1

Caries Case Study

Rio Digby

Pima Medical Institute, Dental Hygiene

Kathleen Pierce, RDH Instructor

January 7th, 2022

Caries Case Study 2

Table of Contents

Title Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Section I: Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Section II: Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

TREATMENT PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Section III: Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Section IV: Treatment Provided and Treatment Revisions . . . . . . . . . . . . . . . . . . . . . . 15

PERIODONTAL RE-EVALUATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Section V: Post-treatment 4-6 reevaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Section VI: Student Summative Evaluation of Therapeutic & Preventive Outcomes . 17

Caries Case Study 3

ASSESSMENT

Section I: Patient Information

This caries case study was conducted on a sixty-four year old caucasian female. She is a

retired paralegal who used to live in the suburbs of Seattle but recently moved to Anacortes. She

came to the clinic for her first appointment on March 8th, 2021 with her initial chief complaint

being that she was overdue for a cleaning, her last cleaning was February of 2020. She is a

relatively healthy individual who has high blood pressure that is being controlled by medication.

Due to her high blood pressure the patient is classified as ASA II. She is also taking medication

for hormone replacement and back pain. She smoked cigarettes most of her life, approximately

10 cigarettes a day for over 30 years. The patient quit when she turned fifty years old and hasn’t

smoked one since she quit in the last 14 years. She understands the oral health concerns of

smoking cigarettes and doesn’t plan on picking up the habit again. The patient also partakes in

recreational marijuana occasionally and drinks approximately 10 alcoholic drinks a week.

She normally goes to the dentist regularly for her six month cleanings and has occasional

restorative work done but most of it was completed in her younger years. She wears a night

guard every night because she grinds and clenches her teeth when she sleeps. She sometimes

wears it during the day when doing extraneous work as well. Due to her recent retirement,

moving to another city and having no dental insurance, the patient hasn’t had regular care. She

also decided to wait to get her cleaning done at Pima when I could complete her cleaning as a

favor to me. Once I graduate from Pima, she plans on establishing regular care at the dental

office that her husband goes to in Anacortes.

Caries Case Study 4

Figure 1: Initial Health History Chart Note

Figure 2: Patient’s Medical History Form

Caries Case Study 5

At the time of the patient’s initial exam she was not worried about having decay in her

mouth. Prior to any treatment completed on the patient at Pima, she came in with #1, #16, #17,

#31, #32 extracted. Amalgam restorations on #2 O, #3 MO, #15 MO, and #29 O. A porcelain

onlay on #4 MODL. Composite on #8 MILF, #13 DO, #18 O, and #20 DO. Root canal and

porcelain crown on #14. Porcelain fused to metal crown on #19 and a porcelain crown on #30.

We moved forward with treatment and cleaned the patient’s mouth and when she came in again

on for her 6 month recall on October 26th, 2021, she was experiencing pain on the LL side of her

mouth and the filling on #8 MILF fell out. At the time of this appointment the patient was

concerned about having decay in her mouth due to the pain and was fearful of what the

restorative treatment would be.

Figure 3: Patient’s Dental Chart Showing Current Restorations and Proposed Restorations
Caries Case Study 6

She is a highly motivated patient and has a moderate dental IQ. She values good oral

health and does not like being in pain so she is proactive about her homecare to not have any

restorative work done. She reported that the majority of the fillings she had done when she was

younger were quite painful and ever since has been an avid flosser and brushes her teeth

regularly.

Figure 4: Three Day Patient Diet

The patient completed a food diary documenting all the things she ate within the span of

three days. She eats a well balanced diet of carbohydrates, proteins, veggies and gets her fruit in

with her smoothies in the morning. It does seem like she gets enough water throughout the day

but she didn’t specify the exact time of day she is drinking the water. Also, she drinks tap water

which is fluoridated in the area she lives in which will help with remineralization. Her alcohol
Caries Case Study 7

intake each evening contains a lot of acidity in it because her go to drink is a greyhound which

contains grapefruit juice and vodka. After reviewing her diet with the patient I educated the

patient on the importance of drinking water before bed to clear away the acidity from the

alcoholic beverages and to not brush her teeth until at least 30 minutes after she finished her last

drink.I praised the patient for mainly just eating at meal times and explained to her that snacking

throughout the day leads to higher chances of acidic attacks and an increased risk for dental

caries.

