Running head: CAPSTONE PROJECT 1

Capstone Project

Lauren Stevens

Theory and Practice 422

Winter Quarter, 2018

January 30, 2018

CAPSTONE 2

Assessments

When every patient arrives at Lake Washington Dental Clinic we begin their dental

treatment with a series of initial assessments to establish their current oral health and what kind

of future treatment they will need. These assessments include procedures done by the dental

hygienist, dental assistants and dentist and were completed over a 2-appointment span. For the

capstone patient, the same dental hygienist will see the patient throughout every aspect of their

hygiene plan to learn effects of hygiene care.

Health History

The patient for my capstone project was a 36-year-old male patient. The patient said his

last dentist was in Arizona and could not remember the name of the practicing doctor or the

name of the office. He said he has not had a dental exam, radiographs or a cleaning since 2012.

The patient said he has not been to the dentist in a while because he was busy moving, then had a

back injury which made him unable to work and consequently lost his dental insurance. His

vitals during the first appointment were a blood pressure reading of 132/90 taken on the right

arm with a manual cuff. We told the patient his blood pressure was higher than the desired

readings of below 120/80 as recommended by the American Heart Association. The patient said

this reading is normal for him and his blood pressure can be high due to his chronic back pain.

The patient also had a pulse of 80 beats per minute with regular rhythm. At the beginning of the

health history the patient had noted he was under a physician’s specialized care for back pain and

numbness. He mentioned several years ago he injured his back somehow and had temporary pain

and ignored it. He said in 2015 he was helping a friend move and lifted a very heavy box. When

he tried to take this box up a U-Haul truck ramp it weighed so much he fell backwards and
CAPSTONE 3

injured his back severely. He had to have a myelogram (radiograph of his back) and a spinal tap.

The patient also mentioned needing MRI images taken of his back in early 2017 since some of

the spinal discs were not in the correct place. Ever since the accident, the patient has had to use a

walker to help with walking. The patient was taking Gabapentin, Flexeril, and Advil daily for his

back pain. Gabapentin is classified as an anticonvulsant but can also be used to help reduce

neuropathic pain. Flexeril is a muscle relaxant, and Advil is a non-steroidal anti-inflammatory

drug. It was also noted that the patient had a history of using chew and is currently still using. He

said he has been using snuff (the specific type of smokeless tobacco) for several years and uses it

every day several times a day.

Extraoral Assessment

At the first appointment there was a scar noted next to the left eye. This scar was 9mm in

length and linear in shape. Another scar was noted above the upper lip on the left side and was

also 9mm in length. The patient had a 6x6mm macule above his left eye. When asked, the patient

said the macule has been there for several years and he has not noticed any changes. Also, there

was right lateral deviation of the temporomandibular joint. The patient said he does not

experience any jaw pain, locking and/or popping in the joint. Pea size and mobile bilateral

submandibular lymph nodes were also noted at this appointment. The patient said they were not

tender during palpation. We discussed with the patient that lymph nodes can be swollen when the

body is battling illness or allergies, so we will monitor them at future appointment.

Intraoral Assessment

During the intraoral assessment, it was noted the patient had a chapped vermillion zone.

Bilateral linea alba was also noted on the buccal mucosa. The patient had slight xerostomia and
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he said that is something that he has experienced while taking his medications. The patient had a

rounded hard palate. There was scar tissue noted on the maxillary tuberosities and retromolar

pads, possibly from past extractions of wisdom teeth. The tongue was slightly coated at the

appointment. It should be noted at the second appointment in October the patient had noticeable

leukoplakia on the gingiva on the maxilla on the facial side of the anterior teeth. When asked, the

patient mentioned he had just used snuff prior to the second appointment where he had not used

it all morning of the first appointment, possibly explaining the difference in intraoral exams.

Gingival Description

The gingival description at the first appointment is described as generalized moderate

erythematous coloration. There was a small red lesion, probably a petechiae, noted on the lingual

of #30. Generalized slight rolling was noted at the gingival margins. The patient had localized

blunted papilla from #23-26. Generalized moderate bulbous papilla was described as well as

generalized moderate edematous. The texture of the gingiva was stippling on the mandible and

smooth on the maxilla.

