Case Document project:
The case document patient was a Caucasian sixty one year old female. She has been a patient at VCU School of Dentistry since 2009. The patient is a retired woman who lives with her son and two grandsons. She is taking care of her older sister who currently is staying in the hospital getting treatment for lung cancer. The case document patient has lost her mother seven years ago and she has been diagnosed with depression since then. The case document project required the patient to come in 4 times in spring of 2014 and once in fall of 2015.
Medical history and medication:
The patient’s health history chart is presented with depression, panic and anxiety disorder after the death of the patient’s mother. Other health history issues include: fibromyalgia, slight spinal bifida, protruded discs, osteopenia, high blood pressure (controlled with diet), severe acid reflux, small hyanal hernia, migraine, vertigo, floaters in the left eye, aggressive basal cell carcinoma on the right side of her nose and skin cancer. The patient has been admitted to the hospital for appendix removal when she was fourteen years old, tubular ligation in her late twenty’s, removed a cyst from the left ovary in 2003, reconstructive surgery by having her cyst removed, which was squamous cell carcinoma from left eyelid in 2007. Other hospitalization history include: Moh’s surgery by removing squamous cell carcinoma from the left side of the face in 2007, basal cell carcinoma was removed from chin in 2002, had throat surgery in 2007 by removing the polyp from vocal cords, Moh’s surgery for basal cell carcinoma in November 2011, facial and nose reconstruction surgery which was about 4 stages between November 2011. Patient been admitted to the hospital for skin cancer treatment on November 3rd of 2014.
Regarding the patients medication history, the first visit which was on September 23rd of 2014, the patient stated that she was taking couple of medication which are: amoxicillin, fluorouracil, oxycodone- acetaminophen, triamcinolone acetonide, bltabital acetaminophen-caff, Klor-Con 10, Xanax, Zantac and Lasix. As of her last visit, which was in March 16th of 2015, the patient stated that she had stopped a lot of these medications herself without the advice of her doctor. She stated that oxycodone-acetaminophen was making her feel sluggish and prevented her from doing any physical activity and that was why she stopped taking it. However, she has been having constant pain in her shoulder from fibromyalgia. As of March 16th of 2015, the patient was only taking a couple of these medications. Patient uses 0.025% of triamcinolone acetonide by applying it to the affected area of the face twice a day for 7 days after the reconstructive surgeries for her face to treat skin cancer with no side effect. Patient is taking 1 mg of Xanax (alprazolam) as needed for anxiety and panic disorder. As of lexicomp websites stated that xanax has a side effect of causing xerostomia and changes in salivation. In addition to that, patient is taking 150 mg of zanatc (PEPCID) to treat severe acid reflux, one tablet by mouth three times a day as needed and has no side effect. In addition to that, the patient has been prescribed to use prevident tooth paste 5000 to prevent dental caries. Patient reported that she has been using it on and off but not on every day basis [1].
Social history
Patient is a widow, retired women who lives with her son and two grandsons. Patient does not smoke tobacco and neither drink alcoholic beverages. Patient stated that she has a family history of cancer and arthritis from both parents and her grandparents had high blood pressure. She has drug allergies to two pain medications, Tornal that caused her kidney to shut down and Morphine caused her to vomit.
Dental/ hard tissue history:
Regarding the patients hard tissue chart, the patient’s teeth numbers that are missing are as follows: 1, 2, 13, 15, 17, 18, 19, 20, 31 and 32. Tooth number 3 has MODL composite restoration. Tooth number 4 has MODBL PFM crown. Tooth number 5 has MOD composite restoration. Tooth number 6 has DL composite restoration. Tooth number 7 has DL composite restoration. Tooth number 8 has ML composite restoration. Tooth number 9 has MD and separate I composite restorations. Tooth number 10 has MFDL composite restoration. Tooth number 11 has DL and separate I composite restoration. Tooth number 12 has MODBL PFM crown. Tooth number 14 has DOL composite restoration. Tooth number 21 has ODB composite restoration. Tooth number 22 has B composite restoration. Tooth number 30 has OD composite restoration. Patient has had multiple restoration work completed on her teeth and she had been diagnosed with high caries risk.
