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PERIODONTAL CARE PLAN

Patient Name: Age: 31


Date of initial exam: 9/21/17 Date completed: 11/9/17

1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance) explain
steps to be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis and/or care.
Patient’s last physical was in February 2017, and sees a doctor at Beaumont Family Practice;
she could not remember his name. Patient is currently under the care of a physician due to having
Type 1 diabetes; this systemic condition will alter treatment in that we will need to monitor her
glucose levels through out appointments to minimize and or avoid occurrence of hypoglycemia.
The patient takes medications to control her diabetes. Ondasnsetron; 1 pill for nausea as needed,
dental considerations are to monitor vitals and fluids, as well as oral cavity for adverse reaction
to medication. Tresiba insulin (if pump is not being used) & Humalog Insulin (regular daily use
insulin) - amount varies as glucose changes, patient has insulin pump; dental considerations are
to monitor vitals at every appointment, patient at risk for hypoglycemia, place on frequent recall
to evaluate healing response. Diabetics may be more susceptible to infection and have delayed
wound healing, assess salivary flow as a factor in caries, periodontal disease, and candidiasis,
Ensure patient is following prescribed diet and is taking medications regularly, keep a readily
available source of sugar or fruit juice available incase of insulin overdose. The patient has her
diabetes under control and takes glucose tests regularly. She instructed to give her gummy
snacks that she carries with her if she begins to endure low blood sugar. Patient also takes over
the counter iron pills for anemia, as well as B12, Fish oil, and Vitamin D. The patient does not
require pre-medication or medical clearance. Having Type 1 diabetes increases the patient’s risk
of having periodontal disease by being more susceptible to infections and having a delayed
wound healing. The patient smoked for 10 years and has not smoked in the last 3 years. Smoking
is a contributor to periodontitis due to the restriction of blood flow in the minor capillaries, when
blood flow is reduced healing response is reduced. The patient’s vitals were all with in normal
limits.

2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint,
present oral hygiene habits, effect on dental hygiene diagnosis and/or care).
The patient is a new patient at Dr. Hagler’s office, she is aware of her existing condition of
periodontitis. She also made note that she has battled with recession over the years. The patient
had an FMX series taken at Dr. Hagler’s office in May of 2017 and had Vertical BWX taken in
the clinic on 9/28/2017 to supplement treatment by checking level of bone loss and carries
condition. The patient’s chief complaint is that she needs a cleaning because it has been 5+ years
since the last cleaning and as come to the clinic to reduce expenses. She is excited for treatment
and is very interested in halting the progression of her periodontitis. Due to infrequent dental
exams and cleanings the patients dental I.Q is low. When chair side patient education is given,
she is at full attention, engaged by asking questions, and is involved when shown a better
technique for oral care. Patient uses an electric oral-b toothbrush and brushes morning and night
using a scrub technique with Colgate Total Care toothpaste. When brushing at the sink, the
patient was taught a modified Stillman’s brushing method and it worked very well for her.
Patient uses floss aids every other day and rinses with Listerine regularly. She is not confident
with the overall appearance of her teeth. The patient states that she has bleeding upon brushing
and flossing sometimes and has varying sensitivity. The patient noted that she does clench at
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night when falling asleep. There are not any signs of attrition nor did she have any TMJ
problems. Bruxism can cause gingival recession and periodontal bone loss and can be a
contributing factor to the patients over all oral condition of periodontitis. Patient does not have
decreased salivary flow, she does drink about 2 sugary drinks per day and when she chews gum
she chooses sugar free.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)
During the head and neck extra-oral exam there were no lesions or swollen lymph nodes
found. During the intraoral exam there were no lesions but there was a mid-palatine tori, the
etiology is developmental. Signs of bruxism were not blatantly present in the oral cavity however
the patient is aware of her clenching habits. Bruxism can cause gingival recession and
periodontal bone loss. The patient does not own a mouth guard and states that she notices her
clenching most when she is trying to fall asleep right before she relaxes. Educate the patient
about how occlusal trauma occurs, some alveolar bone resorption results because of increased
pressure placed on the surrounding bone. This could result in rapid periodontitis. This was the
only oral habit noticed. There was one suspicious area noted on the distobuccal cusp on tooth
#31. Dental caries result in defects of the tooth structure, which causes plaque to accumulate in
that area, which in turn, can cause gingivitis and periodontitis. Patient’s occlusal classification
for right molar is unclassifiable, right canine class I, left molar class I, left canine class I.
Patient has WNL overbite and WNL overjet, with a 1 mm midline shift to the left, no cross bite
and no open bite. There is not a threat to the periodontium or TMJ due to malocclusion.

4. Periodontal Examination: (color, contour, texture, consistency, etc.)

a. Case Classification: V Periodontal Case Type: III


b. Gingival Description:

App't 1: (9/21/17)
Papillae architecture: generalized - scalloped, localized to mandibular anterior - flat.
Gingival color: generalized marginal – red
General Consistency: with-in normal limits
Gingival Margins: Generalized – Rolled
Papillae: Localized to mandibular anterior – Bulbous
Suppuration: None
Surface texture (papillary and marginal): Smooth
Surface texture (attached): Stippled

App't 2: (9/28/17)
There was no change at appointment 2 because, there was not any treatment rendered, only
a gingival index taken.

