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Virginia Commonwealth UniversityDental Hygiene ProgramDENH 302Process of Care Reflection Paper4/14/16IntroductionTo follow HIPPA regulations in the protection of my patient’s confidentiality, we will call my patient Mr. Norris. I have selected my patient carefully for this process of care paper. Mr. Norris presented to the clinic with multiple medical conditions, medications, and a present history of tobacco use. My choice on the selection for Mr. Norris for this paper was solidified after reviewing his medical history, dental history, and list of numerous medications.Medical History SignificanceAs a future dental hygienist, it is my job to understand the implications of a patient’s medical history and medications to accurately plan the best treatment to fit the patient’s needs. Mr. Norris’ existing medical conditions include: type two diabetes mellitus, GERD, hypertension, arthritis, sleep apnea, occasional seasonal allergies, allergy to flagyl and difficult to intubate. He currently takes adult low dose aspirin, atorvastatin, amoxicillin, celebrex (celecoxib), gabapentin, lansoprazole, losartan-hydrochlorothiazide, metformin, onglyza (saxagliptin), zolpidem, and an iron supplement. Many of Mr. Norris’ medical conditions and medications have a significant impact the oral cavity. Type two diabetes mellitus is a disease that affects the body’s ability to manage glucose. WebMD states “Your pancreas makes a hormone called insulin. It’s what lets your cells turn glucose from food you eat into energy. People with type two diabetes make insulin, but their cells don’t use it as well as they should.” The ADA states that diabetes is associated with delayed wound healing, salivary gland dysfunction, taste alteration, tooth decay, periodontitis, lichen planus, and lichenoid reactions. Bacteria flourish with glucose; therefore, the oral cavity of a patient with uncontrolled diabetes is like a bacterial playground. It is important for patients to implement good oral hygiene because without it, patients have an increased risk of forming periodontitis. This is especially important for patients with diabetes because uncontrolled diabetes makes periodontitis worse, and vice versa [2]. Mr. Norris suffers from type two diabetes mellitus, and controls it by taking 1,000 milligrams of metformin and 5 mg of onglyza (saxagliptin).GERD, also known as gastroesophageal reflux, is a condition that affects the lower esophageal sphincter (muscle between the stomach and esophagus), causing the contents in the stomach to return back to the esophagus. According to WebMD, “In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus [3].” The pH level of the acid that is refluxed back into the esophagus is 2.0 [4]. This poses a risk for tooth erosion because enamel begins to erode at a pH level of 5.5. Mr. Norris occasionally suffers from GERD, and when it flares up, he controls it by taking 30 milligrams of lansoprazole.Hypertension is a medical condition that is also defined as having high blood pressure. Normal blood pressure ranges from 120/80mmHg or lower. Hypertension is when the blood pressure ranges between 140/90 mmHg and higher. According to WebMD, “Hypertension increases the risk of heart disease and stroke. Hypertension risk factors include obesity, drinking too much alcohol, smoking, and family history.” There are a few medications on the market that are used for this medical condition that may cause xerostomia, or even cause an alteration of taste [6]. Xerostomia, also known as dry mouth, is a condition that plays a key role in the patient’s caries risk. Mr. Norris suffers from hypertension, and controls it by taking 100-25 milligrams or losartan-hydrochlorothiazide. This proves to be true through his blood pressure reading 120/70 mmHg at his first appointment, and 119/64 mmHg at his second appointment.Sleep apnea is a medical condition that causes a person to repeatedly stop breathing while they are sleeping. This is a serious condition due to the fact that the entire body, including the brain, may not get the amount of oxygen it needs to function properly [7]. According to WebMD, if sleep apnea is left untreated, it can lead to further health risks; these include: hypertension, stroke, heart failure, irregular heartbeats, heart attacks, diabetes, depression, worsening of ADHD, and headaches. Mr. Norris suffers from sleep apnea, and controls it with the use of a CPAP mask when he sleeps.Arthritis is a medical condition that affects the body’s joints. “Osteoarthritis involves degeneration of the synovial cartilage and bony overgrowth on the joint articulating surfaces [8].” This medical condition also results in reduced manual dexterity which can pose a problem when it comes to