Periodontal status:
Patient’s current periodontal health status is indicative of generalized slight chronic periodontitis and localized moderate chronic periodontitis. This dental hygiene diagnosis was based on the patient pocket depth, recession, attachment loss, bleeding, plaque, slight calculus and furcation. There was no mobility involved. The patient has localized pocket depth of 4-5 mm and generalized 2-3 mm. Recession of localized 3mm and generalized 1-2 mm. Localized class I furcation on tooth number 3 and 14. Localized bleeding on probing, slight calculus on lingual of sextant number 5 and generalized plaque on lingual and interproximal area.
Justification of patient selection:
The case document patient was selected for couple of reasons. First reason, patient is at high caries risk. The second reason is to improve the oral hygiene care at home because the patient has been neglecting herself. The patient has poor periodontal disease. Third reason is to study the association between depression and poor oral hygiene.
The problems:
The problem that was presented was that, the patient is at high risk of dental caries due to many restorative works already completed in her mouth as well as taking medication due to her extensive medical history. Another reason is the patients’ oral hygiene at home, the patient stated that she brushes one time a day, does not floss and uses ACT mouth wash once in a while. Teeth were sensitive to sweets, hot, cold and pressure while chewing. According to salivary function, the case document patient stated that her saliva was thick, complained from dry mouth, difficult time chewing food, difficult time swallowing and difficult time speaking. In addition to that, the patient mentioned in her dietary intake history chart that she drank soda on day one, day two she ate a cookie and day three she had a brownie for snack. The article “Symptoms of depression and anxiety in relation to dental health behavior and self-perceived dental treatment need” provided a study to highlight the relationship and the association between anxiety and depression with dental health behavior. The article mentioned that the time elapsed for dental visit was longer, and the preservation of the natural teeth was less important in patients with depression versus those without depression. The article stated that there is an association between depression symptoms and objectives by the perception of oral dryness; and increased lactobacillus counts which in turn shows the subject to be at risk of dental caries. The reason behind their impaired oral health behavior was due to fatigue, psychomotor retardation, lack of motivation and consuming a lot of unhealthy foods and soft drinks all leading to poor oral hygiene. As a result, the article concluded that depression was associated with less frequency of brushing and less dental check-ups [2].
The second reason for selecting this patient was to improve that person’s oral hygiene at home. The patient had stated a couple of times that she has been neglecting her teeth and she was not taking good care of them even though she was aware of the problem. Before her mother passed away, patient stated that “I used to have good and healthy teeth”. The main concern was to improve the patient’s oral hygiene at home to prevent future caries and to improve her oral hygiene care. The patient did seem very sad that she had multiple restorations done in the past and was concerned about her teeth a lot. However, at the same time she was not doing what she should regarding her teeth especially with her health history issues, medication, depression after her mother death and taking care of her family.
On the patient first visit in September 23rd of 2014, Even though the patient stated that she brushed once a day, the amount of plaque deposit was almost at every tooth especially lingual and interproximal area, which showed that the patient brushing technique is not appropriate. Therefore, showing the patient how to brush by using the patient mirror and the circular brush technique and asking the patient to demonstrate thereafter was very essential. During the brushing, the patient stated that she was having a difficult time to remove the plaque from tooth number 10 on facial distal surface that has composite restoration. Therefore, providing the patient with an interdental brush was important to remove the plaque between her teeth. According to the article “depression and dental health” stated that “Decreased energy and motivation, as well as negative self-views associated with depression may have a detrimental effect on oral hygiene habits and compliance with treatment recommendations” [3]
The article “Depression and Dental Health” from the Family Gentle Dental Care talked about how depression was associated with periodontal disease. The important point it mentioned was that “Depression may negatively affect periodontal treatment”. To explain this point a study was done to compare how people with depression respond to periodontal treatment versus those who do not have depression. The study concluded that patients who had been diagnosed with depression are twice as likely to show poor outcome following periodontal treatment over one year compared to those with out depression. Patients who were diagnosed with depression had higher levels of attachment loss and alveolar bone loss. The researchers gave couple reasons as to why there is a difference between patients with depression and those without depression. Those patients with depression may think that the periodontal treatment as an overwhelming ordeal and might be more likely to not comply fully with the treatment recommendations. In addition to that, depression may affect the immune system by slowing down the body’s reaction to fight off infection. Nevertheless, the article mentioned that people with anxiety are at an increased risk of dental caries, periodontal disease and grinding their teeth [4].
