Case study

Patient b is a 45 year old white female, she attended the surgery on her own. Her medical history was that she was a regular smoker, smoking 20 cigarettes per day, other than that her medical history was clear, I verbally checked this with the patient before sitting her in the chair. The patients social history was that she lived at home with her husband and three children and she was a full time housewife. The patients dental attendance wasn’t good, this was her first check up appointment in about 10 years, having been to several emergency dental appointments in the meantime.
The patient has all permanent dentition excluding the upper left first molar, upper right second molar and both lower third molars which had all previously been extracted. The patients DMFT score is 9, the patient has 4 missing teeth and 5 amalgam restorations there are no obvious signs of decay at this present time.
Her history of erosion is low due to the patient having a low intake of acidic drinks and the patients suffers sensitivity around her lower anterior teeth.
Her periodontal health is poor with scores of 3 in each quadrant, her oral hygiene status is also poor, the patient has periodontal disease with gross calculus deposits around lower anterior teeth.
The GDP has refered the patient on to me the application of fluoride varnish on all molar teeth to arrest/prevent any caries. The GDP would also like me to give the patient oral hygiene instructions to help improve her periodontal health.

Overview of care Episode

I began by explaining to the patient what the purpose of today’s visit was, and that I was going to apply fluoride varnish to all her molar teeth in each four quadrants, I then asked the patient had she ever heard of fluoride varnish, she replied no I then explained that the benefits of using fluoride varnish include helping to strengthen the tooth’s enamel and help prevent against tooth decay I explained to the patient that the process is quick, easy and pain free. I also explained that in this area of the country we do not get the advantage of having fluoridated water, therefore it would be very beneficial to have this treatment carried out, I then asked the patient would she like me to commence with the application of fluoride varnish, she replied yes, so consent was obtained. I then checked through the patients medical history both on the medical questionnaire and verbally, there was no change in her medical status I also double checked with the patient that he had not been hospitalized for any allergies/asthma in her lifetime, her reply was no she has never had any allergies which are known to him. I then asked the patient if she had breakfast, she replied yes, I explained it was beneficial to eat before have the treatment as we advise not to eat for 30 minutes after the application and not to eat anything hard or chewy for a further 4 hours. I also explained to the patient the teeth may be slightly discouloured due to the colour of the varnish, I advised this would only be temporary and they should resume back to their original shade after the teeth have been brushed, the patient was happy for me to carry out the treatment. I then asked the patient to sit back in the dental chair, I then gave her a bib and goggles to wear, I then washed my hands in the clean sink and placed on my latex free gloves, mask and visor. I explained to the patient I was going to dry the teeth with cotton wool rolls and placed them at the side of the teeth to help with moisture control, I explained it was essential for the tooth’s surface to be completely dry when applying the varnish, otherwise the varnish will not stick. I identified my clean and dirty zones for infection control. I then asked the patient to open as wide as possible and to stay wide open, I then measured out 0.75ml of fluoride varnish on a mixing pad as the patient had all permanent dentition, I then applied two cotton wool rolls to the upper left and right bucall sulcus’ to help block the paratid gland and improve moisture control, I then placed two rolls to the lower right and lower left buccal sulcus’. I then used a spare cotton roll to dry the lower right and left molars and applied the fluoride varnish to the occlusal, buccal and interproximal areas of the teeth, I then repeated this process on the upper right and left molars, drying the tooth’s surface and applying the varnish. Once I had applied the fluoride varnish I removed all 4 cotton rolls from the mouth, I then sat the patient up and advised her to rinse if he wanted too. I then began to explain the fluoride varnish instructions: * I advised the patient not to eat for 30 minutes, as the varnish needs time to set * I advised not to eat anything hard or chewy for a further 4 hours * I advised not to take any fluoride supplemets ie, fluoride tablets/drops for at least 7 days * I advised the patient to resume brushing the day after * I advised that if an allergic was to occur, the patients needs to brush the varnish off and rinse immediately – I reassured this was very rare.

I then asked the patient if she had any questions to ask regarding what I had just done, she replied she fully understood my instructions and that it was the most comfortable time she had been in a dental chair.

At the end of the procedure I disposed of all my one use items in the clinical waste and placed all my used dirty instruments in the dirty sink ready to be cleaned and sterilised, I then removed my dirty gloves and placed them in the clinical waste. And lastly I wrote up the patient’s notes for today onto the computer.

