1 Foothill College Dental Hygiene Geriatric Patient Assessment Project Fall 2014 By Aimee Shelhamer Introduction CK is a 71 year old Caucasian male who lives in Palo Alto, CA where his community water supply is fluoridated. He currently lives with his wife and often visits his son and grandchildren down in Southern California. He still works as a bartender for an event/catering company that hosts parties and shows. In his free time he likes to hang out in the sun, spend time with his wife and grandchildren, and watch sports. He is originally from the Tahoe area and shared many stories with me about his younger days when he used to ski "8 days a week." Although he can't ski any more, he still stays active by boxing and going on short walks. He is not picky when it comes to food and likes just about anything. However, he does have a major sweet tooth and loves anything chocolate. His favorite chocolate bars are Dove and the Trader Joe's brand and he even puts powdered chocolate in his coffee every morning. He is on the habit stage of the learning ladder because he has good home care habits, tries new suggestions for home care, and understands why it is important to maintain a clean oral cavity. With his past eye problems he has trouble seeing. Due to this problem he is an auditory learner and he learns best from descriptive explanations rather than pictures or diagrams. His motivation to try new oral hygiene techniques and products is to keep all the teeth that he has left healthy because he has already lost too many. With CK being in his 7th decade of life, he presented with great dexterity during oral hygiene instruction and demonstration as well as great motivation to maintain his oral hygiene practices. Currently he brushes 3x/day, with a manual toothbrush, and uses Colgate fluoridated toothpaste. I asked if he was interested in trying an electric toothbrush and he said he has tried one before and did not care for it. He flosses 1x/day when he remembers and uses Listerine mouthwash occasionally. Case Study Presentation Assessments CK is in overall good health. He has been hospitalized in 1992, 1994, and 1996 for failed cornea transplants. Since his last surgery in 1996 he uses two different eye medications and his experienced no other complications. His two medications are Timolol Maletate in his left eye 3x/week, with a dental consideration of xerostomia, and Vexol in both eyes every morning. His medications taken as needed are one Bayer aspirin 3x/week for heart attack prevention and Vitamin C. CK has a past history of melanoma which was found during a routine check-up in The entire mole was removed at the time of discovery and he has had no complications since. He is currently seen by a physician at the VA hospital every 6 months for check-up's on his cornea transplants, screenings for melanoma, and a recently torn tendon in his left arm. Pulse and respiration were WNL at each visit however his blood pressure was
2 consistently pre-hypertensive putting him as an ASA class I. His extraoral and intraoral exams were both WNL and presented with no significant findings. His periodontal exam revealed 2-4mm pocket depths, generalized recession ranging from 1-7mm, slight mobility on tooth #3, #4, #7-10, #22-26, and #28, and light bleeding. He presented with a class I furcation on the distal of tooth #4, a class II furcation on the buccal of #14 with a class I on both palatal furca, and a class II furcation on the buccal of #18 with a class I on the lingual. He has generalized pink, firm tissue with receded/rolled margins and blunted papillae. He has light inflammation, light plaque, and no exudate present. Based on his cuspid relation he has a class 2 occlusion with an overbite of 4mm, and an overjet of 5mm. His midline is shifted to the left with his maxilla at 6mm and his mandible at 3mm. CK has 20 remaining natural teeth with 6 of them containing restorations. He has severe attrition on both his maxillary and mandibular anteriors, as well as multiple tooth fractures. Due to his bruxism the crowns of #6-7 and #9-10 are chipped and he has abfractions on #5, #6, #21, and #28. Tooth #3 and #4 have fractured crowns with retained roots and suspicious caries. His missing teeth were extracted at a dental school to "make room" for a partial denture. He eventually decided against the partial denture because he was afraid they would keep pulling his teeth out. After asking CK a few questions I placed him as a high caries risk because he has several active carious lesions, inadequate saliva flow, saliva reducing medications, and exposed roots. Some preventative factors are that he lives in a community with a fluoridated water supply and he uses a fluoridated tooth paste 2x/daily. His saliva flow was significantly low with a reading of 1 ml and a ph of 7. According to the internet risk assessment program, previser.com, his gum disease score is a 2 which is low risk and his tooth decay risk score is a 5 which puts him at a very high risk. Without home and professional care his oral health could worsen. Before performing his plaque index I disclosed him with a two tone colored solution with pink indicating new plaque and purple indicating old plaque. His plaque index presented as 0.33, which is very low and puts him in the "good" category for plaque accumulation. This could indicate that he is compliant with home oral hygiene care and is motivated to maintain his oral health. His DMFT is 5, indicating he has 2 decayed teeth and 3 teeth filled due to decay. Radiographic Interpretation Upon interpretation of CK's x-rays (figure 1) he has generalized horizontal bone loss with furcations present on #14 and #18. He has radiographic caries on #21-O and #28-D. #3 and #4 are grossly fractured showing some atypical radiolucency. His crown to root ratio is generalized 1:1 and 2:1 between #4-6.