Another important reason was after reviewing the patient medication list; the patient stated that she takes Xanax, which is a medication to treat anxiety disorder associated with depression. Xanax has the ability to cause dry mouth and changes in salivation. From the article “Risks of Oral health with the use of Antidepressants” it mentioned how antidepressant medication could influence the saliva secretion. Antidepressant medications interfere with the autonomic nervous system, which could influence the secretion of saliva [5]. Therefore, there is association for the patient dental caries and medication. Another article “saliva and dental caries” stated that “saliva results in a flushing effect and the clearance of oral debris and noxious agents” [6]. Therefore, taking antidepressant medication cause reduction or elimination of the production of saliva which is important to flush bacteria that forms plaque leading to form dental caries. When bacteria plaque are found, three main organic acids are produced that are lactic, formic and acetic acids. These acidic make an environment with low pH which will cause demineralization of the tooth. Therefore, streptococcus mutans will have a great environment to form dental caries [6]. Saliva is very important just like the article “ Saliva and dental caries” has stated because it has a buffering ability, cleansing effect, antimicrobial action and maintenance of a saliva supersaturated in calcium phosphate [7].
Solutions:
Regarding the patient oral hygiene care at home from assessing her pocket depth, hard tissue and the plaque score, the electric Oral B tooth brush would be a better solution to remove plaque and improve the gingival health than the manual tooth brush. The reason why is because by assessing the patient brushing technique, the patient showed that she was not able to brush appropriately. The patient constantly reported having pain in her right shoulder due to fibromyalgia and that could be a main reason why she was not able to brush well [8]. Therefore the best solution for the case document patient is by providing her with an Oral B electric tooth brush. From the article “Plaque Removal Efficacy of a Prototype Manual Toothbrush versus an ADA Reference Manual Toothbrush with or without Dental floss” it stated that the electric toothbrush is more efficient in removing plaque than the manual tooth brush with or without floss [9].
The patient was aware from the fact that no matter what kind of tooth brush she would use, she would always follow the same brushing technique. She was aware to brush her teeth by using soft bristle tooth brush and aim the bristles at the gum line and then moving the tooth brush up in a circular motion to remove the plaque away from the gums. The patient was aware from the fact that she should spend 2 full minutes on brushing.
Another solution for removing interproximal plaque accumulation is by providing the patient with assess reach flosser. The access reach flosser is designed with its ergonomic handle, no-slip grip to reach posterior teeth and its high potency to withstand breakage. Providing the access reach flosser to the patient was essential especially since she was complaining of having a hard time cleaning the anterior teeth with a regular toothbrush due to her pain from fibromyalgia in her right shoulder. Therefore, the assess reach floss will be great tool to use in her left arm instead and there will be no need to rely on her right arm any more for flossing. Another oral aids to help with removing interproximal plaque is the interdental brush. Patient was giving instruction to use the importance of using prevident tooth paste 5000 every day to prevent caries.
Patient was giving nutritional counseling about her daily eating habit. The patient was informed that beverages such as soda, coffee and juices could contain lot of sugar in it and it is preferable to have it along a meal. The patient was also informed that sugary snacks are bad for her teeth as well. The patient was instructed to have one snack per week and to eat it along with a cup of water or milk. The most important, she was instructed to switch with water and to brush her teeth after 30 minutes.
Regarding the patient dry mouth. The patient was instructed to carry a bottle of water with her all the time and to sip on water constantly just. The patient was aware from the fact that the sensation of thirst reduced with age. The most important solution that the patient understood that she should have a regular dental exam every 3 months. Patient agreed to the treatment and was aware from her problems.
Changes in oral hygiene:
The first visit of the patient was in September 23rd of 2014. The patient had red localized interproximal erythematous areas with blunted papillae, fibrotic tissue on the lower anterior region. The gingival index was 1.4 and the plaque free score was 13 percent. Comparing this with the last visit which was in March 16th of 2015, the patient gingival description status was of pink with knife like edge margin with localized edematous and bulbous papilla around the molar teeth. The gingival index score was 1.1 and the plaque score was 32 percent. This proves that the patient gingival health, gingival index and the plaque score has improved.
