CASE DOCUMENT

Student’s Name: Olivia Parshall

NOTE: Remove the patient’s name from all forms and the document.

*Include a copy of your CPE

*Include a copy of Initial Periodontal Assessment
*Include a copy of the Periodontal Reassessment
*Include a copy of all Patient Education Sessions (INCLUDING PCR)
Use this working document to type in your patient’s data and present your patient’s case.

A. PATIENT PROFILE

DESCRIBE IN DETAIL THE PATIENT’S PAST AND PRESENT SOCIAL HISTORY:

The patient is a 21yo female who presents for a dental cleaning. It has been between 1-2 years
since her last cleaning. She works full-time at Printpack and often works between day shifts and
night shifts, usually spanning from 10–12-hour shifts. She has some college education in
accounting but did not finish her degree and might go on to finish that up soon. She enjoys
hanging out with friends, going out to eat and having an alcoholic beverage.
 White  Single  Student Highest Education
Age: 21yo  Hispanic or Latino  Married  Employed (Full- Level Obtained:
 Black or African  Divorced time)  Some High
 Male American  Widowed  Employed (Part- School
 Female  Native American or  Separated time)  High School or
 Other: American Indian  Self-employed GED
 Asian/Pacific  Unemployed  Some College
________ Islander  Retired  Associate’s
_  Other  Unable to work Degree
 Bachelor’s Degree
 Master’s Degree
 Professional
Degree
 Doctorate Degree

DESCRIBE IN DETAIL THE PATIENT’S CHIEF CONCERN:

The patient presents for a dental cleaning. 1-2 years has lapsed since her last cleaning. She is
concerned about her lower anterior teeth and the swelling, redness and bleeding that she is
seeing in her gums. She also would like to get her teeth cleaned up as she has seen calculus
accumulating on her teeth.
B. ASSESSMENT

DESCRIBE IN DETAIL THE PATIENT’S PAST AND PRESENT MEDICAL HISTORY:

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The patient has a history of a heart murmur but does not take medication (or pre-medication for
dental) or see a cardiologist. She also has a history of recurrent bronchitis for which she has an
inhaler to use during active infection. She did have an asthma attack 3 months ago for which she
visited the ER. Prior to that she was not diagnosed with asthma. The attack seemed to come out
of the blue and was not exercise induced. She does not see a physician regularly as she stated she
“does not like going to the doctor.” Her last physical exam was in 07/2023 when she visited
occupational health for her job. There was nothing abnormal noted at that appointment.

 Heart Disease  Radiation Therapy

 Heart Attack  Chemotherapy
 Congestive Heart Failure  Abnormal Bleeding
 Rheumatic Fever  Diabetes (Type1/Type2)
 Mitral Valve Prolapse  Epilepsy
 Heart Murmur  Seizures
 Artificial Heart Valve  Multiple Sclerosis
 Cardiac Stent  Parkinson’s Disease
 Pacemaker  Emotional/Anxiety Disorder
 High Blood Pressure  Thyroid Condition
 Low Blood Pressure  Appetite Suppressant Drug Use
 Stroke  Venereal Disease
 Arthritis  HIV Positive/AIDS
 Artificial Joint (Knee/Hip)  Cold Sore
 Artificial Pin/Screws/Plates  Aphthous Ulcer
 Respiratory Disease – Recurrent  Rapid Weight Loss
bronchitis  Night Sweats
 Asthma  Swollen Lymph Nodes
 Emphysema  Unexplained Fevers
 Tuberculosis  Significant Hearing Loss
 Liver Disease  Significant Visual Impairment
 Hepatitis  Chronic Headaches (Migraines)
 Spleen Removal  Fainting
 Kidney Problems  Pregnant
 Organ Transplant  Tobacco Use (Smoking/Smokeless)
 Blood Transfusion  Alcohol/Drug/Substance Abuse
 Cancer (Leukemia/Skin/Breast)
MEDICATIONS
NAME/DOSAGE DENTAL SIGNIFICANCE
 Albuterol sulfate inhaler PRN for shortness of  Xerostomia.
breath.

