Clinical Cases in Dental Hygiene
The Editors Cheryl M. Westphal Theile, EdD, RDH, is a Clinical Professor, Associate Dean for Allied Dental Programs, and Director of Dental Hygiene at New York University College of Dentistry in New York, NY, USA. Mea A. Weinberg, DMD, MSD, RPh, is a Diplomate, American Board of Periodontology and a Clinical Professor of Periodontology and Implant Dentistry at the New York University College of Dentistry in New York, NY, USA. Stuart L. Segelnick, DDS, MS, is in private practice in Brooklyn, NY, USA. He is a Diplomate, American Board of Periodontology; Diplomate, International Congress of Oral Implantologists and is an Adjunct Clinical Professor of Periodontology and Implant Dentistry at the New York University College of Dentistry in New York, NY, USA.
Clinical Cases in Dental Hygiene
Examination and Documentation
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.
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 Medical History
The patient was diagnosed with scleroderma and gastroesophageal reflux disease (). She is taking antacids for GERD and immunosuppressant medications and a calcium channel blocker for scleroderma.
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.
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)
The patient has difficulty swallowing (dysphagia) and GERD.
The patient has a history of Raynaud's phenomenon and hypertension (BP: 159/92).
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
The patient exhibited microstomia restricting her mouth opening (<20mm), and the lips were thin and stretched.
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 () and the calculus index () 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.
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 f