Case Documentation Project

DENH 437-001/447-001 Clinical Dental Hygiene II/III

Seminar course
Session Spring 2015
Submitted To
Mrs. Michelle McGregor,
By:
Shauna L. Powell
April 13, 2015

Introduction
Mr. Pills presented to the clinic for an adult prophy appointment. He is a 29 year old African
American male with congestive heart failure, who is very money conscious, and uses marijuana.
The first thing Mr. Pills asked was how much the appointment would cost him. The clinician
chose this patient because she knew she could improve his overall oral health. While going
through the health history the patient admitted to having congestive heart failure. The clinician
noticed one of the side effects of his medications he is taking for CHF is gingival hyperplasia.
Mr. Pills admitted during the healthy history that he smokes marijuana at least 2 to 3 times a
week if not more. Mr. Pills grew up in Richmond, Virginia and worked as a construction worker.
After all of the assessments were completed the clinician presented the patient to faculty. The
focus for this project was the patients oral hygiene regimen, how his drug use effected his new
heart and oral cavity, and his overall oral health status.
Assessments
Mr. Pills, at the age of 24 had a heart transplant due to having congestive heart failure at
birth. He then had to start taking Sirolimus and Mycophenolic acid which both cause gingival
hyperplasia.1 He takes calcium 500 for his bones and aspirin as a blood thinner for his new
heart.1 He has been a patient at the school since 2012. Mr. Pills had not suffered from any
carious lesions since 2012 when he presented with 3 severely decay teeth. His oral hygiene
was poor and his gingiva was edematous, fibrotic, and inflamed. Mr. Pills stated he has no idea
his gingiva was so inflamed and he thought his tissues looked normal. Before his appointment
at VCU in 2012 he stated had had not been to the dentist in at least 6-7 years and he wanted to
get a checkup for his teeth. All assessments recorded, hard tissue updated, and full mouth
probings were done as well as intraoral pictures. He presented with generalized moderate
biofilm and localized calculus on both the facials and lingual on all anterior teeth. After probing
depths were recorded it was noted that Mr. Pills had generalized moderate gingivitis with
localized slight periodontitis.
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Visit one
The first visit with Mr. Pills took place on August 20 2014. This is when the clinician identified
Mr. Pills was well-qualified to be the patient for her case documentation project. At that time Mr.
Pills gladly agreed and said he would love to improve his hygiene. After an intraoral and
extraoral cancer screening was completed, the clinician discovered that Mr. Pills suffered from
gingival hyperplasia. He had generalized edematous margins with spongy bulbous inflamed
gingiva. He had staining on his anterior teeth due to the marijuana use. 2 According to studies
the longer a smoker holds the smoke in their mouth the higher they are at risk for staining. 2 The
THC and Cannabidol in marijuana promotes staining as well. Mr. Pills was advised of the
negative outcome on his oral health from his marijuana use.3 The clinician showed the patient
what healthy tissue looks like with stippling and knife like margins. 4 He was then given a mirror
to look at his gum tissue to see that there was a lack of stippling, recession was starting on
some of his anterior teeth, and a fibrotic appearance. 4 This appointment was used to thoroughly
gather all of the information possible about Mr. Pills and try to implement a few new thing into
his oral hygiene regimen. Mr. Pills was counseled on his drug use and he stated he has no
plans to stop smoking, however he promised to try and reduce his marijuana use. Mr. Pills was
advised of the importance of keeping his teeth cleaned especially where he is suffering from the
gingival hyperplasia. The clinician showed Mr. Pills how the inflamed and overgrown tissue was
a plaque trap and the plaque under the tissue is making the overgrown tissue more inflamed.
Mr. Pills stated he was never told that before but he will work on his plaque control. The
clinician had Mr. Pills demonstrate the way he was flossing to her and he was doing it
incorrectly. The clinician properly showed him how to adapt the floss in the c-shape flossing
technique by slightly sliding the floss under the tissue and gliding it out without causing tissue
trauma.5 Lastly, Mr. Pills was not brushing correctly he was brushing in a sawing motion back
and forth leaving behind the majority of the biofilm accumulated on his teeth. The clinician gave
Mr. Pills the mirror and had him watch how to properly adapt his tooth brush at a 45 degree
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angle making sure he is including the gingival margin. While doing this he was advised to make
sure he focuses on one tooth at a time ensuring he is doing the best job he can.
A personal oral hygiene assessment was done to deem exactly how plaque free his teeth
were and he receive a score of 11% and a gingival index of 1.33. The clinician discovered that
Mr. Pills had generalized 1-3 mm PD with localized 4-5 mm PD with BOP. The clinician
explained the important of the higher probing depths and explained to Mr. Pills some of the
pockets may increase after the calculus removal. Mr. Pills was then advised that his gingiva was
unhealthy and was not bleeding as much because of the reduction of vasculature in his gingiva.
He was given information on the reduction due to his drug use. 7 Mr. Pills and the clinician made
a goal by the end of his treatment he was going to be at least 50% plaque free and have a
gingival index of 0.8. Mr. Pills ensured he was going to improve his oral hygiene and he was
going to return with less biofilm on his teeth.
Visit two
On September 15 2014 Mr. Pills eagerly presented back to clinic to get an adult prophy,
radiographs and a dental exam. Before beginning oral hygiene was reinforced and Mr. Pills
again stated he would reduce the amount of marijuana he was using. The clinician showed the
patient all of the staining on the facial and lingual surfaces of his teeth due to his drug use. 2 Mr.
Pills was advised if he cant stop his drug use he can brush his teeth and or swish with water to
help reduce the staining.5 The clinician gave Mr. Pills an automatic toothbrush opposed to his
manual one he was using. The clinician advised Mr. Pills it would be easier for him to properly
adapt and studies show they remove more biofilm. 8 All he had to do was hold the tooth brush in
place while it did all the work. He was given a few packs of Waxed Reach Floss so he could
put them in random places so he always had floss no matter where he went. Lastly, Mr. Pills
received Listerine Zero so it would not dry his mouth out but still had the antiseptic rinse in it. Mr.
Pills was educated on the brush, floss, and rinse technique. He stated that it was easy to do and
he would be able to incorporate that in his oral hygiene regimen.9
