Risk Assessment Project
JENNIFER KUO
#1211
DH 88
Personal History
 Age: 31 years old
 Sex: Male
 Race: Caucasian
 Marital Status: Single
 Occupation: Air Traffic Controller
Medical History
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Past Medical History
 Patient has a history of childhood
asthma that is no longer observed.
Past medication or drug use: None
Family History
 Patient has a family history of
diabetes from both parents.
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A positive history of diabetes doubles an
offspring's risk of developing the disease
(Franks, 2010).
General Health
 Patient reports he is in good health.
Review of Systems
 Head and Neck: None reported
 Neuromuscular System: None reported
 Respiratory: None reported
 Cardiovascular: None reported
 Gastrointestinal/Genito-urinary: None
reported
 Allergies: None reported
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Hematological: None reported
Behavioral: No disorders reported
 Current Medications
Patient is not currently under
any medications.
 Hospitalizations/Emergency Room
visits: None reported
 Baseline Vital Signs:
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BP: 118/78
Pulse: 76 bpm
Respiration: 16 breaths/min
 ASA Status with rationale:
 The patient is classified as ASA I
due to the fact that he presents
without any systemic disorders,
not currently under any
medications, and presents with a
normal baseline blood pressure.
Dental History
 Last dental exam

11/13/2010
 Last hygiene appt
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11/13/2010
 Last radiographs
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FMX: 11/15/2010
Panoramic: 03/18/2011
 Past treatments
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Orthodontic treatment for 18
months from 1992-1993
Extraction of third molars
from all quadrants
 Present status
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Patient currently has no need
for restorative treatment
Currently on a six months
interval for his recare appts
(due May 13,2011)
The patient is not compliant
with his recare appts.

Prior to his most recent
hygiene visit, his last
hygiene appt was over two
years ago.
Clinical Examination (Pre-treatment)
Extra-oral examination
 Symmetry & Skin

3x4 mm macule on the
labium inferius

The macule developed
within this past year
 Lymph nodes: WNL
 Thyroid & Trachea: WNL
 TMJ
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
Slight crepitus on the
right
Deviation to the right
upon closing
 Maximum opening
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50mm
Clinical Examination (Pre-treatment)
Intra-oral Examination
 Occlusal relationship
 Overjet, overbite, underjet, crossbite: None
 Right side relationship - Molar: class I, Canine: class I
 Left Side relationship - Molar: class I, Canine: class I
Clinical Examination (Pre-treatment)
Intra-oral Examination (Con’t)
 Labial & Buccal mucosa:
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WNL
Frenums: WNL
Alveolar bone: WNL
Tori: None present
Floor of mouth: WNL
Salivary glands/flow:
WNL
Tongue: WNL
Tonsils: WNL
 Uvula: WNL
 Oropharynx: WNL
 Common deviations:

Macroglossia
**photo was not enlarged
Gingival Description
Maxillary
 Free
 Pink, firm, stippled, knifeedged
 Localized rolling on the
buccal and lingual
surfaces of #5
 Attached:
 Pink, firm, stippled,
smooth
Mandibular
 Free
 Pink, blunted, firm,
stippled
 Slight bulbous between
#26,27
 Rolled on the lingual of
#23,24,25, 26
 Attached
 Pink, smooth, stippled,
firm
Baseline Periodontal Record
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Generalized 2-3mm pocket, with localized 4mm pockets on distobuccal surface of
#3, #4, distolingual surface of #3, mesiobuccal of #31, distolingual of #31.
BOP: noted on #3M, 14M, 24F.
MBI: 0%, PI: 100%, PFI: 0%
Furcation: Class I on the buccal aspect of #2, 3, 14, 15, 19, 30. And Class I on the
lingual aspect of #19.
Mobility: none
Recession
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1mm- #2B, 14L, 15L, 20L, 21L, 29L, 28B,
2mm- #3B, 5B, 12B, 13B, 14B, 30L
Calculus code: WLAC code light 2
AAP: Generalized moderate chronic periodontitis
Areas of Concern: existing caries watch on the occlusal of #2
Perpetuating factor: Patient does not present with any restorations or malocclusion
but his inadequate oral hygiene perpetuates his periodontitis
 Etiology:
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Patient is not compliant with his six month recare intervals
his current homecare techniques demonstrate inadequate biofilm control as evidenced by
his PI score and caries watch.
Patient flosses occasionally
Before Disclosing
After Disclosing – Baseline Results
PI: 100%, PFI: 0%
Oral Hygiene Evaluation (Pre-treatment)
 Patient’s skill level
 Poor, as evidenced by his baseline PI score
 Patient demonstrates good dexterity but his current vertical and
horizontal scrubbing method is less effective in removing biofilm
 Patient’s knowledge and awareness of dental and periodontal
disease

