A Case in Point

Mrs. White, a 45-year-old Hispanic female, presents to your practice for an initial dental hygiene appointment. She is new to the area, but reports that she faithfully had dental and dental hygiene care every six months. Mrs. White’s medical history is significant for the following:

  • Myopia for which she wears corrective lenses
  • Borderline hypertension--no medications prescribed
  • Prediabetes--diet and exercise recommendations made by nurse practitioner
  • Overweight--diet and exercise recommendations made by nurse practitioner, advised to lose 20 pounds
  • Smokes 1/2 pack of cigarettes daily for over 20 years

Oral history is significant for the following:

  • Generalized gingivitis with moderate plaque present on lingual surfaces of mandibular premolar and molar teeth and supragingival calculus and plaque noted on the lingual surfaces of mandibular incisors
  • No evidence of current or recurrent decay, previous history of decay with occlusal restorations present on all first molars, and a crown on tooth #31
  • Presence of nicotine stomatitis

Mrs. White reports that she has been advised previously to quit smoking and has attempted to do so on three occasions without success. She states that she was told that she had gingivitis by her previous dentist and dental hygienist, but that it was not serious and that she should brush and floss more. Mrs. White admits that she does not floss regularly, but brushes twice daily with a manual toothbrush.

Given this information about Mrs. White, take a moment and imagine her sitting in the operatory. She is ready for her appointment. What is your next step? Do you need more information or are you ready to proceed with treatment? Have you mentally picked up your curet eagerly anticipating removing the debris from the mandibular region? If your answer is “Yes, let’s get started,” read this paper again. Mrs. White does not need the plaque and calculus removed yet nearly as much as she needs to know about her risk factors for oral and systemic health. Mrs. White needs you to take time out to review your findings from assessments and speak frankly with her about her health status. This is the perfect moment to discuss symptoms of diabetes that Mrs. White may not realize she has, to educate her about the links between smoking, hypertension, diabetes and CVD. Mrs. White is 45, overweight and Hispanic, placing her at greater risk for converting from prediabetes to diabetes. Nevertheless, with some effort, she can avoid that step through a concerted effort of diet and exercise. She may not realize that a modest weight loss will benefit her greatly in terms of improved general health. In addition, now is when you can begin discussing the link between her oral health and general health. The presence of chronic gingivitis coupled with prediabetes and borderline hypertension places Mrs.White at risk for further health issues. Also, she presents with nicotine stomatitis, another reason to incorporate smoking cessation as part of your education discussion and treatment plan. Mrs. White has known she has gingivitis, admits she does not floss regularly, but does brush daily. What recommendations would you make to help improve her oral home care regimen? Would you switch her to a powered toothbrush, have her use a mouth rinse, recommend Colage Total® toothpaste? How often would you want to see Mrs. White for follow-up?

In the course of reviewing this information, it is possible to see how the traditional dental hygiene appointment can be reframed. That 45-minute “cleaning” just does not fit the profile of needs for Mrs. White. She deserves a schedule that allows for assessment and education, treatment and education, and re-evaluation and education. Is all this necessary for a simple case of gingivitis? Perhaps the real question we should be asking is, do we ever see simple cases of gingivitis? What have we been missing by not allowing adequate time to perform comprehensive assessment and risk factor analysis?

This case and the questions posed provide the dental hygiene reader an opportunity to reflect on the prospect of incorporating oral medicine into dental hygiene practice. Continually reviewing the literature related to oral and systemic health--and discerning relevant components--will enable dental hygienists to refine practice and continue to provide quality care to their patients.