CASE STUDY

By Tammy Maahs, RDH, BSDH

SPRING BREAK!
GRANDTWINS 2ND BIRTHDAY

FINISHED MY BOOK AND MOVIES!

Started reading this CHRISTMAS break and

finally finished

Breaking Dawn Part 2

THEN WORK OF COURSE

64 year old female
Medical History: heart attack 2012; cardiac stent
placed. Takes Effient (oral antiplatelet
medication) , metoprolol (for hypertension),
pravastatin (for cholesterol), and 325 mg aspirin
daily.
Chief Concern: toothache #29
Dental diagnosis is advanced periodontitis,
prognosis hopeless, extraction #29 recommended
(and completed at subsequent appointment).

Patient returned for FMS and comprehensive

evaluation. Patient expressed that she worries
that dental cleaning will destabilize existing
teeth but she does not want to lose her teeth.
Anxious, but motivated. States she does not like
the hand scaling and prefers the ultrasonic
scaling.
Recommended perio referral but patient
preferred to have NSPT performed in our office.
She wanted to go off her blood thinner for
treatment but we called her physician who
recommended not discontinuing Effient, but not
to take aspirin the day of treatment.

RADIOGRAPHIC EVALUATION
(NOT MY FILMS!)

FMS shows advanced bone loss and heavy

calculus. Discussed guarded prognosis of
remaining dentition; #1 likely hopeless.

HEAVY SUPRAGINGIVAL AND SUBGINGIVAL

CALCULUS

FIRST HYGIENE APPOINTMENT:

UL QUAD #9-14
Anesthesia left ASA, MSA, SP #14 and 7 (pt.
request due to cold sensitivity), additional AMSA
administered due to insufficient anesthesia in
premolar area. 2-2/3 cartridges articaine used.
Patient reported she uses vitamin E oil (rubs on
gums) for sore spots and asked if she could do
this post-operatively.
Perio charting/probings recorded after anesthesia
for UL only and most recession (except for
mandibular anterior lingual for obvious reasons!)

PERIO ASSESSMENT

UL POST SCALING AND 1 WEEK P.O.

UL ONE WEEK P.O.: BUCCAL 12, LINGUAL

#12-14

#11-13 BUCCAL

SECOND APPOINTMENT: ENTIRE MANDIBLE

(3 HOUR APPOINTMENT)

Obtained consent for bilateral IA/L injections

explaining effects.

ARMAMENTARIUM

Everything but the kitchen sink!

EXCESS TISSUE LINGUAL BETWEEN #23 &

24

CURETTAGE (COOL HUH?)

Fairly certain the body would not resolve that

area of granulated tissue, proceeded to curettage
from the lingual, leaving the contour of the
buccal tissue (even though open contact, blunted
tissue due to migration)

WISH I HAD A LASER!

PROBING AFTER SCALING

Was difficult due to amount of bleeding however I

could still feel calculus on flat facial and lingual
surfaces with my perio probe so got the files out.

AREA OF CURETTAGE FACIAL

ONE WEEK POST-OP

CURETTAGE AREA FROM LINGUAL

(YES, I SEE THE STAIN!)

FINALLY THE UR QUADRANT

(BEFORE DEBRIDEMENT)

Again discussed hopeless prognosis of #1; placed

Arestin in the MB and ML pockets.

UR QUADRANT (#1-8)

LINGUAL #4 & 5; #6-8 (FILES AGAIN!)

REFLECTIONS

Patient was very, very cooperative; pre-med with

Valium for appointments. UL was 1.5 hour,
mandible 3 hours with bilateral IA/L injections.
This method for an advanced case is very well
received and recommended because you dont
have to deal with the midline anesthesia.
Bilateral IA/Ls with a right LB injection served
very well. UR was almost 2 hours because I did
some additional redebridement of some
residual/remaining calculus #17, 22 and 23, as
well as polishing to remove stain.

This patient is very pleased with treatment. To

return in two weeks for a tissue check and reevaluation (I wont probe, just want to check
healing), then a 3 month perio maintenance
appointment.
I was a bit overwhelmed with the amount of
bleeding on the mandible. I called the patient in
the late afternoon to make sure she was doing
okay, and the anesthesia had worn off
sufficiently.

These cases are what make being a dental

hygienist fun and rewarding. I wanted to refer
her due to the degree of difficulty, but the
dentist(s) I work with have the faith that I can
scale just as well as the periodontist (his
brother!) and the patient seemed more
comfortable in our office. I was certain to request
additional time for appointments because I knew
this would be hard work! Rapport is everything;
treat your patients like they are the most
important person in the world, because they are!
I do not just care for my patients teeth, I care for
my patients!