Patient responded to the treatment from brushing once a day to brushing using only the manual tooth brush to brushing once or twice a day using the manual tooth brush then switching to the electric tooth brush. The patient is doing a lot better with her flossing habit as well. From not flossing at all to flossing at least 3 times a week using the reach access flosser. Patient is still using her Act mouth wash. Patient also stated that she has not been using her interdental brush.
In addition to that, the patent first dental exam she was diagnosed with caries lesion on tooth number 9. However, the last dental exam the patient had was on March of 2015, there was no caries lesion found in her teeth. Patient stated that she was eating healthy and was avoiding eating any acidic beverages and sugars. The patient did not complain from dry mouth anymore and she stated that she was drinking a lot of water to keep her mouth moist all the time.
Regarding to the patient pocket depth by comparing the first and last visit, it has stayed the same, but there was less bleeding on probing. However, over all the patient is trying her best to improve her oral hygiene habits at home.
Evaluation of the project:
This project took five essential visits from the case document patients. Every visit, there was something new to be assessed, implemented, documented and then to be evaluated. On the patient initial dental exam in October 2014, a restoration was diagnosed on the mesial gingival of tooth number 9. Comparing to the last dental exam in March of 2015, there was no restoration. This showed that the patient’s oral hygiene care has improved.
However, there is always different ways of making the project more successful. From the article “Effect of a Multi-Faceted Intervention on Gingival Health Among Adults with Systemic Sclerosis” it mentioned how the study group were instructed to record their daily oral hygiene in a calendar. The participants were requested to record whether they had brushed and flossed every day by marking yes or no on the calendar. The participants were asked to return their calendar at the end of each month [10]. Therefore, involving the case document patient in such a daily activity would have ensured that she would remember to brush and floss daily.
The patient’s final visit still showed that there was plaque accumulation in her lingual surfaces of the mouth and specifically interproximal. However, the case document patient was trying her best to improve her oral hygiene habit at home as well as her eating habit. The reason why she would be considered to be compliant because she used to come in even with all her skin cancer treatment and responsibilities toward her family and specifically toward her sick sister. She would always answer her phone and ask to be rescheduled if required in order to proceed with treatments. In addition to that, she agreed for being on 3 months recall. Therefore, as an evaluation for the project, it considered to be successful because the goal of the project has been reached. The goals were to improve the plaque score by 10 percent, start flossing at least 2 or 3 times a week, brushing twice a day for 2 minutes, and prevent having caries in the mouth by reducing dry mouth and eating healthy.
Conclusion:
The project was very helpful in assessing the patient oral hygiene. The fact that I was able to assess and evaluate the patient for a couple of visits, gave me a better option to understand the problem and find a solution for it. The benefits of having the case document patients coming in a couple times are being able to instruct her over and over again until she is fully being aware of the problem she have. Therefore, the hygienist should be able to make a good implementation after taking the assessment and come up with a solution for her/his problem depending on the patient’s needs. As a hygienist I understood that we can provide treatment to the patient by providing prophy or SCRP, but it will be less benefits for the patient if there was no oral hygiene instruction, nutritional counseling and smoking cessation along with the treatment.
Sources:
1. Lexicomp Online for Dentistry [internet]. Hudson OH. 1978. [Updated 2015, cited 2015 April 12] Available from: http://online.lexi.com/lco/action/home;jsessionid=0cd63581a6a5f2c75db2d6239e28?siteid=2
2. Anttila S, Knuutila M, Ylostalo P, Joukamaa M. Symptoms of Depression and Anxiety in Relation to Dental Health Behavior and Self-perceived Dental Treatment Need. European Journal of Oral Sciences [internet]. 2006; 114:109-114. Available from: http://onlinelibrary.wiley.com.proxy.library.vcu.edu/doi/10.1111/j.1600-0722.2006.00334.x/epdf.
3. Reese LR. Depression and Dental Health. Naval Postgraduate Dental School: National Naval Dental Center: Bethesda, Maryland [internet]. 2003 January; 25(1). Available from: http://www.tupeloendo.com/pdfs/Selected-Literature/Depression-and-dental-health.pdf
4. Peterson D. Depression and Dental Health. Family Gentle Dental Care. Available from: http://www.dentalgentlecare.com/depression_and_dental_health.htm
5. Peeters FPML, Devries MW, Vissink A. Risks for Oral Health with the Use of Antidepressants. General Hospital Psychiatry [internet] 1998 May;20(3);150-154. Available from: http://www.sciencedirect.com.proxy.library.vcu.edu/science/article/pii/S0163834398000176
6. Lenander-Lumikari M, Loimaranta V. Saliva and Dental Caries. Department of Cariology and Turku Immunology Centre, Institute of Dentistry, University of Turku [internet]. 2000 Decemeber;14;40-47. Available from: http://web.b.ebscohost.com.proxy.library.vcu.edu/ehost/pdfviewer/pdfviewer?sid=1cc2da16-9e1b-433d-9d66-276f53ba5734%40sessionmgr198&vid=2&hid=106.