Dental History
 Orthodontic Treatment – Full mouth  Xerostomia

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 orthodontics, details in below paragraph.  Sensitive Teeth
 Surgery (Jaw/Implants/Extractions) – All four  Oral Habits
third molars extracted.  Accidental Injuries (Teeth/Mouth/Jaw)
 Candidiasis  Toothaches/Infections
 Bad Taste/Halitosis
 Jaw Joint Problems (Pain/Clenching/Grinding)
DESCRIBE IN DETAIL THE PATIENT’S PAST AND PRESENT DENTAL HISTORY:

The patient is an established patient at Acacia Lane Dental in Rhinelander, WI. Prior to
adulthood she did visit the dentist at least 1x per year for a cleaning. When she was 15yo she
underwent orthodontic treatment at Schmidt Orthodontics in Rhinelander, currently known as
Bruce Orthodontics. She had traditional wired braces for about 1.5 years. Following removal of
the braces, a maxillary and mandibular lingual bar was placed. She was also given clear
vacuumed formed retainers. In about 2020-21 her mandibular lingual bar came off. She went
into the orthodontist and opted not to have it replaced. She continued to wear her clear retainers
after that. She complains that the maxillary lingual bar is so close to her gum-line that it is very
difficult to clean and is sometimes bothersome. She uses floss picks to floss up to the lingual bar,
then uses the pick end to clean the top. She is not able to thread floss through the bar herself.

She has a history of oral surgery for the extraction of all 4 third molars. She underwent this
surgery in about 2016 in Wausau, WI. She is unsure of the surgeon or the office where her teeth
were extracted. She had no complications following the procedure.

She has sealants on #3 and #14 and an occlusal resin on #18. Other than that, her orthodontics
and third molar extractions she has had no significant dental issues or work in the past.

Radiographic Findings
 Incipient Caries  Drifting of tooth
 Recurrent Caries  Supraversion or infraversion
 Horizontal Bone Loss  Poor Contact
 Vertical Bone Loss  Open Contact
 Loss of Crestal Lamina Dura  Periapical Pathology
 Widening of Periodontal Ligament Space  Impaction
 Furcation Involvement  Retained Root
 Calculus  Fracture
 Overhanging Restoration  Missing Teeth
 Poor Margin of Crown or Restoration  Retained Deciduous Tooth
DESCRIBE IN DETAIL THE PATIENT’S RADIOGRAPHIC FINDINGS:

The patient’s radiographic findings showed #1, #16, #17 and #32 have been extracted. There were
no other significant radiographic findings. The patient’s radiographs showed more than adequate
bone levels, adequate contacts and margins and no dental decay.

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Intraoral/Extraoral Findings
 Muscles  Vestibule
 TMJ  Labial/Buccal Mucosa
 Fremitus  Floor of Mouth- slight, bilateral mandibular
 Lymph Nodes – Bilateral submandibular lymph tori.
nodes, moveable, non-tender, pea sized/slightly  Hard/Soft Palate – palatal tori.
larger.  Tonsillar Area
 Thyroid/Trachea  Tongue
 Lips  Occlusal Analysis
 Frena-Low frena attachment, maxillary facial.
DESCRIBE IN DETAIL THE PATIENT’S INTRAORAL/EXTRAORAL FINDINGS:

Extraoral:
The patient’s general appearance of the face showed that she has 2 nose piercings. Her facial
structure and skin appeared otherwise normal. She had bilateral submandibular lymph nodes
present, they were movable, non-tender, and pea-sized or slightly larger.

Intraoral:
She had a low frena attachment on the maxillary facial. Bilateral Linea-alba (patient admits to
biting her cheeks on occasion). There were both palatal tori and slight bilateral mandibular tori
present.

Angles classification:
Class I bilaterally on both the canines and molars. Profile: mesiognathic. Lip closure: complete.

Inter-arch alignment:
Vertical overlap was 20% and horizontal overlap measured 3 mm. There was no crossbite, open
bite, edge or end to end, or midline deviation noted intraorally. There were no “versions” such as
linguoversion, buccoversion, torsoversion, supraversion, or infraversion. There were also no areas
of crowding present.

