Runninghead:RISKASSESSMENTPROJECTWRITTENREPORT

RiskAssessmentProject
TangBlanton
DH189
ProfessorOgamiAvila
WestLosAngelesCollege
June6,2016

RISKASSESSMENTPROJECTWRITTENREPORT

PERSONALHISTORY
1. Age:25
2. Sex:Male
3. Race:Caucasian
4. Occupation:Student
5. Maritalstatus:Single

MEDICALHISTORY
1. PastMedicalHistory
a. Burnson65%ofbody:2013
b. Multipleskingraftrelatedsurgeries:2013Present
c. Spinoplastysurgery:2010
d. Hypertension:Present
e. Lactoseintolerance:Present
2. Pastmedicationordruguse:none
3. FamilyMedicalHistory
a. Brother:hypertension
b. Father:skincancer
c. Paternalgrandfather:hypertension,lungcancer
d. Maternalgrandmother:diabetes
4. General:
a. Overall,patientisobese(BMI:32.5),hashypertension(BP:142/90mmHg),and
hasdifficultyregulatingbodytemperatureduetoburnsandskingrafts.
5. Reviewofsystems
a. Neurological:reducedtactilesensitivityinburnedareasduetolossofnerve
endings.Assessforpossibleinterferencewithoralselfcare.
b. Psychological:WNL
c. Functional:WNL
d. Respiratory:WNL
e. Cardiovascular:
i.
Hypertension:142/90mmHg
f. Dermatological
i.
Burnson65%ofbody.Lossofsweatglandsincreasesriskofbecoming
dehydratedandoverheated.Xerostomiaincreasescariesrisk.During
dentalappointments,rinsefrequentlyandprovidewaterbreaksasneeded.
ii.
Skingraftsonface,arms,andhands.Dry,crackedskinonlipsandhands.
Burnsandscarsreduceelasticityoffacialtissue,possiblyinterferingwith
oralselfcareaswellasdentaltreatment.
g. Gastrointestinal
i.
Lactoseintolerance
h. Sexual:WNL
i. Hematological:WNL
j. Endocrine:WNL
k. Immunological:WNL
6. CurrentMedication

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a. Trazodone,75mg
i.
Antidepressant,serotoninreuptakeinhibitor
ii.
Usesasasleepaid,asneeded,approximatelyonceper2months
iii.
Lasttakenontheeveningpriortoassessmentappointment
iv.
Mechanismofaction:Inhibitsreuptakeofserotonin,causes
adrenoreceptorsubsensitivity,andinducessignificantchangesin5HT
presynapticreceptoradrenoreceptors.Trazodonealsosignificantlyblocks
histamine(H
)andalpha
adrenergicreceptors.
1
1
v. AdverseEffects:sedation(46%),headache(33%),dizziness(25%),
fatigue(15%),nausea(21%),andxerostomia(25%)
vi.
Localanesthetic/vasoconstrictorprecautions:prolongsQTinterval.Use
vasoconstrictorswithcautionandconsultphysicianpriortouseof
vasoconstrictorinpatientsusingmultipleQTprolongingdrugs,duetorisk
oftorsadedepointes.
vii.
Dentaleffects:Xerostomia.Normalsalivaryflowresumesupon
discontinuation.
viii.
Bleedingeffects:none
b. Previouslyprescribedantihypertensivemedication
i.
Patientstatesreduceddosageofantihypertensivemedicationat
physiciansinstructionandthatheisattemptingtocontrolhisblood
pressurethroughdietandexercise.
7. BaselineVitalSigns
a. Pulse:68bpm
b. Respiration:14rpm
c. BloodPressure:142/90mmHg
8. ASAStatus:
a. Bloodpressuremeasurementof142/90mmHgStage1hypertension.
b. Obesity:BMI32.5
c. Burns,compromisedbodytemperatureregulation,andriskofdehydration
d. Useoftheantidepressant,trazodone,withinthelast24hours.Trazodoneprolongs
QTintervalandmaycontraindicateuseofvasoconstrictors.
e. Overall:ASAIII

DENTALHISTORY
1. Pasthistoryofdentalexam,treatment,andhygienevisits
a. Patientstateshehasnotreceiveddentalhygienecaresincethefirein2013.
b. Mostrecentdentalvisitwasinsummerof2013,followingthefire.Dentalcare
wasconstrainedduetofacialburnsandskingrafts.
c. Twoocclusalcompositerestorationswereplacedonteeth#18and#31in2002.
Inspectionshowedrestorationstobeingoodcondition
d. Extractionofteeth#1,16,17,32fororthodonticpurposes
e. Currently:noactivecariouslesionsorfaultyrestorations.
f. NohistoryofSRP
g. Nohistoryofperiodontalsurgery
2. Presentstatus

