Medical Assessment:
Ms. Rosati is a 59 years old Italian-American female who has been a patient of this
office for about a year. Her chief complaint is “I have pain and sensitivity between the
upper right two last molars and I have been experiencing food accumulation on my upper
left bridge”. Her vital signs are as follow: BP: 165/100. Pulse: 78 BPM and Respiration
24 breaths per minute. Her blood pressure falls under stage 2 hypertension because the
systolic is in the 160-179 range, and the diastolic is in the 100-109 range. Patient suffers
from asthma (exercise-induced). Patient was diagnosed with hormone receptor sensitive
breast cancer approximately three years ago and completed chemotherapy for it. The
breast cancer is currrently under control with no recurrence. She sees her Oncologist at
regular intervals for full breast examination. Her last exam was three months ago. No
recurrence was found. Patient’s medications are as follow: Amlodipine (Norvasc) for
hypertension, monthly injection of Leuprorelin (GRH agonist), and daily Tamoxifen, for
breast cancer control and Albuterol (Proventil HFA) for the management of asthma.
Patient has poor nutrition; she eats fast food at least two meals a day and sips on coke at
work and experiences stress due to financial situation. Patient reported that she clenches
her teeth at night. Patient brushes twice a day and uses Listerine mouthrinse in a daily
basis.
Hypertension
It is a chronic medical condition in which the blood pressure in the arteries is elevated. It
is classified as either primary (essential) or secondary. About 90-95% of cases are termed
"primary hypertension", which refers to high blood pressure for which no medical cause
can be found. The remaining 5-10% of cases (Secondary hypertension) is caused by other
conditions that affect the kidneys, arteries, heart, or endocrine system.
Uncomplicated high blood pressure usually occurs without any symptoms (silently) and
so hypertension has been labeled "the silent killer." It is called this because the disease
can progress to finally develop any one or more of the several potentially fatal
complications of hypertension such as heart attacks or strokes. Uncomplicated
hypertension may be present and remain unnoticed for many years, or even decades. This
happens when there are no symptoms, and those affected fail to undergo periodic blood
pressure screening. Some people with uncomplicated hypertension, however, may
experience symptoms such as headache, dizziness, shortness of breath, and blurred vision
Breast Cancer
Breast cancer is a malignant (cancerous) growth that begins in the tissues of the breast.
Cancer is a disease in which abnormal cells grow in an uncontrolled way. Breast cancer is
the most common cancer in women. In the U.S., it affects one in eight women.
Signs and symptoms of breast cancer may include:
 A breast lump or thickening that feels different from the surrounding tissue
 Bloody discharge from the nipple
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Change in the size or shape of a breast
Changes to the skin over the breast, such as dimpling
Inverted nipple
Peeling or flaking of the nipple skin
Redness or pitting of the skin over your breast, like the skin of an orange
Asthma
Asthma is a medical condition that causes narrowing of the small airways in the
lungs. Typically, asthma patients develop wheezing and have increased mucous
production in their lungs. Asthma patients can have episodes of increased shortness of
breath, often triggered by allergic reactions. Asthma sufferers often have the disease
for many years, and the episodes of shortness of breath can be life-threatening.
Asthma signs and symptoms include:
 Shortness of breath
 Chest tightness or pain
 Trouble sleeping caused by shortness of breath, coughing or wheezing
 An audible whistling or wheezing sound when exhaling
 Bouts of coughing or wheezing that are worsened by a respiratory virus such as a
cold or the flu
Medications
Amlodipine (Norvasc)
Dosage: 5 mg. Orally. Once a day.
Pharmacologic Category: This medication is a calcium channel blocker and it is used for
the treatment of hypertension.
Local Anesthetic/Vasoconstrictor Precautions: No information available to require
special precautions.
Effects on dental treatment: gingival hyperplasia, which usually resolves upon
discontinuation. Fewer reports of gingival hyperplasia with this medication compare with
other calcium channel blockers.
Effects on bleeding: No information available to require special precautions.
Leuprorelin
Monthly injection of 7.5mg.
Pharmacologic Category: Antineoplastic agent, Gonadotropin-Releasing Hormone
Agonist.
Use: Treatment of breast, ovarian, and endometrial cancer, infertility and prostatic
hyperplasia.
Local Anesthetic/Vasoconstrictor Precautions: No information available to require
special precautions.
Effects on dental treatment: gum hemorrhage, gingivitis, dry mucous membranes, and
dysphagia.