Teeth:
There was attrition and wear facets present on #6-11 and #22-27. Reduced enamel quality found
throughout including #3,4,14,15,19,21,23,28,30. Especially on the cusp tips and incisal edges of the
teeth listed.
Dental Charting
 Sealants
 Abscess
 Fracture
 Caries
 Extraction
 Amalgam Restoration
 Resin Restoration

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 Crown
 Bridge
 Partial
 Denture
 Implant
 Root Canal

DESCRIBE IN DETAIL THE PATIENT’S DENTAL CHARTING:

The patient’s dental charting included the following findings: #1,#16,#17 and #32 have been
extracted. There is a sealant on #3 occlusal. There is a lingual bar that extends from #7 to #10.
There is a sealant on the occlusal of #14. There is an occlusal resin on #18.
DETERMINE DEGREE OF DIFFICULTY (DOD): 2 DOD
Quad 1 Quad 2
Overall Perio 0 1 2 3 4
Supragingival Deposit/Stain 0 1 2 3 Supragingival Deposit/Stain 0 1 2 3
Subgingival Deposit 0 1 2 3 Subgingival Deposit 0 1 2 3
Quad 4 Quad 3
Supragingival Deposit/Stain 0 1 2 3 Supragingival 0 1 2 3
Deposit/Stain
Subgingival Deposit 0 1 2 3 Subgingival Deposit 0 1 2 3
Overall DOD: ______2______
DESCRIBE IN DETAIL THE PATIENT’S PRE-TREATMENT GINGIVAL CONDITIONS:
INITIAL SBI SCORE → 37%
Quad 1:
Margins:
 Slightly rolled but pink on #2-3 buccal.
 Red and rolled on #6-8 facial.
 Slightly rolled but pink on #2-5 lingual.
 Red and swollen on the lingual of #6-8.
Papilla:
 Red and enlarged on #6-8 lingual.
 Bulbous and red between #8-9 lingual.
 Red and slightly enlarged between #5-9 facial.
There is stippling on the facial of the gingiva around #5. There were 10 areas of bleeding in quad 1.

Quad 2:
Margins:
 Slightly red, rolled and swollen on #9-10 lingual.
 Rolled and pink on the lingual of #11-13.

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 Papilla:
 Red and enlarged between #9-12 facial.
 Bulbous and red between #8-9 and #9-10 lingual.
Tissue is most swollen, red and edematous on the lingual of sextant 2.
There were 11 areas of bleeding in quad 2.

Quad 3:
Margins:
 Rolled but pink on #18-21 buccal.
 Slightly red and rolled on #22-23 facial.
 Very red, swollen and edematous on #24-25 facial.
 Red and slightly rolled on the lingual of #18-19.
 Red, swollen and rolled on the lingual of #22-23.
 Very dark red, swollen and edematous on the L of #24.
Papilla:
 Red and enlarged between #22-23 facial.
 Red and enlarged between #21-22 lingual.
 Somewhat blunted on #24-25 facial with moderate swelling, edema, redness and bleeding.
There were 10 areas of bleeding in quad 3.
Bleeding in sextant 5 when touching the tissue with a gloved finger.

Quad 4:
Margins:
 Rolled on the buccal of #28-31 but are pink in color.
 Very dark red, rolled, swollen and edematous on the facial of #25-26 and #27, but #27 is slightly
less red and milder.
 Red and rolled on #29-31 lingual.
Papilla:
 Very dark red, bulbous between #25-27 facial.
 Enlarged but pink in color between #27-28 buccal.
 Red on the lingual of #29-31.
 Very dark red and slightly blunted on the lingual of #25-27.
 Slightly enlarged on the lingual of #27-28.

There is visible calculus throughout but especially in sextant 5, the molars and the lingual of sextant 2.

