CASE STUDY PRESENTATION #2 BY: KAYLA NUNEZ NYCCT Dental Hygiene Student PATIENT PROFILE

▸ Name: R.A.

▸ Age: 56

▸ Gender: Male

▸ Ethnicity: African American

▸ Last physical exam: March 2019. Patient saw his neurologist in February 2021.

▸ Middle class, single, on disability and lives in Harlem. He does not have dental insurance and comes to City Tech for his dental care.

▸ Last oral hygiene service and radiographs: 11/19/2020.

▸ Patient reports brushing with an Oral B electric toothbrush 1x day using Colgate toothpaste and flossing occasionally. CHIEF COMPLAINT

▸ Periodontal maintenance

▸ CC:“I have lost sensation on left side therefor not chewing on left side.”

R.A. MEDICAL HISTORY OVERVIEW

▸ COVID screening performed: Temp: 97.5

▸ Vitals: BP: 110/79 P:86 ASA: III

▸ Medical Conditions:

▸ Multiple Sclerosis (MS) Diagnosed in 2009. Patient reports he has lost sensation of his left side.

▸ Current Medications:

▸ Tysabri infusion 1x a month for MS

▸ Gabapentin 1x day for pain relief of MS

▸ Vitamin B12 1x day for MS

▸ Social Hx: Smokes medical marijuana 2x a day. EXPLANATION OF CONDITION: MULTIPLE SCLEROSIS Multiple sclerosis (MS) is a progressive, neurodegenerative disorder of the myelin sheath, in which plaques created on the central nervous system (CNS) alter nerve function. CNS changes in motor, sensory and cognitive functions, leading each individual to experience symptoms that vary in degree and severity. Signs and Symptoms: Fatigue Diagnosed By: Neurological exams (which Numbness/tingling requires evidence of demyelination occurring at Bladder disfunction / different times in more than Bowel issues one area of your brain, spinal cord, or optic nerves) Dizziness/ Vertigo Cognitive changes

Depression MANAGEMENT OF CONDITION: MULTIPLE SCLEROSIS Multiple Sclerosis is a lifelong condition without a cure but can be controlled. The primary treatment goal is to slow the disease process and reduce the number and frequency of relapses.

A variety of medications and alternative therapies are used to relieve symptoms and help prevent future relapses.

Drug Class Purpose Common Drugs

Anti-inflammatory Deltasone Steroids To slow progression of disease Medrol Immunosuppressant Decadron

To slow progression of MS Tysabri, Cytoxan, Imuran, Novantrone, Immunomodulators Biological response modifier Cellcept,Copaxone, Avonex, Betaseron and Refib

Gabapentin Pain relievers Pain management Phenytoin Carbamazepine

Anti-spastic, seizure, Baclofen Reduce muscle spasticity muscle relaxers Tizanidine Diazepam

REFERENCE: HTTPS://WWW.MAYOCLINIC.ORG/DISEASES-CONDITIONS/MULTIPLE-SCLEROSIS/DIAGNOSIS-TREATMENT/DRC-20350274 DENTALTEXT HYGIENE MANAGEMENT OF MULTIPLE SCLEROSIS

Individuals with MS are at increased risk for dental caries, and periodontitis due to the physical effects of MS, as well as these patients’ reduced immune response. Customized dental treatment planning and customized oral hygiene regimens must be implemented. Oral Complications Considerations: Leukopenia Paraesthesia Xerostomia Dexterity Candidiasis

Mobility Gingival hyperplasia

Extra-oral facial nerve pain Bruxism Mucositis /ulcerative OHI recommendation considerations: Patients with MS can have limited dexterity and it is Dysgeusia important for oral self-care instructions to be based on the patient’s functional ability and values. Angular REFERENCE: HTTPS://DECISIONSINDENTISTRY.COM/ARTICLE/ORAL-HEALTH-RISKS-MULTIPLE-SCLEROSIS/ DENTAL CONSIDERATIONS FOR MEDICAL MARIJUANA There are no contraindications for dental care. However, dental hygienists should be aware that patient’s who consume marijuana are at an increased risk for: For patients with marijuana use it is Xerostomia important as health care professionals to:

Leukoedema Emphasize the importance of regular dental visits and oral care. Gingival hyperplasia

Cannabis stomatitis Complete comprehensive oral examinations.

Severe caries (Due to Encourage healthy, nutritious snacks over cariogenic snack foods) sweet, cariogenic snacks.

Signs of oral cancer Consider employing preventive measures, such as topical fluorides.

Consider treatment for xerostomia, while avoiding alcohol-containing products.