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a. AAPclassification:Generalizedchronicmoderateperiodontitiswithlocalized
chronicmoderateperiodontitis
b. WLACCalculuscode:2Light

EXTRAORALANDOCCLUSALEXAMINATION
1. Extraoralexam:
a. Burnsandskingraftsonhands,arms,andface.
b. Dry,crackedlipsshowevidenceofchronicxerostomia.
c. Maximumlabialopeningis49mm.Maximumopeningcannotbedeterminedby
measuringfromincisaledgetoincisaledgeduetolipsobscuringteeth.Patientis
abletoopenhismouthwide,butskingraftsmakeitdifficulttoretracthislipsand
cheeks,interferingwithdentalhygieneprocedures.
2. Occlusion,TMJ,andoralhabits:
a. AnglesClassification
i.
Right1stmolar:classI
ii.
Rightcanine:classI
iii.
Leftcanine:classI
iv.
Left1stmolar:classI
b. FacialProfile:mesognathic
c. OralHabits
i.
Edgetoedgeattritiononmaxillaryandmandibularcentralandlateral
incisors.Interferingocclusiononmaxillaryrightlateralincisorand
mandibularrightcanine.Patientreportsgrindingandnailbiting.Referto
DDSforassessmentandpossibleocclusalguard.

CARIESANDDENTALEXAMINATION
1. Decalcification,possiblecaries,defectiverestorations:
a. none
2. Qualityofrestorations
a. Restorationsappeartobeingoodcondition.Theyareproperlycontoured,anddo
notinterferewithoralselfcare.
3. Carieslocations:
a. Noactivecariouslesions
4. CariesIndex(DMFT)=2
a. Decayedteeth:0
b. Missingduetocaries:0
c. Filledteeth:2
d. Teeth:28
5. CariesIndex(DMFS)=2
a. Decayedsurfaces:0
b. Missingduetocaries:0
c. Filledsurfaces:2
d. Surfaces:128
6. Radiographicevaluation

RISKASSESSMENTPROJECTWRITTENREPORT

a. Noevidenceofcariouslesions,faultyrestorations,oroverlycontoured
restorations.

INTRAORALANDPERIODONTALEXAMINATION
1. Intraoralsofttissues:
a. Lowsalivaryflowfromparotidandsublingualsalivaryglands,butoralmucosa
arewithinnormallimits.Patientstatesheexperiencesdrymouthbutfrequently
drinkswater.Xerostomiapresentselevatedcariesrisk.Duringdentaltreatment,
rinsemouthfrequentlyandprovidewaterbreaksasneeded.Recommenddaily
0.05%NaFmouthrinseathomeandprofessional5%fluoridevarnishtobe
performedduring3rdappointment.
2. GingivaldescriptionandMBI(1stappointment)
a. Maxillaryattachedgingiva
i.
Pink,soft,stippled
b. Maxillaryfreegingiva
i.
Pink,soft,scalloped,blunted
c. Mandibularattachedgingiva
i.
Pink,soft,stippled
d. Mandibularfreegingiva
i.
Pink,soft,rounded,rolledbordersonposteriorteeth
e. MBI:0%
3. GingivaldescriptiondescriptionandMBI(3rdappointment)
a. Maxillaryattachedgingiva
i.
Pink,soft,stippled
b. Maxillaryfreegingiva
i.
Pink,soft,scalloped,blunted
c. Mandibularattachedgingiva
i.
Pink,soft,stippled
d. Mandibularfreegingiva
i.
Pink,soft,rounded,rolledbordersonposteriorteeth
e. MBI:0%
4. FullmouthAssessment(1stAppointment):
a. Probing:
i.
Patientexhibitsgeneralized2mmprobingdepths
ii.
Patientexhibitslocalized3mmpockets:#2DL,6MB,6DB,10MB,11
MB,12MB,13MB,13B,13ML,13DL,14MB,14DB,15ML,15DL,
21MB,22MB,22DB,31DB
b. Recession
i.
Patientexhibitslocalized1mmrecession:#3B,5B,6B,7B,11B,12B,
13B,14B,15B,18B,19B,20B,and22B.
c. Furcation
i.
ClassIfurcationson:#1B,#2B,#14B,#15B,#18L,#19L,#30B
d. Mobility
i.
+mobilityonteeth:#7,8,9,10
5. FullmouthAssessment(3rdAppointment):

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6.
7.
8.

