Patient is in good health. Not currently taking any medications. No known medication allergies. Has seasonal allergies. Takes over‐the‐counter antihistamines when necessary.
Review of Systems
- Vital signs:
- Blood pressure: 117/78 mmHg
- Pulse: 62 beats/min
- Respiration: 15 breaths/min
- Height: 5′ 6”
- Weight: 135 lbs
Patient reports a history of clenching and grinding. Patient has had a preventive night guard appliance for two years that she wears to sleep. Patient reports of headaches when she forgets to wear her night guard appliance. She also develops swelling in the muscle on the lower left jaw. Patient reports that she tries to wear it regularly. Patient says that she drinks socially on the weekend, two to four drinks. She also occasionally socially smokes a few cigarettes, one to three. Her diet consists of low carbohydrate and high protein intake. She reports she eats a Paleo diet and chooses to buy only organic foods. Her daily snack consists of a handful of almonds and prefers to juice her vegetables. Patient says she prefers and only purchases 76% dark chocolate. Patient reports two to three cups of coffee and day, with two packets of “sweet and low.” Otherwise, she drinks water throughout the day. Patients reports she brushes twice daily and occasionally flosses.
Patient lives with her boyfriend of seven years and has four children. Her children’s ages range from 11 to 21 years. She solely owns her home. She has a full‐time job as a childcare worker in a local daycare center.
The patient’s current dental home care regimen consists of brushing in the morning with an electric toothbrush. Patient reports she is unaware when to replace the toothbrush heads. She believes her current brush head is over six months old. She occasionally flosses, no other dental aids used. She only uses a rinse to freshen her breath.
Patient presents with normal findings upon palpation of her lymph nodes and glands. Patient presents with slight swelling in masseter muscle on the mandibular left side. There is no clicking or deviation in the temporomandibular joint. However, patient reports slight tenderness. Normal findings upon the assessment of other facial features.
Three intraoral pictures were taken. Please see intraoral images in Figure 8.4.1. This includes a maxillary palatal view, mandibular occlusal view (tori present), and an occlusal view of the left side.
- Soft and hard tissues of the oral cavity:
- Bilateral linea alba buccal mucosa
- Tongue is slightly coated otherwise no significant findings
- Hard palate, soft palate, tonsils, and oropharynx appear normal
- Salivary glands appear normal
- Bilateral mandibular tori
- Occlusal examination:
- Class I occlusion with attrition noted on all posterior teeth especially #19. #10 is labioverted with 2 mm diastema
- Gingival examination:
- Maxillary arch presents with pink stippled tissue, papilla knife shaped, erythematous and edematous gingiva on the buccal of #2, #3, #14, and #15
- Mandibular arch presents with pink stippled tissue, with erythematous and edematous gingiva on the mandibular anterior lingual of teeth #s 22–27
- Patient has light to moderate generalized staining, with stain highly visible on lingual of maxillary and mandibular anterior.
- Light localized calculus deposits noted on the mandibular anterior teeth lingual and the buccal of maxillary molars.
- Periodontal evaluation reveals generalized 1–3 mm pocketing with 4 mm on #2, #3, #14, and #15. Patient has generalized 1 mm recession, with the exception of tooth #19, which has 3 mm recession. A notable change since her last visit six months ago.
- Dental examination:
- Patient is missing teeth #1, #16, #17, and #32
- Minimal number of Class I and II composite restorations
- No current caries are seen
- Patient has visible signs of occlusal wear facets on all posterior teeth
Dental Hygiene Diagnosis
|Problems||Related to Risks and Etiology|
|Dentinal hypersensitivity on tooth #19||Clenching and grinding at night (bruxism), not wearing night guard regularly|
|Occlusal wear facets||Clenching and grinding, bruxism|
|Swollen masseter muscle on left side||Clenching and grinding, bruxism|
|Bleeding on probing #2, #3, #14, and #15||Lack of interproximal cleansing|
|Potential health risks, including periodontal disease|
|Coated tongue||Biofilm accumulation|
|Clinical||Education/Counseling||Oral Hygiene Instructions|
|Take blood pressure once yearly
Adult prophylaxis with a 4‐month re‐evaluation of tissue #2, #3, #14, and #15
Place a desensitizing agent on tooth #19
Refer to DDS for planned examination
|Encourage smoking cessation
Emphasize importance of routinely scheduled dental care visits
Encourage evening use of night guard appliance to prevent continued recession and flare‐up of hypersensitivity
Recommend increase of fluoridated water and toothpaste that contains potassium, stannous fluoride, calcium sodium phosphosilicate, and arginine to block/occlude dentin tubules to prevent hypersensitivity
|Continued use of electric toothbrush
Use of a tongue scraper
Recommend toothpaste that contains fluoride as well as potassium, stannous fluoride, calcium sodium phosphosilicate, and arginine
Once daily flossing or the use of another form of interdental cleaners
Instruction of proper use, cleaning, and care of night guard
