Case #2- Diabetes
Health History

Ryan Alexander is a single 55 year old Caucasian male. He works as a high school teacher.He is currently under the care of his physician Dr. White who can be reached at 1(800)899-1901 and his major reason for coming to the Riverside Community College Dental Hygiene Clinic is to get his teeth cleaned. His previous dentist Dr. Johnson saw him for an DDS Exam on June 3, 2006. He also had an FMX completed on June 3, 2006. He had an adult prophy completed on June 10, 2006, but has not been to the dentist since. He states he has bleeding gums when he brushes, and he gets ulcers in his mouth when is stressed or not feeling well. He just had a ulcer last week, and he believes it is still healing. The patient does wear glasses for far-sightedness. He drinks alcoholic beverages once a week on the weekends, usually a few beers while watching football. The patient does experience frequent urination. The patient states that he has had type II diabetes for the last five years, which he controls with medication along with diet and exercise. His blood glucose levels today were 120 mg/dL. The patient stated he had eggs, potatoes, and wheat bread for breakfast and a chicken sandwich with soup for lunch.The patient had his childhood vaccinations in 1956, last had a Hepatitis B vaccination in 2005, and had a flu vaccination in 2010. The patient has a family history of hypertension and cancer. The patient is allergic to sulfa drugs. The patient visited the ER in 1981 for a broken leg. The patient currently takes a men’s multivitamin daily, tylenol for occasional headaches and muscle aches, and Metformin daily. Ryan took his Metformin and multivitamin this morning. He states that has taken the mulitivitamin and Metformin for the past five years daily.

BP: 120/75, P: 70, R: 18.

Ryan is an ASA II due to his type 2 diabetes.

Ryan’s Medications:
Metformin 850mg daily. Taken for the management of type II diabetes.
Dental implications: Taste disorder. Dental treatment preferred in the morning in order to minimize the chance of stress induced hypoglycemia.
Dental Contraindications: Hypersensitivity to metformin or any component of the formulation.
Men’s multivitamin 1 daily. Taken as a dietary supplement.
Dental Implications: No significant effects or complications reported.
Dental contraindications: none noted.
Tylenol 500mg taken as needed for headaches and muscle pain.
Dental implications: No significant effect or complications reported.
Dental contraindications: Hypersensitivity to acetaminophen or any component of the formulation.

Periodontal Exam:

E&I findings: Extra oral- none.
Intra oral- mandibular tori, bilateral linea alba, and 2X2 erythematous ulceration on patient’s right buccal mucosa.
TMD Findings: None
Salivary Flow: adequate
Maximum Opening: 50 mm

Gingival description- Free gingiva: Generalized erythematous, flat , shiny and smooth with localized bulbousness 6-8 and 22-28
Attached gingiva: Generalized pink, firmly bound to bone and stippled w/ localized edematousness 22-28.

Existing Restorations: O amalgam-2, 3, 18. 15 PFM with RCT, O composite- 30, 31

Facial Profile: mesognathic

Angle’s Classification- class II bilaterally

MBI -45% Probing depths were generalized 2-3 mm with localized 4's, 5's and 6's toward the posterior.

Recession- 2 mm L 22-27, 1 mm gingival recession on B 2 and 3 (toothbrush abrasion)

Mobility- + 6-11, 24-26.

Fremitus- +7-10

Mucogingival defects- none

Calculus code-medium calculus, all 4 quads.
ADA classification- II
AAP classification- Generalized slight chronic periodontitis due to plaque and calculus modified by diabetes.
Missing teeth and reason & impacted teeth: #1,#16,#17 and #32.
Existing Restorations: #2,3 Occlussal amalgam, #15 PFM and RCT, #,18 Occlusal amalgam, O composite #30 and 31.
Possible areas of decay: #2M, #4D,#14D, #18M, #30D
Atypical Findings: abrasions on B2 and 3 toothbrush abrasion.
Radiolucencies on apices (differential diagnosis): Radiolucency on the mesial root #15 Possible periapical abscess.
Intrinsic/Extrinsic Resorption (state etiology): None noted.
Root Resorption (state etiology):None noted.
Dilacerated Roots: #30
Other Atypical Anatomy Findings: None noted
Radiolucent/Radiopaque lesions/Foreign Objects (diff. diag.): None noted

Critical Thinking Form

- Chief complaint: Pt. is here to get his teeth cleaned.
- Medical history/systemic health: Diabetes & Oral risk factors: Xerostomia, candidiasis
- Dental health diagnosis: Perio: uncontrolled, Caries:uncontrolled, Oral Hygiene: uncontrolled
- Influencing cultural and social factors: Pt's occupation may prove to be a high stress enviroment at times, and calls for much time and preparation. He may not make oral hygiene one of his top priorities. Also, nutrition habits may be affected due to is busy schedule.
- Oral health belief model: Precontemplation stage of transtheoretical model; the pt. may not see a need to modify current OH habits in order to be effective. He needs knowledge in order to realize a change is beneficial. 
- Recommend OHI: Bass brushing technique, C-shape flossing technique, Reach flosser, alcohol free fluoride mouthrinse.
- Instrument selection:Piezo, Catoni, ant/post sickles, 7/8 and 5/6 gracey, McCall's and Younger-Good. Nevis 2 and 4.
- Anesthesia/ Rationale: Lidocaine 2% with epinephrine for pt. comfort and operator accessibility
- Reevaluations: 2x2 erythematous ulceration on the right buccal mucosa
- Anticipated treatment outcomes: Reduce pocket depths by 1mm and BOP by 10%
- Referrals: GP-caries #14D, #18M, #30D
- Recall interval/ Rationale: 3months, to re-evaulate patient’s pocket depths, decrease MBI and BOP, assess pt. compliance w/ OH

Treatment Plan:
Appt: 1: X-ray check, FMX (18 films), assessments, Nutrition counseling
Appt: 2: DDS exam, 2nd check in, OHI- Bass brushing technique, discuss correlation between diabetes and peiodontal disease including information about how diabetes can increase inflammation. Plaque Index.
Appt: 3: OHI- Introduce C-shape flossing. Scale URQ w/ anesthesia, fl varnish
Appt: 4: OHI- Introduce Reach flosser. Scale LRQ w/ anesthesia, fl varnish. Nutrition counseling.
Appt: 5: OHI- Reiterate role of plaque in inflammation and the importance of effective plaque control to prevent bone loss. Scale ULQ w/ anesthesia, fl varnish.
Appt.6: OHI- Recommend alcohol-free fluoride mouthrinse. LLQ w/ anesthesia, fl varnish.
Appt.7: Re-eval 4-6 weeks. Nutrition counseling
Appt. 8: Re-care 3 month