JENNIFER KUO#1211DH 88

Risk Assessment Project

Personal History

Age: 31 years oldSex: MaleRace: CaucasianMarital Status: SingleOccupation: Air Traffic Controller

Medical History Past Medical History

Patient has a history of childhood asthma that is no longer observed.

Past medication or drug use: None Family History

Patient has a family history of diabetes from both parents. A positive history of diabetes doubles

an offspring's risk of developing the disease (Franks, 2010).

General Health Patient reports he is in good health.

Review of Systems Head and Neck: None reported Neuromuscular System: None

reported Respiratory: None reported Cardiovascular: None reported Gastrointestinal/Genito-urinary:

None reported Allergies: None reported

Hematological: None reported Behavioral: No disorders reported

Current Medications Patient is not currently

under any medications. Hospitalizations/Emergency

Room visits: None reported Baseline Vital Signs:

BP: 118/78 Pulse: 76 bpm Respiration: 16 breaths/min

ASA Status with rationale: The patient is classified as

ASA I due to the fact that he presents without any systemic disorders, not currently under any medications, and presents with a normal baseline blood pressure.

Dental History

Last dental exam 11/13/2010

Last hygiene appt 11/13/2010

Last radiographs FMX: 11/15/2010 Panoramic:

03/18/2011

Past treatments Orthodontic treatment for 18

months from 1992-1993 Extraction of third molars

from all quadrants Present status

Patient currently has no need for restorative treatment

Currently on a six months interval for his recare appts (due May 13,2011)

The patient is not compliant with his recare appts. Prior to his most recent

hygiene visit, his last hygiene appt was over two years ago.

Clinical Examination (Pre-treatment)Extra-oral examination

Symmetry & Skin 3x4 mm macule on

the labium inferius The macule

developed within this past year

Lymph nodes: WNLThyroid & Trachea:

WNLTMJ

Slight crepitus on the right

Deviation to the right upon closing

Maximum opening 50mm

Clinical Examination (Pre-treatment)Intra-oral Examination

Occlusal relationship Overjet, overbite, underjet, crossbite: None Right side relationship - Molar: class I, Canine:

class I Left Side relationship - Molar: class I, Canine:

class I

Clinical Examination (Pre-treatment)Intra-oral Examination (Con’t)

Labial & Buccal mucosa: WNL

Frenums: WNLAlveolar bone: WNLTori: None presentFloor of mouth: WNLSalivary glands/flow:

WNLTongue: WNLTonsils: WNL

Uvula: WNLOropharynx: WNLCommon deviations:

Macroglossia

**photo was not enlarged

Maxillary Mandibular

Free Pink, firm, stippled,

knife-edged Localized rolling on

the buccal and lingual surfaces of #5

Attached: Pink, firm, stippled,

smooth

Free Pink, blunted, firm,

stippled Slight bulbous between

#26,27 Rolled on the lingual of

#23,24,25, 26Attached

Pink, smooth, stippled, firm

Gingival Description

Baseline Periodontal Record

Generalized 2-3mm pocket, with localized 4mm pockets on distobuccal surface of #3, #4, distolingual surface of #3, mesiobuccal of #31, distolingual of #31.

BOP: noted on #3M, 14M, 24F. MBI: 0%, PI: 100%, PFI: 0% Furcation: Class I on the buccal aspect of #2, 3, 14, 15, 19, 30. And Class I on the

lingual aspect of #19. Mobility: none Recession

1mm- #2B, 14L, 15L, 20L, 21L, 29L, 28B, 2mm- #3B, 5B, 12B, 13B, 14B, 30L

Calculus code: WLAC code light 2 AAP: Generalized moderate chronic periodontitis Areas of Concern: existing caries watch on the occlusal of #2 Perpetuating factor: Patient does not present with any restorations or malocclusion

but his inadequate oral hygiene perpetuates his periodontitis Etiology:

Patient is not compliant with his six month recare intervals his current homecare techniques demonstrate inadequate biofilm control as evidenced by

his PI score and caries watch. Patient flosses occasionally

Before Disclosing

After Disclosing – Baseline Results

PI: 100%, PFI: 0%

Oral Hygiene Evaluation (Pre-treatment)

Patient’s skill level Poor, as evidenced by his baseline PI score Patient demonstrates good dexterity but his current vertical and

horizontal scrubbing method is less effective in removing biofilmPatient’s knowledge and awareness of dental and

periodontal disease Patient possesses basic knowledge of dental diseases such as cavity

development, but was unfamiliar with the cause and effects of periodontal diseases.

