Review of Systems

• Vital signs
  • Blood pressure: 128/85 mmHg
  • Pulse: 72 beats/min
  • Respiration: 16 breaths/min

Social History

Mrs. A is married and is excited to be a new grandma. She is also planning to retire this year from her stressful job as the CFO of a large finance firm. Her friends and family are a big part of her life. She enjoys golf, working out, and traveling. Mrs. A consumes alcohol on a social basis of approximately two to four drinks per week. She admits to taking more Alprazolam during the workweek to help with the stress of her job. She does not smoke or have a history of recreational drugs use.

Extraoral/Intraoral Examination

Details shown in Figure 7.1.2.

Periodontal Charting

Confirmed Periodontitis, Stage III (Severe Periodontitis with potential for additional tooth loss) generalized, Grade A (slow rate of progression) with gingival inflammation and bleeding upon probing localized to sextant one, four, and six (see Figure 7.1.4).

Dental Hygiene Diagnosis

Dental Hygiene Treatment Plan

Discussion

There are myriad options to consider when selecting appropriate oral hygiene aids for patient self‐care programs. The availability of self‐care aids can be overwhelming; therefore it may be useful to limit the number of suggestions and choose an aid, (or aids) that can address multiple conditions. The hygienist should include with their recommendations: why the selected aids are necessary, how to use them correctly, the times and frequency with which they should be used, benefit factors, and expected outcomes. Individualized patient education can be motivational and increase the chances of the patient being responsive to the suggested behavioral modifications as part of their self‐care regimen. Patient education should also include a discussion of the risks factors involved if neglecting to follow the individualized self‐care program. Keep in mind that creating changes in behavior is neither quick nor easy. Research shows that the formation of a new habit can take considerable time and that the patient has to develop intrinsic motivation before new oral hygiene behaviors are likely to become a habit. The road to habit formation starts with unawareness and moves through six steps to finally the habit. Esther M. Wilkins, RDH, DMD describes the six steps of habit formation as follows:

1. Unawareness – many patients have little concept of the new information about dental and periodontal infections and how they are prevented or controlled.
2. Awareness – patient may have a food knowledge of the scientific facts, but they do not apply the facts to personal action.
3. Self‐interest – realization of the application of facts/knowledge to the well‐being of the individual is an initial motivation.
4. Involvement – with awareness and application to self, the response to action is forthcoming when attitude is influenced.
5. Action – testing new knowledge and beginning of change in behavior may lead to an increased awareness that a real health goal is possible to attain.
6. Habit – self‐satisfaction in the comfort and value of sound teeth and healthy periodontal tissues helps to make certain practices become part of a daily routine. Ultimate motivation is finally reached.

In the situation with Mrs. A, she starts with the second stage of habit formation – awareness. She has prior dental knowledge of her periodontal history. Therefore, the best way to help her form a new self‐care habit is to educate her about her current specific stage of oral health. It is helpful to show Mrs. A her most current periodontal charting record, radiographs, and intraoral photos of the areas that need attention. The information presented to Mrs. A is a comprehensive way to describe her individual needs by explaining the concerns regarding her current oral state, and the reasons why new recommendations for a customized plaque removal regime, are taking place. It is important to be clear with instructions, use demonstrations, and to take the time to answer all questions. Mrs. A will be more aware of her oral condition thereby creating self‐interest that will hopefully encourage involvement in new oral self‐care habits.

Mrs. A’s next dental hygiene periodontal maintenance appointment is an excellent time to revisit the past individualized patient education recommendations, and also it is a good opportunity to continue to motivate and or modify techniques with her self‐care regime. Creating proper oral hygiene habits take constant motivation and continuous education plus support from the entire dental team.

The goal for Mrs. A. is to prevent the progression and recurrence of periodontal disease and peri‐implantitis. Patients who have nonsurgical periodontal treatment, and/or restorative treatment including implants and bridges need thorough and customized oral hygiene instructions to keep the tissue, and dental restorations maintained to achieve optimum oral health.

Periodontitis is reactive to plaque‐induced factors. Therefore, plaque accumulation will lead to inflammation that can result in negative outcomes such as alveolar bone loss. This is why daily removal of biofilm is critical for Mrs. A. Data indicates that plaque control is a major contributor when improving gingival health by reducing inflammation (Chapple et al. 2015; Wilkins 2013). The removal of dental plaque by the forces of mechanical interdental cleaning will remove the primary etiological factor for periodontal or gingival diseases (Johnson et al. 2015). Toothbrushing with an acceptable dentifrice is the standard recommended self‐care practice for cleaning the lingual, facial, and occlusal surfaces of all the teeth (Darby and Walsh 2015), but toothbrushing alone does not reach the interproximal surfaces effectively. Dental floss or other interproximal self‐care aids are a helpful tool for plaque removal within the interproximal space and col area. However, the patient’s dexterity and the likelihood of compliance is a consideration when recommending specific aids.

