Running head: CAPSTONE PROJECT

Senior Capstone Project

By: Breanna Cruz

In partial fulfillment of the requirements for

DHYG 438: Senior Capstone & Portfolio

Lake Washington Institute of Technology

Ms. Lindeman​, RDH, MEd

Spring Quarter

May 7th, 2019

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Assessments

Patient’s Chief Concern

The patient’s chief concern was that she wanted to have her teeth cleaned and “fixed”.

She is a student at Lake Washington Technical Institute and is currently working on her

Bachelor’s degree.

Health History

My capstone patient is a 57 year old, female with several health conditions. She presented

to the clinic on November 7th, 2018. Her blood pressure was 148/102. She had a Redbull italian

soda before coming in for her appointment and said her blood pressure may be higher than

normal due to that. I informed the patient that her blood pressure reading was elevated and

recommended doing a medical consult, before proceeding with any treatment. Her primary

physician is Dr. Sharma at Healthpoint, located in Redmond. Her past health history includes: 4

strokes, 3 heart attacks, a brain aneurysm, and 5 facial reconstructive surgeries. Her last stroke

was in 2008 and her last heart attack was in 2011. The surgery for her brain aneurysm was done

March 2017. She had facial reconstructive surgeries in 1973, and 1980 to 1983. In 2000, she had

Breast Cancer and in 1996, she had Ovarian Cancer. She has asthma and carries an inhaler with

her. The patient was diagnosed with sleep apnea & COPD in 2011, but doesn’t use a CPAP. She

was diagnosed with anemia and osteoporosis, but does not take medication for it. Her allergies

include: Aspirin, Penicillin, Sulfa drugs and mushrooms, with anaphylaxis as her reaction. The

patient is taking: Montelukast and Fluticasone for allergies, Cozaar and Spironolactone for blood

pressure, Rexulti for depression, Buspirone for anxiety, Flovent and Ventolin for asthma,

Paroxetine for depression, Xarelto and Clopidogrel for stroke prevention, Welchol for
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cholesterol, Dicyclomine to treat IBS, and Fenofibrate for cholesterol. Due to the patient’s

extensive health history, I sent her physician, Dr. Sharma, a medical consult in order to proceed

with treatment.

When conducting my research on the medications, I found that xerostomia is a common

side effect. Xerostomia is commonly known as “dry mouth” and can cause caries and

candidiasis. Patients should be educated on the effects of xerostomia and ways to treat it, such as

using alcohol-free mouthrinse, xylitol products, brushing two times a day with fluoride

toothpaste, and using biotene products (​Villa, Wolff, & Narayana, 2016​). It is crucial to maintain

excellent home care, since xerostomia can put the patient at a higher risk for caries. Patients who

have dry mouth often have “atrophic and erythematous ​oral mucosa​” (Plemons, Al-Hashimi, &

Marek, p.870, 2014). Other signs of xerostomia may include: fissured tongue, attrition, chapped

lips, increased plaque accumulation, and angular cheilitis.

Extraoral Assessment

For facial symmetry, her ramus is shorter on the right side. She has generalized scattered

macules. She has two prominent papules, one was 4x4x2mm, light pink, semi-firm and was

located on the left side of the upper lip. The second papule is 5x4x2mm, light pink and located

on her right cheek. She presented with subluxation, crepitus, and lateral deviation with pain.

Intraoral Assessment

The patient presented with slight xerostomia, due to an abundance of medications which

cause it. She has tori on her hard palate and lingual tori on the mandible. Her uvula was slightly

red during examination. She has a 4x3mm white plaque that was semi-firm located on the right
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lateral side of her tongue. The patient was unaware of the lesion so I showed her and told her we

would monitor it for changes. Her tongue was scalloped and slightly coated.

Gingival Description

The color of her gingival margins were generalized moderate-severe edematous. There

were localized areas that were fiery red which were along #4-6 buccal and #22-27. She had

generalized moderate rolled margins. The contour of her gingiva was generalized moderate

bulbous. The consistency was generalized moderate edematous. The surface texture was

generalized severe smooth/festooned. Generalized bleeding on probing.