App't 3: (10/5/17)
Appointment 3 was the first day of treatment. There was a slight reduction of
generalized redness due to patient implementing better home care taught during chair side
patient education.
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App't 4: (10/10/17)
Max. Right
#2-5: Scalloped, marginal slight redness, smooth, buccal margins rolled
#6-8: Scalloped, marginal red/pinkness, smooth, buccal margin of #6 rolled
Max. Left
#9-11: Scalloped, marginal slight redness, smooth, buccal margins rolled
#12-15: Scalloped, marginal slight redness, smooth, buccal margins rolled
Mand. Left
#18-21: Scalloped, marginal slight redness, smooth, buccal margins rolled,
#22-24: Localized to anterior bulbous, flat papillae, smooth, marginal redness
Mand. Right
#25-27: less bulbous shape to papillae also becoming more scalloped in shape, pink,
smooth, noticeable reduction of rolled margins
#28-31: Scalloped, pink, smooth, buccal margins are becoming less rolled

App't 5: (10/19/17)
Max. Right
#2-5: Scalloped, marginal slight redness, smooth, buccal margins rolled
#6-8: Scalloped, marginal red/pinkness, smooth, facial margin of #6 rolled
Max. Left
#9-11: Scalloped, marginal slight redness, smooth, facial margins rolled
#12-15: Scalloped, marginal slight redness, smooth, buccal margins rolled
Mand. Left
#18-21: Scalloped, pink, smooth, buccal margins slightly less rolled
#22-24: Localized to anterior slightly bulbous, more scalloped shape to papillae, smooth,
slight marginal redness
Mand. Right
#25-27: papillae are slightly bulbous and more scalloped in shape, pink, smooth, margins
are only slightly rolled
#28-31: Scalloped, pink, smooth, buccal margins are only slightly rolled

App't 6: (10/26/17)
Max. Right
#2-5: Scalloped, marginal slight redness, smooth, buccal margins rolled
#6-8: Scalloped, marginal red/pinkness, smooth, facial margin of #6 rolled
Max. Left
#9-11: Scalloped, pink, smooth, facial margins slightly less rolled
#12-15: Scalloped, pink, smooth, buccal margins only slightly rolled
Mand. Left
#18-21: Scalloped, pink, smooth, buccal margins slightly less rolled
#22-24: slightly less bulbous anterior papillae, more scalloped shape to papillae, smooth,
slight marginal redness
Mand. Right
#25-27: papillae are no longer bulbous and more scalloped in shape as much as they can be
with recession, pink, smooth, margins are no longer rolled
#28-31: Scalloped, pink, smooth, buccal margins are no longer rolled
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Appt 7: (11/9/17)
Max. Right
#2-5: Scalloped, pink, smooth, buccal margins no longer rolled
#6-8: Scalloped, pink, smooth, facial margin of #6 less rolled
Max. Left
#9-11: Scalloped, pink, smooth, facial margins are no longer rolled
#12-15: Scalloped, pink, smooth, buccal margins are no longer rolled
Mand. Left
#18-21: Scalloped, pink, smooth, buccal margins no longer rolled
#22-24: no longer have bulbous anterior papillae, more scalloped shape to papillae, smooth,
slight papillary redness due to newly accumulated supra-gingival calculus deposits
Mand. Right
#25-27: papillae are no longer bulbous and more scalloped in shape as much as they can be
with recession, slight papillary redness due to newly accumulated supra-gingival calculus
deposits, smooth, margins are no longer rolled
#28-31: Scalloped, pink, smooth, buccal margins are no longer rolled
At this point all quadrants had been scaled, the tissues appeared much healthier except for the
papillae in the mandibular anterior where the newly formed deposits appeared and there is slight
redness, this should reduce due to removal during post calculus evaluation. Patients periodontitis
is halted.

c. Plaque Index: Appt 1: 1 – Good Appt 2: N/A Appt 3: 2 – Fair Appt 4: 1.1 – Good Appt
5: 1.3 – Good Appt 6: .83 – Good Appt 7: .5 – Good

d. Gingival Index: Initial: 1.17 GI - Fair Final: .21 GI - Good

e. Bleeding Index: Appt 1: 24% Appt: N/A Appt 3: 18% Appt 4: 0% Appt 5: 0% Appt 6: 0%
Appt 7: 0%

f. Evaluation of Indices:
1. Initial:
Patient’s gingival index was 1.17, fair. Patient’s indices for the mesial, distal, facial, and
lingual surfaces of the designated teeth did not exceed the score of 2, however on tooth
#25 it met the score of 2 on all surfaces. Patient had 6 bleeding points out of 26 teeth
with 156 available surfaces which is an indicator of inflammation and gingivitis, which
periodontitis is preceded by. (The bleeding score and gingival index were taken on
separate days, there was some bleeding where she had a score of 2 only on the day the
gingival index was taken). If the patient’s gingival index continues to grow above a 2,
the patient’s periodontal status could worsen.