C. DIAGNOSIS

SUMMARY OF SIGNIFICANT FINDINGS

AAP Case Type  Healthy  Type I  Type II  Type III  Type IV  Type V
(Gingivitis)

CAMBRA  Low  Moderate  High

Motivational  Physiologic  Safety  Belonging  Esteem  Self-Actualization

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 Level

DH Diagnosis  Healthy  Gingivitis  Periodontitis

DH Prognosis  Excellent  Good  Fair  Poor  Questionable

DESCRIBE IN DETAIL THE PATIENT’S POST-TREATMENT GINGIVAL CONDITIONS:

SBI Score → 11%
Quad 1 (UR)
Margins are slightly rolled on #2-3 buccal but pink in color. Margins are slightly red and rolled on #6-8 facial.
Margins are slightly red and rolled on #6-8 lingual. Margins are slightly rolled but pink in color on #3-5 lingual.

Papilla is slightly red between #7-8 facial but not enlarged. Papilla is slightly enlarged and red between #7-9
lingual.
Quad 2 (UL)
Margins are slightly rolled but pink on #9 and #11 facial. Margins are rolled but pink on #14-15 buccal. Margins
are rolled but pink on #11 #12 and #13 lingual. Margins are red and rolled on #9 and #10 lingual.

Papilla is slightly red between #8 and #9 facial and red and enlarged between #8 and #9 lingual.

Quad 3 (LL)

Margins are slightly rolled but pink on #18-#23 buccal/facial. Margins are slightly red and rolled on #25 facial
and lingual in comparison to the first gingival conditions which were very fiery red and inflamed. Margins are
slightly rolled but pink on #18-20 lingual. Margins on #22 and #23 lingual are slightly darker pink and rolled.

Papilla is slightly red between #23, #24 and #25 facial and lingual. In comparison to the original gingival
conditions that were fiery red and enlarged.

Quad 4 (LR)

Margins are very slightly rolled but pink on #27-#31 buccal. Margins are slightly rolled and red on #25-26 facial
but much less inflamed and red in comparison to the original gingival conditions. Margins are very slightly
rolled and red on #25-26 lingual. Margin on #27 lingual is slightly rolled but pink. The margins on #30 and #31
lingual are slightly rolled and slightly red.

Papilla is slightly red between #25 and #26 facial and lingual. It is much less enlarged than the original
recordings if enlarged at all.

There is some visible calculus beginning to form on the facial and lingual in sextant 5.

D.
E. F. PLANNING

PROVIDE A DETAILED RATIONAL FOR CASE SELECTION

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“I selected this patient because…” She had significant redness and edema in sextant 2 and 5 that
was very tender and bothersome both physically and esthetically. She had reversible gingival
conditions that I could work on getting back to health after removing calculus, providing laser and
patient education. This patient was very open to being my case doc patient and was very interested in
seeing her tissues return to health. She is also compliant and open to working on her oral health at
home.

Goals

 Reduce SBI by 30% by probing at the reassess.

 Decrease PCR by 25% by PCR at every appointment and recall.

 Improve gingival health by performing LBRT.

TREATMENT SEQUENCE
DESCRIBE IN DETAIL THE TREATMENT SEQUENCE FOR THE PATIENT’S PAST AND
PRESENT DENTAL HISTORY: Below is the treatment sequence that I followed with my case
doc patient.

Appointment Treatment and Services

1  Medical History/Temp
 Intraoral/Extraoral exam
 Radiographs - Bitewings
 Periodontal Assessment

2  RMH/Temp
 Periodontal Assessment
 PCR/Patient Education
 Scale quad 4 (Oraquix inserted by RDH instructor, ultrasonic quad 4 then handscale)

3  RMH/Temp
 PCR/Patient Education
 Slimline, de-plaque quad 4
 Laser quad 4
 Laser quad 1
4  RMH/Temp
 PCR/Patient education
 Scale quad 1
 Scale quad 2 and 3 (ultrasonic quad 3, then handscale)
 Dental Charting
 Polish (Engine)
 Floss
 Fluoride varnish
5  Reassess Appt

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  RMH/Temp
 Gingival Conditions
 Probe depths
 SBI
 Slimline de-plaque
 Recall 4 months, patient agreed to 4 months’

G. IMPLEMENTATION

DESCRIBE IN DETAIL THE PATIENT’S CARE PLAN:

The patients ASA is II. She has a heart murmur for which is controlled, and no pre-medication is
required. She also has recurrent bronchitis that is treated with an inhaler as needed. We will
make sure to update her vital signs at each appointment to avoid medical emergency.