Below are intraoral images taken from her recall appointment on October 26th, 2021

when the multiple restorations were diagnosed.

Figure 5: #18 D Fracture. Buildup and Crown is the Recommended Treatment

Figure 6: #13 DO Recurrent Decay. Composite on The Distal and Occlusal is the Recommended Treatment
Caries Case Study 8

Figure 7: #18 filling fell out. Composite on the Mesial, Incisial, Lingual and Facial is the Recommended Treatment

Section II: Clinical Assessment

The patient’s homecare routine prior to visiting the clinic was brushing two times a day

with an electric toothbrush and flosses almost every day. She also wears a nightguard daily

because she grinds her teeth during her sleep. At her recall appointment her homecare was the

same as before.

During her initial extraoral exam in March of 2021, it was noted that she was in general

good health. Several macules were found across her face and neck that were brown in color, well

demarcated, with a mix of regular and irregular borders. She had a patch that was 10mmx10mm

patch on the right anterior forehead, brown in color, well demarcated and another patch that was

12mmx16mm on the left check with an irregular border and is brown. Her submandibular lymph

nodes were felt bilaterally and were soft and movable. She has slight crepitus in her thyroid

gland and occasionally popping on the left side of her jaw with occasional pain. When patient

came back for her October 26th appointment, the two patches noted above were removed with
Caries Case Study 9

nitro and the one located on her forehead was totally removed while the one of the left check was

not fully removed.

The intraoral exam, gingival description and occlusion diagnosis were completed on

April 5th, 2021. Everything found during the exam was within normal limits. The patient’s

palatine tonsils are present and she has tori on the mandibular lingual left side. The gingival

description at the time read as generalized pink, knife edge, firm, pointed, stippled marginal and

papillary with localized redness and rolled margins around the crowns. At the time of her recall

appointment her gingival description did not change much and read as generalized pink, knife

edge, pointed, firm and stippled marginal and papillary with localized enlarged, rolled margins

around the crown and moderate redness around the posterior teeth on the lingual of the mandible.

She was classified with a slight overbite, 5mm overjet and open contacts between 6&7,

7&8, 9&10, 10&11, 21&22, 22&23, 26&27, and 27&28. As stated previously, the patient's

existing restorations were amalgam restorations on #2 O, #3 MO, #15 MO and #29 O. A

porcelain onlay on #4 MODL. Composite on #8 MILF, #13 DO, #18 O and #20 DO. She had her

wisdom teeth removed when she was young and had #30 extracted due to decay and never had it

replaced. At the time of her April 12th appointment, Dr. Magelsen diagnosed recurrent day on

the distal of #13 and recommended a composite to be placed on #13 DO. During her recall

appointment on October 26th, Dr. Nguyen diagnosed #8 MILF composite due to the filling

falling out, reconfirmed Dr. Magelsen’s diagnosis of #13 DO composite due to the recurrent

decay, #18 buildup and crown due to the distal fracture that extends below the gumline, and #29

MOD composite because the current #29 O amalgam is failing. A referral was given to the
Caries Case Study 10

patient for #18 buildup and crown to be completed at an office of her choosing because we do

not perform crown restorations at our clinic.

Figure 8: Patient’s X-Rays taken on March 8th 2021

Above are the patient’s radiographs taken on March 8th. The patient has slight to

moderate horizontal bone loss with localized vertical on the distals of the most posterior molar in

each quadrant. Everything else within her x-rays are within normal limits besides the decay

explained in the previous section.

Caries Case Study 11

Figure 9: Patient’s Perio Chart from April 12th 2021

A perio chart for the patient was completed on April 12th during her new patient exams.