9.

a. Probing:
i.
Patientexhibitsgeneralized2mmprobingdepths
ii.
Patientexhibitslocalized3mmprobingdepths:#2DB,2MB,3DB,3
MB,3ML,4DB,4MB,4ML,5DB,5DL,5ML,6DB,7DB,9DB,10
MB,10DB,11MB,12MB,12DB,12DL,13DB,13ML,14MB,14
DB,14ML,15MB,18DB,18MB,18DL,18ML,19MB,19ML,20
ML,20DL,25MB,27DB,28MB,29ML,29DL,30MB,30ML,30
DL,31MB,31DL
iii.
Patientexhibitslocalized4mmprobingdepths:#13MB,30DB,31DB
b. Recession
i.
Patientexhibitslocalized1mmrecession:#3B,5B,6B,7B,11B,12B,
13B,14B,15B,18B,19B,20B,and22B.
c. Furcation
i.
ClassIfurcationson:#2B,#14B,#15B,#18L,#19L,#30B
d. Mobility
i.
+mobilityonteeth:#7,8,9,10
Periodontaldiseaseetiology:
a. Dentalplaquebiofilm,asevidencedfromgeneralizedplaqueandsupragingival
calculusalonggingivalmarginofallteeth.
Periodontalperpetuatingfactors:
a. Bruxismcontributingtobonelossandgingivalrecession
b. Poororalselfcarewithinadequatefrequencyofbrushingandflossing
Radiographicinterpretationforperiodontiumandoralpathology
a. Patientshowsslightwideningofperiodontalligamentspaceforteeth#4,20
b. Patientshowsslightinterproximalbonelossatalveolarcrestformandibular
anteriorteeth
c. Dilacerationevidentontooth#4
AAPclassificationandrationale
a. Generalizedchronicslightperiodontitiswithlocalizedchronicmoderate
periodontitis
b. Patientexhibitsgeneralized2mmpockets
c. Patientexhibitslocalized1mmrecession:#3B,5B,6B,7B,11B,12B,13B,
14B,15B,18B,19B,20B,and22B.
d. Patientexhibitslocalized3mmpockets:#2DL,6MB,6DB,10MB,11MB,,12
MB,13MB,13B,13ML,13DL,14MB,14DB,15ML,15DL,21MB,22
MB,22DB,31DB
e. 3mmCALon18%(31/168)oftoothsurfaces=localizedmoderateperiodontitis
f. Generalized2mmCAL=generalizedslightperiodontitis
g. Radiographsshowslightboneloss,whichisevidenceofperiodontaldisease.
h. Noknownsystemicfactorsthatwouldinduceperiodontaldisease.Plaqueisthe
etiologicfactor.

ORALHYGIENEEVALUATION
1. Plaquecontrolindex
a. 2ndAppointment:86%

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b. 3rdAppointment:63%
2. Patientsskilllevel:
a. Patientdoesnotunderstandtherationalebehindthesulculartoothbrushing
methodmovingthebristleswithinthegingivalsulcustoremovesubgingival
plaquebiofilm.
b. Hehasdifficultyadaptingthetoothbrushtothemesialanddistallineanglesofhis
teeth.
c. HeunderstandsusingtheCshapetechniqueforflossing.
d. Heismotivatedtoincreasehisbrushingandflossingfrequency,butnot
3. Patientsknowledgeandawarenessofdentalandperiodontaldiseases
a. Hedoesnotunderstandthereasonformeasuringprobingdepthsorthat
measurementsgreater3mmindicategingivitisorattachmentloss.
b. Hedoesnotunderstandhowplaquebiofilmbecomescalculus,whycalculus
exacerbatesperiodontaldisease,orspecificallyhowprofessionalperiodontal
debridementimprovesoralhealth.
c. Heisawareofthelinkbetweensugaranddentaldecay,butdoesnotunderstand
themechanismofenameldemineralizationanditsrelationshiptofrequencyof
sugarexposure.