Tooth Chart
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This patient has a history of decay and has had a substantial amount of dental work in the

past. She also has several composite and amalgam restorations located throughout her mouth on

#5, 7, 9, 10, 11, 14, 15, 19, 20, 27, & 31. Her upper left molar, #14, is fractured. On the maxilla,

#6 & 8 are mesially rotated and #5 & 13 are buccoverted. She has generalized linguoversion on

the mandibular teeth on #22, 24, 27, 28, & 29. She has mesial rotation on #25 and distal rotation

on 31. She is missing #1, 3, 16, 17, 18, and 32. She has WAG (less than 2mm) on #25 and 31.

Occlusion

Her occlusion according to Angle’s Classification, is not applicable for the right side

molars and class II for the left side molars. She has class II occlusion for the canines, right and

left side. She has a moderate overbite and an overjet of 4mm.

Periodontal Chart
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This patient has generalized 4mm pockets with localized 5mm & 6mm pockets in the

posterior teeth. She has generalized BOP and required anesthetic before I was able to probe, due

to sensitivity. She has generalized recession and localized furcations. Her AAP classification is:

IV/3/E; localized IV/2/E on the UL.

Risk Assessment
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My risk assessment shows that my patient is at a high risk for caries. She is taking several

medications causing xerostomia. She drinks fluoridated water, but according to the nutritional

analysis, she isn’t drinking as much as she should be. Her only other source of fluoride is from

her over the counter toothpaste. Her stress load is high, due to being a college student, and her

carb intake is moderate. She is currently brushing 1-2 times a day and she is only flossing 1-2

times a week. Her plaque index was at 26%. Most of her plaque was located interproximally on

the mandibular teeth. Due to her high risk for caries, I suggested that the patient should use

Clinpro 5000 to prevent further decay. I also informed the patient about xylitol to help prevent

xerostomia. I’m hoping to motivate her to become better with her home care regimen, to

decrease her caries risk level.

Radiographs

Since this patient was new to our clinic and had not visited a dental clinic in several

years, I took full mouth x-rays to examine previous dental work, look at the bone health of the

patient and look for any pathologies. She has generalized moderate bone loss, due to periodontal
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disease. She also has several screws throughout her maxilla from jaw surgery, due to a traumatic

accident when she was younger.

Oral Hygiene

The patient’s current daily plaque control methods include brushing 2 times a day with a

soft, manual toothbrush and flossing 1-2 times a week.

Dental Examination

Dr. Lowell performed a dental examination on January 16th, 2019. The patient’s chief

concern was having #14 fixed, so Dr. Lowell suggested doing a build-up and crown, due to the

amount of tooth broken off. The patient also mentioned that she wanted to know what treatment

options she had for tooth #9, to help with the discoloration. The doctor suggested putting a crown

on that tooth, so it would match the rest of the teeth. He found several areas of decay
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interproximally on the maxillary anterior teeth, as well as two areas on the mandible. The doctor

also recommended a night guard, due to wear on the teeth and signs of grinding. The patient

seemed very motivated to get started on completing her restorative treatment.

Plaque Index

The plaque index was 26%. Majority of the plaque was located on the mandibular teeth,

interproximally. Other areas of plaque were found on the maxillary molars. I encouraged the

patient to increase the amount of times she flosses and suggested that she could use sulcabrushes

and/or soft picks.

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Pre-Treatment Intra Oral Photos
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Dental Hygiene Diagnosis

Health History

The patient had a stroke in 2000 and a heart attack in 2008, due to cardiovascular disease.

She has asthma due to chronic respiratory disease and carries her inhaler with her daily. My goal

for her is to maintain regular visits to her primary care physician.

Dental History

Her last dental visit was in 2000, due to not having insurance. The last office she went to

was, ICHS Dental Clinic in Bellevue. My goal for her is to maintain regular dental visits and to

stress the importance of dental care at each visit.

EO/IO

4x4x2mm light pink, semi-firm papule located on the left side of the lip. 5x4x2mm light

pink, semi-firm papule located on the right cheek. 4x3mm white plaque located on the lateral
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right side of the tongue. Etiology is unknown. I informed the patient of my findings and let her

know to monitor the areas for changes.

Gingival Description

Generalized moderate-severe edematous and bulbous. Generalized bleeding on probing.