There were generalized 2-3mm pocket depths with localized 4mm pockets surrounding the

posterior teeth. Minimal bleeding on probing on lingual of maxillary and mandibular with class I

furcations on the buccal of #2, #3, #14, #19, and #30. There is generalized recession and MAG

present as well. No mobility was present in the patient's mouth. After completing all the previous

assessments, the patient was classified as Light II and Stage 1 Grade A. When the patient came

back in for her recall appointment her periodontal status was stable and there was no change in

pocket depths, bleeding on probing, MAG or furcations. The only changes were increased

recession on the posterior mandibular teeth. Her overall periodontal health was classified as

stable and she was classified again as Light II and Stage 1 Grade A.
Caries Case Study 12

(A)

(B)

Figure 10: (A) Initial Dental Hygiene Care Plan Completed At Patient's Initial New Patient Appointment. (B)
Caries Case Study 13

Above are the Dental Care Hygiene Plans (DHCP) for the patient. The first is the initial

DHCP from her initial new patient exams and the second from her recall appointment. The

DHCPs go over the patient’s overall health and dental health and then give guided goals and

treatment recommended to suit the patient's needs. On the back of the DHCPs is a plaque index

map to calculate the patient’s plaque index. When the first DHCP was completed on April 12th,

the patient’s plaque index was 14.81%. At the patient’s recall appointment on October 26th, her

plaque index score was 16.27%. During both appointments majority of the plaque was on the

lingual of the lower anteriors and on the mesial buccal surfaces of the maxillary molars. At the

time of her recall there was a slight increase in plaque located on the lower anteriors.

During the initial exams taken place on April 12th, risk assessments were also completed

for the patient. The patient has high risk for periodontal disease, high risk for oral cancer, and

moderate risk for caries. Majority of what leads the patient to being at high risk for periodontal

disease and oral cancer are her age and history of smoking. She has a moderate risk for caries

due to the amount of current restorations in her mouth, visible decay on x-rays, visible plaque

and diet.

TREATMENT PLANNING

Section III: Treatment Planning

I chose this patient for my caries case study because she is at moderate risk for dental

caries and was diagnosed with multiple restorations. The treatment goals for this patient are to

complete #8 MILF composite, #13 DO composite, #29 MOD composite next semester during

our restorative clinic. Dr. Nguyen explained to the patient that none of her decay needed to be
Caries Case Study 14

completed right away, therefore the wait until February would not be an issue. The other goals is

for the patient to get #18 buildup and crown done at a different office. A general referral was

issued to the patient for her to go to another dental clinic to get the crown completed.

In the meantime while waiting for restorative clinic to start at Pima, I gave the patient

guidance on how to avoid developing more decay. I educated the patient on the importance of

keeping her oral cavity clean to prevent more decay. We talked about paying extra attention to

the backside of #13 when flossing because of the decay that is present there. She knows that area

is a food trap and after going over homecare, she understood the importance of keeping it clean.

We went over the basics on how to brush with a manual toothbrush using the modified bass

method and I showed the patient how to floss using the c wrap floss technique. New tools that

were introduced to the patient were the rubber tip. I taught the patient how to trace it along her

gum lines, mainly focusing on the margins of the posterior of the lingual of the mandible where

there is significantly more redness to her gingiva. Patient understood all the tools.

When it comes time to completing the restorations in February, the expected results and

complications with each individual restoration will be discussed. With the referral of #18 for the

crown and buildup, it was discussed that another dentist might recommend different treatment

when she follows through with her referral. Also, the possibility that the tooth might need to be

extracted if the fracture is worse than expected. It is a vertical fracture in the distal part of her

tooth that could also possibly need endodontic treatment. I explained to the patient that this area

is highly susceptible to decay because of the crack because it is an enticing area for the bacteria

to get stuck in, and that they “...may induce pulpal and periapical inflammation or disease”
Caries Case Study 15

(Rivera, 2015). The patient understood and signed an informed consent for all treatment

including the prophylaxis and restorations.