NUTRITIONALANALYSIS
1. Threedaydietaryanalysis
a. 2ndAppointment:
i.
DeficientinvitaminB2,B5,folate,vitaminC,vitaminD,vitaminE,
calcium,copper,magnesium,manganese,potassium,andzinc.
ii.
ExceedstheupperlimitofsodiumandvitaminA.
b. 3rdAppointment
i.
NolongerdeficientinvitaminB2,vitaminB5,copper,magnesium,
manganese,orzinc.
ii.
NolongerexceedtheupperintakeforvitaminA.
iii.
Stilldeficientinvitaminfolate,vitaminC,vitaminD,vitaminE,calcium,
copper,andpotassium.
iv.
Stillexceedsupperlimitofsodium
2. Carbohydrateintakeanalysis
a. 1stAppointment
i.
Hisaveragesugarexposureforallthreedayswas253minutes.
ii.
Thishighdurationofsugarexposureisduetoeatingmealsoverlong
periodsof40minutesormore,frequentsnacking,andconsumptionof
beveragescontainingsugar.
b. 2ndAppointment
i.
Hisaveragedailysugarconsumptiondecreasedto187minutesperday.
ii.
Thiscanbeattributedtoeliminatingsugarsweetenedbeveragesand
replacingthemwithwater,reducingfrequencyofsnacking,andincreasing
3. BMI:32.5Obese
a. Height:6
b. Weight:240lb.

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4. Activitylevel:Lightlyactive
5. Nutritionalcounseling:
a. 2ndappointment:M.B.wasinstructedtoincorporatewholefruit,broccoli,and
fattyfishintohisdiet,allofwhicharefoodsheenjoys.Thesefoodsarerichin
vitaminsinwhichheisdeficient.Hewasinstructedtoeathissnackscloser
togethersothatthetotaltimesnackingwaslessthan20minutes,consumewater
insteadofsweetenedbeverages,increasetotalwaterconsumption,andshortenthe
durationofhismealstolessthan40minutes.
b. 3rdappointment:M.B.wasinstructedtoreducehisconsumptionoffrozenand
fastfoods,asthesetendtobehighinsodiumandlowinvitaminsrelativetotheir
caloriecontent.Hewasalsoinstructedtoincorporatemorewholefruitintohis
diet.

FLUORIDEANALYSIS
1. Currentfluorideusage:
a. Usesoncedaily2.43%NaFdentifrice
b. Drinksfluoridatedtapwater
i.
Waterfluoridation:GoldenStateWaterCo.Averagemonthlyfluoride=
0.7mg/LFluoride(("StateWaterResourcesControlBoard",2016))
2. FluorideFocusandRationale
a. Duetofrequentsnacking,inadequatebrushingfrequency,andxerostomia,M.B.
wouldbenefitfromanadjunctdaily0.05%NaFmouthrinseand5%NaFvarnish
toreducehisriskofdentalcaries.Thevarnishwouldeffectivelyremineralizehis
toothenameloveralongerperiod,andtherebyeffectivelycontrolscariesin
patientswithpoororalhygienecompliance.5%NaFvarnishwasappliedduring
thethirdappointment.

CARIESRISKASSESSMENT
1. CAMBRAAssessment
a. Protectivefactors:M.B.statedhelivesinafluoridatedcommunity,LosAngeles,
andusesafluoridetoothpasteatleastoncedaily
b. Riskfactors:snacksmorethan3timesperdaybetweenmeals,inadequatesaliva
flow,lossofsweatglandsandchronicdehydrationasasalivareducingfactor,and
exposedrootsfromgingivalrecession.
c. Moderatecariesrisk
2. RecommendationsforPatient
a. Increasebrushingfrequencytotwicedailywithfluoridedentifrice
b. Useadaily0.05%NaFmouthrinse
c. Have5%NaFvarnishprofessionallyappliedatdentalhygieneappointments,at
leastevery6months
d. Usexylitolgumormints4ormoretimesperday
e. Keephydratedtoimprovesalivaryflow
3. EducationonCariesControlandManagement
a. Patientwasinformedthatcaries,ordentaldecay,iscausedbyacid
demineralizationofenamelanddentin.Oralpathogensfermentcarbohydratesand

RISKASSESSMENTPROJECTWRITTENREPORT

produceacidsthatcausethisdemineralization.Cariesisalsoacceleratedbyacid
challengesfromacidicfoodssuchasjuiceandsoda.Thefrequencyofsugar
intakeismoresignificantthantotalsugarintakeincariesformation.Fluoride
exposureremineralizestoothstructures,partiallyreversingaciddemineralization
andpreventingcariesfromprogressing.Greaterfrequencyoffluorideexposure
leadstoacommensurateincreaseinremineralizationandcanbeintheformof
fluoridedentifrice,fluoridemouthrinse,professionalfluoridegelorfoam,and
professionalfluoridevarnish.
4. Cariesriskprognosisanditsrationale
a. Moderatecariesrisk,
i. Noactivecaries,incipientcariouslesions,orrestorationswithinthelast3
years
ii. Multipleriskfactors:frequentsnacking,inadequatesalivaflow,and
exposedroots.
iii. Fewprotectivefactors:usesfluoridedentifriceonlyonceperdayand
drinksfluoridatedwater.