Generalized smooth and festooned. Etiology is due to bacteria. In order to decrease interproximal

bacteria load and help with removal, I encouraged the patient to try using soft picks 3-4 times a

week.

Oral Hygiene

The patient is brushing two times a day with a soft, manual toothbrush. She is flossing

1-2 times a week. She has generalized plaque, which is localized heavy on the lower anterior.

She has generalized moderate calculus. The cause of plaque is due to bacteria. My goal for her is

to focus brushing toward the gumline to completely remove biofilm.

When comparing sonicare to a manual toothbrush, one study showed that the results of

the toothbrushes had no significant difference. The study did find that “rotation oscillation

powered brushes significantly reduce plaque and gingivitis in both the short and long-term”

(British Dental Journal, 2006). As long as the toothbrushes are used correctly, they will both

adequately remove biofilm. For patients at a higher risk, electric toothbrushes can be more

beneficial in the removal of plaque.

In another study on powered versus manual toothbrushes, conducted by Cochrane

researchers, it involved 2,500 trials. The results showed that electric toothbrushes with

oscillation power have better results than manual toothbrushes (​Deacon, Glenny, Deery, &
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Robinson, 2011). According to the research and studies, my capstone patient would benefit from

using an electric toothbrush to decrease plaque accumulation.

Hard Tissues

Her decay status is high due to her caries risk, diet, fluoride intake, and xerostomia. She

has attrition on her anterior teeth. A night guard would be beneficial to prevent any further wear

on her teeth. Using Clinpro 5000 would decrease her caries risk and xylitol would help with

xerostomia.

Periodontal

She has localized 4-6mm pockets on the molars and generalized 3-4mm pockets

throughout the rest of her mouth. She has generalized recession and had generalized severe

bleeding on probing due to bacteria. My goal for her is to maintain regular periodontal

maintenance appointments after scaling and root planing. This will prevent her periodontal status

from declining.

Other

The patient was diagnosed with sleep apnea & COPD in 2011, but doesn’t use a CPAP.

She said it’s very uncomfortable to use.

Planning

After thoroughly assessing my patient, I decided that the best dental hygiene treatment

plan would be four quads of SRP 4341, due to the periodontal pockets, amount of calculus

present and BOP, which indicates inflammation and active disease. Four to six weeks after

completing SRP, I will have the patient return for a tissue re-evaluation. At that appointment I
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will check the periodontal pockets, record bleeding on probing, complete a new plaque index,

take intra-oral photos, and apply 5% fluoride varnish. This will take a total of 5 appointments.

At each appointment I will also assess the patient’s home care and make suggestions on

ways to improve if necessary. A sulcabrush will be beneficial for areas of root exposure and hard

to reach areas for the patient. A perio-aid will help eliminate bacteria from deeper pockets too. I

will continue to monitor my patient’s home care at each appointment by observing her plaque

levels and gingival inflammation, along with bleeding.

For therapeutic interventions, I will use subgingival irrigation with Chlorhexidine after

each SRP appointment and place Arestin in pockets 5mm or greater. I will encourage the patient

to use Chlorhexidine at home to decrease her bacterial load as well.

After planning the dental hygiene treatment, I informed the patient, she understood and

signed the dental hygiene treatment plan. For restorative treatment, I will be seeing her on April

15th to begin her restorative work.

Implementation

It took a total of two appointments to complete the upper right and upper left quadrants.

The lower quadrants are scheduled to be completed by the end of April, with two different

students. The patient canceled her first SRP appointment twice, so treatment took awhile to get

started. I informed the patient over the phone, that I would cover the cost of treatment and that I

would make sure she was comfortable throughout the cleaning. After having that conversation,

she finally came in for her first SRP appointment. I scheduled her tissue re-evaluation for April

29th.
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After the first SRP appointment, I was able to assess the gingiva and noticed they shrunk

and appeared to be more blunted, than bulbous in appearance. The patient seemed more

compliant and motivated after the first appointment, especially once she noticed a difference

with her gingiva. The energy level she displayed after noticing her results, reassured me that she

was pleased with the outcome. I believe the appointment goals were met, due to the patient’s

increased motivation and the results presented.