Effects on bleeding: Although significant myelosuppression with associated altered
hemostasis has been reported for many chemotherapeutic agents, myelosuppression is not
common with leuprolide and no specific precautions appear to be necessary.
Tamoxifen
Dosage: 20mg. Orally. Once a day.
Pharmacologic Category: Antineoplastic Agent, Estrogen Receptor Antagonist; Selective
Estrogen Receptor Modulator (SERM)
Use: Treatment of metastatic breast cancer.
Local Anesthetic/Vasoconstrictor Precautions: No information available to require
special precautions.
Effects on dental treatment: No significant effects or complications reported.
Effects on bleeding: Although significant myelosuppression with associated altered
hemostasis has been reported for many chemotherapeutic agents, myelosuppression is not
common with tamoxifen and no specific precautions appear to be necessary.
Albuterol (Proventil HFA)
Dosage: 4 mg. Usage: 2 puffs every 4-6 hrs as needed.
Pharmacologic Category: Beta2-Adrenergic Agonist.
Use: Used as a bronchodilator in reversible airway obstruction due to asthma or COPD,
prevention of exercise-induced bronchospasm.
Local Anesthetic/Vasoconstrictor Precautions: No information available to require
special precautions.
Effect on Dental Treatment: Xerostomia (normal salivary flow resumes upon
discontinuation)
Effects on bleeding: No information available to require special precautions.
Patient was determined as ASA III the first time she came to our office because her
Blood Pressure was uncontrolled. A patient is considered ASA III when the BP is
between 160-199 mm Hg and/or 95-114 mm Hg. In the consecutive appointments patient
was considered as ASA II because she has hypertension, asthma, had breast cancer three
years ago and takes three medications.
Dental History
Ms. Rosati became a patient of this office about one year ago when she moved to
California. When she came to the first appointment, she said that everything was fine in
her mouth and she only wanted dental hygiene treatment. She brought a full set of
radiographs and a periodontal charting from her previous office; they were two month old
at that time. A comprehensive examination was conducted at that time. Patient never
came back to our office until now.
Existing restorations: Porcelain-fused-to-metal-crown on teeth # 8 and 9. Amalgam
filling on teeth # 5, 4, 3, 2, and 30. Tooth # 12 has a porcelain-fused-to-metal-crown.
Partial Bridges on Upper and Lower Left quadrants.
Partial bridge on the upper left quadrant: From # 13-#15 (Porcelain-fused-to- metal
bridge)
Partial bridge on the lower left quadrant (from # 21-18) (Porcelain-fused-to- metal
bridge)
Missing teeth: 1, 14, 16, 32, 31, 20, 19, 17
Oral Assessment:
Extra/Intraoral Exam findings.
During the extraoral and intraoral exam, we found a “white line” that extends
anteroposteriorly on the buccal mucosa along the occlusal plane on the right side of the
mouth (Linea Alba). Although patient takes a medication which is a calcium channel
blocker, we did not find any gingival hyperplasia upon the examination.
Patient presents with lingual erosion on teeth # 6, 7, 10, and 11.
Patient presents with abrasion at cervical facial of teeth # 5 and 6.
Patient presents with attrition on all mandibular anterior teeth.
Occlusal Classification:
Left Side:
Canine relationship: Class I with tendency to Class III (the mesial edge of the maxillary
canine is distal to the distal of the mandibular Canine)
Molar relationship: Class III malocclusion (mesiocclusion)
MB cusp of the maxillary first molar occludes distal to the MB groove of the mandibular
first molar.
Right side:
Canine Relationship: Class III (mesiocclusion) Distal surface of the mandibular canine is
mesial to the mesial surface of the maxillary canine by at least the width of a premolar.
Molar Relationship: Class I with tendency to class II, there is a large restoration on # 3
(MB)
Special Dental Prostheses: Partial bridge on the lower left quadrant (from # 21-18)
Partial bridge on the upper left quadrant (from teeth # 13-15)
Caries: Tooth # 2 (Mesial)
Tooth # 3 (Distal)
Periodontal assessment:
Gingival Description:
Maxillary Attached Gingiva: pink, shiny, and slightly spongy
Maxillary Free/Marginal Gingiva: pink, smooth, soft, and blunted papilla
Mandibular Attached Gingiva: slightly soft, glossy.
Mandibular Free/Marginal Gingiva: pink, slightly soft, shiny, blunted papilla.