toothbrushing and flossing. Arthritis makes it difficult for a person to hold small objects, such as a normal size tooth brush or dental floss. As a future dental hygienist, I am able to offer alternatives for handling these small oral hygiene products. An example of this would be an at-home project on the handle of a normal sized toothbrush. Replacing most of the handle with a tennis ball or bicycle handle results in a larger mass for the patient to grasp when they are toothbrushing. Mr. Norris suffers from this condition, but he controls it by taking 200 milligrams of Celebrex (celecoxib). Mr. Norris suffers from occasional insomnia, which is a sleeping disorder that affects a person’s ability to sleep. Some medications on the market may cause xerostomia, which can affect the patient’s risk for caries. Mr. Norris controls his occasional insomnia with 10 milligrams of zolpidem.Mr. Norris is allergic to flagyl (an antibiotic for bacterial infections in the vagina, respiratory tract, stomach, skin, and joints) and is difficult to intubate. Thankfully, he carries a warning card with him concerning his intubating difficulty so that, if the situation were to ever arise, doctors would know the correct protocols to take. Seasonal allergies also occasionally affect Mr. Norris, but have only recently begun to do so.Mr. Norris uses four ounces of smokeless tobacco daily. Smokeless tobacco increases the risk of developing lung cancer, periodontitis, heart disease, chronic obstructive lung disease, and other head, neck, and oropharyngeal cancers. This is detrimental to Mr. Norris’ health, and he is currently not undergoing any tobacco cessation. There have been multiple surgeries that Mr. Norris has had to undergo. These surgeries include: carpal tunnel surgery in 2014, right shoulder surgery in 2012, left knee replacement in 2011, right knee replacement in 2009, spur on spine (made it difficult to swallow food) removed in 2007, scar tissue on left shoulder removed in 1997, broken femur resulting in pin/rod placement in 1993, gall bladder removed in 1972, and hernia surgery in 1955. Mr. Norris had to take 2 milligrams of amoxicillin (antibiotic prophylaxis) one hour before the appointment due to multiple joint replacements. This is very important to the patient’s health because if I would have treated Mr. Norris without him taking his premedication, he would be more susceptible to infection which could lead to bigger health problems.Medical Conditions/ DiseaseImpact on Dental TreatmentType II Diabetes MellitusCan cause tooth decay, infection, delayed wound healing, salivary gland dysfunction, periodontitis, taste alteration, lichen planus, and lichenoid reactions.GERDPossible tooth erosion.HypertensionMedications may cause orthostatic hypotension, xerostomia, taste alteration, or gingival hyperplasia.Sleep ApneaMay cause xerostomia (if patient forgets to wear C-pap) due to sleeping with mouth open.ArthritisCould affect the efficiency of brushing and flossing. If not properly managed, may lead to caries, gingivitis, or periodontitis.AllergiesFlagyl and Difficult to IntubateNo dental impacts.Occasional Seasonal AllergiesSome medications may cause xerostomia.MedicationDosagePrescribe for:Dental Side EffectsAdult Low Dose Aspirin81 mgTo reduce risk of heart attack and strokeMay prolong bleeding.Amoxicillin500 mg of 4 tabletsAntibiotic prophylaxisProlonged use may lead to oral candidiasis.Atorvastatin20 mgPrevention of cardiovascular diseaseAssess unusual presentations of muscle weakness or myopathy.Celebrex (Celecoxib)200 mgArthritisStomatitis, taste alteration, and xerostomia.Gabapentin100 mgNerve disorderMay cause xerostomia, dry throat, and dental abnormalities. Risk D interaction with Zolpidem.Lansoprazole30 mgGERDNo Significant Effects.Losartan-hydrochlorothiazide100-25 mgHypertensionMay cause orthostatic hypotension.Metformin1,000 mgType II Diabetes MellitusMay cause taste disorder. Schedule morning appointment to minimize chance of stress-induced hypoglycemia.Onglyza (Saxagliptin)5 mgType II Diabetes MellitusSchedule morning appointment to minimize chance of stress-induced hypoglycemia.Zolpidem10 mgInsomniaMay cause xerostomia. Risk D interaction with Gabapentin.Iron Supplement65 mgAnemiaNo Significant Effects.Dental HistoryMr. Norris became a VCU School of Dentistry patient in 2010. Upon becoming a patient at the school, he only had four previously existing restorations, these included: MO amalgam on tooth #2, L and B amalgam on tooth #3, and O amalgam on tooth #5. The rest of Mr. Norris’ restorations listed in his hard tissue chart were completed here, at VCU School of Dentistry. The dentist did not detect any new carious lesions in Mr. Norris’ dentition. Mr. Norris goes to his recall dentist appointments for regular