Case Documentation Project

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

Course
Session: Spring
Submitted to:
Tammy K Swecker, R.D.H., B.S., M.Ed.
By: Mariela Coronado
April 13th 2015

Patient Name: Mr. Granola

Chart Number: 1100462

Age: 35
Gender: Male
Medical History:
Mr. Granola presented to clinic on August 18, 2014 for adult prophylaxis. He had not
been in for a cleaning in a year and 5 months. His blood pressure was 138/90 mmHg RAS at
2:05pm with no history of hypertension. He is currently not under care of a physician. During
previous appointments his blood pressure has been above 130/90mmHg. He takes no
medications and has occasional seasonal allergies. He was hospitalized in February, 2005 for a
finger burn. He also had an arm injury in November 2014 with no complications. Mr. Granolas
blood pressure was recorded at the end of the initial appointment and was 130/92mmHg. Due
to Mr. Granolas constant high blood pressure reading and the fact that he has not been to the
physician in over 6 years, he has been assigned an ASA III classification.

Dental History:
Mr. Granola has been a patient at VCU School of Dentistry for five years. Mr. Granola
grew up in King Georgia, Virginia and did drink fluoridated water as a child. He uses a medium
toothbrush. He brushes zero sometimes once per day and does not floss. Mr. Granola owns a
Sonicare toothbrush but doesnt use it because of the noise. When he does brush he uses
Colgate toothpaste containing fluoride. Mr. Granola does not use any mouth rinse. He has had a
root canal on #13, crowns, and generalized restorative. Mr.

Social History:
Mr. Granola works night shifts. He is a part time bartender and part time truck driver. He
enjoys going out with his friends during the weekends. He watches television every day for
about two hours each time. He currently does not do any physical activity. He lives with his mom
and sleeps during the day to work during the night. He used to smoke one pack a day for 10

years and recently quit in 2013. Mr. Granola quit smoking to improve his overall health. Mr.
Granola drinks a 6 pack occasionally.

Justification for selection:

Mr. Granola presented to clinic with generalized moderate to severe inflammation. Mr.
Granola has generalized bleeding on probing, generalized heavy biofilm with moderate
subgingival calculus and localized severe calculus in sextant 5. Mr. Granola has areas of
demineralization, especially on the facial surfaces of anterior teeth. He has pocket depths that
are less than or equal to four millimeters with localized five millimeter pockets on mesial-facial of
#3, distal- lingual of #5, distal- buccal of #13, distal-buccal and mesial-buccal of #30. The
deeper pockets are most likely to be pseudopockets due to gingival inflammation. Mr. Granola
has generalized slight recession.
Due to the amount of heavy plaque and calculus that Mr. Granola presents with, he
would be an excellent candidate for the project. Mr. Granola would benefit from the project due
to the lack of knowledge about proper oral hygiene and importance of maintaining his oral
health. Mr. Granola quit smoking to improve his health. Oral health is connected to overall
health. He is an ideal candidate since he is motivated to be involved in the project and see
outcomes. Thorough oral hygiene instructions would focus on improving his ability to reduce his
plaque which will decreased gingival inflammation. Through the use of an individualized
treatment plan that would include specific hygiene products, recommended techniques, patient
participation, and nutritional counselling, Mr. Granola will show improvement in his oral health.
In addition, Mr. Granolas medical history also makes him a good candidate for the
project. He is taking no medications but reports to clinic constantly with elevated blood
pressure. Incorporating research and importance of visiting primary care physician will benefit
his overall health. He will benefit from the dietary analysis portion of this project. Good nutrition
is vital to good health. Poor diet is implicated to oral and systemic diseases including gingivitis,
dental caries, and hypertension. Mr. Granola is always on a rush and stays awake during his