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At this appointment the adult prophy was completed and four bitewings were taken. An
exam was completed to ensure that there was no new decay. On tooth #4 it was determined per
the dentist that Mr. Pills had MO caries. After the exam the clinician reminded Mr. Pills how
important it is to get that tooth filled and taken care of due to the bacteria that is in that tooth.
The clinician advised that the he get that tooth filled at his next appointment since he will be
returning for one last appointment with the clinician. Mr. Pills agreed to get the caries taken care
of at his next appointment so the clinician set that up with a dental student. At the end of visit
one Mr. Pills was given a 3 day dietary analysis form to fill out. The clinician was very interested
in finding out why caries were discovered when Mr. Pills was a low caries risk at his first visit.
Coarse paste was used along with the air polisher to remove the tenacious staining that Mr. Pills
presented with. Five percent sodium fluoride varnish was placed with no adverse reactions. The
clinician advised Mr. Pills not to eat or drink anything too hot, sticky, or crunchy for the next four
to six hours. Lastly advised the Mr. Pills to try and not smoke his marijuana for as long as
possible. At the end of the appointment the clinician broke down the financial aspect of Mr. Pills
drug use. He stated he used about 2-3 time a week and at each time he used about $30 worth.
If he were to completely stop using drugs and get the help he needs he would be saving about
$4,680 a year. The clinician wanted to break down the money aspect for Mr. Pills due to him
being so money conscious. Mr. Pills was not aware exactly how much money he was even
spending on his drug habit. Lastly, Mr. Pills was advised that he was needed to return to the
clinic in 2 weeks tissue resolution and to have his filling completed. He agreed to come back to
the clinic in a few weeks. The same oral hygiene instructions from the first visit were again
reinforced. Advised Mr. Pills to brush, floss, and rinse twice a day.9
Visit three
Mr. Pills was schedule for his final appointment for tissue resolution on October 13 2014.
This appointment was to again reinforce oral hygiene and to go over his dietary analysis. After
reviewing his dietary analysis it was discovered that that Mr. Pills liked to eat high cariogenic
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snacks like cinnamon buns and doughnuts. He likes to drink juices throughout the day and he
only brushes in the morning and at night so the juice is on his teeth all day. The clinician
explained the importance of frequency. If Mr. Pills eats high cariogenic snacks and drinks
throughout the day rather than in one sitting he is at higher risk for developing caries. 10 The
clinician realized by looking at his previous restorative work, that Mr. Pills was a low caries risk.
However, after the 3 day dietary analysis was completed and his oral hygiene practices were
evaluated, it was determined he is a high caries risk patient. Mr. Pills does not state he suffers
from xerostomia but indeed from his drug use his mouth is drier than normal. 10 A full mouth
periodontal chart was again completed at this appointment. It was determined that Mr. Pills had
generalized 1-3 mm PD with localized 4-6 mm PD in the interproximal regions of his posterior
teeth. The clinician explained to Mr. Pills some of the probing depths had increased while other
decreased due to the resolution in the tissue.7 After all probing depths were recorded the new
diagnosis was generalized gingivitis with localized moderate periodontitis in the posterior region.
This appointment consisted of another POH in which he was 49% plaque free and had a
gingival index score of 0.75. He did not reach the goal of being at least 50% plaque free but he
tremendously improved from 11% to 49%. Mr. Pills did reach the goal of his GI from 1.33 to
0.75. His goal was to be 0.8 in which his tissues were even healthier than that. This
appointment was used to fine scale some of the residual calculus that was still remaining.
The clinician presented the information to Mr. Pills since now his oral hygiene is improving it
was time to move to the next step. The clinician advised Mr. Pills when smoking marijuana and
taking his transplant medications, the marijuana is metabolizing the medications. The clinician
explained to Mr. Pills his drug use is effecting the transplant medications that he has to take
every day. While using marijuana and taking transplant medications it is equivalent to not taking
the medications at all. Marijuana caries a mold/fungus called Aspergillus series and when in
contact with someone with a compromised immune system it can be life threatening. 11 The
clinician emailed the sources found to Mr. Pills along with a number to get help for his drug use.
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Lastly, the clinician advised Mr. Pills to do a weekly oral cancer screening on himself if he is not
going to stop his drug use. 7 The clinician gave the patient a mirror and let Mr. Pills watch while
an oral cancer screening was done. Mr. Pills was advised him to look on the lateral borders of
his tongue, floor of his mouth and to look for any color changes in his oral cavity. If something
changes or starts to appear he was told he needs to let his physician or dentists know as soon
as possible.
At the end of the appointment intraoral pictures were taken and Mr. Pills was praised on his
improvement of his oral hygiene. Mr. Pills did have a slight increase on some probing depths
now that the calculus was removed but the tissue appeared to be coral pink, less BOP, and less
fibrotic. Mr. Pills was advised he should stay on a 4 month recall due to the gingival hyperplasia
and it catching all of the biofilm. Mr. Pills was again told to stay in touch with the clinician and if
he had any questions to feel free to email them. Mr. Pills was sick at the tissue resolution
appointment and was told to check his email because more information was going to be sent to
him about his gingival hyperplasia and drug use.
Now
Mr. Pills is suffering from some new/unexpected medical bills. He was not able to pay in full
at his last appointment so his account is locked. His bill is 120 days past due, so a
representative from VCU School of Dentistry called him to reach out and at that point he said he
felt harassed. Mr. Pills cursed out someone of the school so not only is his account locked, but
he is not allowed to return to the school. The clinician and Mr. Pills had been in contact
previously throughout out his treatment so the clinician reached out to him via email. The
clinician thanked Mr. Pills for being a part of the case documentation project and apologized for
the unforeseen events that had just occurred. The clinician asked how he was doing medically
since there is a strong correlation between oral health effecting ones overall health. The
clinician again told Mr. Pills he will probably not be able to be seen again before she graduates,