Tooth Chart

On the tooth chart we noted the patient is missing teeth #1, #15, #17, and #32. He had

previous restorations including an amalgam filling on #3-MOL, a temporary composite and root

canal treatment on #14, #16 had an occlusal amalgam, #4-DO amalgam, and #18- occlusal

amalgam. Visible decay was noted on #31 on the distal, occlusal and buccal surfaces. The patient

had attrition noted on all mandibular and maxillary incisors. Dr. Lowell suspected the wear on

these teeth was due to the anterior crossbite. The patient had several areas of lost width of

attached gingiva on the maxillary and the mandible. There were also some open contacts noted
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on the mandible between the canines and lateral incisors bilaterally. A couple of the patient’s

teeth were rotated, linguoverted or buccoverted, but the crowding was generalized slight.

Occlusion

The occlusal assessment was charted as a Class I molar relationship on the left and right

side. The patient also had a Class I canine relationship on the left and right side. The patient had

a cross bite noted of #22 with #10 and #11. The patient had no open bite due to the anterior

crossbite.

Periodontal Chart

The first periodontal chart had reading of generalized 3-4mm pockets with localized 5mm

pockets in the posterior. He had localized slight recession on the maxilla. There was Class I

mobility noted on teeth #7-10. He had localized Class I furcation involvement on the mandible.

There was also moderate bleeding on probing on the maxilla and slight bleeding on probing on
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the mandible. Using the patient’s periodontal chart readings and calculus detection we

determined his AAP classification was III/2/D1.

Risk Assessment

In the health history portion of the risk assessment we noted the patient’s previous back

injury and the medications he is taking to alleviate his pain. For the hard tissue section, it was

noted that the patient is at risk for bone loss, broken/chipped teeth, bruxism/occlusal trauma,

calculus and plaque, and caries. The patient is at risk for bone loss because it is already clinically

evident on radiographs with generalized slight bone loss and having Class I furcation

involvement. Without proper removal of subgingival biofilm, the patient will continue to have

bacteria retained in the sulcus increasing his risk for periodontal disease. The risk for broken and

chipped teeth and occlusal wear was due to the patient’s anterior crossbite creating attrition

where they are hitting together, as well as his grinding habit. The patient is at risk and already
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had calculus and plaque clinically evident due to inadequate removal of biofilm at home. The

patient also has malaligned teeth clinically present as seen by the linguoversion, buccoversion

and rotations noted on the tooth chart.

In the soft tissues portion of the risk assessment, it was noted that the patient is at risk for

and has xerostomia clinically evident due to his medications. He is also at risk for and had

gingival recession clinically evident due to malalignment and bone loss. The patient had

gingivitis clinically evident and is at risk for further gingivitis in the future due to subgingival

plaque and bacteria retention causing inflammation. The patient is currently using snuff in the

maxillary vestibule above the incisors where leukoplakia was clinically evident, and if he begins

to move the snuff around the mouth there is risk of leukoplakia in other areas. The patient is also

at risk for further periodontal disease.

For the prevention survey portion of the assessment, it was noted that the patient did not

have much access to systemic fluoride since he is using well water that is non-fluoridated. As for

the dental history, the patient stated was having low scale pain/toothache due to #31 causing

discomfort while eating. He said he had localized tooth sensitivity in some areas of recession.

The patient said he had bad breath occasionally, mostly in the mornings when first waking up.

He stated he notices himself grinding occasionally at night but has not experienced any jaw pain

or soreness. The patient said he understands his oral status, values prevention, wants oral hygiene

and product recommendations and is open to new information. The patient stated it has been a

while since he had available dental care and is open to new suggestions on hygiene to improve

his current oral health status. The patient also noted he has annual physicals due to his back

injuries. The patient said he follows medical and dental advice, has a medium stress load,

medium exercise load and is interested in discussing quitting his tobacco habit. He said most of
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his stress is due to finances and physical pain, and his exercise is limited to what he can do at

physical therapy appointments. The patient said he currently has a low intake of sucrose and

carbohydrates.

