Medical History
The patient’s medical history states he is in good health. He currently does not take any medications and is not under the care of a physician. The patient does not smoke and his vital signs were within normal limits.
Dental History
Patient has not had a dental exam or prophylaxis in eight years. He has amalgam and composite restorations, carious lesions, and is missing teeth #3, #14, #18, and #19. The patient brushes using fluoridated toothpaste twice a day and flosses twice a day.
Social History
Patient is between jobs. He is divorced. He does not smoke or drink. He likes to ride bikes and watch sports.
Assessments
Extraoral/intraoral examination – bilateral linea alba, white‐coated tongue, fistula present on the facial attached gingiva around tooth #25.
Periodontal Assessment
- Gingival Statement: Generalized moderate marginal and papillary redness with rolled margins and edematous papilla, localized severe redness facial of lower anterior #22–#26
- Calculus classification: moderate to heavy supragingival and subgingival deposits (see Figure 2.4.2)
- Generalized 4–9 mm pocket depths, recession present, furcation on #30 or mobility (see Figure 2.4.3 for periodontal charting).
- SBI 36%
- PCR 44%
Dental Charting Assessment
- Occlusion: Class II left / Class I on the right
- Amalgam and composite restorations
- Carious lesions: #14, #15
- Generalized
- Missing teeth: #3, #14, #18, and #19
- All third molars are present
Radiographic Findings
- Horizontal bone loss – 30%
Risk Assessments
- Caries: high risk
- Periodontal: high risk
- Cancer: low risk
Problem List
- Gingival inflammation and bleeding
- Probing depths of 4–9 mm
- Plaque accumulation
- Bone loss
- Missing teeth
- Furcation
- Abfractions
- Carious lesions
Dental Hygiene Diagnosis
| Unmet Human Need | Evidenced (caused) by | Signs/Symptoms |
| Freedom from head and neck pain | Untreated dental condition (abfractions and recession) / plaque accumulation / calculus | Sensitivity to cold / sore gums / bleeding |
| Integrity of the skin and mucous membrane | Microbial infection and host response | Bleeding/plaque accumulation |
| Responsibility for oral health | Inadequate dental care | Last dental visit 8 years |
Planned Interventions
| Interventions | Goals | Evaluation |
| Fluoride/desensitization | Patient will return for desensitization treatment Patient will see dentist for evaluation of caries and abfractions |
Patient scheduled an appointment |
| OHI tooth brushing instruction | Patient will demonstrate the proper brushing method Patient will reduce PCR score by 10% |
Immediate + next visit by reduction of PCR |
| Oral Hygiene Education | Patient will understand the disease process | Patient will schedule appointments for care |
| Removal of calculus deposits and biofilm accumulation | Patient will understand the disease process and the importance of dental visits | Patient will schedule appointment for treatment and follow up with a periodontist |
| Biofilm reduction with ultrasonic | Patient will leave office plaque free | End of appointment |
Appointment Schedule
- First appointment
- Assessments
- OHI
- Full mouth debridement (D4355) / oral prophylaxis
- Desensitization as needed
- Second appointment
- OHI
- Nonsurgical periodontal therapy (D4341) URQ
- Local anesthetic or pain control
- Chemotherapeutic as needed
- Desensitization as needed
- Third appointment
- OHI
- Nonsurgical periodontal therapy (D4341) LRQ
- Local anesthetic or pain control
- Chemotherapeutic as needed
- Desensitization as needed
- Fourth appointment
- OHI
- Nonsurgical periodontal therapy (D4341) ULQ
- Local anesthetic or pain control
- Chemotherapeutic as needed
- Desensitization as needed
- Fifth appointment
- OHI
- Nonsurgical periodontal therapy (D4341) LLQ
- Local anesthetic or pain control
- Chemotherapeutic as needed
- Desensitization as needed
- Sixth appointment
- OHI
- Four to six week re‐evaluation – referral to periodontist
- Chemotherapeutic as needed
- Desensitization as needed
Discussion
A dental diagnosis of chronic periodontitis is defined as inflammation of the gingiva extending into the adjacent attachment apparatus. Clinical features include edema, redness, bleeding, and suppuration (American Academy of Periodontology 2000). Chronic periodontitis is further divided into slight to moderate loss of support and advanced loss of support. Treatment considerations for both include much of the same interventions as for the dental hygiene diagnosis. It is important in both diagnosis to include contributing factors, systemic conditions, and the host’s response.
Choosing freedom from head and neck pain addresses the patient’s chief complaint regarding sore gums. Evidence to support this would be plaque accumulation and calculus deposits. Addressing any pain is key to gaining the trust and cooperation of the patient. Interventions to address this would be the nonsurgical periodontal therapy for the plaque and calculus accumulation. Desensitization to address any tooth sensitivity due to the abfractions and recession could be included in the implementation of care. Figure 2.4.1 shows generalized recession and severity of the abfractions. Setting a patient goal of seeing the dentist to address these areas and his concerns is a priority. The patient stated in his chief complaint of “My teeth are rotted out at the bottom.” According to Maslow’s hierarchy of needs one does not move into upper tiers of human needs until the needs at each lower level are met (Jackson et al. 2014). Freedom from pain is on the physiological first‐tier level and must be met first.
Figure 2.4.1: Generalized recession and abfractions causing tooth sensitivity.
Source: Photo courtesy of Rio Salado College.
Secondly using the dental hygiene diagnosis of human need for integrity of the skin and mucous the dental hygienist will be able to provide services they are licensed to treat. Interventions include nonsurgical periodontal therapy, chemotherapeutics, pain control as needed, desensitization as needed, and most importantly oral hygiene education. Addressing the need for therapeutic services such as scaling and debridement will eliminate contributing factors such as calculus and biofilm. Figure 2.4.2 shows calculus accumulation on the lingual of the mandibular anterior teeth. Removal of the calculus can establish a clean environment for healing. Figure 2.4.3 shows the patients periodontal charting with probing depths, bleeding points, and attachment loss all contributing to integrity of the mucosal membrane.
Figure 2.4.2: Calculus accumulation on the mandibular anterior teeth.
Source: Photo courtesy of Rio Salado College.
Figure 2.4.3: Periodontal charting note probing depths and bleeding points on the posterior teeth associated with deeper pockets.
The disease process for chronic periodontitis includes the host’s response. The host response may trigger the patient’s own immune system to destroy tissue and resorb bone (Nield‐Gehrig and Willmann 2016). Addressing all the factors to establish health, including calculus removal, biofilm disruption, and chemotherapeutics to assist the host’s immune response, increase outcomes for care.
Lastly, including responsibility for oral health establishes the patient’s accountability for their health. It takes the burden off the health‐care professional. Is the patient motivated to improve their health? Are they interested in keeping their teeth? Are they physically and financial capable? Incorporating these questions and establishing interventions to address this human need will assist the dental hygienist to transfer ownership of the patient’s health from the clinician to the patient. Education and setting goals can assist with patient’s acceptance and follow through with treatment.
Including a combination of therapies such as debridement, chemotherapeutic agents, and patient education, dental referrals will improve expected outcomes. Assisting the patient with goals and education can improve the patient’s health for years to come and hopefully save teeth in the future. Providing the traditional scaling and root planing and scolding the patient for noncompliance with brushing will not support the patient, coming in for care, to improve his health.
Take‐Home Hints
- Considerations of Maslow’s hierarchy when addressing the problem list.
- Keep the patient involved in the development of goals.
- Relate the dental hygiene care to the dental hygiene diagnosis.
- Interventions can include a variety of procedures, education, and oral hygiene instructions.
- Include dental referrals from the problem list.
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