Kaley O’Brien’s Patient Journal
Date: 3/31/2014 Nelly
Background: Nelly is a 36 year old working mother.
Initial appointment Monday, March 31, 2014
AssessmentMedical/Dental History: No health concerns with medical history; last dental appointment was January
26, 2011 at LCSC Dental Hygiene Clinic. Vitals were normal
Intra/Extraoral Exam showed nothing abnormal, with the exception of TMJ popping that the patient
noticed started after a past injury to the fact 15+ years ago. Nelly remembers the popping starting after
the injury occurred, but it is not painful in anyway.
Occlusion Analysis: Class I with Class III tendencies on the right side Overjet= 1mm Overbite = 2mm
Midline= even
Radiographs: FMX taken February 11, 2014 by Kaley O’Brien as prescribed by Dr. Nash. Radiographic
evidence of decay on tooth #16 was confirmed with an oral exam. No evidence or bone loss. Dr. Shoff
recommended that #16 just be extracted because it is a 3rd molar and the tendency of recurrent decay
on those hard to reach teeth.
Dental: all previous restoration in good condition.
Perio assessment:
Color was generalized moderate hyperemia, with generalized slight papillary and marginal enlargement.
Bleeding was generalized spontaneous with recession on 9-14, and 20-26 all 1mm. Generalized slight
papillary and marginal inflammation and a calculus deposit of 2/2.
Diagnosis: Generalized moderate gingivitis; Periodontal Case Type I. Although English is Nelly’s second
language we were able to discuss her oral hygiene state and implement the proper Oral hygiene
modifications to help reduce her gingivitis. Nelly talked about how she waited before to get her teeth
cleaned and that is when she had to get multiple filling, since then Nelly is sure to get her teeth cleaning
1 per year at the least. It is nice that Nelly took responsibility of her lack of attention to her mouth, and
is now actively brushing so she doesn’t have to get anymore restorative work done.
Plan: Nelly and I talked about the way she brushes her teeth and I had her demonstrate how she is
brushing everyday. We made a few modifications so that she is holding the tooth brush at proper
angulation and is taking at least 2 minutes in her mouth. I also reminded Nelly about the importance of
flossing. As I told Nelly about hand scaling, prophy polishing and fluoride varnish I made she to talk in a
slow, clean voice, and asked if she understood everything I was telling her. Nelly was curious about the
fluoride and after I told her about the vast benefits she was very excited about that.
OHI: I disclosed Nelly’s teeth and she was very shocked at the amount of plaque that was left over from
not flossing her teeth this morning. There was a very distinct film interproximal on all of her teeth. I also
showed Nelly the inflammation that is occurring in her gums, the bass method was retaught, and
flossing with that complete “c” shape was implemented to clean interproximal. I seemed to hit home
when I told Nelly that cavities can form between her teeth if she is not sure to clean between them
everyday.
Next appointment: Nelly was scheduled to have her extraction done on April 7, 2014
Personal Reflection: It was nice to have a patient whose first language was not English it helped to slow
me down and really watch body language and use all of my communication skills. I like spending the
extra time talking to Nelly about any of her concerns and having done radiographs on her previously
helped there to be less of a barrier this time around. I also had the privilege of cleaning her daughters
teeth and was very happy to hear the daughter talk about how happy her mother (Nelly) was with her
appointment.
Date 4/7/2014 Joe
Background: Joe is a 54 year old male, who is enthusiastic about oral hygiene.
Initial Appointment Monday, April 7, 2014:
Assessment:
Medical/Dental History: No health concerns with medical history; last dental appointment was March of
2013 at Dr. Sorensons. Vital were normal.
Intra/Extraoral Exam showed nothing abnormal, but due to patients use of chewing tobacco there is
Fibrotic tissue as a variation of normal generalized slight throughout. Patient was advised that if he is
going to continue the use of chewing tobacco that he at least try to move the deposit around to give his
tissue a chance to heal.
Occlusion Analysis: Occlusion was a Class I with a crossbite on the right side. Midline was right 2-3 mm,
Overjet was 4mm, and Overbite was 4mm.
Radiographs: four bitewings were taken as prescribed by Dr. Shoff. Dr. Sorenson was called to obtain
copy of FMX taken in March of 2013.
Dental:
Perio Exam:
Color was generalized slight papillary and marginal hyperemia, contour was generalized slight papillary
and marginal enlargement, consistency was generalized slight fibrotic, bleeding was generalized
spontaneous, there were no clinical assessment markers and no radiographic evidence of bone loss.
Generalized slight papillary and marginal inflammation with plaque light throughout. Deposit evaluation:
1.5/1.5.
