DHYG 1311 APPENDIX

PERIODONTAL CARE PLAN (PCP)

TEMPLATE

Patient Name: Age: 50

Date of initial exam: 10/13/2021 Date completed: 11/29/2021

1. Medical History: (systemic conditions, pre-medication, medical clearance, medications, etc.) Explain
steps to be taken to minimize or avoid occurrence. Discuss in detail the relationship and effects of
medical findings on patient periodontal diagnosis, progression, and treatment.

My patient is a 50 year od female, who appears to be a healthy adult. However, upon reviewing her
medical history, there were many findings of underlying conditions. My patient was diagnosed with
multiple sclerosis in 1997. She also presents with yearly sinus problems, undiagnosed COPD,
hypothyroidism, high blood pressure, use of tobacco daily, and the daily consumption of sugary
beverages. Due to these factors, she also takes an array of medications. These medications consist of
Ventolin HFA (which is an absolute contraindication for the use of an ultrasonic scaler), Tecfidera,
rosuvastatin, citalopram, lisinopril, omeprazole, gabapentin, armodafinil, and levothyroxine. She also
takes herbal supplements such as vitamin D, fish oil, and a women’s multivitamin daily. My patient is
very well aware she has periodontitis but hasn’t been able to afford the dentist for over 10 years. I
discussed with my patient how the use of tobacco alongside her diagnosis of MS could be a factor in
the progression of her periodontal disease and be a reason for her periodontal staging and grading
she has now.

2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief complaint,
present oral hygiene habits, etc.) Discuss in detail the relationship and effects of findings on patient
periodontal diagnosis, progression, and treatment.

My patient’s chief complaint was the need for a deep cleaning. Due to recently receiving insurance,
she tried to begin treatment at a dental office, but was told her insurance didn’t cover a deep
cleaning. Her last cleaning was over 10 years ago, and she’s excited to get treatment in order to start
keeping up with her 3-month appointments to take care of herself! She has many amalgam
restorations and a few tooth-colored restorations as well. She exhibits notable attrition in all of her
anterior teeth. Her plaque was generalized and had a plaque score of 3.3 which is bad and presents a
bleeding score of 2.7%. She still has her 3rd molars on her mandible and presents missing teeth on her
maxillary jaw. Her bleeding score was surprising due to generalized redness and swelling, but I
associated this with her use of cigarettes. Although, the patient is aware her tobacco habit is not the
best for her current oral health. She had questions regarding brushing and how she could optimize her
home care. I briefly covered/ demonstrated the stillman method, explained the importance of light
pressure while brushing, and discussed brushing for at least 2 minutes. I also recommended trying the
use of mouth rinse. I suggested biotene to help treat xerostomia she may get from her medications,
and odor she may get from cigarettes. I also sent her home with free samples of this mouth rinse in
order for her to give it a try. Although the progression of her treatment may be altered by her tobacco
habits, I have hope for improved execution in her home care/ maintenance.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation, etc.) Discuss in
detail the relationship and effects of findings on patient periodontal diagnosis, progression, and
treatment.
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During her extra oral examination, I noted no palpable lymph nodes or any irregularities. Intraorally
also consisted of no abnormal findings. The patent exhibited signs of clenching and grinding due to
notable attrition. This is another factor that contributes to her periodontitis, because the force from
these habits can cause damage to the supporting tissues, which causes loosening of the teeth and can
increase pocket depths. She presents an overbite of 4mm, and overjet of 3mm, ad a slight midline
shift 1mm to the left. She also has a class one occlusion all the way around. The patient was very
prompt on explaining she knows she has an overbite. I briefly explained to her that it could have an
effect on build up in her anterior teeth.

4. Periodontal Examination: (color, contour, texture, consistency, etc.) Discuss in detail the relationship
and effects of findings on patient periodontal diagnosis, progression, and treatment.

