CASE STUDY

BY NATASHA LONDON DH2

PATIENT OVERVIEW
24 year old male
Last dental exam, cleaning and dental radiographs
(BWS) were in 2011; Smokes 2 packs/week

Chief Concern: Patient suspects cavities in the molar

region
Patient required Nonsurgical Periodontal Therapy (NSPT)

Deposit Evaluation: 3 supra/3 sub

Periodontal Case Type II, slight periodontitis

FIRST HYGIENE APPOINTMENT

Perio charting
Tissue assessments
Probing
Microscope
FMS
Full impression
Intraoral Photos

PERIO ASSESSMENT

PRETREATMENT ASSESSMENT
Tissue assessments revealed generalized moderate
hyperemic, moderate enlarged and moderate
edematous tissue
Microscope revealed highly motile spirochetes,
gliding rods and spinning rods, too numerous to
count. Risk factor C
Probing depths: 1-5mm pockets (#16 is not fully
erupted and has one 6 mm pocket). No recession.
Generalized moderate bleeding on probing (BOP)

PRETREATMENT ASSESSMENT
Extraction of #1, 16, 17, & 32 recommended (to be
completed at the Reservation Clinic)
E/O and I/O were within normal limits

Upper Right,
moderate plaque

Upper Left,
moderate calculus

RADIOGRAPH FINDINGS

RADIOGRAPH FINDINGS
Radiographs revealed slight horizontal bone loss
# 1, 17, & 32 were unerupted

No caries were seen radiographically (or clinically)

much to the patients relief
Localized heavy calculus

Right Side

Front View

Left Side

RISK ASSESSMENT
Systemic and Behavioral Risk Factors
Irregular dental care
Use of tobacco (cigarettes and smokeless tobacco)

Caries Risk Factors

Moderate plaque biofilm
High sugar exposure (Daily soda)

Periodontal Risk Factors

Moderate plaque and calculus
Moderate bleeding on probing
Slight malpositioning in lower anteriors

RISK ASSESSMENT
Client centered goals

Remove third molars

Remove calculus
Improve home care
Cease using smokeless tobacco products (the patient was
not ready to discuss cigarette cessation)

Interventions
Oral homecare instructions
NSPT
Provide education on tobaccos effect on the oral
environment
Provide resource for tobacco cessation programs

RISK ASSESSMENT

Expected outcomes
Decreased plaque biofilm at
subsequent visits
Decreased bleeding and
inflammation

Removed calculus deposits

Tobacco cessation
Upper Right

TREATMENT PLAN
Treatment Plan
Comprehensive oral evaluation, FMS, Local anesthesia,
Periodontal scaling UR,LR, UL, LL; OHI, Application of fluoride
varnish

Rationale based on clinical knowledge

Oral evaluation with FMS to determine caries and oral
pathology. NSPT to decrease deposits, risk of bone loss and
aid in oral homecare. Application of fluoride to reduce
sensitivity and encourage remineralization.

Rational based on behavioral and cultural

knowledge
I suggested decreasing soda intake as well as encouraging
efforts in tobacco cessation.

MOTIVATION STRATEGIES
Intrinsic

Extrinsic

Patient was motivated

to improve oral
hygiene methods
Patient was motivated
to cease smokeless
tobacco use

Fianc was
encouraging him to
get his teeth cleaned
before their wedding,
as well as quit smoking

How were intrinsic and extrinsic motivations utilized in OHI?

At every appointment I reviewed his gingival health, encouraged
his tobacco cessation, and reviewed past OHI suggestions while
introducing new methods.

SECOND HYGIENE APPOINTMENT

LR & 2-3
Vitals: 111/76, resp 16, pulse 81
Local Anesthesia

Right IA, Right Long Buccal, Right PSA, SPs #2,3,24,25

Patient had difficulty reaching profound anesthesia

Ultrasonic and handscaled lower right quadrant

Polished entire dentition and applied fluoride varnish
OHI: Patient had less plaque biofilm for this appointment. Slight
plaque was found in the interproximal areas; reviewed sulcular
brushing and introduced c-shaped flossing
Patient reports to have ceased using smokeless tobacco after
the previous appointment

THIRD HYGIENE APPOINMENT

UR, UL, LL
Vitals 138/71, resp 18, pulse 93
Local Anesthesia
Left IA, Left PSA, Left and Right MSA, Left and Right ASA

Ultrasonic and hand scaled UR (#4-8), UL, and LL quadrants

OHI: Patient was still doing well with homecare and had even
been flossing a few times per week. Patient had difficulty with
the malposed lower anterior teeth. Demonstrated cleaning
the lower anteriors with the toe of an Oral-B 30 toothbrush,
encouraged flossing frequency and use of soft-piks.
Patient is still not using smokeless tobacco

CONTINUING CARE APPOINTMENT

Patient was married shortly after his last
appointment and became unavailable to take
time off of work to return for a recare appointment
Based on his home care progress, had he been
able to return, I would have expected to see
improvements in gingival bleeding and pocket
depths.

REFLECTIONS
I was very happy with the outcome of this patients
treatment. He seemed to be picking up on the oral homecare
well and was motivated to stay with it. His brushing technique
improved with each visit. I was so happy for him that he was
attempting and succeeding at quitting smokeless tobacco. I
hope that he is able to keep it up.
He was the first 3 sub patient that I saw and I was surprised
at his level of bleeding, especially considering that he smoked. I
felt that I was able to scale everything well. The anesthesia
challenges with this patient taught me a lot. Not only how to
troubleshoot, but with how to explain how the anesthesia
worked to a patient.
I saw this patient in Fall term and I feel like I have learned
a lot more since then (including taking better notes!).