ORALHYGIENEINSTRUCTIONANDPLAN
1. Designedtomeetpatientsneeds
a. Patientshowedsignificantplaqueandsupragingivalcalculus,andwasinformed
thatallowingplaquetoremainundisturbedformorethanadaycausesittoharden
intocalculus.Calculusmustberemovedbyaprofessional,sopreventingitfrom
accumulatingrequiresgoodcompliancewithhomecare.
2. DevelopsgoalswithpatientduringOHI
a. Goalsweretoincreaseflossingtooncedaily,brushingtotwicedaily,and
reducinggingivalinflammation.
3. OralHygieneInstructionandrationale
a. Patientwasinstructedtoincreasethefrequencyofhisbrushingtotwiceeachday
andflossingtoeverydaytodisruptplaqueandcalculusformation.
b. Patientwasinstructedtousesulcularbrushingtodisruptshallowsubgingival
plaque.
c. Effectiveplaqueremovalwouldreducethequantityoforalpathogensresponsible
forhisgingivalinflammation.
4. Smokingcessationprogramrecommendations
a. Patientdoesnotsmoke
5. Preventiverecommendations(sealantapplication,fluorideetc)
a. Recommendedsealantsfordeepocclusalpitsonposteriorteeth
b. Recommended5%NaFvarnishtoprotectagainstcaries,whichwasalsoapplied
onthe3rdappointment.
6. Possibleimplicationsofsystemicconditions
a. Hypertensiondoesnotaffectperiodontitis.StageIhypertensiondoesnottypically
contraindicatevasoconstrictors,butusingareduceddosemayberequiredifhis
bloodpressureincreasesandpaincontrolisrequired.
7. Rationaleforthetreatmentplanandpatientneeds

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a. Treatmentplanisoralprophylaxisduetohislightcalculusandrelativelysmall
amountsofattachmentlossandboneresorption.Oralprophylaxiswouldinclude
fullmouthscaling,followedbypolishtoremovethecoffeestainspresentonhis
teeth.
8. Goalsandobjectivesofthedentalhygienetreatment
a. Thegoalsofdentalhygienecarewouldbetoreducehisgingivalinflammation,
whichwouldbeshownbyreducedgingivalenlargementandreducedbleeding
duringprobingorexploring.
9. DDSreferral,MDreferralandspecialtyreferral
a. Refertoadentistorhygienistforfullmouthscaling
b. Refertoadentistorhygienistforpitandfissuresealants
c. Refertodentistforocclusalguard.
d. Refertoaphysiciantomonitorhypertension.

POSTINSTRUCTIONSTATUS
1. E&Iexamination
a. Skingraftsonhands,arms,andface.
b. Dry,crackedlipsshowevidenceofchronicxerostomia.
c. Maximumlabialopeningis49mm.Maximumopeningcannotbedetermineddue
tolipsobscuringteeth.Patientisabletoopenhismouthwide,butskingrafts
makeitdifficulttoretracthislipsandcheeks,interferingwithdentalhygiene
procedures.
d. Lowsalivaryflowfromparotidandsublingualsalivaryglands,butoralmucosa
arewithinnormallimits.Patientstatesheexperiencesdrymouthbutfrequently
drinkswater.Xerostomiapresentselevatedcariesrisk.Duringdentaltreatment,
rinsemouthfrequentlyandprovidewaterbreaksasneeded.
e. Edgetoedgeattritiononmaxillaryandmandibularcentralandlateralincisors.
Interferingocclusiononmaxillaryrightlateralincisorandmandibularright
canine.
2. Evaluationofgingivaltissue
a. Postinstruction,hisgingivaweresimilarinappearancebutshowedlessbleeding
onexploring.Previously,heshowedbleedingonexploringfortheML,DL,MB,
andDBsurfacesofhismaxillaryandmandibularmolars.Followinginstruction,
heonlyshowedbleedingonexploringof2%(4sites).Hisgingivahavenotbeen
fullyrestoredtohealth,astheyplaqueandcalculuspreventthis.
3. PeriodontalReEvaluation(Probing,recession,furcation,mobility)
a. Postinstruction,hisprobingdepthsweresimilarexceptfor4mmpocketson#13
MB,30DB,31DB.
b. Nochangesinrecession
c. Nochangesinfurcation
d. Nochangesinmobility
4. Plaqueindexandphotosofbeforeandafterdisclosing
a. Plaqueindeximprovedfrom86%to63%postinstruction.
b. Photographs:SeeAppendix
5. Patientcompliancewithrecommendedhomecare

