Rachel Cowger

Microscope Narrative
Good afternoon, Richard. My name is Rachel. Follow me right this way and lets get started! I greeted
the patient in the reception area and brought him back to my chair.
Have a seat right here, how has your day been going so far? I asked.
Oh, good. He replied. Just ready to have my teeth cleaned, its been a few years.
Great! Im so glad you could come in today, I can assure you that once we finish your teeth will be very
thoroughly cleaned. Im going to start by taking some radiographs of your teeth, and then Ill begin some
assessments to see what treatment will best suit you.
After taking a full mouth series, I had Richard return to our chair and I began the perio assessment.
Richard, Im going to take a look at your tissue and make some notes in the computer. Then Im going
to take measurements with my probe, have you had this done before?
I think I have, Rachel, but Im not sure. I cant remember the last time Ive had it done. I dont even
know what the measurements mean!
Well, your teeth are all sitting in bone. I use this probe against your tooth and down under the gumline
to measure any pockets you may have in the bone or tissue. In health, the measurements are 1-3 mm,
but once we start getting into bigger numbers like 5-7 this indicates bone loss and disease progression.
Oh, okay. Well, my teeth never hurt so I should be fine, right? Richard asks.
This disease process, especially during the early stages, is not always painful for the teeth. Your gum
tissue may be inflamed and bleed when you brush, and thats a sign of disease.
Oh, I do have bleeding when I brush my teeth. I thought that was normal or maybe I brushed a little too
hard. Richard said.
It is common for people to think that the bleeding is normal, but a healthy mouth actually doesnt
bleed when you brush. Let me take a look and we will see what you have going on.
I had help from clinic duty with the charting. I called out probe measurements and bleeding points, and
once I completed all the assessments I started to fill in my statements. The first thing I noticed was that
Richard had quite a bit of visible plaque and supra deposit (3.5/3.5). The probing measurements ranged
from 2-6 mm with significant bleeding upon probing; the radiographs showed generalized bone loss of
about 25%. I classified Richard as a Perio Case Type III or as having Moderate Periodontitis.
So, you told me that healthy ranges are 1-3mm, but I heard you call out 4, 5, and 6! Is that bad?
Richard asked.
Those higher numbers mean that you have a disease process going on. When you have bacteria in your
mouth for extended periods of time, they can cause the tissues and bone in your mouth to deteriorate.
Thats what gives you those deeper pockets, and once they become higher than 3mm it is more
challenging for you to remove the bacteria with a toothbrush or floss.

I brush my teeth 3 times a day, theres just no way I could have that much bacteria in my mouth!
Richard said.
Well, I think you are a great candidate for a microscope sample! Ill take some plaque from one of your
deepest pockets and put in on a slide, then I can actually show you the bacteria. What do you think of
that? I ask.
Sure, that sounds just fine. Richard replies.
I collect my sample from a nice 6 mm pocket on the distal lingual of tooth #19. I bring Richard over to
the microscope with me and have him read the handout while I look at the slide to find an active area to
show him on the screen.
Okay, Richard. I found something that I think youll be interested to see. I switched over the viewing
area so that Richard could see the slide on the television screen.
Oh, wow! It looks like little bugs runnin around! Richard says.
Yes, these are all the bacteria you have in your mouth right now! This here is the plaque matrix that
hold all of the bacteria, do you see how this looks like a big group or colony of bacteria? These are called
gliding rods and they are organized, which means that they are destructive to your tissue and bone.
Here are some spinning rods, do you see how fast they are moving around? That is another sign of
destruction. I adjust the slide a bit to see what other bacteria we can see. Oh look here, this is called a
spirochete. This is a gram negative organism that is present with destructive periodontitis. This type of
bacteria is what we call anaerobic, which means that it thrives where there is no oxygen. Thats why
they are in those deep pockets, they can multiply and become organized and do a lot of damage.
Richard looks very surprised. I cant believe this is in my mouth, its actually really gross!
Yes, it can be hard to visualize this bacterial activity without the microscope, I explain. Oh look here, I
see a white blood cell. As you may know, white blood cells fight infection, and thats exactly what they
are doing in your mouth. From all of the gliding rods, spinning rods, spirochetes, and white blood cells
weve seen here, I would classify you as being risk factor C.
Alright, so how do I get rid of all of these guys?! Richard is sounding more concerned after seeing his
active slide at the microscope.
Lets go back to our chair and talk about what you can do at home to help prevent disease
progression. I say.
Richard and I return to the chair where we begin to discuss homecare.
Richard, you mentioned earlier that youre brushing three times per day. Why dont you show me with
this tooth brush how you would typically brush your teeth. I hold up the patient mirror and Richard
shows me his back-and-forth technique.
Lets modify this a bit. I suggest. I really want you to try aiming your toothbrush up into your gums,
like this. I show him in the anteriors how to position the toothbrush. Id like you to focus on just one or
two teeth at a time to really get them clean with the strokes, and then sweep the toothbrush away from

