Clinician Capstone Project

By Nancy Sarahi Serna Cabrera

In partial completion of the requirements for
DHYG Senior Capstone & Portfolio
September 25, 2019.
ASSESSESSMENTS
  Patient is a 25- year-old, Latino male. The patient presents
to Lake Washington Technical Institute Dental Clinic for a
comprehensive exam with full set of x-rays and would like a
cleaning, as well. The patient’s last cleaning was on March
2017 at Modern Dentistry located in Des Moines,
Washington. During the first visit to our clinic we asked the
patient to fill out a health history. The health history
indicated that he had a tetanus booster on February 1 st,
2018. He is under the care of a physician for palmoplantar
Health History hyperhidrosis and is currently taking glycopyrrolate 1mg
twice a day for this particular condition. Glycopyrrolate
helps the patient with the excessive sweating of the palms
of his hands and feet. This condition has significantly
affected him socially. The patient reports to have bleeding
gums when flossing every time only in certain areas of the
mouth. This has been going on for the last five years. Pt
wears a nightguard three times a week to protect his teeth
at night because he grinds during his sleep. He is allergic to
pollen.
Health History
Health History
Health History
 Upon arrival at his first appointment, we recorded the patients
vitals. His blood pressure wa 120/78 taken with a manual cuff on the
Health History right arm. His pulse was 68 beats per minute, regular beat. His
primary doctor is Healthpoint clinic in Federal Way.
 Hyperhidrosis is an excessive sweating condition. More sweat is
produced  than what is required by the body to thermoregulate.
Hyperhidrosis can leave a great impact in someone’s social life,
mental health, work, and study life. There are two types of
hyperhidrosis: primary and secondary hyperhidrosis. Primary
hyperhidrosis is idiopathic and involves the excessive sweating of
axillae, palms, sole, face, scalp, and inguinal folds. Secondary
hyperhidrosis is the result of a medication or medical condition.
Hyperhidrosis is thought to be the increased or uncontrolled
sympathetic stimulation of the eccrine sweat glands ( Jacob, 2018).
According to Carolyn I. Jacob, MD, people with primary
hyperhidrosis have an increased response to normal stimuli, like
stress. Studies have shown that hyperhidrosis affects what
everyday activities can be performed, can influence the clothes
someone wears, or career/ job opportunities. This is according to
63% of the study participants. The impact that hyperhidrosis has in
someone’s life has been found to be equal or greater than someone
who suffers from psoriasis, severe acne, Darier disease, Hailey-
Hailey disease, vitiligo, and chronic pruritus. Having hyperhidrosis
can also lead to skin infections. This condition puts patients into
high risk of fungal, bacterial, and viral infections ( Jacob, 2018).
 One of the treatment options for hyperhidrosis is
glycopyrrolate. Glycopyrrolate is a systemic treatment and
is used to treat primary hyperhidrosis (Ozcan and Gulec,
2014). It is an adjunctive treatment for peptic ulcer disease
and chronic drooling but also decreases sweat.
Glycopyrrolate has quaternary ammonium, it is highly polar,
and can not pass the blood-brain barrier. Since it can not
pass the blood-brain barrier it does not have central nervous
system effects (Ozcan and Gulec, 2014). A study done in
2012 tested the efficacy of glycopyrrolate, and showed the
reduction in perspiration in 75%. A side effect of
glycopyrrolate is dry mouth, which was reported in 38.6%
participants taking this medication ( Jacob, 2018). In
conclusion, hyperhidrosis brings down the person’s self-
esteem, confidence level, and can affect a person’s life in
every aspect. A person’s quality of life can be severe limited
by hyperhidrosis.
 Only a few things were noted in the patient’s Initial extraoral
and intraoral assessments. He had a scar on the forehead
12x4mm due to an accident during his childhood. Masseter
Extraoral muscle was pronounced bilaterally upon palpation. Patient
reports that he grinds his teeth at night and he wears a
Assessment nightguard. Scattered macules over the patient’s face.
Chicken pox scar on the right side of the nose.
Picture of
scattered
macules
  Upon the initial intraoral examination a maxillary tag was noted
on the frenum. Anterior pillars were red. Gingiva was slightly
pigmented. Above tooth #10 there was a circular raised bump that
Intraoral measured

Assessment  2x2mm, well circumscribed borders, sessile, elevated, white color,

semifirm consistency, and smooth texture. Located on attached
gingiva above tooth #10. Patient reports no symptoms and did
not noticed it before I showed him on the mirror. No refer needed.
Intraoral
Assessment