night shifts by frequently snacking. Mr. Granola agreed to take part of the project and is excited
to see a visible change in his oral health which will help maintain a healthy lifestyle. Treating this
infection is crucial to reversing gingivitis and prevention of periodontitis.
Assessment:
Extra oral exam for Mr. Granola is within normal limits. Intra oral findings are bilateral
linea alba, coated tongue, and fordyce granules. Mr. Granolas gingival description is
generalized inflamed erythematous gingiva with rolled margins and blunted papilla. During
periodontal charting, the clinician demonstrated the bleeding to Mr. Granola. The clinician
explained that bleeding is a sign of infection and the inflammation can be reversed with optimal
oral hygiene regimen. Mr. Granola was disclosed and showed a 25% plaque free score. The
clinician explained the significance of this percentage and how it can improve with brushing and
flossing every day. He admits to only brushing when he remembers. When the clinician asked
Mr. Granola to demonstrate his brushing technique, he showed an aggressive technique not
angling towards the gum line. He was demonstrated the bass method brushing technique using
a soft toothbrush. According to a study, the hardness of the filaments in a toothbrush is
considered to have a certain influence on gingival retraction and can recession which may lead
to sensitivity. 1 The bass method technique requires positioning the tooth brush bristles up
towards the gum line at 45 degree angle to remove plaque. 1 The c-shape flossing technique
was demonstrated while showing the patient generalized areas of bleeding. The clinician
instructed Mr. Granola to take about 18 inches of floss and wind most of it around one of the
middle fingers. 2 Mr. Granola was instructed to hold the floss tightly between his thumbs and
curve the floss in a c-shape when it reaches the gingival margin. Mr. Granola demonstrated the
techniques successfully. The clinician recommended Mr. Granola to visit a physician due to the
elevated blood pressure before his next dental visit. Mr. Granola stated he would consider
going. Mr. Granola was given a 3 day nutritional journal along with dietary counseling forms to
complete and bring back at the evaluation appointment.

Dental Hygiene Diagnosis:

A dental hygiene diagnosis is defined as the identification of an existing or potential oral
health problem that a dental hygienist is educationally qualified to treat. After gathering the
available assessment data Mr. Granolas dental hygiene diagnosis is plaque induced severe
gingivitis. Developing a treatment plan with customized oral hygiene home care, aids, and
nutritional counseling with be essential to reverse gingivitis.

Planning: Goals
Summary of Initial Assessment Findings:
A. Generalized moderate to heavy plaque accumulation
- PFS at first appointment: 25%
B. Generalized moderate inflammation
- GI at first appointment: 1.5
C. Generalized slight interproximal calculus
D. Generalized moderate subgingival calculus with localized heavy in lingual sextant 5
E. Generalized BOP
F. Generalized pds </= 4mm with localized 5mm
G. Localized recession
H. Patient has a Sonicare automatic toothbrush but does not like to use
Treatment Goals:
A. Patient will obtain a PFS of 60% by last appointment of fall semester
a. 40% for the next appointment
B. Patient will obtain a GI score of 1.2 by next appointment
D. Patient will brush for 2 minutes twice a day, every day, using a the bass method
E. Patient will floss daily using a c-shaped technique
F. Bring Sonicare toothbrush to next appointment

Dietary Findings
Mr. Granola filled out the dietary behavior information sheet. He weighs 186 pounds and
would like to weigh 170 pounds. His chief complaint about his diet is that he is always on the go
and eats out a lot due to his busy work schedule.
A significant finding about Mr. Granolas dietary behavior is that he consumes 4 cans of
soda a day. He consumes fast food and snacks frequently. Fast food restaurants in his dietary
intake include Five Guys, McDonalds, and Wendys. Some of his snacks include popcorn,
starburst, and granola bars. Mr. Granola seems not to be consuming any water throughout the
night. Mr. Granola has a hard time staying awake during his nights shifts, therefore snacks to
help him get through his shift. He does not eat breakfast since it interferes with his sleep. Mr.
Granola eats lunch and two dinners.
According to his dietary intake for lunch, he eats a chicken sandwich with potato chips and
Coca-Cola. For one of his daily dinners, he had a deep fried burger and french fries and soda
from Five Guys. During one day Mr. Granola consumed 4 sodas. He incorporates that he sips
on a can or two of soda during his night shifts. His snacking is frequently, especially while he is
working.
After entering this information into MyPyramid, it was shown that Mr. Granola is not eating
enough from many food groups. MyPyramid recommended that he increase his daily intake of
grains by 1.5 oz/day, vegetables by 2 cups/day, fruits by 2 cups/day, milk by 1 cup/day and meat
2 oz/day. The results also showed that Mr. Granola is not doing well with his intake of sodium,
cholesterol, saturated and total fat each day.
Mr. Granola has already had several restorative work including recurrent decay. The caries
potential of Mr. Granola is classified as being high. Due to the fact that he frequently snacks on
candy and soda it exposes him to a high cariogenic diet. The clinician educated the patient
about the role of frequency exposure of sugar to the oral cavity. Furthermore, the clinician
recommended adding more variety to his diet including fruits and vegetables. The clinician