3 Figure 1: FMX taken on Treatment Plan Below is the treatment plan for CK with regards to his assessment information and findings. Treatment Goals: Assessment Findings Perio Risk: Moderate Bone Recession Abfractions Furcations Mobility Caries Risk: High Suspicious caries Broken teeth Goals (Pt./client centered) 1. Pt will learn the link between plaque and periodontitis 2. Pt will understand the importance of IP brush 2x/day with proper technique 3. Pt will learn the proper way to use a IP brush 1. Refer to DDS 2. Pt will learn proper Stillman's TB technique to decrease plaque 3. Pt will understand the formation of caries 4. Pt will understand the importance of brushing 2x/day to reduce risk of caries Expected outcomes (evaluation methods, time frame) 1. Pt can explain the link between plaque and periodontitis by end of 1st visit 2. Pt will report using IP brush 2x/day by next recall 3. Pt can demonstrate proper use of IP brush by 2nd visit 1. Pt will have appt. with DDS in 2 weeks 2. Pt can demonstrate proper Stillman's TB technique by 2nd visit 3. Pt can explain formation of caries by 1st visit 4. Pt will report brushing 2x/day to prevent risk of caries by next recal
4 Coated Tongue 1. Pt *will understand the effects of +plaque accumulation on the tongue causing bad breath Treatment Plan by Appointments: Appt. Plan for education, # OHI, counseling 1 Educate about plaque in FM relation to periodontitis, Stillmans brushing 2 Reevaluate brushing, teach IP brush 1. Pt will report using a tongue scraper daily by 2nd visit Area Plan for treatment & services * MAX Complete assessments, OHI Update assessment, OHI, saliva test, caries risk, Scale max with USS and hand instruments 3 Reevaluate IP brush Mand Scale mand with USS and hand instruments, polish, fluoride varnish, refer Patient Education CK's current oral hygiene habits are brushing three times per day with a manual toothbrush using fluoridated Colgate toothpaste, flossing once per day, and using Listerine mouthwash as needed. After disclosing CK's teeth with a two tone disclosing solution I educated him on what plaque is and how it relates to caries and periodontal disease formation. He seemed to have a general knowledge of what plaque is and knows that he is supposed to remove it twice a day. However, it was a surprise to him that not removing the plaque from his teeth could ultimately cause either gingivitis or periodontitis. After explaining to him how plaque can affect his oral health, I asked him to point out some areas of plaque in his own mouth. This was somewhat difficult because his plaque indices score was so low it was hard for him to visibly see the pink areas on the lingual sides of his teeth. I chose to teach CK the proper use of an IP brush, because he has generalized blunted papillae and it is hard to clean in the concavities of teeth with just floss. I first showed him a few pictures of how the IP brush works and how it is somewhat of a better choice for him versus using floss. I explained to him that the IP brush works like the big brushes at the car wash. It fits snuggly in between each tooth and scrubs out the plaque and bacteria that gets caught in the grooves and concavities of his teeth. After explaining the use and benefits of an IP brush I showed him how to properly use it in his own mouth. I emphasized the importance of how the IP brush should not be forced in between his teeth and that it should gently slide in with no pressure what so ever. I explained to him that this is very important because if the IP brush is forced in between his teeth it can cause damage to his gum tissue as well as discomfort. After demonstrating it for him I had him show me how to use it in different areas of his own mouth to make sure he understood the concept. His dexterity was great and told me that he really liked to feel of the brush cleaning in between his teeth. He said that he would prefer to use these instead of floss because it is hard for him to reach his back teeth when he flosses.
