Dental And Oral Health - Case Study 47
Patient History
PATIENT #1
Patient Profile:
80-year old Caucasian male. Retired switchman from Burlington Railroad.
Chief Complaint:
“My breath smells.”
Medical History:
Patient sees an internist every six months for physical exam and lab tests. He has a 40 pack-year history of smoking and used fine cut snuff for 20 years. He takes the following prescribed drugs: hydrochlorothiazide (25 mg., b.i.d.), metoprolol (100 mg., q.d.), tamsulosin (0.4 mg., b.i.d.) and pravastatin (80 mg., q.d.).
Dental History:
Had all teeth removed at age 55 yrs. due to severe periodontal disease and wore complete dentures for 10 years. At age 65 yrs. the lower denture was converted to a dental implant supported denture. The implants were placed in the #22 and #27 area (mandibular canines) and connected with a hatter bar that, in turn, allows the denture to clip onto the bar. The denture is semi-fixed and can be removed for oral hygiene purposes.
Health Behaviors:
No longer smokes or uses snuff. He lives in a retirement home and seems sociable and happy.
Extraoral Examination:
No evidence of submandibular or cervical lymphadenopathy. Frontal view of the face is bilaterally symmetrical. Eye movement is normal. Appears to have several facial skin lesions that are possibly actinic keratosis.
Intraoral Examination:
All soft tissue structures are within normal limits. Implants and bar are covered with heavy biofilm and materia alba. Alveolar mucosa associated with implant posts and under bar is inflamed and edematous.
Supplemental Information:
During the oral exam the amount of saliva appeared less than normal. Radiographs to determine level of bone loss, surprisingly revealed very little bone loss. Probing depths were circumferentially 4 mm.
Bleeding Index:
100% for both implants.
Plaque Score:
100% for both implants.
PATIENT #2
Patient Profile:
62-year old Caucasian female. Recently retired as the director of human resources for a manufacturing company that had 525 employees. Admits that the job was at times very stressful – particularly during times of contract negotiations with the labor union.
Chief Complaint:
“My gums have started bleeding and I have a hard time cleaning between my implants.”
Medical History:
Former pack a day smoker but gave up cigarettes about 25 years ago. Has yearly physical; is physically active and takes no prescribed drugs. She does take an 81 mg aspirin every day. Also, takes daily vitamin C (500 mg) and vitamin D3 (1,000 IU). History of basal cell carcinoma involving the right nares that was removed two years ago.
Dental History:
Has received regular dental care over the years (about every 6 months). Lost mandibular left posterior teeth (#18-#21) due to periodontal disease. Implants were placed about a year after the teeth were removed. Patient states that “over the last several years the gum tissue around the implants has become more and more irritated.” Patient recently became disenfranchised with her dentist because he was not addressing her concerns – he just told her to “brush more and better.”
She seems motivated and willing to accept a new approach to oral care. Patient stated that “she wants to save her teeth and implants and wants someone to help her in that regard.”
Extraoral Examination:
No evidence of submandibular or cervical lymphadenopathy. Frontal view of the face is bilaterally symmetrical. Eye movement is normal. No apparent skin lesions.
Intraoral Examination:
All soft tissue structures are within normal limits. Patient is missing all 2nd and 3rd molars and has bilateral 1st molar occlusion. There are no probing depths greater than 4 mm but the gingivae exhibit a generalized edematous texture and bleed on probing. There is generalized interproximal biofilm.
Supplemental Information:
Salivary flow appears normal. Radiographs revealed no carious lesions and periodontal bone support was at normal levels except around the implants. Implants had one-two threads exposed, a result of 1-2 mm of bone loss.
Bleeding Index:
55% (79/144 sites)
Plaque Score:
58% (56/96 sites)
Test
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A comparison of patients #1 and #2 shows both to have obvious and heavy biofilm accumulations. Which of the two patients has the more difficult job of executing adequate oral hygiene control?
Assuming the biofilm accumulation, in both patients, represents a 7-day old undisturbed supragingival accumulation, which one of the following microbes is unlikely to be isolated from the biofilm?
For both patients, the recommended toothbrush of choice would be:
For Patient #1, after using the toothbrush, which one of the following additional oral hygiene aids should the patient use to clean the implant post under the bar attachment?
The problem that Patient #2 has with interproximal oral hygiene between the implants is related to:
Which one of the following features is not a characteristic of peri-implant mucositis?
In Patient #2, all the following issues appear to be related to lingual biofilm accumulation EXCEPT which one of the following:
Patient #1 is taking the following medications: hydrochlorothiazide, metoprolol, tamsulosin and pravastatin. Which drug is NOT associated with possible xerostomia?
Patient #2 takes 1,000 units of vitamin D3 every day. For what reason do you suspect she is taking this self-prescribed supplement?
In Patient #1 what is the importance of “facial skin lesions that are possibly actinic keratosis”?