Treatment Planning Assignment #3

Amy Formanek
I. Assessment
a. Patient Interview
51 year old male who works as an author

511 Caucasian

Was wearing a low brim cap and dark welding glasses with
towel in hand
b. Medical / Dental History
Traumatic brain injury when he was 13 years old

Brain injury causes severe sensitivity to florescent lighting

Causes hypertension and migraines

Had surgery to replace corneas in 2009

All medications include: Aspirin- since 2013 as needed to help

with migraines. This could cause excessive bleeding.

Ibuprofen- since 2013 as needed to help with migraines. This

could cause excessive bleeding. Excedrin Migraine- since

2012 as needed to help with migraines. This could cause

excessive bleeding.

Hadnt had a cleaning in 7 years

Patient had fallen behind on dental appointments

Wanting to get back on track with appointments

Very well kept oral hygiene

Fillings were present on all posteriors

 Crown placement on #30 and #19

Patient had braces when he was young

Bitewings last taken in 2014 and then again 07/01/216

No new findings were made

Patient can dislocate TMJ bilaterally on demand without pain

Slight anterior attrition

Plaque score was 21%

28 teeth were present, no 3rd molars

Generalized recession without sensitivity

c. Implications of treatment
Patient wore the welders glasses and towel over eyes during

treatment

I had to make sure that I did not move the towel on his face

I was unable to show the patient oral lesions or OHI, only

describe them

Patient was feeling a little distressed from the lights

I had to make sure I did not shine the light in his eyes
d. Social History
Never used tobacco

Average family man

Spends a lot of time on his books

e. Vital Signs
Blood Pressure 07/01/2016 was 130/88
 Blood Pressure 02/10/2016 was 134/88

Weight is 207 pounds

f. Extra Oral / Intra Oral Examination
Extra Oral: within normal limits

Intra Oral: slight exostosis of maxillary and mandibular

anteriors. Occlusal class l left and right. 3 mm overjet. #19
and #30 facial class l furcations.
g. Periodontal Examination
Generalized gingivitis with localized slight periodontal disease

isolated to molars

B calculus class

General probing depths 3mm or less with the exception of 25

distal buccal, 23 distal buccal, 19 mesial and distal lingual,
and 18 mesial and distal lingual with 4 mm.
h. Oral changes based on special needs
Overall home care was good

Most all of plaque and calculus was interproximal

Would be beneficial for patient to have more than verbal OHI if

he could look
i. Radiographs
Last set of bitewings were years ago

After evaluating bitewings from 07/01/2016, no new concerns

raised
II. DH Diagnosis
a. Level of Health

Patient is overall healthy

 Patient does very well with homecare considering limited

visual instructions

He could benefit with more flossing instructions if he was able

to watch as I floss so he could mimic the movement
b. Diagnosis
Generalized gingivitis

Localized slight periodontal disease to molars

III. Plan
a. Consultations Necessary

Periodontist

General Dentist

6 month dental hygiene recall

b. Treatment Goals
Improve plaque score

Reduce recession

Improve home care flossing technique

Minimize recurrence and progression of the disease

Good prognosis for his oral health

c. Phases of Treatment
Control dental biofilm

Asses for inflammation

Encourage patient to upkeep homecare

Continue with regular 6 month recall visits

IV. Implementation
 a. Consultations

Make appointments with a periodontist, dentist and 6 month

follow up

Find an area where he can comfortably watch and demo OHI

b. Instruments / Methods used
Cavatron on lower anterior for staining and calculus

Hand instruments- Area specific curettes and sickle scaler

Fluoride Vanish given to support receded areas and margins

Keeping light out of patients eyes

Allowing and being mindful of patient putting towel over eyes

c. Homecare Aids
Patient does well with homecare

Sent him home with new soft brush, floss and toothpaste

Did suggest an electric toothbrush to help with pressure and

hopefully interproximal biofilm
d. Anesthetic
No anesthetic was used on this patient

If it were administered, use epinephrine to control bleeding

Talk to patient so he knows where the needle is and going at

all times
e. Prescriptions
If sensitivity develops from recession Prevident could be
prescribed
V. Evaluation
a. Evaluating care
 I feel I was informative with flossing techniques

In hopes his plaque score and probing depths will be lowered

in 6 months
b. Follow up charting
New full mouth probing chart will be done
c. Radiographs
Made 4 new bitewings and no new evidence present

Continue with radiographs to evaluate homecare at 1 year

d. Patient OH behavior changes
Continued lower plaque score

Patient purchase and use electric toothbrush effectively

Patient have less interproximal calculus