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a. Thepatientshowedimprovementwithhisoralhomecare,buthisoverall
compliancewaspoor.Hereportedthathenowflossesdaily,butonlybrushes
twiceonsomedays.Healsodidnotincorporatea0.05%NaFmouthrinseintohis
dailyhomecare.
6. Patientcompliancewithrecommendednutritionaldiet.
a. Thepatientscompliancewiththenutritionalrecommendationsafterthefirstdiet
journalwasgood.Hecompletelyeliminatedsugarsweetenedbeveragesfromhis
diet,reducedbetweenmealsnacking,andreplacedfermentablecarbohydrates
withfoodsthatwererichinprotein.

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DISCUSSION
ThetreatmentgoalsforM.B.wereto:improveoralhygienecompliance,reducethe
cariogenicityofhisdiet,improvehisconsumptionofdeficientvitaminsandminerals,and
educatehimregardinghowhispersonalbehaviorsaffectedhisoralhealth.Overthecourseofthe
treatment,hisoralhygieneimprovedandwasevidencedbyhislowerplaqueindexscoreand
reducedgingivalbleeding.Hisdietbecamelesscariogenic,asevidencedbythereduced
frequencyofsugarexposureandtotalsugarexposuretimeshowninhisdietjournals.Although
hisdietbecamelesscariogenic,heremaineddeficientinseveralessentialvitaminsandminerals.
Despitethis,hisconsistentcompliancethroughoutthetreatmentdemonstratedthathehad
developedanewunderstandingforimprovinghisoralhealth.
Regardingthenutritionaspectofhisoralhygieneinstruction,heunderstoodgenerally
thatsugarcausesdentaldecay.However,hewasnotawarethatfrequentsugarconsumption
resultedinextendedacidchallengeswhosecumulativeeffectdemineralizedenamelandresulted
indentalcaries.Hewasalsounawarethatxerostomiareducessalivasabilitytocleansebacteria
andfooddebris,andbufferacidicbacterialmetabolites.
ThetreatmentplanforM.B.throughoutthisprojectwastoeducatehim,thereby
motivatinghimtoimprovehisoralhygienehabits.Priortotreatment,hisplaquescorewas86%.
Hestatedthathebrushedoncedailywithapowertoothbrushandflossedonlyafterheavymeals,

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approximatelytwiceperweek.Hewasinstructedtoincreasehisbrushingfrequencytotwiceper
dayandtoflossdaily.Hewasalsoinstructedtoincorporateatimersoastoconsistentlybrush
eachquadrantfor45seconds.Postinstruction,hisplaquescoredeclinedto63%andhestated
thathenowflossesdaily,butdoesnotbrushtwiceeveryday.Hisbleedingonexploringwasalso
reducedto2%,whenpreviouslyitwasdisplayedonallmolars.Muchoftheremainingplaque
wasonthemesialanddistallineanglesofhisteeth,sohewasinstructedtocleanthoseareas
withanendtuftbrushasanadjuncttohisexistinghomecare.Theimportanceoftwicedaily
brushingwasreinforced.
Hisdietbecamelesscariogenicandhisintakeofvitaminsandmineralsimprovedfor
some,butworsenedforothers.Hisaveragedailysugarexposuredeclinedfrom253minutesper
dayto187minutesperdayasubstantialimprovement.Heceasedhisconsumptionofjuiceand
increasedhiswaterintake.Healsonoweatsfewerthanthreebetweenmealsnacksperday.Prior
totreatment,hisdietjournalsshowedhimtobeconsistentlydeficientinvitaminB2,B5,Folate,
vitaminC,vitaminD,vitaminE,calcium,copper,magnesium,manganese,potassium,andzinc.
HewasalsoconsistentlyabovetheupperlimitofsodiumandvitaminA.Hewasinstructedto
incorporatemorebroccoli,fattyfish,eggyolks,andnutsintohisdiettosupplementhis
consumptionofthosedeficientmicronutrients.Aftertreatment,hewasnolongerdeficientin
vitaminB2,vitaminB5,copper,magnesium,manganese,orzincandnolongerexceedtheupper