cleanings every six months, has xerostomia induced by medications, is exposed to fluoride at least once a day, and had minimal plaque and calculus buildup. This information has lead me to the conclusion that Mr. Norris has a moderate caries risk. The gingival description of Mr. Norris is as follows: generalized pink in color, firm consistency, knife edge papilla in anterior regions and blunted papilla in posterior regions. He brushes twice a day and flosses once a day. Mr. Norris also uses ACT fluoride mouthrinse every morning, and Listerine antimicrobial mouthrinse every evening. He uses super floss under his bridge, a Waterpik in the evening, and fluoride, whitening, and tartar control toothpaste. As a future dental hygienist, I believe that Mr. Norris practices impeccable dental hygiene. Hard Tissue Charting:Tooth #12345678910111213141516Existing TreatmentMMOLBMODMODOOSMODMODSOPFMPFMMMMTooth #32313029282726252423222120191817Existing TreatmentMMMDOBLOOSMBSSOSPFMABUTPFMPPFMLABUTMS: Sound M: MissingABUT: abutmentP: PonticPurple: AmalgamGreen: CompositePFM: Porcelain Fused to Metal crownDental HistoryPatient ResponseIndicate and past major dental treatmentOral surgery (extractions and biopsy)YEndodontics (root canal)YCrownsYGeneral dental careYDental HistoryAre you satisfied with the appearance of your teeth?YHave any of the following prevented you from receiving dental care?NHave you ever had problems/complications with past dental care?NDid you drink fluoridated water as a child (age 1-12)?NWhere did you grow up?Fredrick County, VAWas the source of your water a well, city water, or bottled?Y, Well waterHygiene PracticesToothbrushSoftToothbrushing # of times per day?2x dayFlossing # of times per day?1x dayToothpasteFluoride, whitening, and tartar controlBleaching?NMouthrinse # of times per day?ACT in the morning, Listerine at nightOther oral self-care?Super flossAre your teeth sensitive?NDo you have swelling(s) in your mouth?NAre your teeth shifting?NAre your teeth loose?NDoes your saliva feel thick or ropey?NDoes your mouth often feel dry?YDo you have difficulty chewing food?NDo you have difficulty swallowing?NDo you have difficulty speaking?NDo you have excess saliva?NPeriodontal StatusThe periodontal status of Mr. Norris can be defined as an AAP class I: Generalized gingivitis on a reduced periodontium. Generalized 2-4mm pocket depths with localized bleeding on probing associated with tooth #22 and #25. Generalized 1-2mm recession with localized 3-4mm recession associated with tooth #2, #3, and #29. Generalized 3-6mm attachment loss, and no calculus detected. Light plaque buildup in posterior regions with some food impaction due to localized blunted papilla.RadiographsI first saw Mr. Norris on February 2, 2016. During this appointment I planned four vertical bitewings on him due to his increased number of restorations. The dentist approved these radiographs due to Mr. Norris having multiple restorations, as well as he had not had radiographs taken in over two years. The radiographs showed generalized horizontal bone loss on the mandible, and vertical bone loss on the distal of #2.Pre-treatment intraoral photographsSee PowerPoint.Treatment PlanningAppt.#Tooth/QuadTreatmentJustification for txPrognosis Statement1All Present DentitionD0274V – 4 Vertical Bitewing FilmsCaries risk due to increased number of restoration.Detect radiographic calculus and decay.1All Present DentitionD1325 – Vital CompetencyAssess the blood pressure, pulse, and respiration of the patient.Normal blood pressure, pulse, and respiration levels.1All Present DentitionD4955 – Periodontal ChartingAssess the pocket depths, recession, and attachment loss of the patient.Generalized 1-4mm pocket depths, and generalized 1-2mm recession.2All Present DentitionD0120 – Periodic Oral EvaluationDentist to determine oral condition and periodontal health.No decay and a fracture line present on the distal of #2.2All Present DentitionD1110 – Adult ProphyDue to plaque buildup and food impaction.Remove plaque and food impaction to maintain healthy pocket depths, reduce bleeding on probing, and reduce clinical attachment loss.2All Present DentitionD1206 – Topical Fluoride VarnishModerate caries risk.Remineralization of enamel and prevent the formation of future carious lesions. 