The patient brushes 1-3 times per day with a hard bristle manual toothbrush, she uses Crest
Scope toothpaste with fluoride. She uses floss picks about 1 time per day along with a
mouthrinse.

She had a low frena attachment intraorally on the maxillary facial, palatal and mandibular tori
and generalized reduced enamel quality. The highest probe depth was 4 mm. Many areas of very
red swollen gingiva were present, especially in sextant 2 and 5.

Risk factors:
Local: she has a maxillary lingual bar that is close to the gum line and causes irritation. There is
red inflamed gingiva and sub and supragingival calculus.
Systemic: recurrent bronchitis with inhaler use that can cause xerostomia, otherwise N/A. She
does not use tobacco products.
Nutrition: patient eats out 2-3x per week. She does not drink sugary beverages but occasionally
sips on iced coffee throughout the day, which is acidic and can lead to staining and enamel
decalcification.

CAMBRA:
Her CAMBRA was low risk. She has fluoride exposure through toothpaste, her sugar exposure is
primarily at mealtimes, she has an established dental home, no eating disorders, chemotherapy,
drugs or alcohol abuse. No carious lesions or teeth missing due to caries in the past 36 months, no
interproximal restorations, no exposed root surfaces, open contacts or poor margins and no
severe xerostomia. All these reasons placed her in the low-risk category. The only check marks in
the moderate column were visible plaque and dental/orthodontic fixed or removable appliances.
Although a lingual retainer and plaque can harbor and act as an attachment site for bacteria, I
felt that the conditions in the low-risk category outweighed the conditions in the moderate risk,
especially since given the proper prophy and home care regime the patient can maintain her low
risk for caries.

Dental Hygiene Diagnosis:

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Problem Related to…
BOP – Inadequate biofilm removal
Visible plaque and calculus – Inadequate biofilm removal
RED, inflamed gingiva – Inadequate biofilm removal

Specific goals:

 Maintain PT comfort by discussion with patient at every appointment and recall.

 Decrease SBI by 30% by probing at the reassess.
 Decrease PCR by 25% by PCR at every appointment and recall.
 Improve gingival health by performing LBRT.
 Decrease calculus build up by scaling and educating on proper home care at every appointment and
recall.

Education/counseling: Discuss the gingivitis disease process and how it can eventually lead to
periodontitis and tooth loss. Introduce Electric TB and water-pik. Discuss that if patient is using
a manual toothbrush, a soft bristle would be best. Discussed introducing a floss threader, but
even as the operator, the placement of the patient’s lingual bar is extremely difficult to get a floss
threader underneath. A water-pik would serve the same function and help control biofilm
around and under the lingual bar as well as the interproximal spaces.

Patient Education Sessions:

09/26/23 Patient Education

Patient's current PCR: 12.5%

Patient's current oral hygiene practices: Patient brushes 2x DAILY with a hard bristle TB. Patient uses floss
picks on occasion.

Patient's dexterity level: Normal

Patient education recommendations: Recommended electric toothbrush and or water-pik.

Dietary counseling/tobacco cessation/CAMBRA: Low

Patient's comments to recommendations (verbal commitment with quotations): Patient did go buy an electric
TB. She uses it 2x daily. Patient is interested in using a water-pik and might order one.

Oral hygiene aids/products given to patient: None yet.

10/11/23 Patient Education
Patient's current PCR: 20%

Patient's current oral hygiene practices: Brushing 2x daily with electric toothbrush. Placing the head on each
tooth surface, making sure not to press too hard. Crest scope or kids’ bubblegum toothpaste. Flossing about 5x
weekly.

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 Patient's dexterity level: Normal

Patient education recommendations: Flossing 1-2x daily. Make C shape around tooth with floss. Continue with
brushing with electric toothbrush 2x daily to disrupt plaque biofilm.

Dietary counseling/tobacco cessation/CAMBRA: Low CAMBRA.

