Running head: CAPSTONE PROJECT 1

Capstone Presentation

Stephanie Conway

Lake Washington Institute of Technology

Dental Hygiene Program

Assessments

My capstone patient was a 35-year-old woman. She was not currently under the care of a

physician as she just moved to the United States from Tamil Nadu, India in July 2017. She had

her teeth cleaned a year prior to coming to the Lake Washington Institute of Technology dental

clinic and has regularly received dental care throughout her life in India. Her main concern was

to get her teeth cleaned since she had been unable to in the past year. The systemic conditions

she has which have a direct impact on her oral and periodontal health are hypothyroidism and

sports-induced asthma. She takes a brand of Levothyroxine common in Asia called Thyronorm

in the form of a 100mcg pill per day. According to one case study recorded in the Journal of The

Scientific Society, “When the therapy for periodontitis and hypothyroidism was implemented,

there was an improvement in the oral hygiene status and an immense reduction in the bleeding

scores. This finding of increased gingival bleeding with minimal local factors may be due to the

susceptibility of hypothyroid patients to infection. In hypothyroidism, delayed wound healing

occurs due to decrease in the metabolic activity of the fibroblasts. Delayed wound healing may

be associated with an increased risk for infection due to the longer exposure of the unhealed

tissue to pathogenic organisms manifesting clinically with increased gingival bleeding”

(Kothiwale, Panjwani, 2016, p.36). This scientific evidence shows that hypothyroidism can

affect a person’s ability to resist bacterial infection which in turn increases the chance of getting

periodontal disease.

She does not take any medication for her asthma and had not experienced a mild asthma

attack for at least 10 years. She also did not have any allergies. Living in India definitely

impacted the standard of oral health care she had received. As can be seen in the intra-oral

photos and in her radiographs, she had moderate calculus spicules sub-gingivally on her
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maxillary dentition and heavy rings of calculus on her mandibular dentition. The bacteria

harbored within the calculus had severely impacted her bone and gingival health. While she may

have had her teeth cleaned in India, subgingival root debridement had not been achieved due to a

different standard of care in another country.

In the extra oral exam, I noted a 7x4mm diffuse, red rash on the tip of the nose,

generalized scattered macules, and 2x3mm red papules directly under the right eye, which are all

within normal limits. Her thyroid was slightly enlarged side-to-side; however, during her doctor

exam, the doctor did not see a need to refer her for further examination by her primary physician.

In her intra oral exam, I noted her maxillary frenum was slightly restricted, and on her buccal

mucosa she had bilateral linea alba and bilateral scattered 1x1mm petechiae. Her palatine tonsils

and pillars were slightly red, and her tongue had generalized speckled brown pigment. All of

these intraoral findings were within normal limits. During her gingival assessment, I noted that

she had generalized severe edema and erythema on the mandibular tissue buccal and lingual. Her

maxillary tissue was generally red, edematous, and bulbous. She had a generalized smooth

texture on all gingival margins. There was localized severe redness on #2-L and localized severe

rolling, friable, and cyanotic tissue on #26-F. While taking the FMX, I decided to take vertical

bitewings because of recession that could be seen clinically. This allowed me to evaluate

alveolar bone height.

Intra Oral Photographs taken 1/30/18

Radiographs taken 1/10/18

My patient brushes two times a day with a manual, soft bristled toothbrush and flosses

one time per day. She does not use any other aids or mouth rinses. My capstone patient also has

never had a filling. The only dental work she received was the extraction of #1 and #32. On her

tooth chart, I noted localized mesial and distal rotations, marginal ridge discrepancies, and

localized teeth that were linguoverted or buccoverted. Bilaterally, her canines and molars

exhibited Angle’s Class II occlusion. She had an overjet of 3-5mm, a slight overbite, and an end-

to-end relationship between #12 and #21. As can be seen on the periochart attached to this

document, she had generalized 3-4mm pockets, 1-2mm recession, class I furcation’s, and

moderate bleeding upon probing (BOP). She had localized 5mm pockets, 3-4mm of recession,

and class II mobility on #25.