2All Present DentitionD1330 – Oral Hygiene InstructionsExplain the effects of smokeless tobacco and diabetes on the oral cavity.Patient will take the information I provided into consideration for quitting the use of smokeless tobacco.Mr. Norris agreed to all treatment plans. Chemotherapeutic agents were not discussed due to the patient having outstanding oral hygiene.Dental Hygiene DiagnosisRealistic GoalsGeneralized gingivitis on a reduced periodontium due to lack of proper past oral hygiene.Six month recalls and continuing the practice of good oral hygiene with help in the reduction of pocket depths and clinical attachment loss.Slight amount of food impaction in posterior regions due to blunted papilla. Reminded patient to use end tuft brushes after meals to successfully remove any food that gets impacted in the posterior regions.Heavy generalized dentin exposure due to excessive abrasion.Encouraged patient to continue wearing night guard to bed every night to reduce the risk of further damage to his tooth structure.Localized blunted papilla in posterior regions due to improper plaque/ biofilm removal.Suggested holding Waterpik in the posterior areas for a slightly longer period of time to help with the removal of more plaque/ biofilm.Oral Hygiene InstructionsIt is very important for Mr. Norris to continue to practice proper oral hygiene care. He has spent a lot of money on products to help do this job; such as the Waterpik, two forms of mouthrinse (one is Listerine and the other is ACT), and two forms of floss (one is regular floss and the other is super floss). Unfortunately, Mr. Norris also uses four ounces of smokeless tobacco daily. Once I was presented with this information, I decided to educate him on the effects that smokeless tobacco has on the oral cavity, as well as the interaction that smokeless tobacco has with type two diabetes mellitus. I provided Mr. Norris with two dental hygiene journal articles containing information about how smokeless tobacco negatively affects diabetes, as well as different cessations available if he were willing to take the first step in quitting. I took the liberty of highlighting significant information in the articles so that Mr. Norris could easily find the essential information that directly relates to his condition. I stressed the importance of quitting the use of smokeless tobacco and showed him pictures of the effects smokeless tobacco has on the oral mucosa. Mr. Norris was not encouraging about quitting but I did not let that sway my enthusiasm to wanting to educate and help him.Recall/reevaluation IntervalMr. Norris is on a six month recall, and since he has impeccable oral hygiene, and comes back for his appointments regularly, I do not see a reason to change the time between his recall intervals. If Mr. Norris keeps up the good work, he will not need anything less than a six month recall.Evaluation of the ProjectAs a VCU dental hygiene student, this assignment has given me an even better understanding of each step in the process of care for a patient. I think that having this assignment within my first year of the program was very beneficial because it prepared me for the case doc assignments I will have to complete next year. This assignment has also opened my eyes to: the importance of oral hygiene instructions, the understanding that a patient’s habits can interact with their medical conditions, and the realization of how those interactions can be crucial to the patient’s health. These lessons will aid in my journey to become a better dental hygienist. I learned the importance of diligent documentation, and I will be sure to implement this for Mr. Norris’ next appointment, as well as other patient appointments in the future.ConclusionI chose Mr. Norris as my patient for the process of care assignment because I felt he had the largest benefit to gain from evidence based oral health education based on his current medical conditions and habits. Mr. Norris was the first patient I have seen who uses smokeless tobacco daily. It was interesting to be able to see the effects that the smokeless tobacco has on his oral cavity. I also fully enjoyed researching the interaction that smokeless tobacco and diabetes have with each other. I was able to learn something new, and teach the knowledge I had just learned to a patient. Mr. Norris did encouraging about the idea of quitting his use of smokeless tobacco, but I did not let that dull my enthusiasm for the lesson I had planned for him. It made me feel confident when the faculty evaluating me for the day informed me that I had a great spirit throughout the lesson. The faculty also let me know they were proud of me for not letting Mr. Norris discourage me in my endeavors to encourage him to quit the use of smokeless tobacco. I feel as though I made an impact on Mr. Norris that day. I love the dental hygiene profession because of the opportunities we have to educate our patients, as well as ourselves. In this dental hygiene program, every new patient I see is a new lesson I learn. I admire the time, effort, and research that goes into being a great clinician, which is what I will continuously strive to be every day. References ................
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