REFERENCES: HTTPS://WWW.ADA.ORG/EN/MEMBER-CENTER/ORAL-HEALTH-TOPICS/CANNABIS-ORAL-HEALTH-EFFECTS COMPRESSIVE ASSESSMENTS CLINICAL FINDINGS

▸ EO: WNL Palpable submandibular lymph nodes and right external jugular enlarged, palpable, moveable and sensitive to patient.

▸ IO: WNL bilateral linea alba, maxillary torus, bilateral mandibular tori and erythematous right tonsil.

▸ Class of : Bilateral Class II Division I

▸ Overjet: 8mm

▸ : 10 %

▸ Edge to edge: #13 and #14 migrated mesially with #20 and #21.

▸ Recession: Generalized ranging from 2mm -5mm

▸ Other: Local enamel hypoplasia on #3

▸ Calculus detection: Generalized heavy supra and sub gingival calculus. DENTAL CHARTING

MISSING: #5,#12, #18 & #32. CARIES: #3-O & #19-DO GINGIVAL DESCRIPTION

Gingiva appears pigmented with rolled edges. Papilla fills inter proximal space, with generalized marginal inflammation not stippled in texture, soft in consistency with moderate generalized BOP. PERIODONTAL CHARTING AND STATUS

Generalized 5-8mm probing depths

Three (3) 9mm probing depths localized to #2-D, #30-B & #16-M

Generalized 2-5mm of recession

Furcation involvement: Class I #2- BL , #14-BL. Class II #3-BL

Mobility: #26-#22 & #28-Class I and #20 & #21- Class II.

Generalized moderate BOP.

Periodontal Status: Stage III Grade B RADIOGRAPHS

RADIOGRAPHS REVEALED: GENERALIZED 50%-60% VERTICAL AND HORIZONTAL BONELESS, GENERALIZED HEAVY CALCULUS AND DECAY ON 19-DO. CARIES RISK ASSESSMENT

CAMBRA form indicates high risk for caries. This is supported by clinical and radiographic findings.

Radiographic evidence of suspicious decay noted on #19- DO.

Clinical evidence of suspicious decay noted on #3-O DENTAL HYGIENE DIAGNOSES

HIGH RISK FOR CARIES PERIODONTITIS STAGE III GRADE B (DISEASE ACTIVE) Frequent intakes of energy drinks and coffee between meals. Generalized 5-8mm probing depths Frequent smoker Radiographic evidence of generalized 50% bone loss Moderate generalized BOP Clinical & radiographic evidence of suspicious caries Mobility and furcation involvement Does not use oral rinse containing fluoride Smoking serves as a supporting risk factor for periodontal disease. Medication induced xerostomia

CASE VALUE: HEAVY

Generalized heavy supra and sub gingival calculus. DENTAL HYGIENE CARE PLAN After the completion of assessments of R.A.’s oral cavity, his periodontal condition was deemed beyond the scope of care at our dental hygiene faculty.

VISIT ONE

Completed all assessments OHI: Oral B powered toothbrush using modified bass technique. Scaled teeth #6-11 & #22-27 IMPLEMENTATION OF TREATMENT VISIT ONE All assessments were completed with the use of Oraqix, which was administered during assessments as pain management due to the patients sensitivity.

We reviewed the FMS taken in 2019 to help with DH diagnosis.

After employing the disclosing solution, his plaque index score was 1.0 (fair). Biofilm was visible generally on the cervical third and inter-proximal surfaces of the teeth. With localized calculus on the occlusal surface of the left posterior molars. After discussing with the patient his current manual dexterity and possible future oral hygiene needs, I introduced power assisted modified bass toothbrushing technique to the patient. The patient was shown how to correctly angle and place the brush head for greater marginal plaque removal. Our goal was to decrease the plaque score and implement the correct method of toothbrushing even if it was only once a day.

Patient was deemed beyond the scope of DH care because we are limited based on the services we can provide. Our instruments not being able to go as deep as the 9mm pockets he has to effectively remove all the calculus.

Scaling of supra gingival calculus using hand instruments on teeth #6-#11 and #-22-#26 was completed due to patient request. COUNTING CARE RECOMMENDATION ▸ The continuing care recommendation for this patient is to see a periodontist for evaluation of his oral state.

The patient was given a referral for an evaluation of caries as well as an evaluation of advanced periodontal disease.

He was provided a list of dental practices and dental universities in his area that can provide the services he needs.

The patient was also given a letter of beyond the scope of care.

The patient understands the severity of the state of his oral cavity and is aware that the dentist in which he sees to further treat his condition will help him achieve the best outcome for his oral health. REFLECTION

This case is a very complex case with a systemic condition that causes limited dexterity. Being able to identify the patients needs goes beyond the standard of care in which we are able to provide at NYCCT dental clinic, was extremely important. The greatest take away was being able to effectively communicate with the patient about the status of his oral cavity and providing the patient with the correct information and referrals in order to help get the patient to optimal health.