Tooth Chart
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Initial Periochart 1/30/18

The doctor’s treatment plan consisted of the extraction of her remaining wisdom teeth,

#16 and #17, because they were both impacted. #16 was almost fully erupted and #17 had just

barely erupted into the oral cavity. The doctor did not find any decay in the patient’s mouth. The

first plaque index was done on 1/10/18, and the score was 63%. The plaque was not thick and

was mainly located on interproximal surfaces and on the calculus rings located on the mandible.

I reviewed how to attain “C” shaped flossing techniques and the importance of using the bass

technique while brushing. After I demonstrated, I had the patient practice these new techniques. I

did another plaque index on 1/30/18 when we finished her new patient assessments. This time

the plaque index scored 48%. The plaque was still located on the rings of calculus on the

mandible; however, there was significantly less plaque on maxillary interproximal surfaces,
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especially in the posterior teeth, which is why the score reduced by 15%. This was due to the

patient properly adapting the floss while flossing each day.

Referral for the extraction of #16 and #17

Treatment Plan
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Risk Assessment
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Dental Hygiene Diagnosis and Planning

The patient was very eager to get good oral care and currently has active periodontitis.

She was very receptive to receiving and trying new homecare techniques. I firmly believe she

will be able to achieve very good oral health because she already has a good homecare routine.

However, she has never had the opportunity to receive scaling and root planing therapy. The

fluoride she has in her toothpaste and water source is sufficient because she does not have, and

has never had, a carious lesion. Therefore, no changes need to be made regarding her fluoride

intake. My goal as her health care provider is to remove the calculus that is harboring destructive

bacteria, arrest the bacteria to prevent further bone loss, reduce the bacterial load through scaling

a root planing, and help the patient create her own homecare routine since she plays the most

vital role in achieving her own future oral health. I aimed to accomplish these goals by first

providing scaling and root planing therapy. Her AAP code classification on the maxilla was

III/2/D2 and her mandible was classified as III/3/E due to periodontal involvement of more than

4 teeth in all four quads. Other determining factors of her AAP included moderate, horizontal

bone loss on her anterior teeth, generalized 1-2mm recession, class I furcations, and localized

areas of 3-4mm recession in each quad. I also recommended a chlorhexidine rinse to help reduce

as much bacteria in her oral cavity as possible. At her tissue re-evaluation, I will assess if any

adjustments need to be made to her homecare routine, such as the use of a perio-aid after the

calculus is removed on her lower anterior teeth. I will also see if our goals are achieved when her

gingival assessment and perio chart are done at her tissue re-evaluation. I hope to see a reduction

in inflammation, pocket depths, and BOP. My goal is also to get my patient on a regular 3-month

periodontal maintenance to prevent further bone loss and calculus build-up.

Implementation
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To complete this patient’s dental hygiene treatment, 4 appointments were planned to

complete 4 quadrants of scaling and root planing. For the first appointment, the lower right (LR)

quadrant was completed. After I administered local anesthesia, I started cleaning the quadrant

with the blue cavitron tip to remove heavy ledges of calculus. In the LR quadrant, my patient had

rings of calculus on #28 and #29 lingual and a ledge of calculus from #25 to #27 buccal and

lingual. After using the cavitron on the LR quadrant, I then used the explorer to feel for any

remaining clicks of calculus. Then I used files to break down remaining clicks of calculus to

enable effective removal stokes with gracey hand instruments. My patient, as noted earlier, was

an AAP III, so I used gracey instruments to properly adapt to the anatomy of her teeth, especially

on exposed root concavities. As I was scaling, the patient was bleeding heavily in all areas,

especially on the anterior teeth where the calculus was heaviest. After scaling the LR, I

encouraged the patient to rinse with warm salt water to advance gingival healing. I also told her

to soak a black tea bag in warm water for a few minutes, allow it to cool, and gently bite down

on the tea bag on the treated area for 5 minutes. I instructed my patient to do this because black

tea contains tannins which are astringent, meaning blood vessels constrict, and have a hemostatic

effect. Tannins are also a mild antiseptic, so the tea bag reduces further bleeding, absorbs blood,

and helps prevent infection. In addition, I recommended Tylenol or Advil as needed for pain and

swelling.