Dentinal hypersensitivity is a prevalent clinical condition that is experienced by 10–20% of the population (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). Kachalia (2016) suggests that 50% of the population suffers from dentinal hypersensitivity. Dentinal hypersensitivity is characterized by short, often sharp pain originating from exposed dentin in response to stimuli (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). These stimuli can present as thermal, evaporative, tactile, osmotic, or chemical and cannot be attributed to any other form of dental defect or pathology (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). Correct diagnosis of dentinal hypersensitivity is crucial for dental professionals. Assessment begins with a differential investigation to exclude some dental defects such as a fractured tooth, dental caries, and periodontal diseases in order to administer the correct form of treatment (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). Dentinal hypersensitivity is related to exposed dentinal tubules, and the most common clinical cause of exposed dentinal tubules is gingival recession (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). See intraoral images (Figure 8.4.1) for gingival recession on tooth #19. Aggressive brushing habits, high acidic or sugar intake in the diet, all types of tobacco use, and some other illnesses including gastroesophageal reflux may also cause dentin hypersensitivity (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). It also results from abfraction, abrasion, or erosion and denudation of the root surface. See Figure 8.4.2 for excessive wear facets on mesial cusp. It has also been indicated as a result of nonsurgical and surgical periodontal treatment (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016).
The treatment for dentinal hypersensitivity has been classified by mode of delivery as at‐home (patient‐applied) therapy and in‐office (professional) therapy (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). There are many products available on the market that claim to reduce dental hypersensitivity effectively. It is a dental hygienist’s responsibility to use evidence‐based literature as a guide to making clinical decisions regarding what to recommend to patients. Numerous researchers have provided a concise overview of various approaches to occlude the dentinal tubules (Argawahl et al. 2016; Zhong et al. 2015; Kunam et al. 2016; Pathan et al. 2016). Researchers have determined that there are two ways of reducing hypersensitivity: one is that the occlusion of dentinal tubules occurs by natural mineralization in situ and two by the blockage of tubules by fine particle layers (Argawahl et al. 2016). In other words, products either reduce the fluid flow within the dentin tubules by occluding the tubules, while others interrupt the neural response to stimuli (Jena and Shashirekha 2015). Most products are intended to control the hydrodynamic mechanisms of pain (Jena and Shashirekha 2015).
According to Bae et al. (2016) meta‐analysis indicated that there is sufficient evidence to support the use of potassium, stannous fluoride, calcium sodium phosphosilicate, and arginine‐containing desensitizing toothpaste for dentin hypersensitivity, but not the use of strontium‐containing desensitizing toothpaste (Bae et al. 2016). The clinical relevance of meta‐analysis provides support for dental professionals and best‐practice decision making for recommending a desensitizing toothpaste to patients (Bae et al. 2016). Many of these potassium, stannous fluoride, calcium sodium phosphosilicate, and arginine products in toothpaste offer only short‐term relief to patients by means of dentinal hypersensitivity reduction (Kachalia 2016). In fact, other at‐home products such as oxylates, in strips, have been determined to have no effect on dentine hypersensitivity in a single treatment when compared to placebos (Arnold et al. 2015). However, dental professionals have products available that can be applied to the teeth that resolve sensitivity for a longer period. These products are considered in‐office varnishes. Pathan et al. (2016) suggests reduced dentinal hypersensitivity can last one month after one treatment with in‐office products, as opposed to brushing with a sensitive toothpaste whereby reduction of dentinal hypersensitivity begins after two weeks of twice daily use. In‐office desensitizing agents provide immediate, provisional relief from symptoms of dentinal hypersensitivity (Pathan et al. 2016). Currently, there is no “gold standard” for dentinal hypersensitivity treatment (Jena and Shashirekha 2015). A consultation with a dental professional regarding best treatment options along with a recommended home‐care regimen and regularly scheduled dental recare appointments are highly recommended.
- Dental hygienists can recommend desensitizing toothpaste for dentin hypersensitivity in patients, and give other knowledgeable information regarding the effects of desensitizing toothpaste on dentin hypersensitivity with evidence‐based research. This recommendation consists of toothpaste that contain potassium, stannous fluoride, and calcium sodium phosphosilicate, as well as arginine‐containing desensitizing toothpastes, reduce the symptoms of dentin hypersensitivity.
- Patients presenting with dentinal hypersensitivity should have a comprehensive examination and assessment to determine if a possible fracture or recurrent caries is related to pain.
- A patient’s progress with dentinal sensitivity should be monitored during regularly scheduled recare visits.