain
or sensitivity?
Self-care:
Summarizxe J’s progress with
preventive education plan and
discuss rationale for home care aids
or recommendations being
introduced or changed to meet
goals.
 Evaluation
SECTION V:
POST-TRETAMENT EVALUATION
Post-Treatment Evaluation:
1 Oral home care outcomes
1

2 Therapeutic outcomes

3 Discussion points with J

4 Future care recommendations

 Evaluation
SECTION VI:
STUDENT SUMMATIVE
EVALUATION OF THERAPEUTIC &
PREVENTIVE OUTCOMES
 Reflection:

What was learned Which modifications

from treating J’s would enhance
case? treatment outcomes?
Thank you!
SPRING 2024