the gums to help remove the plaque. Richard is adapting the toothbrush very nicely and has no trouble
with dexterity.
So Ive just been brushing my teeth wrong? Richard asks.
This is just the best technique for getting the bristles of the toothbrush under the gumline. Id also like
to discuss flossing technique with you. How often would you say that you use floss?
Well, I dont really like to floss. It just takes way too long! Richard tells me.
Thats pretty common, Richard. I know that flossing isnt everyones favorite, but it is a very important
step in your homecare! When you floss correctly, it is very effective at disrupting the plaque that sits
between your teeth. If this plaque isnt removed, all of those bacteria we just looked at under the
microscope will stick around. If thats the case, the bacteria will continue to produce acids that eat away
at your tissue and bone.
Isnt there anything else I can try? Richard is very reluctant to flossing!
There are a couple other options. The main idea is that you need to be cleaning in between your teeth
somehow. I can show you how to use a toothpick or a plastic dental pick that will help to clean
interproximally.
Oh, that would be much better for me. Richard says.
I show Richard how to properly use a toothpick, making sure he doesnt aim the point into the gum
tissue. He believes thats something he can do more often than trying to floss, so I trust that he will do
so. I let him know that I would be checking in on how that is going at our next appointment.
Alright, Richard, Id like to get you started using this chlorhexidine rinse. Its an antimicrobial rinse that
will kill bacteria, so it will be helpful in reducing the bacterial count in your mouth. And one last thing I
think you would benefit from is a water jet device. Have you used one of those before?
My wife actually has one, but Ive never used it. Richard explains.
Oh great, so you will have one handy and can start using it tonight! The water jet is great because it will
help flush debris out of those deeper pockets that your toothbrush and picks wont be able to reach. It
make take some extra time, but once you are more used to using it, it doesnt take much time at all.
I think that all sounds good, Rachel. Im glad theres more I can do than just floss! Richard says.
Alright, Richard. Lets talk about a treatment plan for you. I think that with your deposit level being so
high, this cleaning may take 4 appointments. This will be a deep cleaning where I focus on one quadrant
of your mouth at a time. Once we get everything cleaned out you will be able to get on a regular
cleaning appointment schedule, so the cleanings would take less appointments.
Yeah, I had a feeling it might take a few appointments to get all of this cleaned up. But Im ready to get
it done! Richard says.
Great! At your next appointment, Id like to take another sample for the microscope to check in on how
things are going. I think that if you keep up on the homecare, we will see a significant improvement! If

not, we can discuss modifications to the homecare routine and check in at the third appointment with
another sample for the microscope. How does that sound?
That sounds great, Rachel. I think I could do that because I dont want all that bacteria in my mouth to
get any worse!
Perfect! Ill bring my instructor over to check us in and then we can get started on cleaning the first
quadrant.