Patient possesses basic knowledge of dental diseases such as cavity
development, but was unfamiliar with the cause and effects of
periodontal diseases.
 Oral Hygiene Instruction
 Educated the patient on the modified bass technique.
 The patient presents with type I gingival embrasures and it is
recommended that the patient continue using dental floss with the spool
method, but increase its frequency
 The Tell-Show-Do method was employed for both techniques
Caries Examination
 Existing caries and quality of restorations
 Caries watch on the occlusal surface of #2 which has been monitored by
his dentist for the last three years.
 Caries Index
 The patient has a DMFS score of 21. This is determined by the following
information:
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1 decayed surface
20 surfaces from 4 missing/extracted teeth
0 filled/crowned teeth
A DMFS score of 21 indicates that there are 21 affected surfaces and 107
out of a total of 128 surfaces are still intact.
 Evaluation of radiographs for caries and restorative needs
 Radiographs reveal no restorations
 The caries watch is not detectable radiographically
Panoramic Radiograph
•Per Dr. Liewen’s Assessment:
•Generalized 2-3mm horizontal bone loss
•Caries watch is not detectable on the radiographs, but is clinically visible.
Nutritional Analysis
Three day dietary analysis
 Patient has a tendency to skip
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breakfast
Frequently consumes fast food
meals high in fat and carbohydrates
ex: McDonald's, Popeye’s, etc.
Frequently snacks between
meals and has a fondness for
sugary sweets such as candy
and brownies
Commonly deficient in
vegetables and dairy which
consequently affected the patient's
intake of essential vitamins such as
Vitamin E
The patient frequently does not
meet the RDAs for many food
groups
Research Correlations

According to Imamura, Lichtenstein,
Dallal, Meigs, & Jacques (2009),
specific dietary patterns such as the
habitual consumption of “soft drinks,
particularly caloric soft drinks, meat
and processed meat, eggs, refined
grains, and French fried potatoes were
positive contributors to the dietary
patterns associated with type II
diabetes”.
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These same foods also appear within the
patient’s dietary diary
The nutritional habits coupled with the
patient’s familial history of type II
diabetes, increases the patient’s risk of
developing the disease even more
Nutritional counseling will focus on
addressing these issues and offer healthy
alternatives
Analysis of Carbohydrate Intake
 1st day – 120 minutes of exposure
 2nd day – 120 minutes of exposure
 3rd day – 140 minutes of exposure
 Avg total exposure for all three days – 126.67
mins.
 The high value is attributed to the frequent sugary
snacks and carbohydrate rich foods at each meal
Nutritional Food Pyramid Results – Day 1
Nutritional Food Pyramid Results – Day 2
Nutritional Food Pyramid Results – Day 3
Caries Risk Assessment
Recommendations based
on the patient’s need
CAMBRA Assessment
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Based on CAMBRA, the patient is
considered to be at high caries risk.
He has an existing caries watch on the
occlusal of #2 as evidenced clinically and
diagnosed by his dentist.
Furthermore, the patient presents with
deep grooves and pits as well as
exposed roots due to gingival recession
Prognosis

Poor - Although the status of the patient’s
caries watch has not changed over the last
three years, his current nutritional habits
coupled with his ineffective tooth
brushing technique and sporadic flossing
regimen, categorizes the caries risk
prognosis as poor. Emphasis will be
placed on encouraging a healthier diet
and OHI to raise the prognosis to an
acceptable and good level.
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Brush 2x/day with fluoridated
toothpaste (Prevident 5000 is also
recommended)
Floss regularly with dental floss
Reduce the frequent consumption of
sugary snacks and sodas; continue
consumption of tap water (0.7ppm)
Incorporate more fruits and vegetable
in the diet
Fluoride rinse (0.05% NaF, ACT, or
Fluorigard) 2x/day
Xylitol – after snacks and as a mint 3-5
times/day
In-office fluoride varnish or tray
Antibacterial rinse - Chlorhexine
gluconate for 1 week/month
Dental Hygiene Treatment Plan
 Rationale for tx plan and patient needs
 Patient demonstrates inadequate biofilm control as evident by
his PI score of 100%.
 Patient also presents with an existing caries watch as well.
 Goal of dental hygiene tx
 Decrease patient’s caries risk and increase the prognosis level
 Encourage the development of oral hygiene habits to improve
oral health
 Increase the patient’s understanding and awareness of the
cause and effects of periodontal disease, as well as its sequence
Dental Hygiene Treatment Plan
First Appointment
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Interpretation of PI results, explanation of the role of carbohydrates and tooth decay, what periodontal
disease is, sequence of periodontal disease development
Because the patient demonstrates good dexterity, the modified bass technique will be introduced to
the patient.
Daily flossing with the spool method will be reinforced and encouraged.
Employment of the tell-show-do method to ensure proper application of the techniques demonstrated.
A goal of 25% plaque reduction was established to encourage the patient to improve their overall oral
hygiene and practice the new techniques taught.
Sealant recommendation for his deep grooves and pits on all mandibular molars
5% NaF in-office varnish is recommended due to the patient’s caries risk and recession. In addition to
the in-office treatment, Prevident 5000 will also be recommended.
Antibacterial rinse – 0.12% Chlorhexidine gluconate is recommended for 1 week/month for patient’s
caries watch and prevention of future caries.
Nutrition recommendation:
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Encourage the reduction of frequent in-between snacking
Increase consumption of fruits and vegetables, and decrease consumption of sodas and retentive sweets
Introduction of xylitol and healthier snack options
Encourage the consumption of breakfast to reduce snacking habits.
Dental Hygiene Treatment Plan
Second Appointment – 3 Week Re-evaluation
 Analysis of the patient’s compliance with the aid of
a second PI score
 Review and reinforced OHI provided at the first
appointment.
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Modified bass technique
Spool method of flossing
Clinical Examination (Post Treatment)
Extra-oral Examination
 Symmetry & Skin