Oral Hygiene Instruction Educated the patient on the modified bass technique. The patient presents with type I gingival embrasures and it is

recommended that the patient continue using dental floss with the spool method, but increase its frequency

The Tell-Show-Do method was employed for both techniques

Caries Examination

Existing caries and quality of restorations Caries watch on the occlusal surface of #2 which has been

monitored by his dentist for the last three years.Caries Index

The patient has a DMFS score of 21. This is determined by the following information: 1 decayed surface 20 surfaces from 4 missing/extracted teeth 0 filled/crowned teeth

A DMFS score of 21 indicates that there are 21 affected surfaces and 107 out of a total of 128 surfaces are still intact.

Evaluation of radiographs for caries and restorative needs Radiographs reveal no restorations The caries watch is not detectable radiographically

Panoramic Radiograph

•Per Dr. Liewen’s Assessment:• Generalized 2-3mm horizontal bone loss

•Caries watch is not detectable on the radiographs, but is clinically visible.

Three day dietary analysis Research Correlations

According to Imamura, Lichtenstein, Dallal, Meigs, & Jacques (2009), specific dietary patterns such as the habitual consumption of “soft drinks, particularly caloric soft drinks, meat and processed meat, eggs, refined grains, and French fried potatoes were positive contributors to the dietary patterns associated with type II diabetes”. These same foods also appear within the

patient’s dietary diary The nutritional habits coupled with the

patient’s familial history of type II diabetes, increases the patient’s risk of developing the disease even more

Nutritional counseling will focus on addressing these issues and offer healthy alternatives

Nutritional Analysis

Patient has a tendency to skip breakfast

Frequently consumes fast food meals high in fat and carbohydrates ex: McDonald's, Popeye’s, etc.

Frequently snacks between meals and has a fondness for sugary sweets such as candy and brownies

Commonly deficient in vegetables and dairy which consequently affected the patient's intake of essential vitamins such as Vitamin E

The patient frequently does not meet the RDAs for many food groups

Analysis of Carbohydrate Intake

1st day – 120 minutes of exposure2nd day – 120 minutes of exposure3rd day – 140 minutes of exposureAvg total exposure for all three days –

126.67 mins.The high value is attributed to the frequent

sugary snacks and carbohydrate rich foods at each meal

Nutritional Food Pyramid Results – Day 1

Nutritional Food Pyramid Results – Day 2

Nutritional Food Pyramid Results – Day 3

CAMBRA AssessmentRecommendations

based on the patient’s need

Based on CAMBRA, the patient is considered to be at high caries risk.

He has an existing caries watch on the occlusal of #2 as evidenced clinically and diagnosed by his dentist.

Furthermore, the patient presents with deep grooves and pits as well as exposed roots due to gingival recession

Prognosis Poor - Although the status of the

patient’s caries watch has not changed over the last three years, his current nutritional habits coupled with his ineffective tooth brushing technique and sporadic flossing regimen, categorizes the caries risk prognosis as poor. Emphasis will be placed on encouraging a healthier diet and OHI to raise the prognosis to an acceptable and good level.

Brush 2x/day with fluoridated toothpaste (Prevident 5000 is also recommended)

Floss regularly with dental floss Reduce the frequent consumption

of sugary snacks and sodas; continue consumption of tap water (0.7ppm)

Incorporate more fruits and vegetable in the diet

Fluoride rinse (0.05% NaF, ACT, or Fluorigard) 2x/day

Xylitol – after snacks and as a mint 3-5 times/day

In-office fluoride varnish or tray Antibacterial rinse - Chlorhexine

gluconate for 1 week/month

Caries Risk Assessment

Dental Hygiene Treatment Plan

Rationale for tx plan and patient needs Patient demonstrates inadequate biofilm control as evident

by his PI score of 100%. Patient also presents with an existing caries watch as well.

Goal of dental hygiene tx Decrease patient’s caries risk and increase the prognosis

level Encourage the development of oral hygiene habits to

improve oral health Increase the patient’s understanding and awareness of the

cause and effects of periodontal disease, as well as its sequence

Dental Hygiene Treatment PlanFirst Appointment

Interpretation of PI results, explanation of the role of carbohydrates and tooth decay, what periodontal disease is, sequence of periodontal disease development

Because the patient demonstrates good dexterity, the modified bass technique will be introduced to the patient.

Daily flossing with the spool method will be reinforced and encouraged. Employment of the tell-show-do method to ensure proper application of the techniques

demonstrated. A goal of 25% plaque reduction was established to encourage the patient to improve

their overall oral hygiene and practice the new techniques taught. Sealant recommendation for his deep grooves and pits on all mandibular molars 5% NaF in-office varnish is recommended due to the patient’s caries risk and recession.

In addition to the in-office treatment, Prevident 5000 will also be recommended. Antibacterial rinse – 0.12% Chlorhexidine gluconate is recommended for 1 week/month

for patient’s caries watch and prevention of future caries. Nutrition recommendation:

Encourage the reduction of frequent in-between snacking Increase consumption of fruits and vegetables, and decrease consumption of sodas and retentive

sweets Introduction of xylitol and healthier snack options Encourage the consumption of breakfast to reduce snacking habits.