When performing her periodontal examination, I noticed she had scalloped architecture, generalized
redness, with edematous and spongy consistency. Her margins were thickened with blunted papilla.
Her surface texture of her papillary and marginal tissues presented smooth and shiny, while her
surface texture of attached tissues was stippled. There were no signs of suppuration present. Due to
these findings, it’s clear her periodontitis is active, and she has suffered clinical attachment loss.
Reduction of bacteria after treatment will contribute to having the appearance of her intraoral tissues
return to health.

a. Periodontitis Stage: 3 Periodontitis Grade: C Extent & Distribution: Generalized Marginal

Describe determining factors/ etiology behind Stage AND Grade:

The patient presented both horizontal and vertical bone loss of greater than 33%. She had widened
PDL spaces in all quadrants and furcation involvement in the upper and lower right quadrants, and
signs of caries in the lower right quadrant. The extent of these furcation’s will be assessed after
complete periodontal charting once scaling is completed. Her pocket depths could not be determined
due to the extent of calculus in her mouth. However, with examination of her x-rays, due the extent
of her diseases and her age, she was diagnosed as a periodontitis stage 3 grade C.

b. Gingival Description: (describe by quadrant at each appointment)

Appointment 1 (initial): Scalloped margins, generalized redness, edematous/ spongy consistency,

thickened margins, blunted papilla, no suppuration, smooth and shiny papillary and marginal surface
texture, and stippled texture of the attached gingiva.

Appointment 2: Scalloped margins, generalized redness, edematous/ spongy consistency, thickened

margins, blunted & bulbous papilla, no suppuration, smooth and shiny papillary and marginal surface
texture, and stippled texture of the attached gingiva.

Appointment 3: Scalloped margins, generalized redness, edematous/ spongy consistency, thickened

margins, blunted& bulbous papilla, no suppuration, smooth and shiny papillary and marginal surface
texture, and stippled texture of the attached gingiva.

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Appointment 4: Scalloped margins, generalized redness, edematous/ spongy consistency, thickened

margins, blunted papilla, no suppuration, smooth and shiny papillary and marginal surface texture,
and stippled texture of the attached gingiva.

Appointment 5: Scalloped margins, generalized redness, edematous/ spongy consistency, thickened

margins, blunted & bulbous papilla, no suppuration, smooth and shiny papillary and marginal surface
texture, and stippled texture of the attached gingiva.

Appointment 6: Scalloped margins, generalized redness, edematous/ spongy consistency, thickened

margins, blunted& bulbous papilla, no suppuration, smooth and shiny papillary and marginal surface
texture, and stippled texture of the attached gingiva. Although there is still generalized redness, the
redness is slight and it is clear we are dealing with healthier gingiva after complete treatment.

c. Plaque Index: Appointment 1: 3.3 (FAIR) 2 1.6 (GOOD) 3 .6 (GOOD) 4 .3 (GOOD) 5 .3 (GOOD)
6 .5 (GOOD)

d. Gingival Index: Initial: 1.04 Final: 1

e. Bleeding Index: Appointment 1: 2.7% 2 0% 3 0% 4 0% 5 0% 6 0% ( she never has bleeding on

any of the 6 teeth when doing a bleeding score, I believe this is from her tobacco use)

f. Evaluation of all index findings. Discuss in detail the relationship and effects of findings on
patient periodontal diagnosis, progression, and treatment. (Do this for initial and final appts and
compare progress at final appt).

1. Initial appointment (baseline): The patient has generalized, marginal severe

periodontitis with slight bleeding and heavy calculus. The patient exhibits both horizontal and
vertical bone loss of greater than 33%. She exhibited radiographic signs of furcation
involvement in her lower left and right quadrants, which will be assessed in future quad
periodontal assessments. She also exhibited caries in her lower right quadrant. All of these
factors contribute to her periodontitis along with her systemic conditions and tobacco use.
Her gingival index presented itself as a 1.04. After treatment, the reduction of her gingival
seems promising with the patient’s interest to improve home care and her commitment to
visits. Her plaque score is poor, and this bacteria not being removed effectively contributes to
her inflammation, and without proper removal, will continue to contribute to disease
progression. Her bleeding score is 2.7%, and this concerns me, because she doesn’t have much
bleeding regardless of her inflammation. I have associated this with her smoking habit, and
have educated her that smoking causes restriction in her blood vessels and can hide signs of
irritation and inflammation.

2. Final appointment (re-evaluation): The patient has shown significant improvement

since the beginning of her treatment. The patient still exhibits generalized, marginal
periodontitis, however she has greatly decreased her redness and inflammation. Also, as
stated in her initial appointment her interest has also helped her greatly decrease her plaque
score. With this effective removal and an intent to complete tobacco cessation by her recall
appointment, it is extremely likely to see her halt her periodontal disease. She will obviously
still suffer from systemic factors, however she has already stated feeling a clear difference in
her overall health and intends on handling all referrals to contribute to her oral health. She is
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extremely excited and prepared for recall in January of 2022. Her gingival index at her final
appointment was 1, and I still believe a lack of bleeding is due to tobacco use, but with
cessation I’m hopeful to see more accurate BOP in January at her recall appointment.

g. Periodontal Chart: (pocket depths, recession, CAL, furcation, mobility, etc.) Discuss in detail the
relationship and effects of findings on patient periodontal diagnosis, progression, and treatment.
Compare progress at final appt.