3x4 mm macule on the
labium inferius

The macule remained
unchanged and the same
size
 Lymph nodes: WNL
 Thyroid & Trachea: WNL
 TMJ


Slight crepitus on the right
Deviation to the right
upon closing
 Maximum opening

50mm
Clinical Examination (Post Treatment)
Intra-oral Examination
 Occlusal relationship
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Overjet, overbite, underjet,
crossbite: None
Right and Left side relationship Molar: class I, Canine: class I
Labial & Buccal mucosa: WNL
Frenums: WNL
Alveolar bone: WNL
Tori: None present
Floor of mouth: WNL
Salivary glands/flow: WNL
Tongue: WNL
Tonsils: WNL
Uvula: WNL
Oropharynx: WNL
Common deviations:

Macroglossia
 Gingival Description
 Max Free: Pink firm,
stippled, blunted,
localized rolling on the
buccal and lingual
surfaces of #5
 Max attached: Pink, firm
stippled, smooth
 Mand Free: Pink, blunted
firm, slight bulbous
between #26,27, rolled
on the lingual of
#23,24,25, 26
 Mand attached: Pink,
smooth, stippled, firm
Clinical Examination (Post Treatment)
Intra-oral Examination (con’t)
 Periodontal Record
 Generalized 2-3mm, with localized 4mm pockets on
distobuccal surface of #3, #4, distolingual surface of #3,
mesiobuccal of #31, distolingual of #31.
 BOP: noted on #2B, 12D, 30L
 MBI: 0%
 Furcation: Class I on the buccal aspect of #2, 3, 14, 15, 19,
30. And Class I on the lingual aspect of #19.
 Mobility: none
 Recession
1mm- #2B, 14L, 15L, 20L, 21L, 29L, 28B,
 2mm- #3B, 5B, 12B, 13B, 14B, 30L

After Disclosing – Post Treatment Results
PI: 68%, PFI: 32%
Post Instructions Status
 Patients compliance resulted in a 32% reduction in biofilm.
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Patient exceeded the improvement goal established during the first appointment.
 Based on the areas where biofilm remained, I recommend the patient
continue his homecare regimen
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Recommended the use of an electric toothbrush
 “electric brushes are significantly more effective at maintaining low plaque levels
compared to a manual brush with or without the daily use of floss” (Rosema et al.,
2008)
 “Provides long-term biofilm control and improve gingival condition for more than
6 months compared to manual brushes with or without the use of floss”. (Rosema
et al., 2008)
Recommended the additional use of mouthrinses to aid with
interproximal biofilm control as these are the areas the patient is missing
 “twice daily rinsing reduced P.gingivalis (64.5%), Veillonella sp. (56.6%, F.
nucleatum (76.6%), and total anaerobes (74.9%) within the interproximal regions”
(Teles & Teles, 2009)
 Even single 30 second rinses demonstrated a significant reduction (43.8%) 5
minutes later (Teles & Teles, 2009)
 Essential oil containing mouthrinses are “as effective as daily flossing in reducing
interproximal plaque and gingivitis” (Teles & Teles, 2009)
Referrals
 Patient was referred to his dental hygienist for
hygiene services as dictated by his six month recare
interval; Due May 13, 2011
 Patient is also referred to a specialist for the macule
present on his labium inferius
Research
 First article
 Periodontal Disease and diabetes – review of the literature – BasconesMartinez et al. (2011)

Analyzes the interrelationship between periondotitis and diabetes.
 Second Article:
 Diabetes family history: a metabolic storm you should not sit out – Franks
(2010)
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Analyzes the contribution of family history to the development of diabetes and the
mechanism of various genetic risk factors.
 Third Article:
 Generalizability of dietary patterns associated with incidence of type 2 diabetes
mellitus – Imamura, Lichtenstein, Dallal, Meigs, & Jacques (2009)

Analysis of the dietary patterns associated with type 2 diabetes
 Fourth Article:
 Comparison of the use of different modes of mechanical oral hygiene in
prevention of plaque and gingivitis – Nanning et al. (2008)

A study that analyzed the efficacy of powered toothbrush to their manual
counterparts over a 9 month period.
Research Con’t
 Fifth Article
 Comparison of the use of different modes of mechanical oral
hygiene in prevention of plaque and gingivitis – Rosema et al.
(2010)

Analyzes the efficacy of the modified bass method
 Sixth Article
 Antimicrobial agents used in the control of periodontal
biofilms: effective adjuncts to mechanical plaque control? –
Teles & Teles (2009)

Analyzed the efficacy of antimicrobial rinses