5 I finished my oral hygiene instruction with specific directions for him to use the IP brush two times per day before he brushes his teeth. He seemed very motivated and excited to add them to his daily oral hygiene routine. Nutritional Analysis With the use of a nutritional diary from myplate.gov I was able to analyze CK s daily nutrition for a period of 5 days. He consumed an average of 1550 calories per day out of the 2200 calories he was targeted. Overall CK was under the recommended amount in all categories, except for protein where he was one ounce over. After calculating his nutrients report it showed him to be over in the saturated fat, cholesterol, and sodium categories Grains (ounces) Vegetables (cups) Fruits (cups) Dairy (cups) Protein (ounces) Recommended Actual Figure 2:Comparison of 5-day food diary He consumes a good amount of protein each day, however he also consumes a lot of sugary items as well. His sweet score is a 45 which puts him in the "watch out" zone and he has a total of 88 minutes that his teeth are exposed to acids daily. Out of the two forms of sugar he consumed, they were mostly the liquid form but the solid form was not far behind. His sugars consisted of cool whip and powdered cocoa in his coffee daily, diet coke, chocolate milk and snickers candy bars. Upon presenting his nutritional recommendations I wanted to educate CK on some better food choices. I first informed him that he was 650 calories under his recommended daily intake. I told him that this could be due to him not eating lunch on a regular basis. He told me that he usually only eats when he is hungry and he never seems to be hungry in the middle of the day. I recommended him to try eating a piece of whole wheat toast or english muffin with a piece of fruit even if he is not that hungry, to give him some energy and increase his whole grain intake. He is only 3/4 of a cup below on his vegetable intake, so I recommended him to try adding different colored vegetables, like peppers, to his omelets in the morning and to his spinach salads at dinner. He thought this was a great idea because he loves red and yellow peppers. This will help him reach the recommended amount without him even noticing he's eating more. He is doing a nice job of eating fresh fruits such as bananas, pears, and grapes, however he is slightly under his recommended intake. I told him to try eating another banana or pear for a snack in between lunch and dinner to help increase his intake. This also might help curb his craving for a soda or snickers bar. His
6 second lowest category was his dairy intake. He only consumed about half of his daily recommended intake. When I told him this he seemed confused because he said he drinks chocolate milk quite often. I explained to him that chocolate milk will give him some beneficial nutrition, however regular low-fat or fat-free milk would be much better. I told him that he doesn't have to cut chocolate milk out of his diet completely but suggested that he should have two glasses of regular milk to every one glass of chocolate milk. He did a very good job of consuming enough protein and was even over his recommended daily intake. I commended him on choosing lean meats such as salmon and lean ground beef. I reminded him to try and grill, boil, or roast his meats versus frying them to keep them even healthier. He seemed very compliant with my recommendations and said he looks forward to exploring some new food options. Research Xerostomia A sensation of oral dryness (xerostomia) is a frequent complaint among the elderly. More than 50% of elderly have been reported to have noticed occasional oral dryness, while 10 to 25% experience it constantly. 2 Multiple factors, including systemic diseases, prescription and non-prescription medications, head and neck radiation therapy, psychogenic factors, and decreased mastication, cause xerostomia. The most common cause of salivary gland hypofunction is the intake of medications, over 400 of which possess the ability to diminish the flow of saliva. 3 Age often brings more health problems which often means consumption of multiple medications, resulting in the development of xerostomia. 