7. Dowd FJ. Saliva and Dental caries. Europe PubMed Central, Dental Clinic of North America [internet]. 1999;43(4);579-597. Available from: http://europepmc.org/abstract/med/10553245
8. Aldritt P. Are Electric Toothbrushes Better than Manual?. ABC Health and Wellbeing [internet]. 2012 February. Available from: http://www.abc.net.au/health/talkinghealth/factbuster/stories/2012/02/15/3430307.htm
9. Terezhalmy G, Bsoul SA, Bartizek RD, Biesbrock AR. Plaque Removal Efficacy of a Prototype Manual Toothbrush versus an ADA Refernce Manual Toothbrush with and without Dental Floss. The Journal of Contemporary Dental Practice. 2005 August;5(3). Available from: http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=1618&&TYP=TOP&IN=~/eJournals/images/JPLOGO.gif&IID=143&isPDF=YES
10. Yuen HK, Weng Y, Bandyopadhyay D, Reed SG, Leite RS, Silver RM. Effect of a Multi-Faceted Intervention on Gingival Health Among Adults with Systemic Sclerosis. HHS Public Access. 2011 May. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520125/
Medical history and medication:
The patient’s health history chart is presented with depression, panic and anxiety disorder after the death of the patient’s mother. Other health history issues include: fibromyalgia, slight spinal bifida, protruded discs, osteopenia, high blood pressure (controlled with diet), severe acid reflux, small hyanal hernia, migraine, vertigo, floaters in the left eye, aggressive basal cell carcinoma on the right side of her nose and skin cancer. The patient has been admitted to the hospital for appendix removal when she was fourteen years old, tubular ligation in her late twenty’s, removed a cyst from the left ovary in 2003, reconstructive surgery by having her cyst removed, which was squamous cell carcinoma from left eyelid in 2007. Other hospitalization history include: Moh’s surgery by removing squamous cell carcinoma from the left side of the face in 2007, basal cell carcinoma was removed from chin in 2002, had throat surgery in 2007 by removing the polyp from vocal cords, Moh’s surgery for basal cell carcinoma in November 2011, facial and nose reconstruction surgery which was about 4 stages between November 2011. Patient been admitted to the hospital for skin cancer treatment on November 3rd of 2014.
Regarding the patients medication history, the first visit which was on September 23rd of 2014, the patient stated that she was taking couple of medication which are: amoxicillin, fluorouracil, oxycodone- acetaminophen, triamcinolone acetonide, bltabital acetaminophen-caff, Klor-Con 10, Xanax, Zantac and Lasix. As of her last visit, which was in March 16th of 2015, the patient stated that she had stopped a lot of these medications herself without the advice of her doctor. She stated that oxycodone-acetaminophen was making her feel sluggish and prevented her from doing any physical activity and that was why she stopped taking it. However, she has been having constant pain in her shoulder from fibromyalgia. As of March 16th of 2015, the patient was only taking a couple of these medications. Patient uses 0.025% of triamcinolone acetonide by applying it to the affected area of the face twice a day for 7 days after the reconstructive surgeries for her face to treat skin cancer with no side effect. Patient is taking 1 mg of Xanax (alprazolam) as needed for anxiety and panic disorder. As of lexicomp websites stated that xanax has a side effect of causing xerostomia and changes in salivation. In addition to that, patient is taking 150 mg of zanatc (PEPCID) to treat severe acid reflux, one tablet by mouth three times a day as needed and has no side effect. In addition to that, the patient has been prescribed to use prevident tooth paste 5000 to prevent dental caries. Patient reported that she has been using it on and off but not on every day basis [1].