1. Initial appointment (baseline): Due to extent of calculus buildup, periodontal

assessment will have to be assessed by quadrant. Obvious areas of recession and radiographic
signs of furcation involvement was noted.

2. Final appointment (re-evaluation): After probing her by quad, and then doing
another periodontal evaluation at her last appointment, the patient has been successful in
reducing many pocket depths. Due to this reduction the patient only needed to undergo
treatment of Arestin in two areas. These improvements will be huge factors in assisting her in
plaque control, halting bone loss and recession, and decreasing chances of having furcation
involvement.

5. Dental Examination: (caries, attrition, midline position, mal-positioned teeth, occlusion, abfraction,
missing teeth, etc.) Discuss in detail the relationship and effects of findings on patient periodontal
diagnosis, progression, and treatment.

The patient presented missing teeth, attrition on all anterior teeth and referrals for #32 and #12. With
these missing teeth, the progression of her disease is at a higher risk. Missing teeth can cause chewing
issues, more plaque retention, and contribute to a higher risk of oral infection that can become bigger
issues with your overall health. Like wise, her referrals for teeth with cavities can cause even more
disruption in her oral environment and spread more decay if it’s not taken care of. The patient has a
class 1 occlusion on her left and right sides and only presents a midline shift of 1mm to the left, which
shouldn’t cause any significant impact. After receiving treatment, the patient fully intends on handling
these referrals at a local dentist office to help with the halt of her progression.

6. Radiographic Findings: (bone loss, furcation, crown root ratio, root form, condition of interproximal
bony crests, thickened lamina dura, calculus, root resorption, missing teeth, etc.) Discuss in detail the
relationship and effects of findings on patient periodontal diagnosis, progression, and treatment.

After reviewing her radiographs, I noted the generalized presence of horizontal and vertical bone loss
greater than 33%. I also noted generalized widened PDL space, furcation involvement in the lower left
and right quadrants. Her radiographs also exhibited notable, large deposits of calculus, which is a big
factor in her progression and inflammation. She also presents caries on tooth #32.

7. Periodontal Disease Risk Factors: (include positive findings noted on the Periodontal Risk
Assessment) Discuss in detail the relationship and effects of findings on patient periodontal diagnosis,
progression, and treatment.

In her risk assessment, it was noted that she is a very high-risk patient. The patient exhibits use of
tobacco, personal history of periodontal disease, poor plaque control, infrequent dental exams,
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radiographic loss of crestal bone, furcation involvement, takes medications, has prior caries
experience, has exposed root surfaces, and exhibits missing teeth. Alongside this, she exhibits areas of
attrition. This can cause even greater plaque retention to add to er poor plaque control, which is also
contributed to the risk of xerostomia with her medications. Mixing this with the daily use of tobacco
and sugary beverages without frequent dental examinations opens the door for disease progression.
After treatment and patient education sessions, home care improvement can help with halting her
disease. Tobacco cessation is also a great concern. However, the patient doesn’t have a lack in salivary
flow, presents no demineralization, and avoids the use of alcoholic beverages.

8. Treatment Plan: (Include assessment of patient needs, appropriate treatment, patient education
plan- including individualized long and short-term goals)
Appointment 1:
• Medical & Dental History
• Vital signs
• Pre-rinse
• Head/Neck and Intra/Extra oral exam
• Periodontal Assessment
• Dental charting with x-rays
• Risk Assessment
• Informed Consent
• Initial plaque score
• Initial bleeding score
• Initial gingival index
• Intra oral pictures
• Assess patient learning level
• Chairside patient ed: brushing using stillman method

Appointment 2:
• Update medical & dental history
• Vital signs
• Pre-rinse
• Paque score
• Bleeding score
• Assess and record gingival condition by quadrant
• Patient Education Session 1
• Local Anesthesia
• Hand scale lower left quadrant
• Full periodontal charting of LL quadrant
• Scale check LL quadrant by instructors
• Pt Ed 1: PLAQUE: LTG: lower plaque score to 0 by last appointment; STG: reduce plaque score
by .5 by next appointment; STG: understand the effects of plaque on periodontal disease by
the end of the appointment; STG: plaque removal & brushing method. We will discuss what
exactly plaque is, what causes it, how to properly remove it, and what happens if it is not
properly removed. We will do this by using disclosing solution to show her areas she can
improve, and a tooth brush and a typodont for demonstrating a few brushing methods in
order to show the patient what option may be best for her. After doing so, I will also have the

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patient demonstrate her method of choice to ensure complete understanding. We will also
discuss her obtainable STG and preview her next patient education session.

