SERA: Special Care

Jacob de Werd
Mesa Community College, Dental Hygiene Program
DHE:232: Theory
Dawn Brause
March 3, 2024
S: setting

For my rotation I went to special care clinic at AT Still University. At special care, we

work to serve the underserved population of people who have disabilities or medical histories

that are too complex for normal office care. We are also given more time with the patients in

order to work around accommodation needed to work with these patients in order to give them

the care they need to maintain their oral health. During this semester we worked in a regular

chair setup similar to how we work at in clinic, however due to one of our patient’s

circumstances we worked in a private “quite room” to help assist with one of the patients.

E: experience

I arrived to special care clinic 15 minutes early to meet with Karen and discuss and

prepare for the patients we were going to meet during our visits. At my first rotation my first

patient was an older gentleman who was coming in for a perio- maintenance visit. We then

started with health history which revealed an extensive health history. Health history revealed a

history of kidney cancer and stage 3 kidney disease due to the cancer, Barrett’s disease, Sceptic

arthritis, pre-diabetes, and had history of chewing tobacco (Appendix B). After reviewing Health

history, the patient was due for images. This proved to be a challenge as the patient’s maxillary

molars had inversions causing overlap as well as using a NOMAD device. Although we had been

trained to use a NOMAD device, both my classmate and I had not used one since our time in

radiology. Although we did well with anterior PAs it took us a couple of shots to do the bite wing

angulation (Appendix B). After a few tries trying to get the right molar bite wing shot, Karen

tried herself, but was not able to. After doing radiographs, my classmate performed E/O, I/O

exam. Although E/O exam did not reveal anything, I/O revealed a numerous of atypical findings.

Erosion and attrition was generalized throughout the mouth due to the multiple medications and
Barrett’s disease-causing stomach acid to come up from the esophagus. Additionally, the bottom

lip was severely corrugated from the chewing tobacco along with a few circumscribed

leukoplakia on the lingual side of the premolars, although we had mentioned this to the patient,

we had to be careful with what we had said as he was very sensitive on the subject as he said that

nothing was wrong, and he was fine. Lastly, the patient had coated tongue with some erythema

which was biopsied a while back ago and revealed no cancer. We then moved on to probing, due

to time I decided to probe the entire mouth (Appendix A). Most of the reading were generalized

2-3mm with a few localized 4mm readings with no bleeding. We then split half the mouth for

scaling. Due to the patient’s erosion, we decided it would be a better idea to not use the cavitron

due to the already weakened enamel and decided to use instruments instead. Most of the build up

was areas of heavy plaque and debris. The universal gracey was effective using sweeps on the

buccals and the linguals of the teeth to remove plaque. Anterior sickle scaler was then used on

the anterior teeth to help remove small calculus deposits in sextant 5. Although I was able to get

most of the plaque out with instruments, flossing helped to remove the last little bit in

interproximal areas. After finishing with the instruments, Karen did a check at the end and the

patient was dismissed.

On our next visit we performed a Prophy on a patient with major mental illnesses. The

patient’s health history indicated severe mental illnesses, tardive dyskinesia due to all the

antipsychotic medications the patient was taking, autism, anxiety, bipolar disorders, OCD, and

suicidal tendencies and had a history of pneumonia (Appendix B). The patient needed to be kept

sitting up as well due to her anxiety and not feeling like she is in control of the situation and the

cavitron was not able to be used due to the pneumonia. We met our patient inside one of the quiet

rooms so she could have an easier time with the appointment. The patient was a lively and free-
spirited patient and loved to listen to music, so we decided to play her favorite artists in order to

ease her mind during the appointment. Due to the patient coming in every month to get a

cleaning done to help maintain her oral health, we started by brushing her teeth with a soft bristle

toothbrush to get the majority of the plaque off. The dentist came in and took a look at her bridge

and filling that were recently placed and stated to not touch tooth 18 due to it bothering the

patient. We then split the mouth and used a universal gracey and anterior sickle scaler to help

remove plaque around the mouth. Heavy plaque was present on the premolars, where we had to

go back multiple times to clean them. During this time the patient would like to stop and talk and

sing to the music that was playing, which presented with some challenges as we had to gauge her

actions of when she as going to talk in order to remove instruments from her mouth to avoid any

accidental injuries. Additionally, we had to take some breaks as the patient suffered from Tardive

dyskinesia from her medications and would fling her arms when talking. These small episodes

proved to be easy to follow and overall, the cleaning went well the patient then was finished with

a polish on select teeth due to some of her teeth bothering her.

R: reflection

Overall, reflecting on the two appointments, it was nice to see how different system

manifestations can affect patients. It was interesting to see how a patients Barrett’s disease,

multiple medications, and chewing tobacco can produce significant damage to enamel through

erosion. Additionally, the patient's attitude towards his chewing tobacco also showed me how

autonomy is preserved in some ethical situations. Although Karen recommended a biopsy of the

tissue, he was adamant about not having the procedure done as he had already had his tongue

biopsied, and it came back negative. It showed me that sometimes not everything we would like
to do to give our patient the best possible care is necessary to a patient's point of view, and we

must respect and value their wishes.

With the second appointment it taught me how to be patient with a patient and how to

better converse with them in order to make them feel comfortable. What was also different is that

I had to figure out different ways to avoid talking about the patient’s teeth due to her OCD so she

would not fixate on the issue later on. It taught me to have and think of different talking points

with the patient so she would not be distracted by this and would have a great appointment

overall. Additionally, it also taught me that even though the patient was fun and great, sometimes

I had to set a boundary of getting the patient to open so we could clean the teeth and not just talk

by being respect and asking the patient if they could open so we could continue cleaning.

Overall, the patients were delightful and showed me different aspects of dental hygiene.

A: application

Now that the rotation is over, it has taught me many things that I can apply to my own

patient care as a dental hygienist. Firstly, it has taught me to pay attention to my patient's voice

and respect their choices that they decide are necessary for their health, but also know when their

autonomy is infringing on the standard of care that I need to provide. It allows me to gauge my

patients and to make the proper ethical decision, which I will continue to utilize throughout my

hygiene career. It also has taught me the importance of E/O, I/O examination in order to identify

areas of disease, even though I always do well with E/O, I/O I would like to continue to better

myself at it and identify more atypical findings. I would also like to carry on the patience and

interactions that I had also learned during the rotation. Although I feel like I do well with this

already, some patients are different and need more patience and care than others. I will utilize
what I learned today to help deal with those patients when they cross my path during my career

and help them with this need.

Appendices

Appendix A
Appendix B