In the clinical and radiographic findings, we noted the extraoral and intraoral exam was

within normal limits besides the patient experiencing slight xerostomia. It was noted that the

patient had new/unrestored occlusal and interproximal caries and had 1-7 existing restorations

consisting of amalgams and composites. Also noted in this section was moderate plaque,

moderate bleeding on probing, slight calculus, slight mobility, isolated furcation involvement,

and localized areas with loss of width of attached gingiva. The patient had 25% or less horizontal

bone loss and subluxation noted for the temporomandibular joint.

The oral hygiene habits and goals of the patient noted use of a power toothbrush with soft

bristles two times a day. He is flossing once to twice a week currently and our goal is to have the

patient start flossing at least five times a week. The patient is already using the rubber tip

stimulator multiple times a day, so it was decided it is best to have him continue use. The patient

is also using Crest Pro Health mouth wash daily and we asked him to continue use. The first

plaque index score was 19%.

When gathering all the data together listed on the oral risk assessment we can see the

patient has a moderate caries risk. He does not have fluoride in the water limiting his systemic

exposure. He also has a history or restorations and has visible decay meaning he has high levels

of cavity causing bacteria in the oral cavity. Also, since the patient is not flossing there is no

interproximal biofilm removal happening at home increasing bacteria retention in between the

teeth which can cause caries. Since the patient values oral hygiene advice, has a low plaque
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index and sucrose/carbohydrate intake, modifications to home care can hopefully reduce his risk

for future caries.

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Radiographs

At the first appointment in August the patient had a full mouth series of films taken by

one of the dental assisting students. We chose to take an FMX since the patient has not been

established at a dental office in several years and he did not have the ability to contact his prior

office for previous radiographs. We also wanted to update his films since the patient had several

concerns about specific teeth and what treatment options there were for them.

Oral Hygiene

The patient’s oral hygiene routine consisted of brushing twice daily with a power

toothbrush which has soft bristles. He was also using a rubber tip stimulator multiple times a day

and using Crest Pro Health mouth wash daily. The patient stated he does not floss frequently

since the spaces are so tight between the teeth he struggles to get it between them without

shredding and does not have a habit formed at home. Oral hygiene changes need to concentrate

on interproximal biofilm removal and sulcular brushing technique in the posterior.

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Patient’s Chief Concern

At the first appointment the patient’s main concern was regarding #14 since that tooth

had previous root canal therapy done and a temporary filling, but he was unable to return to

finalize treatment due to loss of insurance. The patient also stated he was aware he still has one

more third molar left and wanted to know if that tooth needs to be extracted. Also, the patient

described having occasional pain while eating and pointed to tooth #30 as the source. He wanted

to know if it needed restorative treatment or extraction.

Dental Examination

Since the patient was complaining of pain on #31 while eating on the date of the doctor

exam, Dr. Lowell decided to use the tooth sleuth to check for cracked tooth syndrome. After

checking all the cusps there was just a slight reaction when testing the more distal cusps. Dr.

Lowell discussed with the patient this can mean there is a cracked area of the molar, or the

sensitivity was due to the decay noted on the distal and occlusal of #31. Dr. Lowell told the

patient when the tooth is being prepped for a restoration it will become more apparent if there is

a crack in the tooth. As for the patient’s other concern regarding the temporary filling on #14, Dr.

Lowell said that does need to be replaced with a more permanent option like a porcelain fused to

metal crown. He said the longer we leave the temporary the more prone it will be to breakage.

The patient said he can afford the fillings that were recommended on the treatment plan, but due

to poor insurance coverage he will need to wait for the crown until next year. The treatment

created during the doctor exam included #4-DO amalgam due to a broken filling, #14 build-up,

porcelain fused to metal crown prep and crown seat, #19-DO amalgam due to caries, #30-DO

amalgam due to caries, and #31-DOB amalgam due to caries.

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Plaque Index

The patient’s plaque index score during initial assessments was 19%. A majority of the

plaque was in the posterior, more so on the maxilla than the mandible. When the patient was

shown his plaque index, I showed him the areas he is missing at home and how easily it can

come off with proper brushing. I demonstrated how to partially close his mouth to move the jaw

out of the way of the buccal aspect of the maxillary molars to increase access with his

toothbrush. I also showed the patient how wrapping the floss around each tooth wipes the

interproximal surface to remove the plaque between the teeth.