2x2mm, well circumscribed borders, sessile, elevated, white

color, semifirm consistency, and smooth texture. Located on
attached gingiva above tooth #10. Patient reports no
symptoms and did not noticed it before I showed him on the
mirror. No refer ne
  The initial condition of the maxillary gingiva was noted as
generalized slight erythematous, slight edematous, knife
Gingival edge, and smooth surface. On the mandible the gingiva was
generalized moderate erythematous, slight edematous,
Description knife edge, and smooth texture. There was localized severe
erythematous, edematous, rolled margins, and glossy
texture on teeth #21-27.
Tooth Chart
 A current tooth charting was completed based on clinical examination and a
doctor’s examination supplemented by a full mouth series of radiographs.
Impacted wisdom teeth:#1, #16, #17, and #32.
Attrition was present on the incisal surfaces if teeth #6-11 and #22-27. The
Tooth Chart contacts were open between #6 and #7. #22 and #23 were linguoverted
and #24 was buccalverted. Width of attached gingiva is generalized on the
mandible with less than 2mm of attachment. The patient has existing
sealants on teeth #2 and #14. He had six existing composite restoration on
the occlusal surfaces od the molars and premolars. Two of these were
interproximal. There is also an existing occlusal amalgam filling on tooth
#30.
  Occlusion was noted as Angle’s Class I on the right and left molar
Occlusion and canine relations. He had a slight overbite., an overjet of 4mm,
no crossbite and no open bite.
Study Models
Periodontal
Chart
  The patients ’s initial periodontal assessment noted
generalized moderate to heavy bleeding upon probing.
Pockets depths were generalized 2-3mm with localized 4-
Periodontal 5mm pockets interproximally. Gingiva recession was
recorded as generally 1-2mm. There were no furcations or
Chart mobility noted.
Risk
Assessment
Risk
Assessment
 The patient’s risk assessment reports health history findings,
prevention survey, clinical and radiographic findings, plaque index,
findings in hard tissues and soft tissues, and oral hygiene habits and
goals. His health history reports that he has a endocrine problem
called palmoplantar hyperhidrosis. He takes the medication,
glycopyrrolate, 1mg twice a day. He has sore bleeding gums, grinds,
and uses a nightguard. The patient understands oral status, values
prevention, wants oral hygiene instructions and product
recommendations, and its open to new information. He lives in a
Risk fluoridated water and drinks bottled water. According to the CDC, the
use of fluoride controls tooth decay. The CDC supports the expansion
Assessment of community water expansion to reduce the imbalance of dental
disease among Americans (Horowitz, 2003). He gets an annual
physical, follows medical and dental advice, his stress load level is low,
and exercise is moderate. His diet consists of medium sucrose and
carbohydrates intake, mainly from bread, juice, pastries, and candy.
Studies have shown that carbohydrates and starches are cariogenic.
Bread and juice are starchy foods has been assessed to be highly
retentive in the mouth, and can be retained in the mouth for 20
minutes increasing the risk for caries (Bradshaw and Lynch, 2013).
 During the clinical and radiographic assessment, intraorally and extra
orally findings were within normal limits. There were 1-7 existing
restorations, amalgam and composite. The periodontium showed
moderate plaque and calculus, heavy bleeding on probing, and
localized loss of width of attached gingiva. The patient has
generalized horizontal bone loss, less than 25%. Attrition, abrasion,
bone loss, bruxism, occlusal trauma, calculus, plaque, and maligned
Risk teeth are clinically present. Patient is at risk for attrition, abrasion,
bone loss, chipped or broken teeth, bruxism, occlusal trauma, calculus,
Assessment plaque, and maligned. His soft tissues are clinically evident and at risk
for gingival recession, gingivitis, and periodontal disease. The patient
reports to use a mechanical soft toothbrush. He brushes his teeth
twice a day, uses floss pick, flosses once a week, and uses tartar
control toothpaste. My goal for the patient is to floss twice a week.
The CDA journal recommends to floss twice or more because is more
significally effective than doing it once or less (Featherstone,
Domenjean-Orliaguet, Jenson, Wolff, Young, 2007)
Radiographs

Gerardo did not remember when his last full set of radiographs were
taken. Comprehensive exam required a full mouth of radiographs.
Radiographs

 Panoramic radiograph was ordered by the doctor to see position

of all four wisdom teeth.
 The patient reported that he brushes once a day, usually in the
morning. He uses a soft, manual toothbrush. He flosses irregularly,
Oral Hygiene maybe once a month. Sometimes he uses Listerine mouthwash,
once a week.
  Patient present to Lake Washington Institute of Technology
Patient’s Chief for a dental examination and cleaning. The patient is
Concern concern about his gums bleeding every time he flosses.
  Upon doctors examination, no decay was found, but teeth
Dental #17 and #32 were recommended to be extracted because of
Examination their mesially drifting.
Treatment
Plan
Plaque Index
The patient has 28 erupted teeth, the wisdom teeth are unerupted.
59 areas of plaque were found and divided by 112 tooth surfaces.
Plaque index was 52%. Plaque was mostly found on cervical areas of
mandibular teeth on the lingual surface and also generalized
interproximally.
Food Intake
Record
Nutritional
Counseling-
Patient
History Form
Diety History
Food Intake
Record
9/22/19