4 CK currently takes Timolol Maletate for his glaucoma and has a side effect of xerostomia which puts him at an increased risk. Based on his salivary flow test performed at his second appointment he has a flow rate of 1ml/min (normal rate 5ml/min), indicating that he suffers from a decrease in saliva. Saliva is approximately 99.5% water and the remaining 0.5% is comprised of inorganic and organic constitutes including electrolytes, antibacterial compounds, mucus, and enzymes. 5 Saliva functions to protect and lubricate the mouth and oral tissues, aids in taste and digestion, and acts as a buffer to acidic foods that we eat. 5 With tooth loss being associated with age, there is an increase in the use of partial and full dentures in the elderly. CK had multiple teeth extracted to prepare for a partial denture. Long-term effects of xerostomia can result in denture wearing becoming uncomfortable and can cause chewing problems. 7 If dentures are not properly cared for a kept meticulously clean there is a high risk of developing oral infections. A decrease in salivary flow rate also affects the defense mechanisms, making the oral cavity susceptible to microbial growth. 2 Unfortunately, xerostomia comes with many more problems that just a dry mouth feeling, denture problems, and oral infections. It makes eating and swallowing difficult, causes bad breath, and leads to irritation and infection of oral tissues. 4 Treatment of xerostomia is something that should be addressed first hand with a patient that suffers from this condition. If management and preventative actions are implemented quickly it can reduce the patient s risk of oral problems significantly. Edentulousness
7 With the advances in fields of medicine and Public health, life expectancy has prolonged throughout the world. It is expected that an increase in the population of people aged 60 years or above will account for more than half of the total growth of the world population. 9 Edentulous by definition is lacking or being without teeth. 7 Edentulousness, partial or complete due to neglect, dental caries, periodontal disease, inadequate access to dental care, financial constraints can result in masticatory problems for older adults. 8 Edentulousness diminishes the quality of life often substantially and is also related to poor general health. The relationship between edentulousness and general health appears to be multidimensional and complex, involving many pathways. As the number of teeth reduce, patient shifts from a wellbalanced diet to softer and high carbohydrate diet, resulting in poor quality of life. 9 CK mentioned that his lack of teeth does not stop him from eating certain foods, however he chooses to only chew soft foods on his right side due to pain he has felt previously from hard or crunchy foods. Advances in oral health care and treatment in the past few decades have resulted in a reduced number of edentulous individuals and the proportion of adults who retain their natural teeth until late in life has increased substantially. 10 Perhaps the most significant change in older adults' oral status is the decline in edentulousness (total tooth loss). 7 Changes in treatment philosophies, restore rather than extract, is what has improved this issue. 7 Most older adults have never been given preventative therapy or taught how to maintain their teeth. Preventative education is important and required for edentulous as well as dentate elderly to keep edentulousness on the decline. 10 Reflection Working with CK this quarter as my geriatric competency challenged my knowledge and experience of normal appointment procedures and treatment planning. With him being in his 7th decade of life I had to make modifications to his dental hygiene care plan as well as patient education, oral hygiene instruction, and diet recommendations. One thing I made sure to take into consideration was his dexterity while giving oral hygiene instruction. I also used very descriptive ways of how the IP brush works and how to use it instead of showing a lot of pictures because he has a hard time seeing due to multiple eye surgeries. This was a great learning experience to broaden my knowledge of how to get the message across to patients with different needs. During the three appointments I had with CK he needed to take a short break about half way through each appointment. I did not even think to ask if he needed a break because my previous patients have never needed one. This is something that I will work on and take into consideration with my future patients. Two things that I struggled with while treating CK was edentulousness and severe recession. He was my first patient with multiple teeth missing which made it somewhat difficult to instrument. With the help of my instructor I was able to learn a few advanced fulcrums to help get to hard to the reach areas. With him having such severe recession it was difficult to get around the crowns of his teeth and reach the