Pre-Treatment Photos

Pre-treatment and post-treatment photos will be found in Appendix A and Appendix B,

respectively.

Dental Hygiene Diagnosis

In the dental hygiene diagnosis some goals listed for the patient are to have him continue

visiting his medical doctor at least annually and continue physical therapy to help improve back

pain and mobility. Another goal is to have the patient begin a consistent recall frequency at the

dental office to help maintain oral health and caries prevention. Since the patient had a macule

noted above his eye and some sun spots, it was recommended he wear sunscreen to prevent cell

change which can lead to possible skin cancer. Since there was lateral deviation noted of the

temporomandibular joint, our goal is to monitor for pain or soreness in the jaw and to

recommend a night guard if needed. For the patient’s xerostomia, our goal is to have him drink

sips of water throughout the day. If he still experiences dry mouth, recommendations like

Biotene or xylitol can be made for a saliva substitute and caries prevention. Our goal for the
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patient to remove more biofilm at home was to have him use the modified bass brushing

technique with the power toothbrush to remove plaque along the gingival margins and sub-

gingivally. Also recommended flossing to remove more interproximal bacteria. Discussing the

caries process at the patient’s future appointments to reinforce the need for proper biofilm

removal is listed to keep patient motivated. If after changing technique in biofilm removal at

home is not enough, it is planned to recommend ClinPro 5000 toothpaste for extra fluoride to aid

in caries prevention. The goal to prevent further periodontal disease is to start with scaling and

root planning then to continue with regular recall appointments to reduce inflammation, calculus

retention and disrupt subgingival bacteria. Brushing gently with the power toothbrush is another

goal is to prevent further recession.

When the patient was presented with the goals and interventions listed on the dental

hygiene diagnosis, he seemed motivated to make changes to improve his oral health status. He

understood the need to begin interproximal biofilm removal with flossing but was hesitant on his

ability to begin doing this regularly to create a habit. The patient also seemed motivated with

beginning the tobacco cessation program since he is aware of the danger of tobacco products and

has attempted to quit on his own in the past. He said the pain in his back is one of the driving

forces for tobacco use but is still hoping to quit while undergoing treatment.

The patient’s history or posterior restorations was considered during the creation of the

dental hygiene diagnosis. He also presented with partially completed treatment on #14 still

requiring a crown due to previous caries. New treatment that was added because of decay was

#19, #30 and #31. Knowing the patient’s moderate risk for caries it was important to discuss how

bacteria breaking down sources of glucose cause decay by releasing acid and the best form of

prevention is thorough oral hygiene. We also discussed prescription strength fluoridated

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toothpaste in the future for an extra benefit since the patient is already using a fluoridated mouth

wash.

To determine if our goals created with the dental hygiene diagnosis have been met we

can use future gingival descriptions, periodontal charts and radiographs for diagnosis of carious

lesions. During the patient’s first gingival description there was generalized edematous tissue

with bulbous papilla, erythematous coloration and rolling of the margins. With proper biofilm

removal the body’s inflammatory response will reduce so the tissues can become firmer in

consistency, knife edge papilla, a lighter pink coloration and less rolling along the gingival

margins. These changes in gingival description should be seen after initial scaling and root

planning therapy. As for the periodontal charting, the probe readings in the posterior should

reduce so there are less localized 5mm pockets. There may be more recession as the tissue

becomes tighter around the tooth. The slight horizontal bone loss should be maintained with the

chance of furcation involvement lessening. We will use the radiographs in the future to check for

changes in bone height and to diagnose carious lesions and success of new restorations.

Planning

The plan for this patient’s treatment consisted of starting with scaling and root planning

as initial therapy, then a tissue re-evaluation with fluoride, and lastly any restorative treatment

that needed to be completed. The goal of the initial therapy is to remove subgingival and

supragingival calculus that is acting as a nidus for bacteria. After removal of these deposits we

expect to see reduced signs of gingival inflammation described in the first gingival assessment.

