Clinical Case Study
By: Victor Arevalos
Assessment
Patient “AA” is a 37-year-old
Demographic and man, with a Hispanic/African
background
Health History Allergies: NKDA
Cc: “ Im here to establish care
since I just moved from Texas”
Health History
ASA: III
Vital signs *at the initial exam
BP: 1st 134/99, 2nd 195/100, 3rd 148/101
P: 90
R: 18
Physical characteristics
Ht: 5'11, Wt: 222
Medical history:
prediabetes, uncontrolled high blood pressure, antisocial personality
disorder, major depressive disorder
Pharmacologic history: Occasional NSIDS, Amlodipine, Wellbutrin
Medical or Dental History: No established PCP nor prior dentist.
Other: The patient consumes a lot of sodium and alcohol.
Treatment modification/Contraindications
Medical/ Dental Indication:
Amlodipine risk factor for gingival overgrowth
Wellbutrin can increase the risk of xerostomia
Patients with depression and anxiety disorders are at risk for periodontal disease,
caries, and tooth loss linked to a loss of motivation with self-care. (Kisely et al.,
2016).
Hippa Compliance
To comply with HIPAA laws, patient identifying
information has been changed to protect the privacy
of the patient.
Any pictures with personally identifying information
are blurred.
Pictures with patient information taken for this
project will be permanently deleted from personal
devices.
Clinical Assessment
Clinical Assessment
Intraoral
photos taken
during comp
exam and prior
to NSPT
Gel ID plaque
Pink: New plaque
Blue: Old plaque
Light blue: High risk plaque
Dental History & Risk Assessments
Dental Hx: AA stated that he hasn't been to the dentist regularly due to him not
staying in one particular city or state for very long. Also
Slight and generalized radiographic calculus and bone loss
No carries at the exam
Stain: Moderate
Plaque: Moderate
Tooth Chart
Caries Risk Assessment
AA was deemed HIGH risk.
EO/IO/GD
EO: WNL
IO: Mod-coated tongue and Lesion
noted on tongue
GD: Gen un, gen mod pink with loc
diffused slt melanin pigmentation, gen
slight rolled, loc mod blunting on ants,
gen soft/spongy, gen stippling, loc
recession.
Lesion: Multiple white patches
15x10mm, lateral surfaces of the
tongue, white in color, irregular boards,
pt reports present since 2022, asym,
benign per Dr “XX”, referral for biopsy
Radiographic Exam
Radiographic Exam: Panoramic
Periodontal Exam
AAP: 1999: III 2D2/2D3, 2017: IIA
Dental Hygiene Diagnosis/Treatment Plan
Dental Hygiene Diagnosis/Treatment Plan
Treatment Plan & Rationale Rationale:
Conducted my case study on this patient due to his uncontrolled high blood pressure and
slow progressing moderate level of disease. In addition, the medications that affect his
mental health status which can affect therapy outcome and motivation to maintain oral care
Treatment goals
Upon undergoing non-surgical periodontal therapy, coupled with patient education, I
expected to see a reduction in inflammation of periodontal tissue, a reduced plaque level, a
reduced calculus level, improved homecare and motivation
Therapeutic Strategy
Patient AA chief complaint “ I would like a cleaning and a check-up.” I explained the entire
process of the NSPT procedure to “AA” in a calm and clear manner to put “AA” at ease
considering he had been anxious during his new patient exam. I invited any questions he may
have had so that he was informed every step of the way. For pain management informed
“AA” of the need for local anesthesia and the risks of undergoing NSPT without LA. With his
consent, I applied 20% benzocaine topical to injection sites and used 4% Septocaine with
1:200,000 Epinephrine.
Treatment Plan & Rationale Cont
Discussion Points With the Patient
Importance of flossing daily to ensure removal of any trapped foods, plaque, and
bacteria that can become trapped and thrive between his teeth and cause further
inflammation and tooth decay. (Worthington et al., 2019).
“AA” enjoyed GC Tri Plaque ID gel
Importance of not only seeking professional care for his level of gum disease but
also how important it is for him to maintain a good and constant homecare strategy
of brushing at least two times per day with fluoridated toothpaste, flossing at night,
and using an alcohol-free mouth rinse.
Homecare Aids
Waterpik & interproximal aids
Benefits of powered toothbrush over manual
Patient Consent
Implementation
Tx Plan Vs Actual tx
Patient Motivation
At the initial appointment, I discussed with “AA”, his stage II grade B status
and provided a visual of the 2017 AAP Classifications. He responded to this
well and expressed an interest in improving his oral health and continuing
treatment.
“AA” seemed increasingly motivated upon every appointment and with
every product suggestion. “AA” had also expressed that he felt his oral health
was getting back on track
Unfortunately, “AA” had also stated that he had not increased his brushing
habits of brushing 2 times per day on most days and one time per day on a couple
to a few days per week.
“AA” seemed to be interested in incorporating water flossing into his daily
routine.
Evalutation
Tissue Re-Evaluation
Improvements
Positive changes: decrease in BOP, decrease in depths
Decrease in marginal inflammation, no dark pink margins, reduced rolling of gingiva,
change from soft/spongy to the slightly firm papilla
Outcomes
Oral Homecare Outcomes:
Based on “AA” reduced pocket readings and reduced areas of BOP of the treated
quadrant, it is apparent that the patient has improved his homecare by flossing with a
Powered toothbrush and has increased his brushing frequency. However, considering
he did appear to have slight plaque buildup he may continue to skip some nights and
mornings. With this information, I informed him of the importance of brushing toward
the gumline and brushing 2x/day.
Therapeutic Outcomes:
From the decrease in pocket depth measurements, it can be concluded that non-
surgical periodontal therapy has been an effective treatment in reducing
inflammation and BOP in the LL quadrant.
Future Care Recommendations:
I suggested that he begin a 4-month recall for periodontal maintenance therapy to
improve the health of his periodontium.
Student Summative Evaluation
Periodontal disease, if left untreated, may cause decay, attachment loss, bone loss,
and tooth loss. Non-surgical periodontal therapy is fundamental to treating
periodontal disease. It includes removing plaque biofilm and calculus deposits from
the teeth and root surfaces, by way of ultrasonic instrumentation as well as hand
scaling. NSPT has been demonstrated to improve periodontal health and reduce the
risk of tooth loss as well as improving overall systemic health. (Gasner et al., 2022).
Upon this case study project, the importance of the work that we conduct as dental
hygienists was clear and reinforced. It was rewarding to be able to quantify the hard
work and skills that we have spent so much time and energy learning.
References
Worthington, H. V., MacDonald, L., Poklepovic Pericic, T., Sambunjak, D., Johnson, T.
M., Imai, P., & Clarkson, J. E. (2019). Home use of interdental cleaning devices, in
addition to toothbrushing, for preventing and controlling periodontal diseases and
dental caries. The Cochrane database of systematic reviews, 4(4), CD012018.
https://doi.org/10.1002/14651858.CD012018.pub2
Gasner NS, Schure RS. Periodontal Disease. [Updated 2022 Aug 16]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK554590/