Appointment 3:
• Update medical & dental history
• Vital signs
• Pre-rinse
• Paque score
• Bleeding score
• Assess and record gingival condition by quadrant
• Patient Education Session 2
• Local anesthesia
• Hand scale upper left quadrant
• Full periodontal charting of UL quadrant
• Scale check UL quadrant by instructors
• Pt Ed 2: FLOSSING & PERIODONTITIS: LTG: halt periodontitis by las appointment; STG: floss
once daily; STG: understand how to properly floss; STG: understand what periodontitis is. We
will review our previous session and goals, and then we will address flossing. We will go over
the proper technique of using a “c” shape and why it is important to have flossing in her oral
care regimen, and we will discuss periodontitis, and the reasoning for her staging and grading.

Appointment 4:
• Update medical & dental history
• Vital signs
• Pre-rinse
• Paque score
• Bleeding score
• Assess and record gingival condition by quadrant
• Patient Education Session 3
• Local anesthesia
• Hand scale lower quadrant
• Full periodontal charting of LR quadrant
• Scale check UL quadrant by instructors
• Pt ed 3: TOBACCO CESSATION: LTG: complete cessation by recall appointment STG: set a
cessation date (January 1); STG: understand the effect her smoking habit has on her disease
progression. We will talk about how smoking effects the periodontium, how it effects
inflammatory response, and how it contributes to worsening her periodontitis. I will use
photos from my flip book to show her the extent of how bad tobacco can affect her
periodontal disease, and we will talk about forms of cessation and choose what is best for her.

Appointment 5:
• Update medical & dental history
• Vital signs
• Pre-rinse
• Paque score
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• Bleeding score
• Assess and record gingival condition by quadrant
• Local anesthesia
• Hand scale upper right quadrant
• Full periodontal charting of UR quadrant
• Scale check UL quadrant by instructors
• Plaque Free
• Fluoride varnish application and instructions
• Discuss 2 week post cal appointment

Appointment 6:
• Update medical & dental history
• Vital signs
• Pre-rinse
• Assess current gingiva condition
• Final bleeding score
• Final plaque score
• Arestin
• Final periodontal charting
• Set 3-month recall date
• Review all long-term goals
• Encourage patient to follow regimen and meet long term goals

9. Journal Notes: (Record in detail the treatment provided at each appointment, oral hygiene
education, patient response, complications, improvements, diet recommendations, learning level,
progress towards short and long-term goals, expectations, etc.) The notes should be written by
appointment date.
10/13/21: for her first appointment we completed and went over her medical history, covid screened,
took a full mouth radiographic survey with vertical bitewings, did an intra and extra oral head &
neck exam, took a plaque and bleeding score to assess home care, completed informed consent,
completed a risk assessment, completed dental charting, diagnosed sealants, patient education on
sealants and mouth rinse, completed a periodontal assessment, took a gingival index, and took
intra oral pictures.

10/29/21: for her second appointment we reviewed/ updated her medical and dental history, covid
screened, took a plaque and bleeding score to assess progress, patient education on brushing and
plaque, had the dentist administer local anesthetic on mandibular right quadrant, began scaling
her mandibular right quadrant, probed mandibular right quadrant.

11/5/21: for her third appointment we reviewed/ updated her medical and dental history, covid
screened, took a plaque and bleeding score to assess progress, patient education on flossing and
periodontitis, completed scaling on mandibular right quadrant, administered 1.7g gel of oraquix
on maxillary right quadrant, and began scaling on maxillary right quadrant, probed maxillary right
quadrant, more patient education on gum detoxify toothpaste

11/9/21: for her fourth appointment we reviewed/ updated her medical and dental history, covid
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screened, took a plaque and bleeding score to assess progress, patient education over tobacco
cessation and its effect on her health, administered .425g gel oraquix on maxillary let quadrant,
completed scaling on maxillary left and right quadrants, probed each quad after scaling, additional
patient ed on tooth brush abrasion.

