Treatment Plan

Keely Pernicka
Patient: ​Carrie Cavity

Patient introduction: ​Patient is a 33 year old Caucasian female.

Chief Complaint: ​Patient is concerned about the staining on her teeth.

Medical History: ​Patient does not have any allergies or medical problems. Patient

wears corrective lenses. Other problems include the patient does not to be excessively

touched so it is recommended that you state what you are going to be doing next before

touching the patient.

Medications: ​Patient is currently not taking any medications.

Vital Signs: ​Blood pressure 132/82 on February 13th, 2019 and 130/90 on March 2019.

Dental History: ​Patient does attend annual dental exams and it has been 8 months

since last dental visit. She uses an Oral B electric toothbrush with Crest White

toothpaste. Patient flosses teeth most times at night and uses a Crest mouthwash.

Patient bites fingernails. Patient had orthodontic treatment and oral surgery to remove

teeth #1, 16, 17, and 32. Patient has sealants on teeth #3, 14, 19, 28, 29, 30, 31.

Social History: ​Patient enjoys drinking coffee and tea. Patient consumes alcoholic

beverages once a week.

Dental Examination:

● Extra Oral Exam: ​Clicking in her left TMJ. Patient is reporting that it is not

causing her any pain or discomfort. All other extra oral assessments are within

normal limits.

● Intra Oral Exam: ​Patient has chapped lips and a bite on the lower lip. Bilateral

linea alba, a cheek bite on the right buccal mucosa, and scarring on the left
 buccal mucosa. Patient has a small palate. Patient also has a yellow to white

color of coating on the tongue. Light extrinsic staining on the anterior linguals.

Generalized pink gingiva with marginal redness on the linguals of the maxillary

posteriors. Generalized pointed interdental papilla. Generalized knife edged

marginal gingiva with recession on #19, 20, 22, 28, and 29. Generalized firm and

resilient, stippled gingiva. Spontaneous bleeding on probing in the buccals and

linguals. Patient is experiencing thicker than normal saliva. Her plaque score is

50%. Patient would benefit from calculus removal on #20 distal with an

ultrasonic.

● Caries: ​#12, 13, 14, 18, and 20 resin based composite.

● Periodontal Exam: ​Generalized 1-2mm probing depths with some 3mm probing

depths in the posteriors.

● Radiographs: ​Patient has 4 vertical bitewings presenting no visible bone loss.

Radiographs taken on 6/13/2018.

DH Diagnosis (problem identification):

Level of health:

lll: Plan:

Consultations necessary: ​No consultations are necessary.

Treatment goals: ​Our goal is to improve the patient’s overall oral health

● Better home care by the patient

● Continuing with recall appointments

● No bleeding on probing
 ● Decrease in the plaque score

● Maintaining her current pocket depths.

Addresses phases of treatment:

● Preliminary Phase: ​Assessment data collection (collect baseline probing

depths, record extraoral and intraoral exams.

● Phase 1 Therapy:

○ Supra and subgingival plaque and calculus removal

○ OHI

■ Discuss flossing once daily using the C-wrap method and using soft

picks.

■ Discuss brushing with the Bass method using her Oral B electric

toothbrush twice daily.

■ Discussed using a fluoride mouthwash to use after brushing her

teeth.

○ Calculus removal

■ Handscale full mouth

○ 5% Fluoride varnish treatment. POI given.

● Evaluate of Phase 1:

○ Re-evaluate patient at 6 month recall appointment for:

■ Bleeding upon probing

■ Lowered plaque score

 ■ Patient’s participation (changed behaviors, brushing twice a day

using Bass Method, flossing once a day using C-wrap Method,

using fluoride mouthwash.

● Phase 2 Surgical: ​No surgery needed.

● Phase 3 Restorative: ​No restorative work needed.

● Evaluation Overall: ​If no improvements have been made, go back to Phase 1,

repeat the steps and make any changes that are necessary.

● Maintenance: ​Patient is scheduled for 6 month recall appointments in the DHYG

clinic.

○ Remove plaque and calculus

○ Compare clinical data from previous dental appointment

○ Review OHI and patients oral health routine.

IV: Implementation:

● Handscale full mouth

● Methods: Bass Method, C-wrap flossing method.

● Homecare: Oral B electric toothbrush, Crest White toothpaste, floss, soft picks

V: Evaluation:

How will you or how did you evaluate care: ​By performing extraoral and intraoral

exams, re-probing the entire mouth and comparing probing depths from previous

appointment, performing another plaque score.

Follow up charting: ​Probing at every appointment.

Radiographs: ​Take radiographs as prescribed by doctor.

Patient OH behavior changes: ​Continue using her Oral B electric toothbrush twice a

day using the Bass Method. Floss once a day at night before bed using C-wrap Method.

Continue using Crest mouth rinse after brushing twice daily. Patient may use soft picks

to help with successful flossing and plaque removal.

References:

Wlkins, E., (2017). ​Clinical Practice of the Dental Hygienist​. Philadelphia, PA: Wolters

Kluwer. 12th edition, 143, 187, 290, 298-325, 408-418, 700-735.

Clark, S., (2019). Dental Hygiene ll [Powerpoint Slides], Kirkwood Community College