The tissue re-evaluation was scheduled to check the patient’s tissues to be certain he is

responding properly to initial therapy. At this appointment we expect to see improvement in

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gingival inflammation, reduced pocket depths and less bleeding on probing. If there are still sites

not responding to therapy, we will check for residual calculus and determine if subgingival

chemotherapeutics are necessary to reduce bacterial load in these pockets and/or recommend a

chlorhexidine rinse. Restorative treatment is necessary to lessen patient pain and decrease the

amount of caries causing bacteria in the mouth which increase the risk of future decay.

Our patient education will be centered around subgingival biofilm removal. We will

discuss with the patient the bleeding and puffiness in the gums is due to bacteria in the sulcus

causing destruction when they excrete acid. To properly remove this biofilm, we will

demonstrate to the patient how to wrap floss around each tooth, wiping the sides, and how the

floss should go underneath the gums to disturb the bacteria. We will also show the patient how to

remove plaque from the posterior teeth by using the modified bass technique and partially

closing his mouth to shift the jaw out of the way. Since the patient is already using the rubber tip

stimulator, we want to go over proper use to ensure it is effective. We also want to discuss the

importance of continuing the daily, over the counter fluoridate mouth wash he is using for caries

prevention. If the patient continues to get caries with these modifications in hygiene we can

recommend ClinPro 5000 as well.

The treatment plan created consisted of four quadrants of scaling and root planning (SRP)

under code D4342. We decided this is best for the patient since there are 1-3 teeth in each

quadrant that was periodontally involved due to periodontal pockets over 3mm, recession, and

furcation involvement. Since he had an AAP classification of III/2/D1, we knew there was

generalized light subgingival calculus and this treatment can be finished in one appointment. To

complete the SRP treatment we planned on using the cavitron and hand-scaling. Due to his

recession and areas of sensitivity during probing we discussed using aides during the cleaning
CAPSTONE 16

such as desensitizing toothpaste and Oraqix to make him more comfortable. The treatment plan

signed at this appointment only had the four quadrants of SRP, we had forgotten to plan for the

tissue re-evaluation and fluoride. We made a note to have the patient sign and consent for the

tissue re-evaluation and fluoride at the next appointment.

Implementation

The treatment plan reflects four quadrants of code 4342 scaling and root planing (SRP) to

be done as means of initial therapy. Since the patient had generalized light subgingival calculus

and localized light supragingival calculus it was expected to complete the full mouth SRP in one

appointment. This goal was met by finishing the full mouth scaling and root planing and polish

in about two hours. The universal slim green cavitron tip was used followed by hand

instrumentation with mostly universal curettes and sickles. Since this procedure was completed

early in the hygiene program, I did not have much experience with Gracey curettes and relied

heavily on universals to remove all the deposits. Also, the offset sickle was the dominant scaler
CAPSTONE 17

of choice for the mandibular and maxillary incisors. Due to the moderate gingival inflammation

noted from #6-11, Oraqix was used subgingivally on the facial surfaces as a topical anesthetic to

improve patient comfort. The result of the SRP was successful with the overseeing instructor

finding only a couple of rough spots on the mandibular incisors where supragingival calculus

was present.

After completion of the initial therapy I discussed with the patient about his homecare

routine and if he has made any changes. He said he hasn’t at this time but has been meaning to

start brushing twice a day regularly to make it a habit. I reminded the patient brushing twice a

day, especially before bed, is important for biofilm removal to reduce gingival inflammation and

caries risk. Also, the patient’s leukoplakia on the maxillary buccal mucosa was prominent that

day and we showed this to the him using a hand-held mirror. We discussed with the patient when

the tissue starts to change colors that it is indicative of cellular changes from tobacco use and we

will continue to monitor it due to the heightened risk of oral cancer. I told the patient at the next

appointment we can go into more detail with our tobacco cessation program since we had run out

of time that day, and he responded he’d like to discuss some options then.