2. Final:
Patient’s gingival index was .21 (good). This gingival index improved from the initial
index. The mesial, distal, facial, and lingual surfaces were all ranked a 0 or a 1. #25
which previously presented with 2 on all surfaces now presented with 0 on all surfaces.
The removal of calculus enabled a positive healing response. At this point the patients
periodontal disease is halted

g. Periodontal Chart: (Record Baseline and First Re-evaluation data)


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1.Baseline:
The patient’s probing depths for maxillary arch facial are all within normal limits (1-3
mm) except for #3 which has recession with a Pocket Depth (PD) 1mm and 1mm Tissue
Height (TH) with a CAL of -2mm, #15 – (Buccal) PD 5mm. Patient’s probing depths for
maxillary arch lingual are all within normal limits except for tooth #3 – (Distal) PD
5mm with slight furcation involvement #15 – (Distal) PD 5mm, #14 - (Distal) PD 5mm.
Patient’s probing depths for mandibular arch facial are all within normal limits except
for #19 – (Buccal) PD 5mm (Mesial) PD 5mm, Recession recorded on #20 (Facial) PD
1mm TH 2mm CAL -3mm #21 (Facial) PD 1mm TH 2mm CAL -3mm #24 (Mesial)
PD 1mm TH 1mm CAL -2mm #25 (Facial) PD 1mm TH 2mm CAL -3mm, #31
(Distal) PD 4mm. Patient’s probing depths for the mandibular arch lingual are within
normal limits except that #22-#27 were inconclusive due to excessive amount of supra-
gingival calculus, which is a contributing factor to her recession on the facial of those
teeth and the active periodontitis. Because the patient has low numbers of CAL she is
classified to have slight to moderate periodontitis and is at risk for further progression of
periodontitis into the severe category especially with her systemic disorder of type 1
diabetes. The patient had no suppuration. Class I furcation involvement on #3.Give
patient education about how furcation involvement could cause mobility and eventually
tooth loss if periodontitis is not halted.

2.Firstevaluation:
All of the patient’s probing depths were with in normal limits (below 3mm). She did have a few
areas of significant recession; #2DF – 2mm CAL 5mm, #15DF – 3mm CAL 6mm, #24DF – 3mm
CAL 5mm, #25MF – 4mm CAL 7mm, #25F - 3mm CAL 4mm. The tissues healed to reduce the
class 1 furcation in #2 (found after removing calculus), #3 and #15. The patient’s gingival tissues
have healed very well. I praised her on her home care, fore it is a large contributing factor of her
improvement into a healthy state. Patient’s periodontal disease is currently halted.

5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth, occlusion,
abfractions)
Midline shift: 1 mm to the left
Amalgam Rest.: #2 2-O, #15 3-O, #31 3-O
Missing: #1, #4, #16, #17, #30, #32
TCR: #8 DF
Porcelain Fused to Metal crown: #12
Caries: #32 O (Could possibly cause tooth loss if not restored & detrimental to other teeth)
(History of caries puts this patient at a greater risk for future caries, causing potential increase
in periodontal disease.)

6. Treatment Plan: (Include assessment of patient needs and education plan)


App't 1: (9/21/17)
Medical/Dental history
Patient appointment
HIPAA
Statement of release
Pre-rinse
Head & neck/ Intraoral exam
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Periodontal assessment (radiographic findings completed w/o pt on 9/27/17)