Generalized 2-4 pockets with localized 3-7 mm pockets in the posterior teeth (upper right
quadrant) and 5 mm pockets (upper left quadrant).
Generalized 2 mm recession.
Horizontal Bone Loss: Generalized.
Vertical Bone Loss: Lower Right Area.
No furcation or mobility indicated.
PFI: 37%
MBI: 21%
Periodontal Classification:
AAP: Generalized Moderate Chronic Periodontitis with localized severe chronic
periodontitis of teeth 2, 3, 15, 30, and 29, perpetuated by bacterial plaque and poor oral
hygiene. Modified by systemic diseases, and medications.
Calculus Code:
Generalized Medium Calculus.
Dental Hygiene Treatment Plan.
Appointment 1 (1hour) 5/1/10
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$65
Asses the general health of the patient through a thorough medical history.
Inquiries should be made regarding current physician information; medication
that patient is taking, history of breast cancer, asthma, and hypertension.
Take vital signs, BP: 165 /100 | Pulse: 78 BPM | Respiration: 24 Breaths/Minute.
Refer to Primary Physician for consultation regarding patient vital signs because
according to our readings she presents with Stage 2 Hypertension, and the
respiration rate is abnormal.
Contact the patient’s oncologist (with the patient’s consent) to determine is the
patient attends to her regular medical consultations and the status of her disease.
Instruct patient to bring her inhaler (bronchodilator) to each appointment and
inform the dental hygienist at the earliest sign of symptom of an asthma attack.
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Obtain information on what triggers the asthma attack. Avoid of known
precipitating factors.
Refer to DDS to restore teeth # 2 and 3 because they have caries.
Refer to DDS for evaluation of the Partial Upper left bridge: From # 13-#15
(PFM) because patient complaints of food accumulation
Refer to DDS to evaluate the findings during the extraoral/intraoral exam (the
“white line” that extends anteroposteriorly on the buccal mucosa along the
occlusal plane on the right side of the mouth: linea alba, which is a sign of
bruxism.
Refer to DDS for fabrication of an occlusal guard or protective dental appliance
(splint) to prevent more damage to the teeth from bruxism and clenching habits.
OHI: Recommend modified Bass toothbrushing technique twice a day; along
with interproximal plaque removal using dental floss (superfloss will be ideal, so
patient will be able to floss under the bridges). Demonstrate the instructions and
have the patient demonstrate them back to me. Provide patient with some
samples of toothbrushes and dental floss.
Instruct patient on the use of an ADA-accepted antimicrobial dentifrice (Crest
Pro-Health). As patient did not present with xerostomia, we can recommend an
over-the-counter antiplaque and antigingivitis mouthrinse such as Crest ProHealth Enamel Shield, which contains fluoride to help strengthen enamel and
prevent cavities and does not contain alcohol. Provide patient with samples of
them.
Appointment 2: Nonsurgical Therapy Appointment (1 hour) 5/15/10 $105
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Contact Primary Physician to determine if the patient attended to the
recommended medical consultation.
Primary Physician increased the dosage of patient’s blood pressure medication
(from 5 mg to 10 mg).
Patient attended to the DDS, who restored the carious lesions on teeth # 2 and 3.
DDS replaced the Partial Upper left bridge (from # 13-#15).
DDS fabricated an occlusal guard.
Appoint patient in the morning to avoid stress induced hypertension. When sitting
the patient up do so slowly to avoid inducing the orthostatic hypotension.
Schedule short appointment, allowing the patient to assume a semirecline
position, and encouraging frequent change in positions for management of
hypertension and asthma.
Update personal, health, dental and pharmacologic history.
Measure vital signs: BP: 140/89 mm/Hg, P: 64 BPM, R: 13 Breaths/Minute.
Ask patient if she brought the inhaler to the appointment as she was instructed
E&I Exam
Dental and Periodontal Exam (MBI, Mobility, Periodontal Probe and plaque
index).
PFI 37%
Reinforce OHI instruction given at initial appointment.
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Reinforce the importance of continued proper brushing to prevent any further
teeth abrasion.
Diet counseling, with emphasis on limited intake of refined carbohydrates and
carbonated soft drinks. Discuss the patients eating habits and assist her to set
some reasonable alternatives to lessen eating from fast food meals (such as
packing healthy snacks and lunch).
Reduces stress and anxiety of the patient by establishing a good patient/dental
hygienist relationship that encourages openness and trust. Show concern for
patient’s financial situation. Offer stress reducing activities like laughing, reading,
doing breathing exercises, stretching, etc.
