Course:DHYG400/September-Block 5 Group D

This does look much better in the Word document that I posted in the discussion forum. If you want a PDF copy of the old WIKI please let me know! Willena

Block 5 Group D: Marianne, Willena, Christine, Amy, Nicole, Rosie HISTORY Your client, Mr. Cross, has been a client at your office for 6 years and is recently divorced. You welcome Mr. Cross to the office and make him feel comfortable and safe and update medical history and dental concerns.

Explain to Mr. Cross what today’s appointment is about, from recall to BW’s to full mouth probe, scaling and polishing/fluoride if necessary. Mr. Cross agrees to have everything done for today’s appointment. After the exam you determine that he now presents with generalized interproximal gingivitis and localized chronic periodontitis in the mandibular molars. He has isolated 5 mm pockets interproximally. After PPDs are recorded and BWs taken, you would disclose Mr. Cross' whole mouth with a 2-tone dye and show him with a mirror where his plaque traps are, letting him know what each color represents and take intraoral pictures of darker areas. I would ask him what his oral hygiene consists of and its frequency at home.

You discuss with Mr. Cross the findings on the xrays comparing past and recent xrays and show good/bad prognosis. Along with xrays, discuss past and present full mouth probing results and explain what the numbers mean. In this situation it seems that things are not improving or don’t look so good so by allowing Mr. Cross to see radiographs and explaining what “deep pockets”, “gingivitis” and “periodontitis are”, it will allow him to see for himself that he has areas of concern and that you would like to make things better. If Mr. Cross seems concerned, make sure you take the time to answer any questions he may have or if he doesn’t have any questions, perhaps have him relay the information you just gave him so that you can make sure he understands the certain conditions he has. Always make the patient feel reassured that you are there to help them and that things will improve if he is willing to.

Develop an individualized intervention related to flossing that would be appropriate for each stage of change that Mr. Cross is in(i.e. one for each of the 6 stages). Intervention for each stage of change:

1) Pre contemplation -“A pre contemplator of a healthy behavior would need to acknowledge the benefits of adopting a new behavior in order to move to the contemplation stage.” (1) In the pre-contemplation stage you try to use any medical or family history like diabetes or heart problems to periodontitis... so I could stress the importance of increased interproximal hygiene. This would also show the client how the pro's outweigh the cons. Mr Cross does not take ownership for his perio condition. After disclosing, Mr Cross states that he wants all of the pink/purple dye off his teeth, he is not interested in seeing any plaque traps in his mouth. Mr Cross: “I am not interested in flossing it takes too much time, its too difficult to get my chubby fingers in my mouth and my gums do not hurt or bleed when I brush. My parents both had gum disease it’s hereditary.” Hygienist: “Periodontal disease is a silent disease, although once plaque sits along the gumline or between the teeth, it causes inflammation and the tissue between the gum and bone, called a pocket swells. Measurements of 1-3mm are manageable @ home by toothbrush and floss, measurements over 3mm where your toothbrush cannot reach will continue to trap bacteria and continue to increase in depth eventually destroys the bone that holds your teeth.” Mr Cross: “I am not interested in being lectured today. Please do what you have to do, I have another appointment I have to be at.” Hygienist: “Please feel free to ask any questions at any time because we are concerned for your oral and systemic health. Let’s continue seeing you every (3,4, 6 or 9) months and keep an eye on things. Keep up with your brushing and we will talk next time. And here is some information on an electric toothbrush to consider since it would keep more bacteria out of your mouth.” 2) Contemplation -“Contemplators seek out information and start to reevaluate themselves in relation to the particular behavior.” (1) If Mr. Cross is in this stage he would ask what we can do to make his current condition better, so you would explain to him his options. Options given could be:

•	more frequent visits to remove the plaque
            •	better oral hygiene at home by flossing more frequently 

By providing two different options in the contemplation stage the dental hygienist is providing the client with more ways to be sucessful; Allowing the client to be self efficient and encouraging a change to the preparation stage. (1) Since dental hygienists are able to provide individualized treatment plans it is important to stress the individualized pros for adopting this new behavoir; since Mr. Cross is a newly divorced the pros of having a more attective smile and fresh breath are used. (2) From here we will see what Mr. Cross thinks about the suggestions and answer any questions he may about the recommendations. After disclosing, Mr Cross is surprised to see pink purple areas between his teeth when showed in the mirror. Mr Cross: “What can I do to remove the all that junk off my teeth, will an electric toothbrush help?” Hygienist: “Removing the bacteria from between your teeth once a day with floss will get rid of the plaque and help control the periodontal disease in your mouth. As for an electric toothbrush, I can demo some models that will best meet your needs.” Mr Cross: “Flossing daily? It takes too long.” Hygienist: “Daily flossing will help remove the bacteria and allow the gums to properly heal adhering tighter to the tooth. Show me how you floss your front teeth, I'll hold the mirror for you and give you suggestions your flossing technique”. Mr Cross: “I might give flossing a try and see if it improves the health of my gums.” After debridement, send a sample of floss home with client. 3) Preparation -“A state of readiness for change in both attitude and behavior.” (1) When Mr. Cross agrees to making the following changes, discuss treatment plans of seeing him every 3 to 4 months for scaling and going over OHI for flossing, brushing and oral rinses. If Mr. Cross is worried about insurance coverage, have Mr. Cross check with his insurance plan or send in a pre determination to his insurance about scaling units.