Dental charting w/o xrays
Plaque score: 1 - Good
Bleeding score: 24%
Pt. ed. – Patient had previously been informed of gum disease and periodontitis during her
dentist appointment in June. I gave my patient further explanation of what gum disease and
periodontitis (periodontal disease) is. I explained to patient that periodontal disease consists of
gingivitis, which is the inflammation of her gums and is reversible, and periodontitis that is the
inflammation of bone and is irreversible. I informed her with out using her own radiographs that
she has some moderate bone loss at least in the maxillary right quadrant due to the furcation on
tooth #3 and when bone loss occurs periodontitis is present, and all we can do is halt the
progression. I also informed her that her periodontitis is mostly due to her irregular dental visits
and is enhanced by having Type 1 diabetes. While at sink during tooth brushing after plaque
score was take I also gave instructions on how to use the modified Stillman’s method by adding
a 45 degree angle to the sulcus to her circular scrub method. I asked patient to be my periodontal
case study patient, and patient accepted.
App't 2: (9/28/17)
Medical/Dental History
Vertical bitewings taken
Gingival Index: 1.17% Fair
(apt. was only 1 hour and no pt ed was given)
App't 3: (10/5/17)
Medical/ dental history
Pre-rinse
Take intraoral pictures
Retake any X-Rays if necessary
Take plaque score
Take bleeding score
Take Full Periodontal charting for the Mandibular Right Quadrant
Take detailed gingival description for entire mouth
Patient Education session 1 (Brushing & plaque)
Complete Mandibular Right Quadrant Ultrasonic scaling
Complete Mandibular Right Quadrant fine scaling
Patient Education session 1 (Brushing & plaque)
LTG- Patient will maintain plaque score of 1 or lower at each appointment
STG- Patient will be able to define plaque by next apt.
STG- Patient will reduce gingival inflammation by next apt.
STG- Patient will be able to effectively demonstrate sulcular brushing by next apt.
Open patient education session with an explanation of the topics that are going to be covered
(Session1- Plaque and Brushing, Session2- Periodontitis and Flossing, Session3 – Caries
and Fluoride) along with short and long-term goals, then begin first topic.
Teach Topic (plaque): Question patient for knowledge, “Can you tell me what plaque is, and
what it can cause?” Using flip book and intraoral pictures to show patient tartar that
develops when plaque is not removed, talk about plaque score and how we plan to
improve it. Define plaque: soft, sticky, colorless film of harmful bacteria that constantly
forms on teeth. Causes cavities, & periodontal disease (gingivitis & periodontitis).
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Explain that plaque develops when food is left on teeth then turns into calculus (tartar)
when not removed.
Teach Skill (Brushing): Using typodont show patient bass method, and let the patient
demonstrate on typodont. Instruct patient to make sure to brush morning and night for at
least two minutes. While at sink: Use PPE, patient looking in the mirror, modify
technique, disclose, point out missed areas, and teach tongue brushing.
Ending the session: Ask the patient if she has any questions. Then ask the patient questions:
“Tell me what I taught you about plaque. Do you remember what plaque can cause?”
conclude with noting the topic for the next session (periodontitis and flossing). Remind
the patient that we are a team.
App't 4: (10/10/17)
Medical/Dental History
Pre-Rinse
Take Plaque Score
Take Bleeding Score
Patient Education Session 2 (Periodontitis & Flossing)
Complete Full Periodontal Charting for Mandibular Left Quadrant
Take detailed gingival description of entire mouth
Complete ultrasonic scaling Mandibular Left Quadrant
Complete fine scaling Mandibular Left quadrant
Patient education session 2 (Periodontitis & flossing)
LTG- Patient will halt the progression of disease by implementing taught techniques and
will reduce gingival bleeding to less than 5% by the end of treatment.
STG- Patient will be able to define Periodontitis by next apt.
STG- Patient will correctly demonstrate flossing by next apt.
STG- Patient will reduce bleeding score by 5% at each appointment
Open session by asking the patient if she has any questions from the plaque/brushing session.
Review any areas that the patient has a question about.
Teach topic (periodontitis): Question the patient for knowledge of periodontitis “Can you tell
me what periodontal disease is? Are you aware you have periodontitis?” Use flipbook,
pictures and patient’s radiographs to show patient bone loss. Define periodontal disease,
starts as gingivitis and leads to periodontitis, bone level migrates apically, and teeth can
become loose, and eventually be lost. Demonstrate good flossing techniques on
typodont. Allow patient to practice on typodont.
Teach skill (Flossing). Put on PPE, let patient floss while looking in the mirror. Modify
technique as they are flossing. Disclose and allow patient to evaluate how well the
interproximal plaque was removed. Point out areas that they missed and assist patient if
needed.
Ending the session: Ask the patient if she has any questions. Then ask the patient: “Tell me what
you remember about periodontitis. Why is it so important to floss?” Encourage patient
to apply new techniques taught at home. Preview the next patient education session topic.
Remind patient that we are a team.
App't 5: (10/19/17)
Medical/Dental History
Pre-Rinse
Take Plaque Score
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Take Bleeding Score


Patient Education Session 3 (Caries and Fluoride)
Complete Full Periodontal Charting for Maxillary Right Quadrant
Take detailed gingival description of entire mouth
Complete ultrasonic scaling Maxillary Right Quadrant
Complete fine scaling Maxillary Right Quadrant
(Pt. Ed. Caries & Fluoride)
LTG- Patient will have caries restored by 4 month recall appointment
STG- Patient will make an apt with dentist to restore caries as soon as treatment is
complete
STG- Patient will define caries process by 2 week recall apt
STG- Patient will implement a fluoride treatment to her daily routine by 2 week recall apt
Open session by asking the patient if she has any questions from the periodontitis/flossing
session. Review any areas that the patient has a question about.
Teach topic (Caries): Question the patient for knowledge of the caries process “Can you tell
me what caries are? Are you aware you have carries?” Use flipbook, pictures and
patient’s radiographs to show patient carries. Define carries, decay that occurs when
specific types of bacteria produce acid that breaks down the tooth. The process begins
with demineralization (or destruction), a chalky, white area on the tooth surface. Then,
can progress into a brown area, where the tooth surface is being broken down. It is the
most common disease in the world. Once the decay has reached the pulp of the tooth, a
root canal can be done to save the natural tooth. In some cases, a root canal is not
possible and an extraction is the only option. Options include fluoride or Restoration
(Filling). typodont.
Teach skill (Fluoride). Explain to patient what fluoride can do for her teeth. Fluoride is a
naturally occurring mineral that re-mineralizes tooth enamel and reduces sensitivity. It
helps prevent decay and is naturally in some foods and water. Explain to patient the
different ways that fluoride can be applied to her oral hygiene routine. Through
toothpaste, public drinking water, varnish applied in the dental offices, and rinses.
Ending the session: Ask the patient if she has any questions. Ask the patient: “Tell me
what you remember about carries. How can fluoride help reduce cavities?” Encourage
patient to apply new techniques taught at home. Evaluate the patient’s progress towards
all of the goals that have been specified for her. Help the patient determine the next steps
toward achieving those goals. Remind patient that we are a team. Establish a recall
schedule that meets the patient’s needs.

