Clinical Cases in Dental Hygiene

Cheryl M. Westphal Theile, Mea A. Weinberg, Stuart L. Segelnick, Cheryl M. Westphal Theile, Mea A. Weinberg, Stuart L. Segelnick

• Publisher: Wiley-Blackwell
• Year: 2018
• ISBN:
  9781119145042
• Edition: 1
• Topic: Medizin
• Subtopic: Zahnmedizin

Clinical Cases in Dental Hygiene is an indispensable resource to understanding both the theory and practice of dental hygiene, illustrated by real-life cases in a clinically relevant format.

• Offers a unique case-based format that supports problem-based learning
• Promotes independent learning through self-assessment and critical thinking
• Includes a wealth of relevant cases for understanding dental procedures and management of patients
• Covers all essential topics within the scope of dental hygiene

1
Patient Examination

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1. Case 1: Examination and Documentation
   Stefania Moglia Willis
2. Case 2: Head and Neck Examination
   Stefania Moglia Willis
3. Case 3: Radiographic Exam
   Aaron E. Yancoskie
4. Case 4: Occlusal Examination
   Stefania Moglia Willis
5. Case 5: Gingival Examination
   Aaron E. Yancoskie
6. Case 6: Periodontal Exam
   Aaron E. Yancoskie

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Case 1
Examination and Documentation

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CASE STORY

A 55‐year‐old Caucasian female presented with a chief complaint of: “My mouth is always dry, and I have difficulty swallowing.” She said, “I was recently diagnosed with scleroderma, and my doctor told me I should see a dentist.” The vital signs were blood pressure: 159/92 mmHg; respiration: 16 breaths/min; pulse: 72 beats/min, temperature: 98°F; and nonsmoker.

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PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Discuss the role of the patient's medical, social, and dental histories (comprehensive health history) in the patient examination
• List and describe the five parts of a comprehensive clinical examination
• Differentiate between types of findings in a clinical examination including signs and symptoms, and significant and insignificant findings
• Discuss the definition, purpose, and methods of documentation
• Identify the components of care documented in the patient's permanent record

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Medical History

The patient was diagnosed with scleroderma and gastroesophageal reflux disease (GERD). She is taking antacids for GERD and immunosuppressant medications and a calcium channel blocker for scleroderma.

Dental History

The patient reported that her last dental visit was one year ago. She has a history of childhood caries but has been caries free since college. Also, she has symptoms of dry mouth and difficulty opening her mouth and swallowing.

Social History

The patient is a self‐described over‐achieving professional concerned about her health and the appearance of her teeth. She lives with her husband in a suburb of Manhattan, has three adult children, and enjoys reading.

Review of Systems (Physical Examination)

Gastrointestinal Examination

The patient has difficulty swallowing (dysphagia) and GERD.

Cardiovascular Examination

The patient has a history of Raynaud's phenomenon and hypertension (BP: 159/92).

Cutaneous Examination

The patient stated that her fingers are extremely sensitive to the cold. The skin of her hands appeared shiny and stretched with varying degrees of pigmentation. The patient struggled to hold the pen while signing consent forms.

Head and Neck Examination

Extraoral

The patient exhibited microstomia restricting her mouth opening (<20 mm), and the lips were thin and stretched.

Intraoral

Examination of the major and minor salivary gland duct openings showed loss of quality and quantity of saliva.

Periodontal charting showed areas of bleeding on probing without CAL (clinical attachment loss).

Generalized fibrotic changes in mucosal tissues were noted with mucogingival paresthesia. Oral mucosal tissues appeared pale and tight with hardening of the soft palate. The patient's GI score was 2. Several restorations and crowns were noted. No caries present. Generalized moderate biofilm accumulation was apparent. The debris index (DI‐S) and the calculus index (CI‐S) were both scored as 1 (debris and calculus covered less than 1/3 of the examined tooth surfaces).

Class I: right and left sides; teeth #7 and #10 are in torso version and overlap slightly with #8 and #9.

Radiographic Examination

No significant findings.

Dental Hygiene Diagnosis

Problems	Related to Risks and Etiology
Xerostomia	Loss of quality and quantity of saliva and scleroderma Goal: The patient will experience relief from xerostomia due to scleroderma immediately upon initiation of local and systemic measures to stimulate saliva flow
Increased periodontal disease risk	Insufficient daily biofilm management, limited hand strength and mouth opening as evidenced by gingival inflammation an...