but she wanted to know if there was anything she could do for him. Lastly, the clinician told Mr.
Pills she was here to answer any questions he may have and to feel free to reach out to her.

Closing
Mr. Pills oral hygiene had improved tremendously over the past four months. I was very
eager to bring him back in and see how well he was maintaining. I was able to get him to reduce
his marijuana use, increase his oral hygiene, do weekly oral cancer screenings on himself, and
lastly get him to realize the link between his drug use and the effects on his oral cavity. Although
I was not able to get him to quit using drugs, I am proud I was able to get him to reduce his drug
use.
This was a very interesting case and overall I enjoyed researching the topic of drug use on
the gingiva via the heat, the periodontal status, and the effects of it on someone suffering from
gingival hyperplasia. If I could do something differently I would have done a POH at the second
appointment after all of the oral hygiene instructions were reinforced, like I did at the first and
tissue conditioning appointment. It is very important to properly document everything that is said
and done in each appointment. I think I was so excited to find such a good patient like Mr. Pills
my notes were not written as well as I know I can write one. It is a legal documentation and
each and every note needs to have a diagnosis of the condition of his oral cavity. If I could go
back and change something, I would like to improve my note writing skills from August. I did
make sure to tell my Mr. Pills he was on a 4 month recall schedule due to the gingival
hyperplasia but I again did not correctly document that. This shows us the importance of
documentation, because if it is not documented or done so incorrectly it didnt happen. It was a
great idea to keep reinforcing the same oral hygiene regimen into his practice before introducing
new ones. It is very important to focus on one or two minor things before moving onto bigger
things. Overall, I think I did well on this project and I think Mr. Pills has truly benefited from this
project in many ways.
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This project reminded me that not every patient is the same and the same oral hygiene
instruction we give to one patient may not work for the next. In our field we never know what to
expect and I am so glad I came in contact with Mr. Pills. This was a learning lesson for the both
of us and I am glad I got to work with him. He was very reliable and always punctual. Although
he did not reach the POH goal we set forth, he did improve the overall condition of his gingiva.
The main focus of this project was to put all aspects of the dental hygiene process of care
together and being able to implement it. With Mr. Pills help, we were able to make that happen.
Being able to make a change in ones life by impacting their oral health, is why I am so
passionate about dental hygiene.

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