App't 6: (10/26/17)
Medical/Dental History
Pre-Rinse
Take Plaque Score
Take Bleeding Score
Complete Full Periodontal Charting for Maxillary Left Quadrant
Take detailed gingival description of Maxillary Left Quadrant
Complete ultrasonic scaling Maxillary Left Quadrant
Complete fine scaling Maxillary Left Quadrant
Polish/Plague free
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Fluoride
Patient education - Teach patient that gingival status will change after dental hygiene treatment
and that some areas may be sensitive. Let the patient know that Arestin will be placed at the next
appointment. Arestin is an antimicrobial to prevent any further bleeding and increase healing of
the gingival tissue and periodontal pocket. Let patient know that she will need to come back in 2
weeks for a post operation appointment. Explain that this will allow us to show her how her
gingival tissue has healed. Ask the patient how well the brushing and flossing is going after
learning the new techniques that were taught in the patient education sessions. Allow the patient
to ask any questions about the learned techniques and information.
App't 7: (11/9/17)
Medical/ dental history
Pre-rinse
Take plaque score
Take bleeding score
Take final gingival index
Post calculus
Post periodontal
Arestin
Note any referrals if needed
Establish recall
Patient education:
Take time to answer any questions the patient may have about the treatment she received and
about the new oral care techniques she was taught during the patient education sessions. Stress
the importance of maintaining frequent dental visits in order to keep the disease progression at a
minimum and to stop it completely. Regular dental cleanings promote the health of gingival
tissues and allow carries to found in the early stages so they can be stopped early on. Inform
patient not to brush in the areas for 24 hours or floss in the areas where Arestin is placed for 10
days. Patient MUST be shown the exact areas where Arestin was placed. Let patient know that
she will be seen again in the spring for a recall cleaning and also to evaluate tissues.

7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony
crests, thickened lamina dura, calculus, and root resorption)
Localized slight horizontal bone loss in the upper left #14-15. Localized moderate horizontal
bone loss in the upper right, lower right, lower left, and lower anterior #18-20 #23-26 #28-30
with slight furcation involvement on #3. #30 had a defective restoration at the time Xrays were
taken; the tooth is now extracted. Calculus can be noted in the upper right, upper left, lower left,
lower right, and lower anterior. The cavity on #31 is distorted by the amalgam restorations on the
tooth; however, cavities allow for further destruction and should have it restored. The existing
bone loss indicates disease presence, it is the humoral (over reactive) response to the pathogenic
bacteria that causes periodontitis. The calculus effects the overall periodontal health by causing
the gingival inflammation and gingivitis that progressed into periodontitis because of the living
layer of bacteria that lives upon it.

