Patient Treatment Plan

1. Assessment
a. Patient Interview
i. Problem is plaque and calculus
ii. 34 year old male
b. Medical/Dental History
i. Patient visits the dentist and a physician regularly
ii. Experiences high blood pressure
iii. Has asthma
iv. Crohn’s disease
v. Wisdom teeth removed
vi. Had braces previously
vii. Brushes 2 times a day using an electric Sonicare toothbrush
viii. Flosses 1 time a day
ix. Uses ACT mouth rinse 1 time a day
x. Ingests fluoride from water
xi. Allergic to penicillin and supprax – develops hives
xii. Medications include – Allegra, Lialda, Lisinopril, Zocor
c. Social History
i. Regular drinker – 10 a week
ii. Snacks between meals – apples, chips
d. Vital Signs
i. Blood pressure – 136/88
ii. Pulse, temperature, and respirations not available
e. Intra/Extra Oral Examination
i. Extra oral – experiences jaw clicking and soreness sometimes
ii. Chipped lips
iii. Fordyce granules on lips
iv. Linea alba on buccal mucosa
v. Incisive papilla present
vi. Tonsils absent
vii. Bilateral mandibular tori
viii. White tongue coating
ix. Generalized light decalcification
x. Light extrinsic staining – colored brown
xi. Gingiva – generalized pink, pointed, knife-edged, firm and resilient,
stippled. Localized red, receded, spongy and edematous.
xii. Plaque score – 13%
f. Periodontal Examination
i. Generalized probing depths < 3mm
ii. Localized 4 mm depths
g. Radiographs
i. 4 bitewings
 ii. Slight localized bone loss -- #3,4,5
2. DH Diagnosis (Problem Identification)
a. Level of Health
i. Generally good gingival health, localized areas that need improvements
and modifications (mandibular anteriors)
b. Diagnosis
i. Generalized gingivitis
ii. Slight localized periodontitis
c. Prognosis
i. Good and can be turned around if patient uses proper brushing and
flossing techniques and follows the treatment plan
3. Plan
a. Consultations Necessary
i. None necessary
ii. 6 month DHYG recall in order to keep up on health
b. Treatment Goals
i. Successfully remove plaque and calculus without harming tissue
ii. Reinforce brushing and flossing techniques
iii. Motivate to improve oral health and reverse disease
c. Addresses Phases of Treatment
i. There is no physical, mental or medical conditions that require
appointment modifications
ii. There are no conditions on the intra and extra oral exam that require
modifications
iii. Plaque – light
iv. Bleeding – light
v. Calculus – moderate
vi. Some gingival recession and furcation involvement
vii. Needs OHI on brushing, flossing, and developing a routine
viii. Hand scale 4 quadrants
ix. Plaque removal with a prophy angle and medium paste
x. Fluoride varnish
xi. No need for auxiliary procedures such as anesthesia
xii. Does not need radiographs as they are up to date
4. Implementation
a. Take patient’s blood pressure and go over medical/dental history, review
medications and allergies
b. Perform intra and extra oral examination and document anything found that is
abnormal
c. Probe
d. Check for calculus on ramfjord teeth
e. Disclose teeth and calculate plaque score
 f. Give oral hygiene instruction. Show patient BASS technique and how to properly
floss in order to improve gingivitis. Discuss eating/snacking habits and the impact
they have on tooth decay
g. Explore all teeth and hand scale those with calculus. Patient does not need any
anesthesia or the cavitron because the calculus isn’t too heavy
h. Polish using a medium paste to remove extrinsic stains and floss all teeth
i. Apply fluoride varnish
5. Evaluation
a. How care is evaluated
i. Check for any remaining calculus with explorer
ii. Use disclosing solution to check for remaining plaque
b. Follow up charting
i. New probing depths and hope to see improvements
c. Radiographs
i. Update radiographs ( 4 bitewings and a CMS) and check bone level and
for areas of decay
d. Patient OH behavior changes
i. Improvements on probing depths
ii. Improved plaque score
iii. Decreased amounts of bleeding and inflammation
6. References
a. Wilkins, E. M. (2017). Clinical practice of the dental hygienist. Philadelphia:
Wolters Kluwer.
b. Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2014). Drug information
handbook for dentistry: including oral medicine for medically compromised
patients & specific oral conditions (20th ed.). Hudson, OH: Lexicomp.