Diagnosis: Generalized slight Gingivitis; Periodontal case type I. Although Joe had no present signs of
decay, Joe had repeatedly talked about consistent occurrence of “every time I go to the dentist I have to
pay for a filling”, I figured this would be a good doorway to discuss how he can prevent that and tied it in
with his probing depths and inflammation around the facial anterior where the chewing tobacco was
placed. Because Joe is enthusiastic about his oral hygiene I talked to him about the signs of where he
was doing good and the areas that needed some attention. Joe was willing to listen to everything I had
to offer as new techniques
Plan: Before I began cleaning I talked to Joe about everything that I would be doing for him. I told him
that I would be scaling his teeth from every angle to get off the calculus that was contributing to his
inflammation. I then told Joe that after all of the calculus had been removed I would then polish his
teeth and apply a fluoride that would help with some of the sensitivity that may occur from the
debrided areas being exposed to the oral conditions.
OHI: After we discussed all of dental exam I showed Joe (after disclosing his teeth) that there is a great
deal of plaque isolated around the gingival margins, interproximal and that there is calculus on this
lingual anteriors, I taught Joe that with the proper angulation of his tooth brush in the 45 degree angle
that he would be able to disrupt and remove the plaque from the pockets that I had probed and
measure earlier. I had him demonstrate the technique to me and he said that he could “feel the bristles
tickle in the gaps”. Along with the Bass method for brushing, I also talked to Joe about flossing with a “C”
shape and introduced the perio aid to be used around his drown margins to help with the inflammation
in that area. I told Joe that healthy gums are tight and pink, and with consistent oral hygiene he will be
able to see a change in his overall oral health.
Personal Reflection:
I found that with Joe having a previously acquired mindset that whenever he went to the dentist that he
was going to have to pay for restorations, along with his eagerness to have good oral hygiene I was able
to teach Joe a lot. He was like a sponge that I was able to squeeze some of the negativity out off and fill
with good knowledge. Without correcting Joe, or making him feel like I wasn’t listening I helped Joe to
understand that consistent dental visits are preventative and less expensive than waiting for a
toothache. I felt like Joe was truly trying to take good care of his mouth, but hadn’t gotten the one on
one discussions before like I was able to offer him. I found that patients like Joe, who are wanting to
learn, can be so refreshing and help you to feel like very positive about your education.
Date: 4/14/14 George
Background: George is a 57 year old male who has not been to the dentist in 10+ years.
Initial Appointment Monday, April 14th, 2014
Assessment:
Medical/Dental History: No current health concerns, except a joint replacement that requires
premedication for dental appointments.; last dental appointment was 10+ years ago. Vitals were normal
Intra/Extraoral were normal with intraoral variations of normal: lingual tori, Linea Alba, and 2mm x 2mm
varicosity on left side of lower lip.
Occlusal Analysis: Right Class III, Left Class I, Overjet = 1mm, Overbite = 1mm, and Midline = Left 1mm
Radiographs: FMX taken 4/14/14 as prescribed by Dr. Shoff. No radiographic evidence of boneloss.
Decay present on the Mesial Occlusal of tooth 31.
Dental: All previous dental restorations are in excellent condition with the exception of tooth 31, which
had a piece of an existing amalgam missing and recurrent decay along the margin.
Perio Exam: Color is generalized slight papillary and marginal hyperemia with localized moderate
papillary and marginal hyperemia. Contour is generalized slight papillary and marginal enlargement with
localized moderate papillary and marginal enlargement on the lingual of teeth 30 and 31. Consistency is
generalized normal. Bleeding is generalized spontaneous. No clinical assessment markers. No
radiographic evidence of bone loss. Deposit evaluation 1.5/1.5
Diagnosis:
DHD- Generalized slight gingivitis; Perio Case Type I. Although George had not been to the dentist in 10+
years and there was no significant negative findings, I talked to George about the importance of regular
dental visits. I told George about all of the information that I had found and broke down the terminology
to him. I told George that even if his teeth are holding up to irregular dental care, his gums have
gingivitis. I told him how this is an infection of the gums and is the first step to periodontal disease.
George takes multiple medications, so I talked to him about Xerostomia and how it can add to the
development of periodontal disease.
Plan:
George and I discussed everything from his dental exam and current decay and decided what our plan of
action would be. George remember what scaling felt like from years ago, so I told him we would start
with that to remove all the deposits which are causing his gum inflammation. After the debridement
George was told we would have my instructor double check my work, and I would then polish his teeth
and apply a fluoride varnish. I informed George that the restorative that he needed was simple enough
that a second year student could do it for him, and that after I informed the girls he would receive a
phone call to get it taken care of.
OHI: I taught George the Bass Method of brushing with a 45 degree angle. Flossing with a “c” shape
around every tooth once a day and regular dental visits.
Self Reflection: I found that it was harder to encourage George to work harder at his oral hygiene,
because there was so little decay and not that much calculus even though he had not been to the
dentist in over 10 years. I talked to George about periodontal disease and how this could start to effect
his mouth if he was not more consistent with his cleanings. I really hope that I was able to make an
impression on George, so that he didn’t have to learn the hard way and end up with major oral
problems.
Date 4/1/2014 Carmen
Background: Patient is a 6 year old girl who is not afraid of the dentist at all, but has a “hole” in one of
her teeth.