Let patient talk about fears and concerns related to oral healthcare visits.
Nitrous oxide-oxygen was used, but hypoxia must be avoided.
Therapeutic scaling and root planning of upper and lower right quadrants.
The upper right quadrant presents with pocket depths from 4-7 mm, patient was
very sensitive when probing, for this reason we decide to use local
anesthesia with epinephrine, which is acceptable to use on hypertensive patients.
UR quadrant: Posterior Superior Alveolar Nerve Block (PSA) (0.9 ml of 2%
lidocaine with 1:100,000 epinephrine).
Greater Palatine Nerve Block (GP) (0.45 ml of 2%
lidocaine with 1:100,000 epinephrine.
Aspirate before injection and inject slowly
Patient was able to tolerate the procedure without local anesthesia on the
remaining of the UR quadrant and the LR quadrant.
Post-up instructions: Tylenol for any discomfort and avoid spicy foods.
Appointment 3 Nonsurgical Therapy Appointment (1hour) 5/25/2010 (10 days after
first appointment) $ 105
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Update health history.
Measure vital signs. BP: 134/88 mm/Hg, P: 65 BPM, R: 13 Breaths/Minute.
Make sure patient brought the inhaler to the appointment as she was instructed.
E & I exam.
Assess tissue response to self-care and periodontal debridement of UR and LR
quadrants.
Determine plaque free index. PFI: 75% (Notable Improvement)
OHI: Review toothbrushing technique and use of floss. Re-evaluation by having
the patient show me the way she is brushing and flossing her teeth. Motivate the
patient by showing her the improvements.
Improvement in nutritional habits. Patient reported decreasing intake of fast food
and that she is packing healthy lunch and snacks at least three times a week.
Therapeutic periodontal debridement of upper and lower left quadrants. Patient
was able to tolerate the procedure without local anesthesia.
Nitrous oxide-oxygen was used, but hypoxia must be avoided.
Post-op instructions.
Appointment 4: Evaluation of Response to Nonsurgical Therapy Appointment
(1 hour) 6/25/2010 $ 95
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Update medical history.
Measure vital signs: BP: 133/85 mm/Hg, P: 67 BPM, R: 13 Breaths/Minute.
Make sure patient brought the inhaler to the appointment as she was instructed.
Extra/Intraoral Exam.
Assess all quadrants for tissue response to self-care and periodontal debridement.
Determine plaque free index. PFI: 82% (Notable Improvement)
OHI: Review, reinforce and motivate patient.
Selective polish (extrinsic stains on facial surface of anterior teeth)
5% Sodium Fluoride application (varnish).This is a gel of 5% Sodium Fluoride
which contains 22600 ppm Fluoride. It should be applied at a minimum of two
times a year. It is safe to use with any dental restorative material. This fluoride
treatment has a lower risk of fluoride ingestion compare with other types of
fluoride treatments.
 Explain justification for 3 month maintenance visits.
Justification:
 Although currently not present, patient is at a continued future risk for the
development of gingival hyperplasia, especially since the medication dosage
of Norvasc has been increased to manage her hypertension. It is important to
regularly monitor her tissue for hyperplastic changes.
 Patient has a periodontal condition that requires short intervals maintenance
appointments.
 Although patient is working on applying stress reduction in her life, stress is a
key influence in an elevated risk for periodontal disease.
 Systemic health of patient perpetuates and modifies her periodontal
condition, for this reason regular hygiene care is essential to maintain the
results of non-surgical periodontal therapy.
Maintenance
 Three months re-care visits to maintain periodontal health.
 PFI re-assessed at each visit, along with all other necessary assessments (MBI,
probing, E and I, etc)
 OHI reviewed and modified if needed at each visit.
 Maintain patient-provider trust by consulting with the patient on the status and
progress of stress management.
 Encouragement to continue a healthy diet.
Overall prognosis and outcome
Overall outcome for this patient was positive.
Rationale:
 Patient had significant improvement in PFI scores from baseline to re-evaluation
visit
 Patient tissue response was good. Baseline MBI was 21%, re-evaluation MBI was
12%
 Patient complied with referrals
 Patient complied with the majority of the nutrition and stress reduction
recommendations to promote overall periodontal and systemic health.
Prognosis: Fair-Good based on the overall previously stated treatment outcomes.
Prognosis is also dependant on continued compliance with periodontal maintenance visits
and given recommendations.