In between the initial therapy appointment and the tissue re-evaluation the patient came

back to the dental clinic for some restorative treatment. The first appointment one week after

initial therapy was an amalgam restoration on #19-DO that I did. We placed a rubber dam from

teeth #18-24 for isolation during treatment. The prep for the restoration included the distal

marginal ridge, the central pit and almost extended to the mesial pit. After the prep was

completed decalcification was visible on #18-M as seen by a dark brown area with white

chalkiness surrounding it. Upon use of the explorer the doctor determined the area was not

decayed but told the patient the need of interproximal biofilm removal to slow the growth of
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decay. The restoration was of moderate size and required Vitrebond on the floor of the prep to

help with sensitivity do to the proximity to the pulpal chamber. We gave the patient post-

operative instructions of avoiding the numb areas to avoid self-trauma, to not chew food with

that tooth for 24 hours to allow the amalgam to harden and to call us if the occlusion still feels

high once the numbness wears off, so we could make further adjustments if needed. The patient

chose amalgam for this restoration since that material was fully covered by his insurance and the

tooth was far enough posterior where he wasn’t concerned about aesthetic issues.

The prep photo was taken using direct vision whereas the post restoration photo was

taken with use of a mirror for improved visibility after rubber dam removal.

The next restorative treatment was about a month after initial SRP on #4-DO with

composite. The patient decided to pay the extra expense for this restoration to be in composite

since it was visible when he smiles. This restoration was also very large and required an indirect

pulp cap with Dycal then Vitrebond to separate the Dycal from the composite material and extra

insulation in the deeper areas of the prep. The patient was told due to the depth of the decay he

may experience sensitivity and there is a chance root canal therapy will be needed in the future if

the composite fails. Since it was early in my restorative hygiene education and having the
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restoration so large the matrix placement was difficult ultimately resulting in a loose contact. The

patient was told since the contact wasn’t very tight there is a chance of food impaction so to let

us know if this occurs, we can then discuss replacement options of the composite if needed. Also

noted at this visit was a small lesion on the left lateral border of the tongue that was slightly

erythematous and bulbous. The patient said he recalled biting his tongue recently and it created a

sore. We told the patient that we will make of it today then check it at his future tissue re-

evaluation appointment.

Other restorative needs were met with the practicing dentists at the school due to their

difficulty level and the size of the fillings.

Evaluation

During the tissue re-evaluation appointment, it was apparent there was very little changes

to the gingival tissues as compared to the gingival description prior to initial therapy. During this

appointment the gingival description included generalized moderate bulbous papilla, generalized

coral pink coloration with dark pink lingual to the mandibular incisors. Also, the gingival

margins were moderately edematous with localized slight edematous in the anterior of the

mandible. The maxilla still noted the wrinkled texture due to leukoplakia. I discussed with the

patient that there were still areas of inflammation after the initial SRP meaning there is still

bacteria underneath the gums not allowing them to heal. When asked if he has made any changes

to his homecare routine he mentioned he has not had time to dedicate to changing his homecare

routine. He said he is still brushing every morning and more often at night, using the manual

toothbrush in the morning and Sonicare sometimes at night and has increased flossed to 3-4

nights a week rather than 1-2 times. I did the plaque index again and the score was 29% plaque. I
CAPSTONE 20

showed the patient most of his biofilm build up was on the molars (buccal and lingual surfaces)

and demonstrated modified bass technique and how to close the mouth to create space to access

the maxillary molars with the toothbrush. I told the patient it is important to brush twice daily for

ideal biofilm removal and told him to continue using floss as often as possible, and toothpicks

throughout the day as long as he is careful around the gingival margins. I asked the patient if we

included a water pick into the routine if he’d be willing to try it, and he said he probably

wouldn’t use it because he already has a hard time keeping his current routine.

When the patient arrived, we re-explored the full mouth found there was very minimal

calculus build up. There was very slight calculus subgingivally on the mandibular molars and

light supragingival calculus on the mandibular incisors. This was removed using hand

instrumentation with universal scalers. I then polished his teeth and flossed. After completion the

instructor and myself found a previous restoration on #3-MO amalgam that had an overhang so I

removed it to allow for better tissue healing and less biofilm retention.

