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Adult Therapy Case Report Example

Diploma in Dental Hygiene and Therapy

Adult Therapy Presentation Case Report

Candidate Number:                               68

Diagnosis:                                                  dental caries

Date Treatment Commenced:          21st May

Date Treatment Completed:             18th September

Patient’s Details

Gender:                               female

Age:                                      40yrs


Referred by:                      Professor P Preshaw

Background History

This patient was referred by his general dental practitioner to professor Preshaw’s consultant clinic at the Newcastle dental hospital regarding her periodontal condition. GDP tried routine scaling and OHI, yet there has been no change

The patient was examined on professor Preshaw’s clinic and patient was then referred to myself for treatment of dental caries and generalised mild chronic periodontitis.

Adult Therapy Case Report Example

Restorative History

She is a regular attender to GDP every 6-12 months. She has been attending scale appointments for 30minutes, without LA; 31 is root filled with composite.

Presenting Complaint

Patient noticed bleeding upon brushing, but other than that she did not have any concerns.

Medical History

Patient is fit and well

Social History

None smoker and drinks about 3 units per week

Oral Hygiene Habits

Patient brushes twice a day with an electric tooth brush and also reports using bottle brushes once per day

Basic Periodontal Examination
3 1 4
2 2 3

Minimal soft deposits present, generalised extensive hard deposits present, caries present on 16, 26, 27, 28, 46

Treatment Plan

  1. caries management 16, 26, 27, 28, 46
  2. plaque score
  3. full periodontal indices
  4. course of RSI on pockets of 4mm+ with LA
  5. OHI basis technique and interdental cleaning
  6. Bitewings to confirm caries 46

Radiographic Report: (DPT/OPG and Bitewings)


Quality: Grade 1

18 17 16 14 13 12 11 21 22 23 24 26 27  28
47 46 44 43 42 41 31 32 33 34 36 37 38

Teeth present:

Unerupted: 48 horizontal impacted                              

Restorations:  36m, 31 lingual

Root Filled: 31

Horizontal Bone Loss: 20-30%

Calculus Present: 18d, 17dm, 16m, 26dm, 28d, 44d, 46m, 36m, 37dm

Radiographic Report: (Bitewing)

View: bitewing

Quality: grade 1 and 2

18 17 16 14 13 24 26 27
47 46 34 36 37 38

Teeth Present on Radiograph:

Restorations: 36m

Crestal Bone Loss: 10-15%

Overerrupted: 17

Caries into Dentine: 16, 26, 27, 28, 46o

Treatment Visits: (Verbal Consent was Gained from Patient and Medical History was Checked, with no changes throughout)

Visit 1: 21/05/13

Explained to patient that the treatment was to be carried out over several visits. Verbal Consent gained from patient for photographs and the use of the treatment carried out as my case study.

  • intra oral exam was undertaken
  • PPD’s under taken
  • recession and mobility completed
  • Plaque score completed 39%
  • OHI given, electric tooth brushing instructions given and introduced bottle brushes green, purple and red
Visit 2: 11/06/13
  • Pre-treatment photos taken with patient’s consent
  • bitewings taken
  • plaque score 29%
  • re-enforced OHI
Visit 3: 09/07/13
  • Buccal infiltration administered to 26, 27, 28 with epinephrine 1:80, 000 2,2ml
  • Access gained with high speed and round heard diamond bur
  • Caries removed on 26, 27, 28
  • 26 and 27 filled with composite a1 shade and occlusion checked
  • 28 filled with amalgam and calcium hydroxide placed before the restoration as filling was deep
  • Post ope given and patient warned about 28 being deep and might be sensitive to hot and cold
Visit 4 :10/09/13
  • 46 and 16 caries removed without LA as patient requested to try without LA first and if needed she would let me know and it was not required at this time
  • 46 setting calcium hydroxide placed before amalgam
  • 16 was filled with composite a1 shade
  • occlusion checked for both dentations
  • gross scale lower arch
  • introduced single tufted brush and re-enforced OHI
  • diet sheet given
Visit 5: 18/09/13
  • plaque score 17%
  • vitality test done on the 28 and it gave positive response
  • localised RSI completed on pockets greater than 4mm without LA as patient declined LA
  • Full mouth fine scale
  • reviewed bottle brushes
  • re- enforced OHI
  • diet analysis carried out and diet advice given

Maintenance Phase Patient to be Reviewed every 3months, for 6months on her Periodontal Condition


One of my concerns, while treating this patient, was the fact that the patient did not seem to have any concerns about her teeth and she also didn’t seem to understand why she had been referred to professor Preshaw’s clinic by her GDP as she said her teeth didn’t bother her that much other than a little bit of bleeding upon brushing occasionally. Going by this, it made me assume that patient might not be ready to make any changes.

Yet, this turned out to be a mistake, because patient seemed very open to change. So even though, as a health care professional I am to understand that not everybody is ready for a change and I have to respect patient’s wishes, it would be wrong to rash to conclusions based on other observations than the one done by myself.

When I met the patient, she was very interested in what I was advising her and she was open to making changes. This taught me that I should not just read the letters and the notes and assume that patient might not be ready for a change. This also made me think about the methods of identifying patients that are ready for change and the ones that are not. Never take patients at face value, but always observe them and communicate with them in order to find out their inner concerns.

Another thing that I realised while treating this patient, was that sometimes when you are looking at the carious teeth on the radiograph, you cannot predict how deep the lesions are, before carrying out treatment; I always told myself that the lesions are not that deep, only to find them deeper than what I actually anticipated.

Overall I am quite pleased with the outcome of the treatment and patient was happy with the results.

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