Narrative

I firstly began by explaining to the patient what the purpose of today’s visit was, and that I was going to show her some more effective tooth brushing tecniques and instructions. I explained to the patient that she has severe gum disease, a condition we call Periodontal disease, I explained that this happens when the bone and fibres surrounding the teeth are destroyed (The scientific basis of oral health education) causing the teeth to become loose and ultimately lost. I explained that as this disease cannot be reversed once it has reached this stage the process can be slowed down by effective personal care and professional care and advice. The patient went on to say that she hasn’t looked after her teeth and she regrets that now, I reassured her that we would do everything we can to help maintain her oral hygiene providing she does her bit at home and brushes regular and tries to cut down on the cigarettes I advised the patient that smoking is one of the main causes of gum disease and that I strongly advise her to quit or at least cut down as it not only effects her gums but increases the risk of oral cancer and risks also to her general well-being, the patient replied she would try her very best to quit, I congratulated her for her effort. I then told the patient that dental plaque is also one of the causes of periodontal disease therefore it is essential we brush our teeth twice daily, I then asked how many times a day do you brush? She replied just the once in the morning , I advised the patient that it is better to brush twice daily, once in the evening as our salivary flow is reduced at night so our teeth cannot be ‘washed’ and there is no fluoride on our teeth to protect them, and on one other occasion and to avoid rinsing after brushing, and to just spit out the excess toothpaste, the patient said she never rinses after brushing, I congratulated her on this.
I then asked what type of toothbrush she used, she said she used a colgate 360 toothbrush, I advised her that this was a good brush as it had soft round ended filaments and a small head and to carry on using this if not try to get a electric brush with an oscillating/rotating action, as these are proven to be very beneficial. I advised the patient that she needs to systematically clean all surfaces spending time in each part of the mouth ensuring that all surfaces are thouroghly cleaned.
I then asked the patient which brand of toothpaste she used, she replied ‘’colgate Oxygen’’ I advised the patient that this had a sufficient amount of fluoride, and we recommend toothpaste with at least 1350PPMF-1500PPMF, as we do not have the advantage of fluoridated water in this area. I then explained that evidence suggests that toothpastes containing triclosan in combination with a copolymer or with zinc citrate are effective in improving plaque control and gingival health, therefore it would be beneficial for her to buy a toothpaste containing this as she had gum disease, I then gave her a printed out list of all the toothpastes containing triclosan and told her to take it along with her to the supermarket so she knows which ones are the best to use. The patient thanked me for this list and said it would be a huge help. The patient then asked me which type of mouthwash would be beneficial, I explained that chlorhexidine mouthrinses are effective in improving plaque control and gingival health also, when they are used at a separate time to toothbrushing (DBOHTK) and these mouthrinses are available in chemist/supermarket under the branded name of corsodyl daily.
I then asked the patient if she understood everything that I had said and if there was any confusion to just say so, she replied that I had given her some very good advice and she now knows the seriosness of her neglect to her teeth and that she is determined to change her ways and to start looking after them, I told the patient that is exactly what we want to hear and as a dental team we are here to help and improve.

Reflection i feel I had good background information from the gdp beforehand as the dentist clearly explained that the patient had periodontal disease and was a heavy smoker, I briefly gave the patient advice on smoking but I was focusing my advice on toothbrushing, I feel maybe I could of allowed more time and to talk more about the risks of smoking. As I was limited for time I could not carry out the ‘’show tell do’ tecnique as I had originally planned, I feel the patient would of benefited from me showing her the correct way to brush, and this is something I will definitely make time for next time. Also, the advice could have been put across better with the use of visual aids for example pictures of healthy gums and pictures of patients with periodontal disease to help the patient distinguish the difference between both, I maybe could of invested in a mouth model to show the patient how toothbrushing is done correctly and effectively – this is now something I am definitely going to invest in to help me with my future advice.
I feel the information I gave was SMART and I believe I met my initial objectives of putting across information well and help the patient motivate herself to improve her oral hygiene, as at the end of the session she seemed very keen and eager to change her ways as I managed to point out the risks of smoking and the risk of periodontal disease resulting in tooth loss. The environment of the surgery during the session was very calming and relaxing as I wanted my patients to feel at ease and comfortable whilst in the dental chair, as I know a lot of our patients are initially anxious and scared, I put some relaxing music on the radio to help make the atmosphere more calm. I do feel the session went well, but could have been more structured in what I was going to advise the patient on next – next time I will write exactly what I am going to cover in a notepad and stick to that to ensure my advise comes across at an understandable level and to try and not use jargon words which the patient may not fully understand.