Sadie Keeney

Treatment Planning Assignment #2

Dental Hygiene II

1. Assessment
a. Health History: This patient is a 25 year old woman from Venezuela.
b. Medical/Dental History: Patient wanted to be seen because she
thought she had a cavity. Patient has never had her teeth cleaned in
the United States. She was seen for a routine teeth cleaning. She has
had other appointments at the college, but not in the dental hygiene
clinic. The patient has seen a dentist regularly. Patient brushes with a
soft bristle manual toothbrush. She flosses once a week. The patient
has asthma. She is allergic to penicillin and metronidazole. She takes
an Albuterol/salmeterol for the treatment of asthma.
Albuterol/salmeterol inhaler has no effects on the oral cavity or dental
treatment. She also takes a birth control pill (Ethinyl Estradiol and
Desogestrel) for the prevention of pregnancy. The birth control pill has
no effects on the oral cavity or dental treatment.
c. She has no history of alcohol or drug abuse.
d. BP: 100/70.
e. Extraoral Examination: Patient looked healthy from a visual
perspective. Patient had a unilateral TMJ crepitis on her left side.
Patient complained of having difficulty in opening/closing her mouth.
Patient bruxes. Intraoral Examination: She had melanotic macules on
the lips, maxillary tori, and a white coating on her tongue. Patient had
light extrinsic staining on her lower lingual anterior teeth. Gingiva were
generalized pink, pointed, knife edged, firm and resilient, and stippled.
Patient has very tight contacts and very tight tissue. She had localized
receded marginal gingiva on teeth 24, 25, 26, and 27. The patients
plaque score was 41%. Patient had a significant amount of subgingival
calculus. She was a Class B calculus.
f. Periodontal Exam: Patient had generalized probing depths of <4 mm.
She did have BOP.

g. Radiographs: My patients last radiographs were bitewings on

4/10/14. Her radiographs showed horizontal bone loss localized to the
molars. I would recommend doing a complete CMS when she returns
for her six month re-call.
2. Diagnosis: This patients main concern is her and localized slight
periodontitis.
3. Plan
a. Periodontist.
b. Treatment goals: improve the patients gingival tissue and prevent
her bone loss from progressing.
c. The preliminary phase includes the assessment data. Phase 1 is the
therapy phase. The therapy phase would involve removal of biofilm
and calculus, and talking with patient about preventative measures
such as flossing every day and brushing with an electric toothbrush to
stimulate gum tissue. We measure dental biofilm by taking a plaque
score. Dental biofilm is removed by flossing, polishing, and scaling.
Prevention techniques will be taught to the patient. These will include
teaching my patient the correct flossing technique to keep her tight
interproximal spaces free of bacteria. I will do calculus detection using
the Ramjford teeth. Calculus will be removed using an ultrasonic
scaler, Gracey 13/14, Gracey 11/12, Gracey 1/2, and a Sickle Scaler.
The outcomes of the therapy phase are clinical signs of inflammation,
dental biofilm control, and patient cooperation. Fluoride will be given
using fluoride foam in APF trays for four minutes. This patient does not
need the surgical phase, phase 2. Phase 3 is the restorative phase.
This patient does not need this. The evaluation of outcome would be
evaluating the periodontal response after getting restorations,
implants, or prosthetics. This patient does not have any of these so it
does not affect the patient. Phase 4 is maintenance. This entails
further appointments to keep up with care and using proper oral
hygiene instruction. The status of the patients bone loss and gingiva
will need to be evaluated to know if the problems have gotten worse or
improved. She seemed to be very willing to improve her overall oral
hygiene. She has very tight contacts so it is very important to keep
using proper flossing techniques and interdental aids to keep bacteria
out.

d. My role is to provide the best care during the appointment through

hand scaling, OHI, polishing, and fluoride trays. The patients role is to
improve OHI by creating a flossing habit, especially interproximally and
stimulating her gum tissue. The patient should be sure to comply with
the OHI instruction to use the correct flossing method, the interdental
brushes, brushing with an electric toothbrush, and forming a habit of
brushing twice a day and flossing once a day.
4. Implementation
a. Sickle, 11/12, 13/14 Graceys, Ultrasonic, Explorer
b. Hand scaled entire mouth, ultrasonic debridement, polished full
mouth with fine prophy paste, flossed, applied fluoride trays
c. Home care aids: Flossing, Interdental brushes and an electric
toothbrush.
d. No anesthetic necessary
e. No prescriptions were given.
5. Evaluation
a. I will evaluate the improvement of oral hygiene, probing depths,
signs of inflammation, plaque score, bleeding on probing, and calculus
detection during my patients recall appointment.
b. I think she would benefit from getting a complete CMS done to
monitor bone loss on her molars.
c. Determine if plaque and calculus has decreased and if her brushing
and flossing habits have improved. Also, check to see if the bone loss
has remained the same or worsened.

References:
Wilkins, Esther. (2013). The dental hygiene care plan. Clinical Practice of the
Dental Hygienist. (351-360).

Crossley, H.L, Meiller, T.F. & Wynn, R.L. (2013). Drug Information Handbook
for Dentistry.