When comparing the periodontal charts from initial assessments to the tissue evaluation

appointment there were signs of improvement. In the posterior the pockets were averaging 4-

5mm interproximally with moderate bleeding on probing on the maxilla and slight on the

mandible. There was also several 3-4mm pockets in sextant 2 where leukoplakia is noted. The

patient also had class I furcations on the buccal surface of the mandibular molars. At the tissue

re-evaluation there were very few 4mm pockets noted in the maxilla showing at least 1mm

pocket reduction interproximally. On the mandible the pocket depths also reduced but not as

significantly. There was also a reduction in bleeding on the maxilla being considered generalized

light rather than moderate. There were some classification changes in furcation involvement

including a new class I furcation on the buccal of #2, a class II furcation on #18 buccal and a
CAPSTONE 21

class I furcation on #18 lingual. There was a couple of 1mm changes in recession in the posterior

as well. I feel the changes noted from the initial therapy to the tissue evaluation show positive

changes in gingival health, however there is still room for improvement considering the 4-5mm

pockets remaining in the mandible and new furcation involvement that can cause biofilm

retention.

Since the leukoplakia was quite notable during this appointment we decided to do a

cancer screening with the VELscope. We told the patient when using the VELscope we were

able to see two radiolucent areas, one above #7 and one above #10 in the area of the leukoplakia.

We discussed with the patient that these radiolucent areas can be signs of tissue changes due to

the continual exposure to tobacco products. It was discussed with the patient that if there are any
CAPSTONE 22

significant changes in the future we may need to refer him to an oral surgeon for evaluation. We

told the patient we will continue to monitor this area in future appointments and asked if we

could discuss tobacco cessation since we highly recommend trying a cessation program to allow

the tissue to heal.

I asked the patient if he would like to discuss tobacco cessation at this appointment and

he said he was open to the conversation. During the advisory step of the process I discussed how

the changes in his maxillary mucosa (leukoplakia) is related to tobacco use causing cell damage.

I told the patient constantly having snuff in the same location under the lip increases his oral

cancer risks. We also discussed that tobacco can suppress the body’s ability to heal properly

which may influence the therapy and surgeries for his back injury. At the assess step the patient

said he has heard of these risks and said he still does not want to quit tobacco use at this time.

We then discussed the relevance of tobacco use relating it to overall body healing during a time

when he is so motivated to improve his back pain and for oral cancer prevention. The patient said

he was already aware of the risks of tobacco use because it has been discussed with him before

through other medical professionals and knows it affects his whole body systemically, not just

the changes in the mucosa. The rewards the patient discussed would be increasing his life span

so he can live longer with his children. The major roadblock for this patient was having the

amount of back pain he’s experiencing from his injury and the stress that comes with it. He says

using snuff helps keep his body and mind relaxed and when he tries to reduce his snuff use it

causes his anxiety to peak. He said he also doesn’t like the changes he notices in his personality

because he becomes more irritable and he feels like that changes the family dynamics with his

kids. The patient said he did attempt quitting tobacco products, however six months later he went

through a bad break up and he started using it again and more frequently. He said since then he
CAPSTONE 23

hasn’t been interested in trying to quit again. To help the patient reduce his snuff use we

recommended he mixes his full tobacco snuff with a non-tobacco version to reduce carcinogen

exposures. We recommended to try and reduce the amount of time the snuff is in his mouth. The

patient said he could try and stop sleeping with the snuff under his lip and agreed to try and

move it around more often. The patient said right now he wakes up and immediately puts snuff

in, but he said he’d be willing to try and wait until after breakfast before putting it in. I told the

patient at his next appointment we will discuss how it is going with trying to reduce tobacco use

and we can discuss modifications if needed.

Once the tissue re-evaluation appointment was completed I determined his recall

frequency. The patient had very minimal calculus and plaque accumulation today showing he is

doing some biofilm removal at home. Also, he presented with localized 4-5mm pockets in the

posterior and slight recession. It was determined the current state of the periodontal condition

can be maintained at 4-month periodontal maintenance intervals. Discussed with the patient he

needs to be regular with the four-month recall period so we can monitor changes in mucosal

health on the maxilla, debride and lavage the deeper pockets around the molars to maintain

bacteria levels and for caries control.