The next quadrant I treated was the lower left (LL). I used the same techniques for the LL

as I did for the LR because the level of calculus and bone loss was almost exactly the same.

During her initial doctor exam, the treatment plan included the removal of her remaining wisdom

teeth, #16 and #17. Tooth #17 was partially erupted with only the occlusal surface showing

through the epithelial tissue. I did not scale #17 for this reason. However, a few days after
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treating this quadrant, my patient informed me that tooth #17 was giving her some pain. The

night before she came for her cleaning of the upper right (UR) quadrant, which was a week after

her appointment for the LL, my patient said her cheek was very swollen and she was

experiencing constant, intense pain around the wisdom tooth area. The pain also spread to the

upper neck, and she had been using salt water rinses to help clear the infection. I noted in her

extra and intra oral examination that her left cheek was severely swollen, and her left

submandibular lymph node and lymph nodes in the anterior cervical chain at the superior part of

her neck were sore, mobile, and moderately swollen. The tissue of #17 had swollen over the

occlusal surface and was slightly red. The doctor prescribed a week of antibiotics to reduce the

infection, and I encouraged the patient to get her wisdom teeth removed as soon as possible.

Before I started scaling, I gave the patient Tylenol to help reduce pain and swelling, and she

agreed to continue treatment of the UR quadrant.

After the fourth and final appointment of scaling and root planing of her UL quadrant, I

explained how using Chlorhexidine rinse will facilitate the reduction of the bacterial load in her

oral cavity so as to prevent further bone loss and stop the progression periodontal disease. I told

her to rinse for 30 seconds with half an ounce after breakfast and after brushing her teeth at

night. I also told her not to eat or drink water for 30 minutes after rinsing with Chlorhexidine,

since it temporarily reduces taste bud function. In summary, after all her appointments of scaling

and root planing, I learned to use extreme caution while scaling around an impacted tooth that is

extremely susceptible to infection. Next time, I will scale very judiciously around #18, so I am

not a contributing factor for deep infection.

Evaluation
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6 weeks after completing initial non-surgical periodontal treatment, my patient came to

have her tissue evaluated. During her intra oral exam, I noted the swelling on her tissue around

#17 was no longer present. Overall, the patient’s gingival tissue was significantly less inflamed.

Her previous gingival description was generalized severe edema and erythema on the mandibular

tissue buccal and lingual with localized severe rolling, friable, and cyanotic tissue on #26 facial.

Her maxillary tissue was generally slight red, edematous, and bulbous with localized severe

redness on #2-L. She had a generalized smooth texture on all gingival margins. 6 weeks after

treatment, the patient’s tissue was generalized pink, firm, and stippled with localized slight

rolling on the mandibular lingual surfaces. There was localized moderate edema and redness on

teeth 23-27 and localized slight redness on 18 and 19 lingual. The tissue that was previously

friable and cyanotic on #26 had attached and was less inflamed. Her papilla was less bulbous.

Overall, the patient’s gingival health and attachment improved and my patient was very happy to

see less calculus on her teeth. I also explained that reducing the inflammation in her

periodontium will contribute to her overall health. When my patient saw the before and after

photographs, she could see how her gingival health improved greatly.

The new periochart taken showed the depth of my patient’s periodontal pockets greatly

improved. Many 4mm pockets in the anterior teeth reduced to 3mm. While there were still

generalized 4mm pockets in the posterior teeth, the rest of her pockets were generally 2-3mm. I

was also happy to see in her new periochart a reduction of bleeding points. Previously, she had

generalized, moderate BOP, but now she only had localized, slight BOP. Her recession,

furcations, and mobility remained the same.