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intakeforvitaminA.Hewasstilldeficientintheremainingmicronutrients,stillconsumed
excesssodium,andbecamedeficientinvitaminK.Hewasthereafterinstructedtoconsumemore
wholefruittoobtainmorevitaminCandtoconsumelessfrozenandfastfood,asthesetypically
arehighinsodiumandfat,butlowinvitaminsrelativetotheircaloriecontent.
Intraoralexaminationrevealedmultipleoralhealthconcerns:attritiononhismaxillary
andmandibularanteriorteethduetogrinding,lowsalivaryflow,deepocclusalpitsonhis
posteriorteeth,andgeneralizedsupragingivalcalculus.Assuch,hewasreferredtoadentistfor
fullmouthscaling,sealantstopreventocclusalcaries,andapossibleocclusalguard.
Treatmentcouldhavebeenimprovedforthepatientbyinstructinghimtobringhis
personaltoothbrushfromhomeandusingthatfororalhygieneinstruction.Hewasprovideda
manualtoothbrushateachappointment,butusesapowertoothbrushathome.Thus,
incorporatinghistoothbrushintotheinstructioncouldhavemadeitmorepersonalizedand
effective.
Hemetthegoalofimprovinghisoralhygiene,andthisprogressshowsthatheismotivatedto
augmenthisoralhomecare.Assuch,consistentreinforcementofidealoralhygienehabitsare
likelytoleadtoincrementalimprovementsinhisoralhygiene.However,hisoveralloralhygiene
isstillpoor,givenhisplaquescores.Thegoalofreducingthecariogenicityofhisdietwas
successful,asthetotalsugarexposureperdaydeclinedsignificantly:heminimizedsnacking,
drankmorewater,andavoidedsweetenedbeverages.Therewasmoderatesuccessinimproving
hisnutritionaldeficiencies,butachievingabalanceddietisdifficult.Eatinghabitsarecomplex

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andoftenreflectamultiplicityoffactors.Assuch,theyaremoredifficulttomodifyinthe
shortterm,becausesolutionstonutritionaldeficienciesarelessstraightforward.

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CONCLUSION
Thepatient,M.B.,displaysxerostomiaasaresultofthedamagetohissweatglandsafter
beinginjuredduringafire.Xerostomiaisperceivedasthesensationofdrymouthandisrelated
toreducedsalivaryflow.Duetothelossofhissweatglands,M.B.isregularlydehydratedand
showsreducedsalivationasaresult.Healsousestheantidepressant,trazodone,whichlists
xerostomiaasoneofitsadverseeffects.Hisoralmucosaarewithinnormallimits,butovertime
arelikelytobecomecompromised.
Inpatientswithxerostomia,inadequatesalivapresentsanumberoforalhealthrisks.
Salivaprovidesantibacterialproperties,buffersacidsbyproductsofbacterialcarbohydrate
fermentation,andfacilitatesremineralizationoftoothstructures(Saxena,Chaudhary,Pandey,
Reddy,&Rao,2015).Assuch,xerostomiapresentsanelevatedcariesriskduetoreduced
inhibitionofcariogenicbacteria,lackofcleansingactionandbufferingpotential,and
compromisedabilitytoreverseaciddemineralization.Meticulousplaqueremoval,proper
hydration,salivasubstitutes,andconsumingxylitolcanmitigatethisincreasedcariesrisk.In
addition,thereareprotectivemeasuresthatcanbeappliedbydentalprofessionals:occlusal
sealantsprovideaphysicalbarriertocariogenicbacteria,and5%sodiumfluoridevarnish
providesareservoiroffluoridethatadherestotoothsurfacesandremineralizesthemoveran
extendedperiod.Thesemeasuresprovideacumulativebenefitwhencombinedwitha

