Whitney Van Kampen

I. Assessment

- Patient interview:

 45-year-old, white Caucasian male weighing 210 lbs. and is 5’8”

 He has not been to the dentist in 4-5 years, and had x-rays, a cleaning and fillings placed.

 Chief complaint: His upper right gingival tissues are swollen, bleed, and are sore.

 Both parents are Type II diabetics with more systemic issues.

 His IT technician job requires traveling 12-14 days per month.

- Medical/dental history:

 Past surgeries: Tonsillectomy, appendectomy and laser mediated kidney stone ablation

 No known allergies

 Medications: Hydrochlorothiazide (25mg., b.i.d.); lisinopril (10mg., q.d.); pravastatin

(40mg., q.d), metformin (500mg., q.d), combined with alogliptin and ioglitazone

(25mg./15mg., q.d.) and aspirin (325 mg., q.d.).

 Med side effects-

o Hydrochlorothiazide- May cause orthostatic hypotension, use caution when standing

o Lisinopril -Also may cause orthostatic hypotension, xerostomia, cough, Stevens-Johnson syndrome, and

dysgeusia. The ACE inhibitor may cause dry, hacking cough that can interfere with dental procedures.

o Pravastatin- Muscle weakness, patient may have difficult time brushing teeth or chewing

o Metformin- Taste disorder (note pt w/diabetes should have morning appts)

o Alogliptin and Pioglitazone -pt w/diabetes should have morning appts.

o Aspirin-May increase bleeding

 Brushes his teeth 1x daily, doesn’t know toothbrush or toothpaste he uses. Uses round

toothpick to remove food between teeth.

 His BMI is considered obese (31.9)

 Previous ortho therapy from 14-17 y/o

- Social History:
 Whitney Van Kampen

 Both parents alive, no siblings

 Full time IT tech for large national company, travels 12-14 days per month

- Vital signs:

 Blood pressure: 90/140, HbA1c = 9.3.

 The patients high blood pressure is stage two and needs to be considered during the

appointment. Recommended to change lifestyle habits and continue medication until BP is

controlled. Blood/glucose is considered high. Pt has poorly controlled diabetes, consult with

his physician is scheduled for 1 week after dental treatment to discuss health/medications.

- EO: Enlarged right submandibular lymph node. No skin lesions or other concerns.

- IO: Max right molars are spongy, swollen and slightly painful upon palpation.

- Periodontal exam:

 During probing of interproximal between teeth #2-3, pus and bleeding were seen.

 78% bleeding score and 70% plaque score. 26 total teeth. GEN light yellow staining

 Generalized PD of 5-7mm and 1-2mm recession. Localized PD probing of 9mm on #30-31

 Furcation involvement on teeth #2, 3, 14, 15, 16, 17, and 30. Stages II and III

 Mobility most likely seen with the amount of bone loss seen in radiographs.

 #24-27 tissues are bulbous

- Radiographs:

 Periapical of max/mand right posterior, right cuspid area and BWs of left molar area

 Findings show generalized bone loss, mod-heavy calc, and restorations

 Interproximal crater bone defect between #31 and 32 and perio abscess by #2-3

II. Diagnosis:

- Pt presents with Stage IV Grade C periodontal disease and perio class: GEN adv. Perio dz.

- HbA1c >7% in pt with diabetes (9.3)

- Missing teeth due to periodontal disease

- Level of health: ASA III due to poorly controlled diabetes and high bp

III. Plan:

- Consultations needed:

 Consult with doctor about diabetes and medication adjustments

 Primary dentist will interpret radiographs and chart any caries/restoration work to be done

(preliminary phase)

 Pathologist could evaluate enlarged lymph node, may be linked to perio abscess.

 Consult with periodontist/dentist/endodontist about periodontal disease and abscess tx plan

(Phase 1)

- Tx goals:

 Reduce plaque score, reduce bleeding index, and remove plaque and calc with SRP

 Maintain periodontal charting depths without progression of disease

 Reduce inflammation/pocket depths

- Preliminary phase

 Stabilize stage IV periodontal disease with SRP and evaluate perio abscess

 Work to save remaining teeth

 High risk for caries due to poorly controlled diabetes as well as other systemic health

concerns

 Patient’s goal should be to control inflammation, future calculus deposit, and working with

doctor to get diabetes under control. Due to medications pt may be experiencing muscle

weakness, pt should switch to an electric toothbrush to help control inflammation and

bleeding. I would recommend fluoride varnish to help stop any incipiencies. Recommend

increasing brushing to 2x a day with proper technique. Patient should come back for a 3 mos

recall to re-evaluate pts periodontal health and home health habits

- Phase 1 (initial therapy)

 Calculus and plaque removal through Prophy TX – use of ultrasonic, hand scaling, and

anesthetic, to SRP posterior regions.

- Introduce preventative measures- provide OHI, explain changing his toothbrush/head every 3

mos should be done to avoid bacteria, and he would benefit from using a softer, power brush

instead. Encourage using different floss aids such as floss sticks to better get food and debris out

between teeth.

- -Phase 2 (surgical)

 consult with periodontist about overall periodontal health

 Consult with general dentist regarding periodontal abscess found on teeth #2-3, may need to

be seen by endo

 Surgical procedures may be necessary and a consult with PROS regarding bone loss/loose

teeth after SRP

- Phase 3 (restorative)

 discuss with primary dentist possible restorations as dentist sees fit

 discuss future plans for implants, fixed or removable prosthesis as dentist sees fit

 discuss antibiotic treatment and lancing of periodontal abscess on teeth #2-3

- Phase 4 (Maintenance)

 Schedule recall appointment for 3 months

 At recall appointment we will assess homecare and improvement/stability

 Reduce BOP, biofilm, inflammation, and access periodontal abscess

 Reduce general pocket depths

 educate patient on OHI importance and technique

IV. Implementation:

- Consultations to primary care provider, periodontist, surgeon, pros

- Potentially send patient to pathologist for enlarged lymph node

- Local anesthetic for SRP on max right side, if needed on other posterior regions as well.

- Physician should reevaluate meds for high blood pressure and for diabetic concerns

- Dentist may prescribe chlorohexidine for inflammation

- use show/tell method to demonstrate OHI (power brush does the cleaning/stimulating gums)

- Homecare aids: soft bristle toothbrush or power brush, floss/stick floss, and fluoridated tooth

paste

- Take further radiographs in 6 months to evaluate bone loss

- Will use ultrasonic, prophy (use med polish), disclosing solution, floss, anesthetic and hand

scalers for FM tx/ localized SRP

- Advise pt to increase brushing to 2x daily and flossing daily. Advise changing brush head every 3

mos and brushing the gumline to stimulate healing by removing bacteria to reduce future

bleeding. Advised a power toothbrush to more easily stimulate tissues and promote healing and

stop inflammation.

- Recall appointment for 3 months

V. Evaluate:

- Probe to see if depths decrease/if BOP decreased and periodontal abscess

- Follow up with homecare instructions. Evaluate patients at home care

- Check plaque score, and bleeding index. Did he improve?

- Make radiographs in 6 months to evaluate any vertical/horizontal bone loss, and calculus. VBWX

- Evaluate high blood pressure, new medications/doses, and diabetes status.

References:

Wilkins, E. M., Wyche, C. J., & Boyd, L. D. (2017). Clinical practice of the dental hygienist. Wolters

Kluwer.

Wynn, R. L., Meiller,. T. F., & Crossley, H. L. (2021). Drug information handbook for dentistry:

Including oral medicine for medically compromised patients & specific oral conditions.

Lexicomp/Wolters Kluwer.