1.

Special Needs Assessment

a. Patient interview: Perry Perio
i. Pt. is a functionally independent 72 yr. old, male with hearing
loss.

ii. Chief complaint: Plaque and calculus removal.

iii. Health behaviors: Brushes/Scope rinses 1 qd., flosses every
other day

b. Medical/Dental history
i. Medical History: Knee replacement surgery 2 years prior, premed. is required. Medications: Pt. reports the following med.s 1
x qd.: Levothyroxine, 50 mg. for hypothyroidism and
Hydrochloret (HCTZ) 12.5 mg. for water retention. There are no
dental concerns with these meds.

ii. Dental history: 6 mo. recall, reports to yearly exams, last

cleaning 7 mo. ago.

iii. Special need:

1. Age related concerns: Frequent breaks in position and
restroom visits.

2. Hearing loss concerns: Hearing aids in both ears. Pt.

reports to significant hearing loss without hearing aids.
Pt. hears and responds well to direct, face to face
communication and lower tones.

c.

Implications to treatment: Due to age, pt. requires frequent breaks in

position and restroom visits, a shorter appointment time may be
helpful. Due to hearing loss, pt. reported face-to-face communication,
slower speech and lower tones are beneficial.

d. Social history: Pt. maintains good health. Food intake is regular and
pt. stated a preference of nuts for snacking and drinks a lot of water.
Fluoride exposure is high.

e. Vital signs: Blood pressure: 125/75.

f. Intra-oral/Extra-oral examination:
i. Intra-oral: Missing teeth #1, 16, 17, 32. Plaque score: 12%.
ii. Gingiva: Recession gen. facial. Color is pink gen, interdental
papilla is pointed/normal gen. mand. blunted gen. max., contour
of marginal gingiva is gen. facial recession, with Class I furc.
buccal of #18, 19. Consistency is firm/resilient gen., and texture
is stippled gen. B.O.P.: spontaneous mand. anteriors. Attrition:
mand. anteriors.

iii. Extra-oral: Gen. w.n.l.

g. Periodontal examination:
i. Localized B.O.P.: #23, 24, 25, 26.
ii. Furcation involvement: Class I buccal #18 and 19.
iii. Probing depths: Did not probe new pt. and previous depths not

recorded.

iv. Depths and range were not recorded.

h. Oral changes: No oral changes in connection with pt. age/hearing loss.
i. Radiographs: n/a.
2. Diagnosis (Problem Identification)
a. Gingivitis: Localized mand. anteriors. Pt. has arrested gen. mod. perio.
disease. Neither are related to age/hearing loss.

3. Plan
a. Consultations necessary: n/a.
b. Treatment goals:
i. Education: Demonstrate brushing/flossing with attention to
lower lingual anteriors, show/discuss recession areas and
concerns of BOP, discuss increase flossing routine to 1 qd.
Educate patient on gingivitis and need to continue arrestment of
periodontal disease.

ii. Treatment: hand scale FM, plaque removal with prophy/fine

paste, floss FM with waxed floss, fluoride varnish treatment due
to recession. Patient role: follow OH instructions of
brushing/flossing with soft-bristle toothbrush, develop a regular
routine of flossing and returning for 6 month recall to check
progress, plaque and calculus removal.

c. Phases of Treatment
i. Preliminary: Reassure pt. to take breaks/change position as
needed. Discuss hearing loss needs with pt. and best way to
communicate.

ii. Phase I therapy: Plaque/calc. removal via hand scale, polish,

fluoride varnish.

iii. Outcomes evaluation of phase I: Six month recall for eval. of pt.
compliance.

iv. Phase II surgical: If disease progresses at 6 mo. recall, possible

further periodontal evaluation and pt. education.

v. Phase III restorative: Pt consult of next phase of the disease.

vi. Evaluation of overall outcomes: 6 mo. recall.
vii. Phase IV maintenance: 6 mo. recall for evaluation and further
education.

d. Hygienist role: Anticipate/meet needs of pt. for breaks, appointment

time and communication, evaluate health/dental history including
premedication/medications and med codes, cleaning/scaling, taking
prescribed radiographs, status checks of probing, fluoridation,
polishing, education of OH and gingivitis and how it relates to perio.
disease progression, offer alternate tx. options, 6 mo. recall for eval. of
patient.

e. Patient role: Provide best communication process, feedback regarding

positioning needs/restroom breaks, accurate/up to date information of

health/dental history, adherence to home OH treatment plan, and show
up at 6 mo. recall.

4. Implementation:
a. Instruments used: UNC15 periodontal probe, hand mirror, Gracey 1/2,
11/12, 13/14, Explorer, Sickle scaler (hand scaling cassette). Hand
scaling of the FM, polish, fluoride varnish, OHI to discuss homecare
needs and have the pt. demo. brushing and flossing with suggestion of
adjustments as needed, offer anesthesia as needed for sensitivity,
offer different positioning options as needed for patient comfort.
Encourage pt. to use a soft bristled toothbrush, waxed floss, and
fluoridated toothpaste.

5. Evaluation:
a. At recall appointment, evaluate/check compliance, gingival conditions
& current state of gingivitis, reversibility of B.O.P. paying attention to
mand. anteriors, establish a baseline for probing depths and current
state of perio. disease, record findings on follow up charting, scaling,
while monitoring pt. discomfort and effectiveness of tx. methods. OHI
is within the scope of pt. age and abilities. Encourage 6 mo. recall to
reverse active gingivitis and continue arrestment of periodontal
disease. Follow-up radiographs may be prescribed by the dentist as
needed to monitor bone loss levels

Works Cited

Wilkins, E. M. (2013). Clinical Practice of the Dental Hygienist, 11th Edition. Philadelphia,
PA: Lippincott Williams & Wilkins.

Drug Information Handbook for Dentistry (18th ed.). (2012). Hudson, OH: Lexicomp.

Hebl, L (2014) Dental Hygiene III Notes, KCC.