Social history
Patient is a widow, retired women who lives with her son and two grandsons. Patient does not smoke tobacco and neither drink alcoholic beverages. Patient stated that she has a family history of cancer and arthritis from both parents and her grandparents had high blood pressure. She has drug allergies to two pain medications, Tornal that caused her kidney to shut down and Morphine caused her to vomit.
Dental/ hard tissue history:
Regarding the patients hard tissue chart, the patient’s teeth numbers that are missing are as follows: 1, 2, 13, 15, 17, 18, 19, 20, 31 and 32. Tooth number 3 has MODL composite restoration. Tooth number 4 has MODBL PFM crown. Tooth number 5 has MOD composite restoration. Tooth number 6 has DL composite restoration. Tooth number 7 has DL composite restoration. Tooth number 8 has ML composite restoration. Tooth number 9 has MD and separate I composite restorations. Tooth number 10 has MFDL composite restoration. Tooth number 11 has DL and separate I composite restoration. Tooth number 12 has MODBL PFM crown. Tooth number 14 has DOL composite restoration. Tooth number 21 has ODB composite restoration. Tooth number 22 has B composite restoration. Tooth number 30 has OD composite restoration. Patient has had multiple restoration work completed on her teeth and she had been diagnosed with high caries risk.
Periodontal status:
Patient’s current periodontal health status is indicative of generalized slight chronic periodontitis and localized moderate chronic periodontitis. This dental hygiene diagnosis was based on the patient pocket depth, recession, attachment loss, bleeding, plaque, slight calculus and furcation. There was no mobility involved. The patient has localized pocket depth of 4-5 mm and generalized 2-3 mm. Recession of localized 3mm and generalized 1-2 mm. Localized class I furcation on tooth number 3 and 14. Localized bleeding on probing, slight calculus on lingual of sextant number 5 and generalized plaque on lingual and interproximal area.
Justification of patient selection:
The case document patient was selected for couple of reasons. First reason, patient is at high caries risk. The second reason is to improve the oral hygiene care at home because the patient has been neglecting herself. The patient has poor periodontal disease. Third reason is to study the association between depression and poor oral hygiene.
The problems:
The problem that was presented was that, the patient is at high risk of dental caries due to many restorative works already completed in her mouth as well as taking medication due to her extensive medical history. Another reason is the patients’ oral hygiene at home, the patient stated that she brushes one time a day, does not floss and uses ACT mouth wash once in a while. Teeth were sensitive to sweets, hot, cold and pressure while chewing. According to salivary function, the case document patient stated that her saliva was thick, complained from dry mouth, difficult time chewing food, difficult time swallowing and difficult time speaking. In addition to that, the patient mentioned in her dietary intake history chart that she drank soda on day one, day two she ate a cookie and day three she had a brownie for snack. The article “Symptoms of depression and anxiety in relation to dental health behavior and self-perceived dental treatment need” provided a study to highlight the relationship and the association between anxiety and depression with dental health behavior. The article mentioned that the time elapsed for dental visit was longer, and the preservation of the natural teeth was less important in patients with depression versus those without depression. The article stated that there is an association between depression symptoms and objectives by the perception of oral dryness; and increased lactobacillus counts which in turn shows the subject to be at risk of dental caries. The reason behind their impaired oral health behavior was due to fatigue, psychomotor retardation, lack of motivation and consuming a lot of unhealthy foods and soft drinks all leading to poor oral hygiene. As a result, the article concluded that depression was associated with less frequency of brushing and less dental check-ups [2].
The second reason for selecting this patient was to improve that person’s oral hygiene at home. The patient had stated a couple of times that she has been neglecting her teeth and she was not taking good care of them even though she was aware of the problem. Before her mother passed away, patient stated that “I used to have good and healthy teeth”. The main concern was to improve the patient’s oral hygiene at home to prevent future caries and to improve her oral hygiene care. The patient did seem very sad that she had multiple restorations done in the past and was concerned about her teeth a lot. However, at the same time she was not doing what she should regarding her teeth especially with her health history issues, medication, depression after her mother death and taking care of her family.