Dental Hygiene Treatment PlanSecond Appointment – 3 Week Re-evaluation

Analysis of the patient’s compliance with the aid of a second PI score

Review and reinforced OHI provided at the first appointment. Modified bass technique Spool method of flossing

Clinical Examination (Post Treatment)Extra-oral Examination

Symmetry & Skin 3x4 mm macule on the

labium inferius The macule remained

unchanged and the same size

Lymph nodes: WNLThyroid & Trachea:

WNL

TMJ Slight crepitus on the

right Deviation to the right

upon closingMaximum opening

50mm

Clinical Examination (Post Treatment)Intra-oral Examination

Occlusal relationship Overjet, overbite, underjet,

crossbite: None Right and Left side relationship -

Molar: class I, Canine: class I Labial & Buccal mucosa: WNL Frenums: WNL Alveolar bone: WNL Tori: None present Floor of mouth: WNL Salivary glands/flow: WNL Tongue: WNL Tonsils: WNL Uvula: WNL Oropharynx: WNL Common deviations:

Macroglossia

Gingival Description Max Free: Pink firm,

stippled, blunted, localized rolling on the buccal and lingual surfaces of #5

Max attached: Pink, firm stippled, smooth

Mand Free: Pink, blunted firm, slight bulbous between #26,27, rolled on the lingual of #23,24,25, 26

Mand attached: Pink, smooth, stippled, firm

Clinical Examination (Post Treatment)Intra-oral Examination (con’t)

Periodontal Record Generalized 2-3mm, with localized 4mm pockets on

distobuccal surface of #3, #4, distolingual surface of #3, mesiobuccal of #31, distolingual of #31.

BOP: noted on #2B, 12D, 30L MBI: 0% Furcation: Class I on the buccal aspect of #2, 3, 14,

15, 19, 30. And Class I on the lingual aspect of #19. Mobility: none Recession

1mm- #2B, 14L, 15L, 20L, 21L, 29L, 28B, 2mm- #3B, 5B, 12B, 13B, 14B, 30L

After Disclosing – Post Treatment Results

PI: 68%, PFI: 32%

Post Instructions Status

Patients compliance resulted in a 32% reduction in biofilm. Patient exceeded the improvement goal established during the first appointment.

Based on the areas where biofilm remained, I recommend the patient continue his homecare regimen Recommended the use of an electric toothbrush

“electric brushes are significantly more effective at maintaining low plaque levels compared to a manual brush with or without the daily use of floss” (Rosema et al., 2008)

“Provides long-term biofilm control and improve gingival condition for more than 6 months compared to manual brushes with or without the use of floss”. (Rosema et al., 2008)

Recommended the additional use of mouthrinses to aid with interproximal biofilm control as these are the areas the patient is missing “twice daily rinsing reduced P.gingivalis (64.5%), Veillonella sp. (56.6%, F. nucleatum

(76.6%), and total anaerobes (74.9%) within the interproximal regions” (Teles & Teles, 2009)

Even single 30 second rinses demonstrated a significant reduction (43.8%) 5 minutes later (Teles & Teles, 2009)

Essential oil containing mouthrinses are “as effective as daily flossing in reducing interproximal plaque and gingivitis” (Teles & Teles, 2009)

Referrals

Patient was referred to his dental hygienist for hygiene services as dictated by his six month recare interval; Due May 13, 2011

Patient is also referred to a specialist for the macule present on his labium inferius

Research

First article Periodontal Disease and diabetes – review of the literature – Bascones-Martinez

et al. (2011) Analyzes the interrelationship between periondotitis and diabetes.

Second Article: Diabetes family history: a metabolic storm you should not sit out – Franks (2010)

Analyzes the contribution of family history to the development of diabetes and the mechanism of various genetic risk factors.

Third Article: Generalizability of dietary patterns associated with incidence of type 2 diabetes

mellitus – Imamura, Lichtenstein, Dallal, Meigs, & Jacques (2009) Analysis of the dietary patterns associated with type 2 diabetes

Fourth Article: Comparison of the use of different modes of mechanical oral hygiene in

prevention of plaque and gingivitis – Nanning et al. (2008) A study that analyzed the efficacy of powered toothbrush to their manual counterparts

over a 9 month period.

Research Con’t

Fifth Article Comparison of the use of different modes of

mechanical oral hygiene in prevention of plaque and gingivitis – Rosema et al. (2010) Analyzes the efficacy of the modified bass method

Sixth Article Antimicrobial agents used in the control of

periodontal biofilms: effective adjuncts to mechanical plaque control? – Teles & Teles (2009) Analyzed the efficacy of antimicrobial rinses