11/10/21: for her fifth appointment we updated/ reviewed her medical and dental history, covid
screened, took a plaque and bleeding score to assess progress, scaled mandibular left quadrant,
probed mandibular left quadrant, administered 1.7g gel on mandibular left quadrant, placed
sealants on #20 & #21, administered 5% NaF varnish, plaque free, patient education on fluoride
and exposed root surfaces, took a gingival statement, scheduled her post cal/ post perio
appointment

11/29/21: for her sixth and final appointment we reviewed/ updated her medical and dental history,
covid screened, took a plaque and bleeding score to assess progress, took a gingival index, post cal
(check for any buildup), post perio (complete perio assessment to asses progress), administered
arestin on #32 M and #3 D, patient education on arestin and post appointment care, took a final
gingival statement

10. Prognosis: (Based on attitude, age, number of teeth, systemic/ social background, malocclusion,
tooth morphology, periodontal examination, recall availability)
Considering the patient’s attitude, age, and other clinical findings/ medical history, the prognosis I
have for my patient is very promising. Due to her improvement throughout her treatment, and
her positive attitude in pursuing better home care, my prognosis is that she will be able to halt the
progression of her disease. This prognosis is also very promising if she sticks to her cessation date
and is successful in quitting.

11. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall schedule.
(Note: Include date of recall appointment below.)
Suggestions I have/ gave my patient consisted of flossing with floss alongside her waterpik, taking
care of her referrals as soon as possible, maintaining a 3 month recall to stay on top of her oral
health, and complete tobacco cessation if possible. Mrs. Vann has already been proactive in these
suggestions and scheduled her recall appointment with me for January of 2022 with the exact date
to be determined. We have set and agreed on the cessation date of January 1, 2022 and as of her
last appointment on 11/29/21 she is still confident in that date and her ability to quit by then. She
is also actively searching for a dentist that will take her insurance to take care of her referrals.

12. Assessment of Changes: (note “Periodontal Grade” at the end of treatment, compare changes in
periodontitis classification, changes in plaque control, bleeding tendency, gingival health, probing
depths, effect on future periodontal disease management)
The patients overall changes are very exciting and promising for her future oral health. She has
successfully conquered good plaque control, which has also helped her successfully reduce
pocket depths, and she has reduced her redness and inflammation. Her bleeding tendencies are
still extremely similar, and although this doesn’t seem as promising as her other
accomplishments, I believe we will see better tendencies at her recall in January of 2022 if she
sticks to her goal of cessation. However, due to her age and amount of bone loss she wil continue
to be a perio stage 3/C.

13. Patient Attitudes and Cooperation:

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Mrs. Vann shows exemplary cooperation and an extremely positive attitude. She takes patient
education very seriously and she always has many questions and curiosities in order to make her
home care better. Halfway through treatment she purchased a waterpik and now uses it daily! She
has even set a tobacco cessation date and is very confident in her ability to quit. In her post-perio/
post-cal appointment she even stated, “I notice a huge difference and I feel so much better”.
Throughout her treatment she would always ask about the best toothpaste, toothbrushes, and mouth
rinses to use. After her treatment Mrs. Vann has begun using gum detoxify toothpaste, bought an
array of soft toothbrushes with different bristles, and she also plans on investing in oxyfresh mouth
rinse. Her curiosities have also helped her understand that her oral health affects her over all health
and is very excited to see the difference. She has also already scheduled her recall appointment for
January 2022. Mrs. Vann is also actively searching for a dentist that takes her insurance in order to
take care of her referrals.

14. Personal evaluation/ educational progression with this experience:

Throughout treatment with Mrs. Vann I’ve seen and felt a lot of personal growth. Clinically, Mrs. Vann
has helped me with my confidence and instrumentation. She was a class 8 that I hand scaled, and
although it was challenging, I passed every quadrant. Progression in my abilities to convey
information in patient ed were greatly improved due to the patient’s attitude towards learning
the educational topics. It has also helped me with time management, really assessing patient
comfort/needs, and understanding periodontitis better than I did before. Her treatment has also
shown me the true difference I can make. I know I help a lot of patients with their oral health and
improving their home care, but I’ve never actually had a patient tell me they physically feel
better. Once I heard this from my patient it kind of gratified me and really pointed out how much
we truly help our patients. She also helped me boost my confidence in my knowledge, because at
one point she contacted me personally with concerns about issues she was having with her
tongue, and I was able to successfully diagnose her with thrush! (this was confirmed at her
doctor once I recommend her to see her physician). Overall, her treatment plan as helped me
gain the confidence and understanding I lacked in certain areas. I now perio chart, educate,
communicate, and scale with a comfort/confidence I didn’t have before.