Assessments for Mrs. A include vitals, extraoral and intraoral exams, FMX (full mouth x‐rays), periodontal charting, plaque index, calculus detection, following up today’s reports of bleeding upon probing around the upper right implant bridge, the lower left three‐unit bridge, and the lower right molars with Class II embrasure spaces around porcelain fused to metal crowns. Mrs. A’s assessment results are an immediate concern to the dental hygienist to avoid peri‐implantitis and the advancement of periodontitis.

Individualized patient education was created for Mrs. A to help restore her to gingival health and prevent further periodontal destruction. Mrs. A was instructed with regards to the following:

• Toothbrushing twice a day for at least two minutes

  Toothbrushing was recommended for the patient twice per day, morning and night after meals, for a duration of two minutes (minimum) using the Bass Sulcular method. Clinical evidence shows that brushing with a mechanical toothbrush can be more efficient than using a manual toothbrush (Lyle 2015; Yaacob et al. 2014), so with that in mind, and considering the moderate loss of dexterity she reported, Mrs. A was encouraged to use a mechanical brush. She was instructed focus on the lingual surfaces because she has higher rates of plaque and inflammation in these areas. To address Mrs. A’s complaint of malodor, she was instructed to brush her tongue each time she brushes her teeth to reduce the bacteria that inhabit the dorsal surface (Darby and Walsh 2015).

• Interdental brushes for daily interproximal cleaning

  Interdental brushes were recommended for the patient over dental floss because they will be easier for her to use with her appliances, and evidence suggests that interdental brushes are the most efficient method for interproximal plaque control (Chapple et al. 2015; Lyle 2015). Interdental brushes come in a variety of sizes for a range of embrasure spaces, including type II and III and recently even small or slim sizes are available for tight interproximal spaces. It is important to demonstrate the use of interdental brushes: if used incorrectly there is a chance that the patient can cause harm to the papilla or dental restoration. Interdental brushes for cleaning around implants should have a coated wire to avoid scratching the titanium or implant material (Johnson et al. 2015). Mrs. A was instructed how to determine the appropriate size and shape of interdental brush for her embrasure spaces, implants, bridges, and crowns. The dental hygienist demonstrated how to insert the brush into the embrasure space at a 90° angle while moving the brush in and out from facial to lingual. The wire should not bend when inserting into the embrasure space; this will be an indicator that the brush size is too big. Insertion should be easy, yet the brush bristles should be slightly larger than embrasure space to be able to reach both interproximal tooth surfaces.

• Water irrigation at least once per day

  Daily water irrigation can help reduce the levels of biofilm and inflammation. A water irrigator is helpful to remove plaque and food debris around and implants and under pontic teeth. Irrigation is beneficial to implants, crowns, and bridges due to the hydrokinetic activity, which produces a pulsating stream of fluid subgingivally where toothbrushes and interdental aids cannot reach (Darby and Walsh 2015; Jahn 2010; Johnson et al. 2015). The water stream of the irrigator can reach deeper than any other self‐care aid. Multiple studies have shown that adding a dental water irrigator to self‐care regimes can help reduce periodontal pathogens, bleeding, pocket depth, and inflammatory mediators (Jahn 2010; Lyle 2015). Oral irrigators should be used with caution because incorrect use around implants can cause damage to the junctional epithelium (Johnson et al. 2015). Mrs. A was instructed to use a low setting and to hold the irrigator tip horizontally while the nozzle tip is directed toward the interproximal area along the implant to avoid excessive water pressure and to help flush the aspects under the pontic teeth. Chlorhexidine gluconate or phenol compounds can be added to the water irrigators’ reservoir to aid in the reduction of bacteria (Ernst et al. 2004; Jahn 2010; Johnson et al. 2015).

• Floss threader or tufted/braided floss

  Mrs. A has a two unit implant bridge on the upper right quadrant (URQ) tooth #3–4, a three unit implant bridge in the upper left quadrant (ULQ) tooth #’s 13–15, and a three unit bridge in the lower left quadrant (LLQ) tooth #’s 18–20. Dental tape or tufted/braided dental floss can clean around the abutments and crown margins. Some tufted or braided floss comes with a rigid needle attached to the floss acting as a floss threader to help with insertion into the abutment interproximal space. Gently guide the floss facial to lingual to cleanse interproximal space and then swept under pontic to the next interproximal space to remove and disturb biofilm accumulation. The tufted or braided floss can be wrapped around the implant to help clean the sulcular areas (Darby and Walsh 2015; Wilkins 2013).

  Include follow‐up discussions with Mrs. A. regarding her self‐care regime at every dental or dental hygiene appointment. Other self‐care aid options can help Mrs. A. achieve optimum oral health if these above aids do not produce expected outcomes, and/or cause a lack of compliance (see Table 7.1.1).