On the patient first visit in September 23rd of 2014, Even though the patient stated that she brushed once a day, the amount of plaque deposit was almost at every tooth especially lingual and interproximal area, which showed that the patient brushing technique is not appropriate. Therefore, showing the patient how to brush by using the patient mirror and the circular brush technique and asking the patient to demonstrate thereafter was very essential. During the brushing, the patient stated that she was having a difficult time to remove the plaque from tooth number 10 on facial distal surface that has composite restoration. Therefore, providing the patient with an interdental brush was important to remove the plaque between her teeth. According to the article “depression and dental health” stated that “Decreased energy and motivation, as well as negative self-views associated with depression may have a detrimental effect on oral hygiene habits and compliance with treatment recommendations” [3]
The article “Depression and Dental Health” from the Family Gentle Dental Care talked about how depression was associated with periodontal disease. The important point it mentioned was that “Depression may negatively affect periodontal treatment”. To explain this point a study was done to compare how people with depression respond to periodontal treatment versus those who do not have depression. The study concluded that patients who had been diagnosed with depression are twice as likely to show poor outcome following periodontal treatment over one year compared to those with out depression. Patients who were diagnosed with depression had higher levels of attachment loss and alveolar bone loss. The researchers gave couple reasons as to why there is a difference between patients with depression and those without depression. Those patients with depression may think that the periodontal treatment as an overwhelming ordeal and might be more likely to not comply fully with the treatment recommendations. In addition to that, depression may affect the immune system by slowing down the body’s reaction to fight off infection. Nevertheless, the article mentioned that people with anxiety are at an increased risk of dental caries, periodontal disease and grinding their teeth [4].
Another important reason was after reviewing the patient medication list; the patient stated that she takes Xanax, which is a medication to treat anxiety disorder associated with depression. Xanax has the ability to cause dry mouth and changes in salivation. From the article “Risks of Oral health with the use of Antidepressants” it mentioned how antidepressant medication could influence the saliva secretion. Antidepressant medications interfere with the autonomic nervous system, which could influence the secretion of saliva [5]. Therefore, there is association for the patient dental caries and medication. Another article “saliva and dental caries” stated that “saliva results in a flushing effect and the clearance of oral debris and noxious agents” [6]. Therefore, taking antidepressant medication cause reduction or elimination of the production of saliva which is important to flush bacteria that forms plaque leading to form dental caries. When bacteria plaque are found, three main organic acids are produced that are lactic, formic and acetic acids. These acidic make an environment with low pH which will cause demineralization of the tooth. Therefore, streptococcus mutans will have a great environment to form dental caries [6]. Saliva is very important just like the article “ Saliva and dental caries” has stated because it has a buffering ability, cleansing effect, antimicrobial action and maintenance of a saliva supersaturated in calcium phosphate [7].
Solutions:
Regarding the patient oral hygiene care at home from assessing her pocket depth, hard tissue and the plaque score, the electric Oral B tooth brush would be a better solution to remove plaque and improve the gingival health than the manual tooth brush. The reason why is because by assessing the patient brushing technique, the patient showed that she was not able to brush appropriately. The patient constantly reported having pain in her right shoulder due to fibromyalgia and that could be a main reason why she was not able to brush well [8]. Therefore the best solution for the case document patient is by providing her with an Oral B electric tooth brush. From the article “Plaque Removal Efficacy of a Prototype Manual Toothbrush versus an ADA Reference Manual Toothbrush with or without Dental floss” it stated that the electric toothbrush is more efficient in removing plaque than the manual tooth brush with or without floss [9].
The patient was aware from the fact that no matter what kind of tooth brush she would use, she would always follow the same brushing technique. She was aware to brush her teeth by using soft bristle tooth brush and aim the bristles at the gum line and then moving the tooth brush up in a circular motion to remove the plaque away from the gums. The patient was aware from the fact that she should spend 2 full minutes on brushing.
Another solution for removing interproximal plaque accumulation is by providing the patient with assess reach flosser. The access reach flosser is designed with its ergonomic handle, no-slip grip to reach posterior teeth and its high potency to withstand breakage. Providing the access reach flosser to the patient was essential especially since she was complaining of having a hard time cleaning the anterior teeth with a regular toothbrush due to her pain from fibromyalgia in her right shoulder. Therefore, the assess reach floss will be great tool to use in her left arm instead and there will be no need to rely on her right arm any more for flossing. Another oral aids to help with removing interproximal plaque is the interdental brush. Patient was giving instruction to use the importance of using prevident tooth paste 5000 every day to prevent caries.