8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient response,
complications, improvements, diet recommendations, learning level, progress towards short and long
term goals, expectations, etc.) The progress notes should be written by appointment date.
Appt. 1 (9/21/17): Patient appointment practice, HIPAA, and statement of release were all
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signed. Medical/dental history, pre-rinse, head and neck exam, periodontal assessment with
full periodontal charting except for radiographic findings and dental charting with out x-rays
were completed. Plaque score and bleeding score were also taken. Patient was classed as a
prophylaxis class V and periodontal case III. I explained to my patient what the periodontal
case study was and that if she agreed to be a part of it she will need to come in once a week
and only one quadrant can be cleaned at a time, patient agreed. We discussed how plaque
causes gingivitis and gingivitis can lead to periodontitis, especially while having a systemic
disease such as diabetes like she has. While brushing at the sink, I taught patient to modify
her tooth brushing method to a modified Stillman’s method by turning the brush 45 degrees
towards the sulcus. Learning level: Involvement.
Appt. 2 (9/28/17): Medical/ dental history, pre-rinse, initial gingival index was taken,
vertical bitewings were also taken to supplement treatment and to check for cavities the
patient knew about from previous dental visit. There was no patient education at this
appointment. It was only for 1 hour to finish collecting data for periodontal care plan.
Appt. 3 (10/5/17) Medical/dental history, pre-rinse, and intra oral pictures were taken of
patient, plaque score 2 Fair, bleeding score 18%. First patient education session was
completed; discussed all LTG/STG (Plaque & brushing) Long-term goal: Patient will
maintain plaque score of 1 or lower at each appointment. Short-term goal: Patient will be
able to define plaque. Short-term goal: Patient will reduce gingival inflammation by using
effective sulcular brushing. (Pt. Ed. Periodontitis & flossing) Long-term goal: Patient will
halt the progression of disease and gingival bleeding by implementing taught techniques.
Short-term goal: Patient will be able to define Periodontitis. Short-term goal: Patient will
correctly demonstrate flossing. Short-term goal: Patient will reduce bleeding score by 5% at
each appointment. (Pt. Ed. Caries & Fluoride) Long-term goal: Patient will have caries
restored by 4-month recall appointment. Short-term goal: Patient will make an apt with
dentist to restore caries as soon as treatment is complete. Short-term goal: Patient will define
caries process. Short-term goal: Patient will implement a fluoride treatment to her daily
routine. Patient’s response to the Brushing goals: She was able to maintain the adequate
plaque score and was able to describe plaque. Patient was questioned about knowledge about
plaque and asked what is can cause. Explained that plaque causes gingivitis and can lead to
periodontitis, and caries. Plaque reforms in the mouth daily, you must brush twice a day,
angling the toothbrush toward gum-line. Told patient to brush extremely light, because of
exposed root surfaces. Showed the patient pictures of plaque in the patient education flip
book. Patient demonstrated brushing at the sink. Disclosed the patient at the sink, and
showed patient how to brush on the typodont, then the patient brushed the typodont.
Instructed patient to brush tongue as well. Reviewed with the patient what plaque is and what
it can cause. Discussed that the next session will be about flossing and periodontitis.
Learning level-Involvement. Plaque score 1, Good, bleeding score 24%. Completed
ultrasonic scaling of the mandibular right quadrant, and full quadrant periodontal charting,
and began fine scaling of the mandibular right quadrant.
Appt. 4 (10/05/17)
Medical/ dental history, pre-rinse, completed fine scaling on mandibular right, ultrasonic
scaling of the mandibular left quadrant, fine scaling and full quadrant periodontal charting.
Plaque score: 2 Fair, Bleeding score: 18%. Second patient education session; topic was
about flossing and periodontitis. Reviewed all LTG/STG (Plaque & brushing) Long-term
goal: Patient will maintain plaque score of 1 or lower at each appointment. Short-term goal:
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Patient will be able to define plaque. Short-term goal: Patient will reduce gingival
inflammation. (Pt. Ed. Periodontitis & flossing) Long-term goal: Patient will halt the
progression of disease and gingival bleeding by implementing taught techniques. Short-term
goal: Patient will be able to define Periodontitis. Short-term goal: Patient will correctly
demonstrate flossing. Short-term goal: Patient will reduce bleeding score by 5% at each
appointment. (Pt. Ed. Caries & Fluoride) Long-term goal: Patient will have caries restored by
4-month recall appointment. Short-term goal: Patient will make an apt with dentist to restore
caries as soon as treatment is complete. Short-term goal: Patient will define caries process.
Short-term goal: Patient will implement a fluoride treatment to her daily routine. Asked
patient to review what plaque is and what it can cause. Patient has lowered his plaque score
from the previous appointment. Questioned patient about knowledge about periodontitis.
The patient was aware that she has periodontitis. We discussed that periodontal disease has 2
types: gingivitis and periodontitis. This process starts as gingivitis and then it can progress to
periodontitis. We discussed that gingivitis is reversible, but periodontitis is not, bone level
will not grow back. Used the patient education flip book to show the patient pictures of
severe periodontitis and gingivitis on a progression scale. I forgot to bring up the patients x-
rays during the patient education session to show the areas she had severe periodontitis and
compare the areas to normal bone level areas, however the progression scale in my flip book
was used as examples and the patient responded very well in that she did not want her
disease to progress. Demonstrated how to floss on the typodont. Told the patient to floss in
between the teeth and go down into the sulcus as far as possible and to make a “C” shape.
Asked the patient to demonstrate how to use floss on the typodont, then had the patient floss
at the sink. The patient did not respond well to using floss but did agree to continue using her
floss pick aids. Asked the patient to tell me what periodontal disease is and discussed the
topic for the next session (caries). Learning level, self-interest.
Appt.5 (10/10/17)
Medical/ dental history, pre-rinse, plaque score 1.1 Good, bleeding score 0. Third patient
education session was completed, topic was caries and fluoride. Reviewed all LTG/STG
(Plaque & brushing) Long-term goal: Patient will maintain plaque score of 1 or lower at each
appointment. Short-term goal: Patient will be able to define plaque. Short-term goal: Patient
will reduce gingival inflammation. (Pt. Ed. Periodontitis & flossing) Long-term goal: Patient
will halt the progression of disease and gingival bleeding by implementing taught techniques.
Short-term goal: Patient will be able to define Periodontitis. Short-term goal: Patient will
correctly demonstrate flossing. Short-term goal: Patient will reduce bleeding score by 5% at
each appointment. (Pt. Ed. Caries & Fluoride) Long-term goal: Patient will have caries
restored by 4-month recall appointment. Short-term goal: Patient will make an apt with
dentist to restore caries as soon as treatment is complete. Short-term goal: Patient will define
caries process. Short-term goal: Patient will implement a fluoride treatment to her daily
routine. Taught patient about the carries process and how her diet influences the ability for
caries to occur. Since she is type 1 diabetic we talked about how she can implement a protein
such as beef jerky or a fat such as cheese to neutralize the pH in her mouth after consuming a
sugar. Explained that caries is from plaque / acid that begins to demineralize tooth enamel.
Starts as a white or chalky area, then it can turn into a brown area if not treated. Once decay
has reached the pulp, a root canal may be needed and in some cases, possibly an extraction.
Talked about fluoride and how it re-mineralizes enamel and slows the carries process and
that it is found in public drinking water, most tooth pastes and in over the counter mouth
| Jorden Prewitt 12