recommended Mr. Granola to take bananas and apples to replace the chocolate snacks in his
diet.
Dental Hygiene Treatment Plan:
Fall 2014
1

Assessments PFS, GI
OHI
Dietary Education (based on dietary forms and MyPyramid
recommendations)
Adult prophylaxis/ Fluoride treatment
Dental Exam

Evaluation: PFS GI
OHI Reinforcement- discuss any areas of difficulty
More dietary education if needed

Spring 2015
1

Re-evaluation
Intraoral photographs
Assessments PFS, GI, Existing Oral Conditions Charting updated,
Periodontal Charting updated
Review OHI discuss areas of difficulty and improvement

Review dietary changes discuss areas of difficulty and improvement

Adult prophylaxis
OHI reinforcement (as needed)

Final evaluation
Discuss success with patient

Second appointment: Mr. Granola presented to clinic with blood pressure of

132/90mmHg on September 11, 2014. There has been no change to his medical history from
last time. Mr. Granola has not visited a physician to discuss blood pressure. He was disclosed
and showed a 10% plaque free score. He did not reach his goal of 40%. His GI score did
however improve from a 1.8 to 1.5. He admitted to not being as complaint with brushing and
flossing. Flossing takes too long, he stated. Explanation of the need to brush twice per day,
every day, for at least two minutes each time was discussed including the formation of calculus.
The clinician recommended Mr. Granola to use his electric toothbrush with soft bristles for better
plaque removal. Studies have shown that sonicare toothbrushes can remove significantly more

plaque than a manual toothbrush. 2 The clinician advised Mr. Granola to bring in his Sonicare at
the next visit to adjust the settings. Mr. Granola received a dental exam and was prescribed
Prevident due to his high caries risk. The clinician explained instructions on how to use
Prevident once a night, not to rinse after, and no drinking or eating for 30 minutes. Furthermore,
the clinician educated Mr. Granola on the role of fluoride in preventing cavities. According to
research, the use of fluoride has been considered for years as being the main foundation of
caries prevention and control by reducing the rate of demineralization, stopping caries
progression, and promoting remineralization. 3 Fluoride has shown under certain conditions to
even stop small carious lesions. Furthermore, fluoride can interfere with the physiology of oral
bacteria in the tooth biofilm, decreasing the acid production and inducing cariogenic bacteria
acid intolerance fluoride remineralizes and strengthens the tooth structure preventing cavities
from forming. 3
Mr. Granola will receive a Waterpik flosser and instructions on how using it can be
beneficial in removing debris interproximal. According to a study conducted at the University of
Amsterdam, waterpiks have shown to be twice as effective as traditional floss at reducing
gingival bleeding with used in conjunction with manual toothbrushing. 4 The Waterpik flosser is
easy to use by pointing the flosser tip between the teeth along the gingival margin and let it do
the work. It is fast, only taking one minute a day, and it is effective in plaque removal. 4 A tongue
scraper was given to Mr. Granola during this appointment to help with his coated tongue. The
clinician explained that the coated tongue is due to bacteria and demonstrated how to use the
tongue scraper starting from the end of the tongue bringing it forward. Mr. Granola is currently
not using any type of mouthrinse. The clinician has decided to recommend Listerine antiseptic.
Mr. Granola will be introduced to the 21 day challenge.