Patient was giving nutritional counseling about her daily eating habit. The patient was informed that beverages such as soda, coffee and juices could contain lot of sugar in it and it is preferable to have it along a meal. The patient was also informed that sugary snacks are bad for her teeth as well. The patient was instructed to have one snack per week and to eat it along with a cup of water or milk. The most important, she was instructed to switch with water and to brush her teeth after 30 minutes.
Regarding the patient dry mouth. The patient was instructed to carry a bottle of water with her all the time and to sip on water constantly just. The patient was aware from the fact that the sensation of thirst reduced with age. The most important solution that the patient understood that she should have a regular dental exam every 3 months. Patient agreed to the treatment and was aware from her problems.
Changes in oral hygiene:
The first visit of the patient was in September 23rd of 2014. The patient had red localized interproximal erythematous areas with blunted papillae, fibrotic tissue on the lower anterior region. The gingival index was 1.4 and the plaque free score was 13 percent. Comparing this with the last visit which was in March 16th of 2015, the patient gingival description status was of pink with knife like edge margin with localized edematous and bulbous papilla around the molar teeth. The gingival index score was 1.1 and the plaque score was 32 percent. This proves that the patient gingival health, gingival index and the plaque score has improved.
Patient responded to the treatment from brushing once a day to brushing using only the manual tooth brush to brushing once or twice a day using the manual tooth brush then switching to the electric tooth brush. The patient is doing a lot better with her flossing habit as well. From not flossing at all to flossing at least 3 times a week using the reach access flosser. Patient is still using her Act mouth wash. Patient also stated that she has not been using her interdental brush.
In addition to that, the patent first dental exam she was diagnosed with caries lesion on tooth number 9. However, the last dental exam the patient had was on March of 2015, there was no caries lesion found in her teeth. Patient stated that she was eating healthy and was avoiding eating any acidic beverages and sugars. The patient did not complain from dry mouth anymore and she stated that she was drinking a lot of water to keep her mouth moist all the time.
Regarding to the patient pocket depth by comparing the first and last visit, it has stayed the same, but there was less bleeding on probing. However, over all the patient is trying her best to improve her oral hygiene habits at home.
Evaluation of the project:
This project took five essential visits from the case document patients. Every visit, there was something new to be assessed, implemented, documented and then to be evaluated. On the patient initial dental exam in October 2014, a restoration was diagnosed on the mesial gingival of tooth number 9. Comparing to the last dental exam in March of 2015, there was no restoration. This showed that the patient’s oral hygiene care has improved.
However, there is always different ways of making the project more successful. From the article “Effect of a Multi-Faceted Intervention on Gingival Health Among Adults with Systemic Sclerosis” it mentioned how the study group were instructed to record their daily oral hygiene in a calendar. The participants were requested to record whether they had brushed and flossed every day by marking yes or no on the calendar. The participants were asked to return their calendar at the end of each month [10]. Therefore, involving the case document patient in such a daily activity would have ensured that she would remember to brush and floss daily.
The patient’s final visit still showed that there was plaque accumulation in her lingual surfaces of the mouth and specifically interproximal. However, the case document patient was trying her best to improve her oral hygiene habit at home as well as her eating habit. The reason why she would be considered to be compliant because she used to come in even with all her skin cancer treatment and responsibilities toward her family and specifically toward her sick sister. She would always answer her phone and ask to be rescheduled if required in order to proceed with treatments. In addition to that, she agreed for being on 3 months recall. Therefore, as an evaluation for the project, it considered to be successful because the goal of the project has been reached. The goals were to improve the plaque score by 10 percent, start flossing at least 2 or 3 times a week, brushing twice a day for 2 minutes, and prevent having caries in the mouth by reducing dry mouth and eating healthy.
Conclusion:
The project was very helpful in assessing the patient oral hygiene. The fact that I was able to assess and evaluate the patient for a couple of visits, gave me a better option to understand the problem and find a solution for it. The benefits of having the case document patients coming in a couple times are being able to instruct her over and over again until she is fully being aware of the problem she have. Therefore, the hygienist should be able to make a good implementation after taking the assessment and come up with a solution for her/his problem depending on the patient’s needs. As a hygienist I understood that we can provide treatment to the patient by providing prophy or SCRP, but it will be less benefits for the patient if there was no oral hygiene instruction, nutritional counseling and smoking cessation along with the treatment.
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