rinses. It was strongly suggested that she implement a fluoride rinse into her daily routine. I
congratulated patient for accomplishing most of her short-term goals so far! She had
continually reduced her plaque score at every appointment so far, improved her gingival
tissue with every cleaning, maintained a score of 0 for bleeding at almost every appointment,
and has demonstrated knowledge of plaque and periodontitis when questioned. When asked
if patient had made contact with Dr. Hagler’s office yet, she said she had not yet but still
plans to make an appointment with them to have her caries (#32 O) restored after the first of
the year due to insurance. Went back over brushing and flossing at sink with patient, gave the
patient a floss aid with disposable floss heads to aid patient with flossing. Patient asked if she
was using her electric tooth brush correctly also. I demonstrated with the demo electric brush
and typodont in patient education room. Discussed recall schedule of 4 months (March of
2018). Learning level, action. Completed ultrasonic scaling and fine scaling of maxillary left
quadrant and full quadrant periodontal charting. At chairside I gave the patient an interdental
brush to clean areas not easily cleaned with floss with instructions to use it gently due to
having multiple exposed root surfaces. Patient responded very well to use of interdental
brush.
Appt. 6 (10/26/17)
Medical dental history, pre-rinse, plaque score .83 Good bleeding score 0%. Completed
ultrasonic and fine scale of maxillary right quadrant and full quadrant periodontal charting.
Completed plaque free and topical fluoride treatments with instructions to not eat or drink for
30 minutes, to not brush her teeth again until tonight, and that fluoride re-mineralizes the
enamel and slows the carries process. Asked patient how using the interdental brush going,
patient loves it and is using it every other night due to fear of abrading root surfaces.
Explained to be gentle and to use every night. Went back over brushing to ensure patient was
confident in sulcular brushing. Learning level, Action.
Appt. 7 (11/9/17)
Medical/ dental history, pre-rinse, plaque score .5 Good bleeding score 0%. Completed full
post periodontal charting. Post calculus was completed, there were a few new soft supra-
gingival deposits on the interproximal exposed root surface of #24 and #25 and one on the
facial of #3. Post Op intra oral pictures were not taken due to lack of time. Patient is
successful in meeting all of the long and short-term goals except for making the appointment
with Dr. Hagler due to insurance circumstances, she is very adamant in getting it taken care
of, I believe she will be as successful as she already has been Arestin was not place because
the patient did not have any pockets over 3mm, she is also trying to become pregnant, the
tetracycline in Arestin would not be safe. Patient had no questions regarding treatment.
Referrals to DDS for caries #32O. Ending gingival statement; patient has generalized
moderate periodontitis with no bleeding. Recall- 4 months March 2018.

9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion, tooth
morphology, periodontal examination, recare availability)

The prognosis for my periodontal patient is moderate. She is systemically involved with type 1
diabetes, if it were not for being systemically involved, her prognosis would be good. The
patient’s attitude toward treatment was great however, and even assured me that she will
continue to meet her goals even after treatment is completed. The patient was excited to learn
about her dental health during treatment, and was always involved by asking questions and
making sure she was doing her home care correctly. The patient has 26 teeth and several
| Jorden Prewitt 13

restorations, and infrequent dental visits, she is 31 years old, this puts her at a high risk for
caries. She had class I furcation involvement on #2, #3, #15, if inflammation were to reoccur,
these sites could show again and become more involved. Because of her furcation
involvement this puts my patient at severe risk for more periodontal involvement. All of the
patient’s pockets that were over 3mm have reduced to within normal limits. I believe the
patient is now aware that it is highly important to keep up with her oral health. The patient
now has a regular dentist to go to for restorative care, she does have insurance, but needs to
wait until after the first of the year. The patient is still interested in having her cleanings done
in the clinic and is willing to come back in the March for her recall. I feel as though my
patient will continue to heal before I see her next semester, but with being systemically
involved with type 1 diabetic and constantly having to consume sugars that cause plaque
accumulation, she is at a higher risk for reoccurrence of progression of periodontitis.