Dietary:

To increase his daily grain recommendation by 1.5 oz, Mr. Granola could purchase
different types of whole grain cereals, and increase the serving size. Mr. Granola could add to
his daily vegetable intake by 1.5 cups by having a serving of fresh vegetables as a side dish
with one of his dinner meals. For variety, he could include different kinds of vegetables such as
broccoli and cucumbers in his salads. To boost his fruit consumption by 1 cup/day, he could
increase the amount of fruit that he usually eats as part of his lunch. Mr. Granola can make
sandwiches with different kinds of lean meats, such as turkey and chicken. The use of nonprocessed meats will be discussed, since they are lower in salt. According to the American
Heart Association, hypertension in an adult is defined as a systolic pressure of 140mmHg or
higher and/or a diastolic pressure of 90mmHg or higher for an extended time period. 5 A diet that
eliminates fiber, fruits, vegetables and nonfat dairy reduces key minerals. The dietary guidelines
for Americans recommends lowering the intake of sodium to 2,300mg/day. 5 Mr. Granola has
been consuming twice the sodium. Monitoring consumption of high sodium foods is helpful in
controlling blood pressure. 8
Rinsing with water following soda consumption to reduce staining and cariogenic effect
from carbonic acid was recommended. The dangers of snacking or sipping on fermentable
carbohydrate foods and drinks throughout the day was discussed. This keeps them in contact
with the teeth longer, leading to an increased risk of decay. The clinician recommended Mr.
Granola to drink his soda with a meal versus alone.

Third appointment:
Mr. Granola reports to clinic with a blood pressure of 138/84mmHg on October 23, 2014.
He has not visited a physician. His chief complaint was that he recently chipped a tooth eating a
granola bar. Upon reviewing assessments, the clinician found a 6 millimeter probing depth on
mesial of #5 and distal of #30. The clinician explained the significance of the periodontal pocket
reading and the importance of maintaining the area plaque free after the cleaning. Mr. Granola

received a dental exam to examine tooth #8 which chipped. The dentist recommended getting a
filling if he wasnt happy with the way his tooth looked. Mr. Granola stated it was not giving him
any pain and he would leave it as is for now. Cavitron, hand instruments, and rubber cup polish
were used to complete Mr. Granola cleaning. Mr. Granola was demonstrated a video on how to
use the Waterpik flosser to remove interproximal plaque. The link was written in a piece of paper
in case he needs to refer back to it. The clinician introduced the Listerine 21 day challenge to
Mr. Granola. A comparative studied showed Listerine antiseptic significantly reduced plaque
growth and gingivitis compared to a placebo. 9 The clinician helped Mr. Granola download the
Listerine challenge app on his IPhone. This app contains a virtual life coach, Iya Villania which
helps guide the patient to achieve their goal. It takes 21 days to form a habit and this app would
help Mr. Granola log in the time of day he rinses with Listerine. Furthermore the app would work
as a reminder to help Mr. Granola with his busy schedule. Mr. Granola received a 1.5 liter
Listerine antiseptic from the clinician to start his challenge.

Fourth appointment:
Mr. Granola came in February 12, 2015. He was overdue for his 1 month evaluation. It had
been 4 months since his last visit. Mr. Granolas gingival index improved to 1.0 compared to last
visit which was 1.5. Mr. Granolas plaque free score was 39 percent. This was also improved
compared to 10 percent in the last visit. The clinician praised the patient for the improvement.
Mr. Granola really likes using the Waterpik. He feels like its quick and convenient. The gingival
description was still erythematous with less inflammation. During the evaluation, the clinician
examined probing depths which remained the same from the previous. Mr. Granola presented
with slight to moderate subgingival calculus. The clinician performed the adult prophylaxis. The
clinician recommended Mr. Granola arrestin antimicrobial to help with the 6mm pocket of #30
distal lingual. According to research, a local antimicrobial has been shown to have a beneficial
impact with a mean reduction of periodontal probing depths and gain in clinical attachment level