In addition to the dental hygiene treatment, I wanted to make sure that treatment was

comfortable for my patient. I gave her Septocaine for each appointment and administered local

anesthesia before starting her cleaning. She responded very well to the anesthesia and it allowed

me to do a thorough job removing all the calculus. I used the piezo, gracey’s, and files to debride

the maxillary quadrants.

Evaluation

Tissue Re-Evaluation

When my patient came in for her appointment, 6 weeks after her last SRP on the

maxillary arch, I immediately noticed a difference with her gingiva. They appeared much

healthier, firm, and blunted than before. It was obvious when comparing the before and after

pictures that there was a major improvement. Upon probing, some of probing depths had

decreased and there was noticeably less bleeding. She was very happy with the results.

According to a study conducted on patients with periodontal disease, “​Periodontal

achievements may be sustained in the long-term with appropriate oral home care and

professional maintenance.” (Bokhari, 2012). With this information, as a clinician it is our job to
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inform the patient of their risks of their periodontal disease declining. As long as the patient is

compliant, their periodontal disease will remain the same.

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Post-Treatment Intraoral Photos
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Post-Treatment Periodontal Chart

At the tissue re-evaluation appointment, I measured her pockets and discovered some of

the probing depths decreased from a 4 to a 3. She also had less bleeding and inflammation. She

was still really sensitive when I was probing, so I had to use Oraqix.

Post-Treatment Gingival Description

Her gingiva was generalized erythematous. It was generalized slight bulbous along the

gingival margins. Her papilla was generalized moderate blunted and the texture was generalized

smooth and glossy. She had localized fiery, red gingiva on the facial of #6, 7, and 11. I discussed

focusing on those areas to remove plaque and how to angle the toothbrush, to reach the areas of

recession. Overall, I noticed great results after SRP.

Daily Biofilm Control

Her homecare seemed to have decreased. Her plaque index score was 60%. She had

generalized plaque interproximal and buccal of all maxillary teeth. I asked if anything had
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changed and she said no. I emphasized the importance of spending two minutes brushing her

teeth, at least once a day.

Therapeutic Intervention Outcome

There were no changes to her nonsurgical periodontal therapy during treatment. I

completed 3 sextants on the maxillary arch and two other students completed the mandible. I

used piezo, cavitron, gracey’s, universals, and subgingival irrigation for her SRP appointments.

During her tissue re-evaluation, the patient was very sensitive. I was unable to use the cavitron or

hand scale so I just polished with coarse polish to remove plaque and stain.

Maintenance Interval

For this patient, I would recommend periodontal maintenance every 3 months. Due to her

recession, xerostomia, inflammation, caries risk, and plaque levels, I think that more frequent

appointments would benefit the patient. Compliance and home care needs to be addressed at

each appointment as well.

Reflective Conclusion

During my implementation phase, I used knowledge I learned from prior courses to

accurately evaluate my patient. I was able to analyze the patient’s health history and establish an

appropriate treatment plan that the patient would benefit from. While providing treatment to the

patient, I was able to understand how to appropriately treat a patient with hypertension, a blood

disorder, and xerostomia. In the process, I was able to expand my knowledge on

recommendations to help with xerostomia, to prevent caries, infections, and most importantly,

how to make the patient feel comfortable. I believe I excelled in providing suitable knowledge to

the patient. I feel like I could improve on finding more ways to encourage brushing. For this
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patient specifically, I feel that a power toothbrush would be most beneficial for her. Since her

plaque index was high, focusing on brushing would be my first goal. My second goal to achieve

for this patient, would be to have her use an oral aid to help her clean her teeth interproximally. I

think a proxy brush would be an excellent tool to use in her embrasure spaces, that would make

it quick and easy for her. Overall, after seeing my patient from start to finish, I was able to

recognize the improvement firsthand.

Documentation

All aspects of documentation were completed. I made detailed chart notes for each

appointment, along with the completing the appropriate codes. I updated her maintenance

interval during the tissue re-evaluation appointment, to every 3 months. Her paperwork was

filled out accurately and signed by instructors.

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Nutritional Analysis
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After the patient completed the nutritional analysis for seven days, I was able to assess

her diet and determine that she is getting an adequate amount of grains, dairy, and protein.