IMPLEMENTATION

Section IV: Treatment Provided and Treatment Revisions

The patient has come in for a total of six appointments that included her initial new

patient exams, x-rays, prophylaxis and recall appointment with an exam and prophylaxis.

Figure 11: Patient’s first appointment at Pima on March 8th, 2021

Figure 12: Patient’s second appointment at Pima on April 5th, 2021

Figure 13: Patient’s third appointment at Pima on April 12th, 2021

Caries Case Study 16

Figure 14: Patient’s forth appointment at Pima on June 9th, 2021

Figure 15: Patient’s fifth appointment at Pima on June 30th, 2021

Figure 16: Patient’s fifth appointment at Pima on October 26th, 2021

Figures 11-16 are chart notes from all of the patient’s appointments that goes over what

was completed in each appointment. The treatment for this patient was pretty straight forward

with no complications. She was easy to communicate with, understood the importance of oral

health and took direction well. There was nothing that went outside of normal limits in her

extraoral or intraoral exams. There was minimal light calculus present with minimal plaque so

the two prophylaxis were straightforward but provided a little bit of challenge because she was
Caries Case Study 17

the first patient I saw who had restorations in her mouth where I had to scale differently around. I

had never scaled around crowns prior to this patient so it provided a good learning opportunity.

The patient responded well to care. Now that she has a better understanding of oral health

and good oral hygiene she is more motivated. She noticed a difference in how much she was

removing when flossing with the c wrap floss technique. She didn’t experience any sensitivity of

pain after any of the six appointments. She came into the sixth appointment experience pain in

#18 and left with that pain but that is due to the distal fracture on the tooth.

PERIODONTAL RE-EVALUATION

Section V: Post-treatment 4-6 Re-evaluation

A 4-6 revaluation was not completed on this patient. I did not think it was necessary

because the patient is a prophylaxis patient with good periodontal health. She also commutes

from Anacortes and does not have insurance so the patient wanted to put off coming in until her

restorative appointment in February 2022. She is due for her next recall appointment in May

2022 and will be coming in for two restorative appointments to complete the recommended

treatment.

Section VI: Student Summative Evaluation of Therapeutic and Preventative Outcomes

There was a lot of learned material that came from treating this patient. I experienced

scaling a mouth with multiple restorations for the first time and got to see recurrent decay in

person for the first time. This patient was my first for many things as a practicing dental

hygienist. She was the first patient I completed all the way through and plan on seeing her one
Caries Case Study 18

more time before I graduate Pima for a hygiene appointment and an additional two times for

restorative treatment.

My patient also learned a lot as well. She didn’t realize that amalgam fillings wouldn't

last forever and she didn’t know that they leach with time. The recommended restoration for #29

MOD composite is to replace a worn down and cracked amalgam filling placed on the occlusal

of #29. I learned that depending on a person’s diet, they can have more or less leaching from

their amalgam fillings. People who consume drinks with high citric acidity rates, such as this

caries case study patient, experience more erosion of the amalgam (Anjun, p.2). At the patient’s

next recall appointment I’ll incorporate this information into her next oral hygiene instruction.

Since completing both of her cleanings, I have learned a great deal in how to hand scale

better and how to properly sharpen my instruments and I think that would greatly enhance the

treatment outcome for the patient in the future. It would make the appointments not as long and I

would have more confidence and ease when scaling around her restorations. All the

recommended restorations have not been completed yet due to where I am at in my education

and the patients has yet to contact another office to complete the crown and build up on #18.
Caries Case Study 19

References

Anjum, A. S., Ganapaththy, D., & Pandurangan, K. (2019). Mercury leaching from amalgam.

Drug Invention Today, 12(10).

https://www.researchgate.net/profile/Kiran-Pandurangan/publication/343961736_Mercur

y_leaching_from_amalgam/links/5f49f80692851c6cfdf7e8b9/Mercury-leaching-from-am

algam.pdf

Rivera, E. M., & Walton, R. E. (2015, November 25). Longitudinal tooth cracks and fractures: an

update and review. Endodontic Topics, 33(1), 14-42. https://doi.org/10.1111/etp.12085