10

improvements of about 0.6 and 0.3 mm. 10 The arrestin was placed on distal lingual of #30 and
Mr. Granola was instructed not to floss the area for two weeks. 10 Oral hygiene instructions were
reinforced. Mr. Granola has starting using his sonicare about 2 times per week. Mr. Granola is
still not compliant with brushing twice a day. He is enjoying the Listerine challenge.
Final Appointment:
Mr. Granola presented to clinic March 12, 2015 for evaluation with blood pressure 128/82
mmHg. This has been the lowest it has been over the past 7 months. Mr. Granola has not had
fast food for the past three weeks. He completed his 21 Listerine challenge and has been
brushing twice a day. Mr. Granola presents with generalized pink gingiva with localized marginal
redness. The clinician completed a full mouth periodontal chart and revealed generalized 1
millimeter probing depths. The site where arrestin was placed, #30 distal-lingual, improved from
a 6 millimeters to 5 millimeters. The clinician shared the improvement with Mr. Granola and
praised him to keep up the good work.
Recall/Reevaluation Interval:

11

Due to the plaque load and localized heavy calculus that Mr. Granola presented with, he
was placed on a 4 month recall interval. This time period will allow for closer evaluation of how
effective he is in removing daily plaque. It is increasingly important for Mr. Granola maintain
good oral health due to the increased risk of periodontal disease and caries. Once his gingival
condition and oral hygiene has improved, he will go back to a 6 month recall.
Reflection:
I was very pleased with the success my patient had during the project. It took baby steps
to get him to the stage where he is at today but it was worth it. His busy schedule was a
challenge since working at night interfered with his diet. One thing I would have changed is
persuading him with more research to visit his physician. I feel like a huge part of patient
success is patient motivation. This was something Mr. Granola had and maintained even when
there wasnt significant improvement.

References
1. Peter A. Evidence for the occurrence of gingival recession and non-carious
cervical lesions as a consequence of traumatic toothbrushing, Journal of
Clinical Periodontology, 2015 [cited April 1, 2015]
2. Putt M, Milleman J, Jenkins W, Schmitt P. Comparison of plaque removal by
novel Philips Sonicare sensitive brush head and a manual toothbrush. 2010;
cited April 6 Available from:
http://www.sonicare.com/professional/en_US/pdf/Plaque_SBH_2010_Putt.pdf
3. Petersson L. The role of fluoride in the preventive management of dentin
hypersensitivity and root caries. Clinical Oral Investigations [serial on the
Internet]. (2013, Mar 2), [cited April 1, 2015]; 1763-71. Available from:
Dentistry & Oral Sciences Source.
4. Rosema NAM, et al. J Int Acad Periodontol 2011; 13(1):2-10.
Study conducted at the University of Amsterdam, Academic Center for
Dentistry, Amsterdam.
5. Sanda M. Hypertensive Patients and Their Management in Dentistry. ISRN
Hypertension, vol. 2013.
6. Hujoel P, Cunha-Cruz J, Banting D, Loesche W. Dental Flossing and

Interproximal Caries: a Systematic Review. Journal Of Dental Research

[serial on the Internet]. (2006, Apr), [cited April 11, 2015]; 85(4): 298-305.
Available from: Dentistry & Oral Sciences Source.
7. Rosema NAM et al. The effect of different interdental cleaning devices on
gingival bleeding. J Int Acad Periodontol 2011; 13(1):2-10
8. Stegeman C, Kunselman B, McClure E, Pacak D. Fad Diets: Implications for
Oral Health Care Treatment. Access [serial on the Internet]. (2006, Mar),
[cited April 13, 2015]; 20(3): 30-35. Available from: Dentistry & Oral Sciences
Source.
9. Goutham B. Efficacy of two commercially available Oral Rinses Chlorohexidine and Listrine on Plaque and Gingivitis - A Comparative Study.
Journal Of International Oral Health [serial on the Internet]. (2013, July),
[cited April 1, 2015]; 5(4): 56-61. Available from: Dentistry & Oral Sciences
Source.

10. Flemmig TF, Petersilka G, Volp A, Gravemeier M, Zilly M, Mross D, et al:

Local and Systemic Antimicrobial Therapy in Periodontics. J Periodontol
2011; 82: pp. 96-105