I.

Assessment
A. Patient interview
No sensitivity or other concerns
Uses a Sonicare electric toothbrush, Crest Prohealth toothpaste,

flosses daily
B. Medical/Dental history
Osteoarthritis
Thyroid dysfunction
Penicillin allergy
Medications
Diphenhydramine: histamine antagonist (xerostomia)
Lortab: pain reliever (no dental effects)
Metoprolol: anti-hypertensive (local anesthesia with

vasoconstrictor may be safely used)

Synthroid: thyroid product (no dental effects),
Mirapex: anti-Parkinsons (xerostomia)
Follows regular re-care appointments
C. Social History
Smokes 1 pack of cigarettes a day
Likes to snack on fruit and pretzels between meals
D. Vital Signs
BP- 128/70 on 3-28-16, 122/78 on 4-11-16
E. Intra/Extra oral
Extra oral- WNL
Intra oral- generalized recession, generalized healthy gingiva

with localized inflammation, generalized extrinsic staining,

erosion on all anteriors, Fordyce granules on lips and buccal

mucosa, scar tissue on vestibule and maxillary tuberosity,

hematoma on incisive papilla, exostosis of maxilla and mandible,

fissured tongue with yellow coating, plaque score- 41% (1 st

appointment), 21% (2nd appointment)

F. Periodontal Exam
Generalized 1-3mm, localized 4-5mm on mandibular molars
Generalized recession, no bleeding present
Periodontal case type = generalized gingivitis, localized slight on

mandibular molars
G. Radiographs
Slight bone loss
II. Dental Hygiene Diagnosis (Problem, Identification)
A. Level of Health: Good, localized areas that are fair
 B. Diagnosis: Gingivitis
III. Plan
A. Consultations Necessary
DDS for regular comprehensive oral exam
B. Treatment Goals
Remove all plaque and calculus
Implement OHI
C. Addresses Phases of Treatment
Perform intra/extra oral exam
Assess gingiva and hard tissue
Probe full mouth
Detect calculus on probability teeth
Perform plaque score
Hand scale, polish, and floss full mouth
Apply fluoride varnish
IV. Implementation
A. Consultations
DDS for regular comprehensive oral exam
B. Instruments used
11/12 Explorer, Gracey 1/2 and sickle H5/33 for anteriors,

Gracey 11/12 and 13/14 for posteriors, periodontal probe, and

slow speed prophy angle

C. Methods
(1) Extra/intra oral exam
(2) Assess gingiva and hard tissue and record findings
(3) Probe full mouth and record findings
(4) Use explorer to detect and record areas of calculus on

probability teeth (3, 9, 12, 19, 25, 28)

(5) Perform plaque score and discuss OHI
(6) Hand scale full mouth
(7) Polish full mouth with fine prophy paste
(8) Floss full mouth
(9) Apply fluoride varnish to the full mouth and provide post-op

instruction

D. Homecare Aids
Rubber tips to stimulate areas of inflammation (mandibular

molars)
E. Anesthetic
None needed
F. Prescriptions
None needed
V. Evaluation
A. Evaluate care
 6 month recall; patient is overall healthy with good homecare
B. Follow up charting
Plaque score
Probing depths and any bleeding
Recession
Calculus detect
C. Radiographs
Bitewings, periapicals, and CMS as needed
D. Patient OHI behavior changes
Compare plaque scores
Ask patient about current homecare behavior
Type of toothbrush and toothpaste?
BASS technique twice a day?
Flossing and using rubber tip?
Assess any bleeding of gingival tissue

References

Wilkins, E. M. (2013). Clinical practice of the dental hygienist. Philadelphia, PA:

Lippincott Williams and Wilkins.

Wynn, R. L., Meiler, T. F., Crossley, H. L. (2014). Drug information handbook for

dentistry. Hudson, OH: Lexi Comp, Inc.