10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
(Note: Include date of recall appointment below.)

Suggestions for re-evaluation would be for the patient to have all pockets remain at 3mm and
below and to see Dr. Hagler to have her carries fixed before she comes back in. Plaque score
and bleeding score of reduced to 0, along with continued use of soft, sulcular brushing
techniques. Referrals to DDS for caries #32O. Patient’s recall schedule is 4 months; the
patient’s next appointment will be March of 2018.

11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health, probing
depths)

The patient expressed great efforts of plaque control. Her plaque score bell curved a little
due to consuming sugar to control her glucose levels, but the score decreased at the last two
appointments. I did not have the patient brush before the plaque score was taken after she
had consumed sugar so that she could see the impact it has on her oral cavity. The initial
plaque score from the first appointment was 1 and at the final appointment, the plaque score
was .5. The patient’s bleeding score started as 24%, and ended with 0%, the patient’s
gingival index did decrease from 1.17 fair to 0.21 good. At the initial appointment, the
patient had localized 4-5 mm pocket depths in the posterior region. By the final appointment
at the end of treatment, the patient had generalized 1-3 mm throughout the entire mouth.
The overall gingival health changed by showing a color change. At the start of treatment,
most areas were red especially in the marginal region; at the end of treatment almost all
areas were pink, after removal of the calculus deposits, those areas should become pink as
well.

12. Patient Attitudes and Cooperation:

My periodontal patient was interested and excited to be my periodontal patient when I


explained she was eligible to be my patient. When I explained the requirements needed from
the patient, she happily agreed. She was always on time to her appointments and was
enthused to be at every appointment and asked about anything she wanted to know
regarding her oral health. During patient education sessions, she asked questions, and was
very engaged about her oral health. She was active in wanting to achieve her goals in the
| Jorden Prewitt 14

patient education sessions, and if she believed she would not be able to meet a particular
goal, she let me know, and we modified the goals as needed. At every appointment, she
would be excited to tell me that she is following through with her goals, and always asked
about the state of her tissues, and that she could see and feel the changes. The most difficult
goal for her was and is flossing. She agreed to use the disposable flossers and rinse it after
each tooth but did not enjoy and actually refused to use floss. The patient was actually very
excited when I gave her the interdental brush. She could see where she was missing the
interproximal areas with the tooth brush in the mirror with the disclosing solution and was
amazed at how well the interdental brush removed the plaque. Overall the patient was very
compliant and wanted to improve her overall oral health. At the final appointment, I let the
patient know that she will come back for her recall appointment in 4 months, and we will
follow up with the treatment, she agreed.

(Brushing & plaque)


LTG- Patient will maintain plaque score of 1 or lower at each appointment
- Patient completed this goal by end of treatment
STG- Patient will be able to define plaque by next apt.
- Patient successfully completed this goal
STG- Patient will reduce gingival inflammation by next apt.
- Patient successfully completed this goal
STG- Patient will be able to effectively demonstrate sulcular brushing by next apt.
- Patient successfully completed this goal
(Periodontitis & flossing)
LTG- Patient will halt the progression of disease by implementing taught techniques and
will reduce gingival bleeding to less than 5% by the end of treatment.
- Patient successfully completed this goal
STG- Patient will be able to define Periodontitis by next apt.
- Patient successfully completed this goal
STG- Patient will correctly demonstrate flossing by next apt.
- Patient successfully completed this goal but is using flosser instead of floss at
home
STG- Patient will reduce bleeding score by 5% at each appointment
- Patient successfully completed this goal

(Caries & Fluoride)


LTG- Patient will have caries restored by 4 month recall appointment
- Patient plans to have this goal completed
STG- Patient will make an apt with dentist to restore caries as soon as treatment is
complete
- Patient plans to complete this goal
STG- Patient will define caries process by 2 week recall apt
- Patient successfully completed this goal
STG- Patient will implement a fluoride treatment to her daily routine by 2 week recall apt
-Patient has successfully completed this goal by using a more fluoridated
Colgate tooth paste.
| Jorden Prewitt 15

13. Personal Evaluation/Reaction to Experience:

During the periodontal patient treatment, I was able to see how much of a difference a
dental hygienist can make on patient’s oral health. I was able to see the difference in tissues
once they had been scaled. This also helped the learning level for my patient as well. I was
able to show her the difference of health compared to inflammation in her own mouth. I did
my best to stay on track at each appointment for my periodontal patient there were a couple
of times that the second fine scale check had to be completed at the next appointment due to
lack of time and/or instructor availably. I was able to stick to a strict time schedule, that way
I would not fall behind. I was very fortunate to have such a cooperative patient during this
process. I could not be more ecstatic about my patients results. It is an amazing feeling to be
able to impact someone in such a positive manner.