Even though her plaque index score was 17% and had improved from the last plaque

index, I could still detect generalized slight sub-gingival and supra-gingival plaque, especially on
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interproximal surfaces. I also noted supra-gingival calculus building on the exposed root surfaces

of teeth 23-26. She said she is brushing morning and night with a manual toothbrush and flossing

every night, so I knew I needed to help her with her technique. I watched her brush her teeth and

saw that she was not aiming the bristles toward her gum line, so I demonstrated the bass brushing

technique again, and she practiced brushing using this technique. I also showed her how to use

long strokes from below the gum line to under the contact while flossing in a “C” shape so she

can thoroughly remove biofilm on interproximal surfaces. When she comes back for her

periodontal maintenance appointment, I will see how effective her homecare routine is, and I

plan to introduce new homecare methods, such as an end tuft brush or soft pics, as needed. She

had also been rinsing with Chlorhexidine every night during the last 6 weeks and I told her that

she can stop using it because she healed nicely, so it is therefore no longer needed. I explained

Chlorhexidine also kills good and bad bacteria, contributes to calculus build-up and stain, and

alters taste sensation, so it is not advised to use for too long. Chlorhexidine is most effective

during the first few weeks after treatment; however, commended her for complying so carefully

with the directions I gave her. I then used a cavitron and gracey instruments to remove the

generalized plaque and localized calculus build-up on 23-26. I decided that she should be on a 3-

month periodontal maintenance routine because of her plaque and biofilm levels, how quickly

she builds calculus on her lower anterior teeth, and so she can continue to refine and improve her

homecare routine. I expounded that biofilm matures in 3 months, so it is important to remove it

before it causes further breakdown of her alveolar bone.

Documentation

I thoroughly documented all aspects of my patient’s treatment. I kept a copy of my chart

notes from each appointment so I could compare and contrast one appointment from the next.
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This also allowed me to compare how her gingival health improved. My appointments were

audited in my patient paperwork and checked by instructors which allowed me to maintain

accurate documentation throughout treatment and not miss any aspects of treatment. One area I

missed was when I dispensed Chlorhexidine rinse to my patient. At her second appointment, I

charted in her dental hygiene diagnosis that Chlorhexidine would be a valuable aid for my

patient to include in her homecare routine. Instead of dispensing it before treatment when I

should have, I dispensed it after I completed her non-surgical periodontal treatment.

Reflective Conclusion

Theory from my education in the dental hygiene program is what made providing

treatment possible for this patient. For example, learning about the process of inflammation in

the periodontium and how bacteria colonize in periodontology helped me to understand the

purpose of the treatment I provided, and learning basic and advanced instrumentation techniques

allowed me to care for my periodontally involved patient. Working on this capstone project

challenged my ability to apply all the theory in my education to the specific circumstances of my

patient. This project also made me aware of areas I need to improve. I needed to do research on

how to properly use Chlorhexidine rinse before prescribing it. This would have allowed me to

educate my patient more thoroughly on the purpose of Chlorhexidine and may have achieved

better results. I was also made aware of the importance of cautiously scaling around an impacted

third molar that his partially erupted. I could have prevented the infection on #17 by doing

Chlorhexidine rinses before treatment and gently scaling the distal surface of #18. I did well on

instrumentation and was able to successfully removed heavy ledges of calculus. My patient was

motivated to improve her oral health as well, which I think is a great achievement. Her plaque

index score also continuously improved, so while my patient still needs to improve her homecare
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technique, progress was made. When she came in for 3-month periodontal maintenance on May

9th, 2018, it was obvious she was implementing the homecare techniques I discussed with her.

When I told her that plaque was still building up heavily on her posterior teeth on the lingual, she

was very eager to learn how to improve. As I observed her brush her teeth, I could see that she

was angling her toothbrush toward her gums but the bristles of the toothbrush were only on the

enamel and not on the gingival margins. She was able to see in the mirror how to make the

needed changes to address this concern. I was pleased to see that my patient was educated

through this process. She now understands the value of going to her dentist regularly, and she has

been educated about periodontal disease. She understands why a 3-month recall is important to

keep the bacterial load in her mouth at a low level. This project really helped to enhance my

skills as a dental hygienist and will prepare me to provide high quality treatment for the rest of

my career.
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References:
Kothiwale, S., & Panjwani, V. (2016). Impact of thyroid hormone dysfunction on periodontal disease.
Journal of The Scientific Society, 43(1), 34-37. Doi:10.4103/0974-5009.175456
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Pre and Post Op Photographs. (Pre are above and post are below)
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Pre and Post-Op Periocharts (Pre are above and post are below)