Elizabeth Hart

Patient 1 - 2/11/19 and 2/18/19

I. Assessment
A. Patient is a 23 year old caucasian male. He is 5’3 and 125 lbs. He is in for

a recall prophy.

B. Medical: Past Surgery within the last 5 years “to get rod in femur”. Quit

smoking 3 months ago. Used methamphetamine 5 years ago. Pt has

exercise induced asthma and uses an albuterol inhaler (xerostomia). Acid

reflux that is controlled by the medication Ondansetron (slower heart rate).

Pt has a history of bipolar disorder, depression, and ADD. All are being

monitored by his physician. Pt is allergic to penicillins reporting his

“mouth swells up” if he receives it. Pt reported a history of high thyroid

levels in his family. He takes cyclobenzaprine for TMJ pain (xerostomia).

Dental: Pt seen multiple times in 2018 for TMJ pain. Last cleaning

4/19/18. Last comprehensive exam 8/4/17.

C. Social: None.

D. Vital Signs: 1st appt - BP 92/60 2nd appt - BP: 106/62 Pulse: 55

E. Extra Oral: Bilateral TMJ popping.

Intra Oral: Oral piercing taken out around 2/4/19. Irritation on facial tissue

of #25. Probing depths gen 1-4 mm with gen BOP. Plaque score: 89% at

first appt. 27% at second appt.

F. Radiographs: 4 BWs

II. DH Diagnosis
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A. Level of Health: Due to pt family history, physical, and mental disorders,

the patient is in fair health.

Diagnosis: Perio case type: Generalized moderate-severe gingivitis. Calc

class: B. Scaling in the presence of gingival inflammation.

III. Plan

A. Consultations Necessary: Pt has an incomplete tx plan for #14 occ.

Schedule with Minor OP. #18 Class V DS glass ionomer in Major OP.

Continued consultations with DIAG for TMJ pain.

B. Treatment goals: Remove plaque and calculus. Improved home care to

decrease level of gingivitis and bleeding. Get patient to understand the

importance of plaque removal to maintain the health of his oral cavity.

C. Address phase of treatment: Phase one- Plaque debridement due to the

89% plaque score. No probing on this appointment. Have pt back for

second appt and continue with FM probe and FM scaling. Evaluate pt

homecare with plaque score.

Phase two- Continue with consultations to DIAG for TMJ pain.

Phase three- Restore #14 in Minor OP and #18 in Major OP.

Phase four- Recall appt at 4 mos to monitor pt homecare and gingivitis.

IV. Implementation

A. Consultation: Explain to pt what plaque is and how it is disease causing,

and that is evident in his level of gingivitis. Explain what gingivitis is and

how it affects the longevity of our teeth, gums, and bone health. Explain
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his plaque score and review Bass Technique and C wrap floss.

Recommend brushing 2x/day and flossing either before bed or in the

morning, whichever works best for him. Try starting with 1-2 time/week.

B. Instruments used methods: Plaque debridement FM. Hand

Scale FM.

C. Homecare aids: Floss picks.

D. Prescriptions: None.

V. Evaluation

A. How do you evaluate care? With plaque score, and assessing inflammation

of gums. Follow up with pt about how home care is going, if he has been

able to brush twice daily, and floss once or twice with regular floss or the

floss picks.

B. Follow up charting: Compare probing and BOP at 4 mos recall to assess pt

OH.

C. Radiographs: No BWs needed until 2/11/2020. No CMS on file, take CMS

at next appt. Peri of #14 and 18 if Dr needs. OP200 from 3/30/15 - take

new one 4/2020.

D. Patient OHI behavior changes: Pt reported trying the floss picks and liking

them better than string floss. At next appt review OHI from previous

appts, and as pt if he feels like he is doing better than he was before.

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Other Items:

Wilkins, E. M. (2017). ​Clinical Practice of the Dental Hygienist​ (12th ed., pp. ​409).

Philadelphia, PA: Wolters Kluwer.

Crossley, H.L.; Meiller, T.F.; Wynn, R. L. (2018). ​Lexicomp drug information handbook for

dentistry ​(24th ed., pp. ​699-701​).

Philadelphia, PA: Wolters Kluwer