A month and a half later the patient returned for re-evaluation of the dark areas within the

leuoplakia noted on the VELscope. At this appointment the dark areas above #7 and #10 looked

the same and the doctor decided at the next appointment we will do VELscope again and if there

are any changes we will refer to have these areas tested due to high risk from carcinogen

exposure. The patient was also having sensitivity in the upper right quadrant to cold and

occasionally with pressure. After a posterior periapical radiograph, it was determined there was a

crack in the amalgam on #3 and it needed a new restoration. Lastly, I discussed with the patient
CAPSTONE 24

about any progress in the tobacco cessation program. The patient said immediately after the

tissue re-evaluation appointment he reduced his frequency of snuff use and moved it around the

mouth rather than keeping it under the upper lip. He said about a month later he went back to his

old habits and is using snuff as often as before. The patient said he was not interested in quitting

at this time but is willing to discuss it again at future appointments.

Documentation

All required documentation was completed for this patient throughout his appointment

history. Looking at some of the notes I do think they would benefit from more oral hygiene

instruction. I feel the patient had so many other topics to discuss through the appointment like his

leukoplakia, VELscope results and tobacco use that it used a lot of time and oral hygiene wasn’t

discussed as thoroughly. I also think the documentation on the tobacco cessation program was

well recorded so that any future hygienists seeing the patient can know the patient’s point of

view on tobacco use, what is stopping him on being able to quit and his openness to discussion.

Also, a chart audit was completed on this patient’s appointment history and there were no missed

areas. There was a comment noted on the patient’s hygiene treatment plan because there were

two plans created; one for the initial scaling and root planning and one for the tissue re-

evaluation and fluoride which isn’t the schools protocol. I believe the ability to maintain

accurate documentation was withheld throughout the patient’s history and there was good follow

up on information from pervious appointments to create a continuous record.

Reflective Conclusion

The part of my education that benefited me the most when treating this patient was our

training on tobacco cessation programs. This education made me better prepared for the
CAPSTONE 25

conversation by having an outline and examples to use which I feel is important during an

uncomfortable topic. It also helped me educate the patient on the way tobacco is a carcinogen

and increases his risk for oral cancer. The information from our theory classes also prepared me

on what the expectations should be after initial therapy and what changes should be made to the

patient’s oral hygiene habits to better improve gingival inflammation and further reduce pocket

depths.

The professional growth I experienced during this Capstone project is the benefit of

seeing one patient regularly and establishing a relationship. This is because it allowed me to

speak to the patient more comfortably about tobacco cessation since I knew more about his

personality, and it was also important when following up on the leukoplakia and VELscope

results because I was able to recall what they looked like prior. I also learned how beneficial

initial therapy can be to the gingival health of the patient and that it is important to follow up

after this treatment to be sure the tissues are healing properly.

An area I felt I excelled in was documentation. I felt at each appointment there was very

thorough chart notes which allowed me to continue a discussion into the next appointment. I also

felt I excelled at patient education by explaining the importance of reducing or quitting tobacco

use to improve general health and reduce oral cancer risk. I felt this education temporarily

motivated the patient to reduce the use of snuff, but ultimately the patient needs to decide when

he’s ready. An area I needed to improve in was oral hygiene education and recommending

different products when the patient doesn’t make changes. I kept expressing the importance of

biofilm removal along the gingival margins due to plaque build-up and inflammation. Instead of

only recommending modified bass technique several times perhaps I should’ve suggested a

rubber tip stimulator or soft picks in larger embrasure spaces.

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I think this patient was a great Capstone patient because he was at a point in his life

where he wanted to improve his oral health and became motivated to make all the appointments

necessary to do so. Unfortunately, due to the pain, stress and financial burden of the treatments

he is going through with his back he said he is unable to return to the office for his continuing

care appointment and is unsure when he may return. Hopefully the education we provided during

his initial care provided him the tools to maintain his oral condition until he is once again

capable of returning his focus on his oral health.

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Appendix A

Pre-Treatment Intraoral Photos

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Appendix B

Post-Treatment Intraoral Photos