8 gingival margin because his teeth are elongated. My instructor suggested using my after five gracey curets to solve this problem. This was my first time using these new instruments, and it made the world of a difference. With the new fulcrum techniques and instrument suggestions from my instructor I feel a lot more confident in treating a patient similar to CK in the future. Treating CK was something I enjoyed experiencing because it helped remind me that not every patient learns the same way, has the same motivation, or needs the same care. References 1. California Department of Public Health, Drinking Water Program, 2012 Annual Fluoridation Report [Internet]. Available from: 12.pdf [cited 2014 November 30]. 2. Närhi T, Meurman J, Ainamo A. Xerostomia and Hyposalivation: Causes, Consequences and Treatment in the Elderly. Drugs & Aging [serial online]. August 1999;15(2): Available from: Academic Search Premier, Ipswich, MA. Accessed November 30, Kharevich O, Shipman B, Goldman B, Nahon M. Salese to Buffer Saliva in Elderly Patients with Xerostomia: a Pilot Study. Journal Of Prosthodontics [serial online]. February 2011;20(2): Available from: Dentistry & Oral Sciences Source, Ipswich, MA. Accessed November 30, The aging mouth--and how to keep it younger. Harvard Health Letter [serial online]. January 2010 [Cited 2014 November 30];35(3): Macpherson P. The role of saliva in oral health and disease. Dental Nursing [serial online]. October 2013 [Cited 2014 November 30];9(10): Talwar M, Malik G. Review Article: Oral health considerations for the elderly problems and management strategies. Indian Journal Of Dentistry [serial online]. September 1, 2013;4: Available from: ScienceDirect, Ipswich, MA. Accessed November 30, Darby ML, Walsh MM. Dental hygiene theory and practice. 3rd ed. St. Louis: Elsevier, Saunders; pg Talwar M, Malik G. Review Article: Oral health considerations for the elderly problems and management strategies. Indian Journal Of Dentistry [serial online]. September 1, 2013;4: Available from: ScienceDirect, Ipswich, MA. Accessed November 30, Hari Krishnam Raju. S, Fareed N, Sudhir K. M, Krishna Kumar R, Muralidharan D. Edentulousness in Relation to Self-perceived General Health and Oral Health Among Institutionalized Elderly Population in Nellore City, Andhra Pradesh. Indian Journal Of Gerontology [serial online]. October 2013;27(4): Available from: Academic Search Premier, Ipswich, MA. Accessed November 30, van der Putten G, De Visschere L, van der Maarel-Wierink C, Vanobbergen J, Schols J. Hot topic in geriatric medicine: The importance of oral health in (frail) elderly people a review. European Geriatric Medicine [serial online]. November 1, 2013;4: Available from: ScienceDirect, Ipswich, MA. Accessed November 30, 2014.
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managingdiabetes TM SELECTHEALTH WINTER 2015 Healthy Meals for Diabetes Your doctor can help you make a meal plan that fits your needs. Your meal plan tells you when to eat meals and snacks, how much to
Jessica Brandt Julie Medeiros Heather Middleton Pam Piccione Oral Health Disparities and the Elderly According to the United States Department of Health and Human Services, elderly is defined as the chronological
Cigna Dental Oral Health Integration Program customers who need more, get more For eligible Cigna Dental customers. The Cigna Dental Oral Health Integration Program was first to enhance dental coverage
This information is to help you make an informed decision about having implant treatment. You should take as much time as you wish to make the decision in relation to signing the following consent form.
compliments of Delta Dental of Arizona Smile. Sparkle. Shine. Your Oral Health Guide to a Healthier Body The Importance Of Oral Health Make your whole body smile. A great smile can make all the difference.