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noncariogenicdietthatislowinrefinedcarbohydrates.However,xerostomiamakessuchdiets
difficulttoachieve.
Xerostomiaalsonegativelyaffectsfoodchoices,creatingatendencytoseekoutfoods
thatareconvenient,comfortabletoeat,andhighlycariogenic.Personswithseverexerostomia
oftenconsumehigherquantitiesofsugarcontainingbeveragestoalleviatetheirdrymouth
symptoms(Quandtetal.,2011).Assuch,thesepeopleareatelevatedcariesriskduetothe
frequencyofsugarexposuretheyexperience.Peoplewithxerostomiaalsotendtoavoidwhole
grainsandotherdryfoods,insteadoptingforfoodswithhighliquidcontent,suchascanned
fruit.Hyposalivationmakesdryfoodsunappealingastheymaybedifficultorevenpainfulto
chew(Quandtetal.,2011).Unfortunately,thesetendenciescompromiseoverallnutrition.Fruit
juicesarelargelystrippedofthefiberfoundintheirwholefruitcounterparts,andwholegrain
foodsarefrequentlyfortifiedwithfolate,vitaminD,andothermicronutrients.Therefore,food
preferencesthatareextremelycommoninpeoplewithxerostomiawouldsignificantlyincrease
M.B.scariesriskaswellashisriskofvitamindeficiency.
M.B.showedgeneralizedcervicalplaquewhichmay,overtime,exacerbatehis
xerostomia.AstudybyTakeuchietal.foundthathighplaquescoreswerestronglyassociated
withincreasedriskofdevelopingreducedsalivaryflow,puttingforthamodelthatexposureto
highlevelsoflipopolysaccharideendotoxinleadtoaccumulationofprostaglandinsinsalivary

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glandsandblockedsalivarysecretion(Takeuchietal.,2015).Assuch,poororalhygienemay
potentiateM.B.sxerostomiaandtherebymagnifyhisalreadyelevatedriskofdentalcaries.
PrognosisforM.B.soveralloralhealthisfairandislargelyinfluencedbyhiscompliancewith
dentalhygieneandnutritionrecommendations.Ifheshowsconsistentimprovementinthe
frequencyofhisoralhomecare,hisprognosisbecomesmorefavorable.Hehasgeneralized
slightchronicperiodontitisandexhibitsclassIfurcations,butradiographsshowthathisbone
lossisnotextensive.Hiscrownrootratiois1:2,signifyingthatthereisadequateremaining
periodontalsupport.However,hiscurrentoralhygieneispoor.Byonlybrushingonceperday,
heallowsbacterialplaquetoremainundisturbed,formcalculus,andpersistasanetiologicfactor
forinflammatorybreakdownofhisperiodontium.Andwithoutregularprofessionalscaling,his
periodontiumwillbecomingincreasinglycompromised,resultinginprogressivetoothloss.

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SUMMARY
Overall,theexperiencewashighlyeducationalandIbelieveitwasbeneficialforbothme
andmypatient.Idevelopedasenseofhowimprovementstohomecarecansignificantly
improveapersonsoralhealth.Fortunately,mypatientwaseagertotrymyrecommendations,
thoughhewasnotwithoutchallenges.Theburnscarsandskingraftsonhisfacemade
periodontalassessmentdifficult,asIwasnotabletoretracthischeeks.Thexerostomiaalso
causedhissalivatobecomethickandfoamy,whichinterferedwithmyabilitytousemymirror
forindirectvision.Ihavedevelopedanappreciationforhowpowerfulitistoeducatepatients.
Patientsdowanttobeactiveparticipantsintheirownhealth,andprovidingthemthetoolstodo
soisperhapsthebestserviceIcanoffer.

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WORKSCITED

1)Quandt,S.,Savoca,M.,Leng,X.,Chen,H.,Bell,R.,&Gilbert,G.etal.(2011).DryMouth
andDietaryQualityinOlderAdultsinNorthCarolina.
JournalOfTheAmerican
GeriatricsSociety
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59
(3),439445.
http://dx.doi.org/10.1111/j.15325415.2010.03309.x

2)

Saxena,A.,Chaudhary,C.,Pandey,P.,Reddy,N.,&Rao,V.(2015).Estimationofsalivary
flowrate,pH,buffercapacity,calcium,totalproteincontentandtotalantioxidantcapacity
inrelationtodentalcariesseverity,ageandgender.
ContemporaryClinicalDentistry
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6
(5),65.
http://dx.doi.org/10.4103/0976237x.152943

3)
StateWaterResourcesControlBoard
.(2016).
Waterboards.ca.gov
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from
http://www.waterboards.ca.gov/drinking_water/certlic/drinkingwater/Fluoridation.shtml

4)Takeuchi,K.,Furuta,M.,Takeshita,T.,Shibata,Y.,Shimazaki,Y.,&Akifusa,S.etal.
(2015).RiskFactorsforReducedSalivaryFlowRateinaJapanesePopulation:The
HisayamaStudy.
BiomedResearchInternational
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2015
,17.
http://dx.doi.org/10.1155/2015/381821

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APPENDIX

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