Initial Appointment Tuesday April 1, 2014
Assessment:
Medical/Dental History: Medical history clear, but chief dental concern is a hole in one of the lower
teeth. Last dental appointment was just sealants placed in school.
Intra/Extraoral: All normal
Occlusal Analysis: Class I, Overjet= 1mm, Overbite= 1mm
Radiographs: 2 Bitewings taken 4/1/14 as prescribed by Dr. George to check for interproximal decay. Dr.
George diagnosed a Occlusal composite on K, Sealants on 3,14,19, and 30, and a Pulpotomy and
stainless steel crown on teeth S & T.
Dental: It appears that the “hole” that the mother and daughter and concerned about is decay on both S
& T.
Perio Assessments: color was generalized slight papillary and marginal hyperemia. Contour is
generalized slight papillary and marginal enlargement. No bleeding or clinical assessment markers.
Generalized slight papillary and marginal inflammation and a deposit of .5/.5 making Carmen a Case
Type I.
Diagnosis: Carmen has slight gingivitis and caries caused from neglect of brushing teeth. Because it is
hard at this age to help children understand that if they do not brush their teeth they will have problems
with their teeth, I also talked to Carmen’s mother about supervising when she brushes her teeth and to
make it a fun part of the day instead of a chore. Carmen is a very high energy child and with some
encouragement I believe oral hygiene could be just as fun at home as it was with myself today.
Plan: I will debride the plaque from Carmen’s mouth, polish (or tickle her teeth as I told her), and apply
fluoride (vitamins for her teeth). I plan to make this appointment the very fun, but also very educational
to help Carmen improve her oral hygiene as much as possible to good habits can be maintained
throughout her life.
OHI: Carmen and I took time to look in the mirror and brush every side of her teeth, I showed mom how
to teach her to floss, and gave Carmen some bubblegum flavored mouthwash she could use after
brushing her teeth, to help her want to brush her teeth more.
Self reflection: It was hard seeing a child her caries like Carmen had, but it was so nice to know that I
was the hygienist that could help turn around her habits. The mother and I really talked about how
important it is to watch her children brush their teeth until they are old enough to remember to do it on
their own everyday. Carmen really enjoyed her time in the clinic and at the end of the appointment I
was thanked with a really big smile and a huge hug! This appointment really made my day and I will
always remember Carmen 
Date: 5/5/2014
Background: Bethany is a 28 year old female with outstanding Oral Hygiene, but has recession due to
occlusion
Initial Appointment May 5, 2014
Assessment:
Medical/Dental History: Medical history normal.
Intra/Extraoral Exam: all normal
Occlusal Analysis: End to End bite and Class III Occlusion. Bethany’s bite was observed by myself at her
evaluation, and Vonni and I both thought it would be beneficial that she schedule an orthodontic
evaluation. Bethany had that appointment between the eval and today’s appointment and is looking for
another opinion from the Dentist on site today.
Radiographs: 4 Bitewings taken 5/5/14 as prescribed by Dr. Evers. No radiographic evidence of boneloss
or caries.
Dental: Oral hygiene really well, just the recession is present due to occlusion
Perio assessment: Generalized slight papillary and marginal hyperemia with generalized slight papillary
and marginal enlargement. Stillman’s cleft on 4&5 and recession on all of the maxillary facials and 8 of
the facial aspects of the mandibular teeth. Generalized slight papillary and marginal inflammation with
a deposit of 1/1
Diagnosis: Bethany really cares about her oral hygiene and it is evident. Not only is Bethany very good at
brushing morning and night, but she also flosses and was wuick to make an orthodontic evaluation
based on given advise. Dr. Ever thinks that orthodontic treatment would help stop the recession from
progressing any further and recommends that she see the one other orthodontist in town and make her
decision based off of an overall analysis of what each one has told her.
Plan: Because Bethany is doing such a great job I plan to encourage her to keep it up and show her a few
modifications that will benefit her. I will hand scale the whole mouth, prophy polish, and apply a fluoride
varnish.
OHI: I had Bethany show me the way that she brushes her teeth, and then in a mirror I showed her the
bass method and she felt the “tickle” of the bristles under her gums. Bethany is going to brush her
whole mouth with this method and then thoroughly scrub afterwards just for her own satisfaction. I also
showed Bethany that the “C” shape with the floss is going to benefit her as well. An active plan of these
combine will help get rid of the slight gingivitis she currently has.
Self Reflection: Bethany taught me that even if a patient takes care of their mouth the absolute best that
they can there are still things that can harm their mouth. Bethany’s bite was never an issue for her and
she was completely unaware of the fact there could be a link between her bite and her recession. It was
too bad that she had this happen, but it was also nice to have a patient who was so driven to have good
oral hygiene, and I could definitely tell that everything I taught her was going to be implemented. I just
wish that the people who really needed to modify their oral hygiene would do the same when they left
the clinic.