In this stage the pros and cons are close together, so it is important to address the cons in an informative and encouraging manner. (2) This is especially done through instructions on flossing; This is done by demonstrating it in Mr. Crosses mouth using a mirror, followed by watching him floss, and adapting his flossing techniques. When encouraging Mr Cross to floss you can discuss the importance of incorperating it into a regular routine.

After disclosing, Mr Cross wants to decrease bacteria load in his mouth and wants to know what he can do @ home to stop the progress of his periodontal disease. Mr Cross: I can't believe I miss that much plaque between my teeth, what am I doing wrong? Hygienist: Please show me your flossing technique so I can work with you to effectively remove the plaque, I'll hold the mirror. Mr Cross: Client demo's c-shape flossing technique but leaves a gap between both hands while between the teeth. Hygienist: Great technique, although you can make it simpler on you by holding the floss about an inch apart each hand so that you have more control. Try incorporating flossing in your daily routine, example if you watch the news before going to bed, floss while watching the news, therefore you will make it part of your daily routine. After debridement, give sample of floss to client and book his next periodontal maintenance appointment in 3-4mos. 4) Action -“Effective strategies and techniques are needed to facilitate the adoption of positive behaviors to subsequently sustain the behavior and to prevent relapse.” (1)

While Mr. Cross is in this stage it is important to encourage him by showing him his improvements and monitor his flossing technique regularly, making the scaling appointments very important.

Mr. Cross’ s maintenance appointment, 3 months later. After disclosing, Mr Cross is happy with lowered plaque scores from previous appt. Mr Cross: “I am brushing 2x/day, and flossing 1x/day, my gums do not bleed!” Hygienist: “I love seeing the success you have made in your mouth. This is great since it has improved the appearance of your smile and will even lengthen your life! Do you have any problem areas? Do you find it to get easier to make your way around your mouth now then before?” Mr. Cross: “I can floss in just a few minutes now… its great and part of my routine.” After debridement, give sample of floss to Mr Cross and book his next perio maintenance appointment in 3-4mos. 5) Maintenance -“Maintenance may require engaging in reinforcement strategies and techniques for a period of six months to several years after the action stage so that the change can be sustained.” (1) -At the next recal visit that Mr. Cross comes to, make sure to go over his current periodontal statues, by using intra oral cameras or mirrors. By engaging him in every appointment, it keeps me aware of what his progress is. -Perform PSR or full mouth probing often to see results -Review flossing and TB techniques with Mr. Cross and discuss other options if necessary like floss picks, floss holders or rubber tip stimulators or soft picks. After disclosing, Mr Cross is happy with plaque score and his arrested perio status. Mr Cross: “I have no concerns with my oral hygiene habits, I start with flossing, then brushing then rinse morning and night.” After debridement, give sample of floss to Mr Cross and book his next perio maintenance appointment in 3-4mos.

6) Relapse -If Mr. Cross happens to relapse, which can happy at any stage (1), begin all over again and find out the reason for the relapse. See where things went wrong and work with a different approach or angle depending on his current attitude or situation. One year later – Mr Cross presents with interproximal plaque and gingivitis Hygienist: Mr. Cross it looks like you have not been flossing as regularly. Any problems we can help you with?” Mr. Cross: “I just needed a good cleaning to remember how great it felt to have a clean and health mouth. I’m looking forward to keeping it up better again.” References: 1) Astroth DB, Cross-Poline GN, Stach DJ, Tilliss TSI, Annan SD. The transtheoretical model: an approach to behavioral change. J Dent Hyg. 2002 Fall;76(4):286-95. 2) Tilliss, TSI, Stach DJ, Cross-Poline GN, Annan SD, Astroth DB, Wolfe MS. The transtheoretical model applied to an oral self-care behavioral change: development and testing of instruments for stages of change and decisional balance. J Dent Hyg. 2003 Winter;77(1):16-25.

This was some information I didn’t use… I’m not sure if you want me to include it and where! Just let me know! Then I would discuss etiology of plaque and its association to periodontal disease, if any he presents with any systemic diseases then I would also make a correlation to perio to emphasize importance of decreasing overall plaque in his mouth. I would show BWs to client and point out any boneloss and let him know how periodontal disease can be a silent disease and if its not treated show him on his BWs how it can continue to progress. We have visual/audio mini presentations in our office that I use consistently (Caesy) and I usually show them videos on Periodontal disease, it uses layman explanations where I sometimes use jargon when talking tooth talk. Once the video is finished I would ask Mr Cross if he has any questions or concerns.