Patient's comments to recommendations (verbal commitment with quotations): Pt will continue to floss daily and
use electric tb. Has noticed better tissue health in quad 4.

Oral hygiene aids/products given to patient: Toothbrush, floss, Crest Densify, mouth rinse.

10/31/23 Patient Education

Patient's current PCR: 25%

Patient's current oral hygiene practices: Patient brushes 2x daily with electric toothbrush. Patient is flossing 1x
daily with floss pics.

Patient's dexterity level: Normal

Patient education recommendations: Continue brushing 2x daily with electric TB. Try to incorporate regular
string floss especially in the lower anterior. It looks like she accumulates calculus IP very quickly. Flossing will
help disrupt the biofilm before it hardens.

Dietary counseling/tobacco cessation/CAMBRA: Low

Patient's comments to recommendations (verbal commitment with quotations): Patient will continue to brush 2x
daily with electric TB and floss 2x daily with floss picks and incorporate sting floss into her flossing routine
making sure to form the floss in a "C" around the tooth.

Oral hygiene aids/products given to patient: None.

Treatment Revisions
 Instructor recommended that I add electric TB and water-pik to the care plan.
 Oraquix administered by instructor for topical anesthetic in sextant 5.

H.I. EVALUATION

REFLECTION UPON AND DESCRIBE IN DETAIL THE RESULTS OF THE PROVIDED

TREATMENT:

When my patient came in initially, she had fiery red, inflamed gum tissue in sextant 5. It bothered her
both because it was uncomfortable and bled significantly when she brushed and that it didn’t “look”
right. I recorded very specific gingival conditions initially as I really wanted to compare the changes

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intraorally come time for her reassess. In between each appointment I could see small improvements in
her gingival conditions and overall oral health. Prior to treatment the tissue was also very easily
displaced with air and deposit could be seen under that tissue when air was applied. After LBRT and
scaling (both ultrasonic scaling and hand scaling) the tissue became tighter to the tooth, less red and
less swollen. The patient also made changes in her home oral care routine, buying an electric
toothbrush and starting to increase her flossing frequency. That also lead to the improvement in her
oral health.

When she presented for her reassess, and I evaluated intraorally, I was amazed. The patient reported
almost no bleeding when brushing, compared to significant bleeding prior to treatment. She stated she
is more comfortable with how her teeth/gums look and feel. The tissue was slightly darker pink in
color, tight to the tooth and no inflammation was present. I took detailed post treatment gingival
conditions as described in this paper. There were significant changes in gingival conditions and probe
depths, especially around the maxillary and mandibular molars and in sextant 5.

There was some calculus build up already occurring in sextant 5 despite the patient flossing daily and
brushing 2x daily with an electric toothbrush. I believe the patient just accumulates calculus more
quickly than normal. This is why I put her on a 4-month recall for another prophy to remove deposit
and check up on her gingival, periodontal health and home care routine. At that time, we can reevaluate
her recall status.

J. REFLECTION OF OVERALL PROJECT

This project was very rewarding. Dental Hygiene school is difficult and sometimes it feels like nothing
is going right and I don’t necessarily see the difference I am making. This project allowed me to really
lay out the pre and post treatment findings and see the positive changes that were made. What really
stunned me more than that was simply looking intraorally at the first appointment vs at the reassess.
Just the visual of healthy tissue just a month after seeing how inflamed and angry her tissue was the
first time, further motivated me to make a difference in every single patient’s oral health. Whether it be
a patient who already has a meticulous home care routine and almost “perfect” health or a patient who
has no regard for oral health and doesn’t every brush.

I believe that this project is very fitting for process III. We, as students, are at the point where we have
learned a lot, seen many patients but haven’t had the chance to perform advanced procedures on a
patient who is suffering from gingivitis. This project had us compile every aspect of clinic that we have
done up to this point, put it into action, and add treatment such as LBRT to our patient. This project
was a great eye opener about not only how to treat a patient with reversible gingival conditions but to
give our all for each patient we see and praise them for the positive changes they have made with their
oral health. And pat ourselves on the back afterwards as well. There was nothing about the project that
I thought was not relevant or exciting to do.

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