However, she is insufficient for receiving the proper amount of fruits, vegetables, and water. The

fats & sweets exposure was very high and I recommended that she decreased her intake in that

category. A contributing factor to her fats and sweets intake, is due to her eating McDonald’s

almost everyday. I recommended that the patient should pack healthy snacks to eat before and

after classes. A dietary change commitment she made, was that she was going to try to avoid

eating fast food daily and pack more healthy snacks. Her current plaque index is 26%, which can

cause an increased risk for caries.

Due to her lack of fruits, vegetables, and water, she is at risk for several vitamin and

mineral deficiency such as: vitamin K, vitamin C, potassium, iron, and more. In an article on
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dietary deficiencies, it stated: “​A class of medications called ACE inhibitors, used to treat high

blood pressure, may decrease the levels of zinc in your blood, potentially lowering immunity and

slowing wound healing.” (Boosting dietary deficiencies with multivitamin supplements, 2011).

Understanding the effects that certain medications have on the patient, can contribute to

appropriate dietary recommendations. “Some cholesterol-lowering drugs may negatively impact

on coenzyme Q10 levels, thus decreasing energy levels and increasing fatigue.” (Boosting

dietary deficiencies with multivitamin supplements, 2011). Educating the patient of these risks

could motivate the patient to become more aware of her nutritional choices.
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Study Models
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The study models show generalized bulbous, rolled margins. There is a fracture on the

buccal of #14 and the distolingual of #9. Her maxillary frenum is directed more towards the left

side. The patient is missing #1, 3, 16, 17, 18, and 32. There is slight crowding on the maxillary

arch and severe crowding on the mandibular arch.

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Restorative

Before:

After:

The patient had recurrent decay in tooth #31. The doctor treatment planned an MO

amalgam filling during her exam. She previously had an amalgam filling placed years ago. I

restored the tooth successfully, but faced a few difficulties, due to the rotation and marginal

discrepancy. Overall, the patient was very satisfied with the results.
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Medical Consult

I sent a medical consult to the patient’s primary care physician expressing concern for the

patient’s high blood pressure, bleeding disorder, history of stroke, heart attack, and asthma. Her

physician returned the consult stating that it was safe to perform dental procedures, as long as her

blood pressure was below 140/90. There were no other contraindications to dental treatment.
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References

Bokhari SA, Khan AA, Butt AK, Azhar M, Hanif M, Izhar M, et al. Non-surgical periodontal

therapy reduces coronary heart disease risk markers: a randomized controlled trial. J Clin

Periodontol. 2012 Nov;39(11):1065–1074.

Boosting dietary deficiencies with multivitamin supplements. (2011, Mar 22). ​Canada NewsWire

Retrieved from:

http://168.156.198.98:2048/login?url=https://lmcproxy.lwtech.edu:2482/docview/857944

251?accountid=1553

Deacon, S. A., Glenny, A., Deery, C., Robinson, P. G., Heanue, M., Walmsley, A. D., & Shaw,

W. C. (2011). Cochrane Review: Different powered toothbrushes for plaque control and

gingival health. ​Evidence-Based Child Health: A Cochrane Review Journal,6(​ 6),

2275-2321. doi:10.1002/ebch.891

The effectiveness of manual versus powered toothbrushes for dental health: A systematic review.

(2004). ​British Dental Journal,197(​ 10), 619-619. doi:10.1038/sj.bdj.4811827

Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at

improving oral health. 1998. In: Database of Abstracts of Reviews of Effects (DARE):

Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination

(UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK67424/

Plemons, J. M., Al-Hashimi, I., & Marek, C. L. (2014). Managing xerostomia and salivary gland

hypofunction. ​The Journal of the American Dental Association,​ ​145​(8), 867-873.

doi:10.14219/jada.2014.44
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Villa, A., Wolff, A., Narayana, N., Dawes, C., Aframian, D., Pedersen, A. L., Proctor, G. (2016).

World Workshop on Oral Medicine VI: A systematic review of medication-induced

salivary gland dysfunction. ​Oral Diseases,22(​ 5), 365-382. doi:10.1111/odi.12402