Boyd, L. D., Mallonee, L. F., & Wyche, C. J. (2021). Chapter 23.

In Wilkins’ clincal practice of

the dental hygienist (pp. 393-402). essay, Jones & Bartlett Learning.

Wynn, R. L., Meiller, T. F., & Crossley, H. L, (2021). Drug information handbook for dentistry

(26th ed.). Lexicomp.

Addie Bardon

Case Study: #17

https://www.dentalcare.com/en-us/professional-education/case-studies/case-study-17

Treatment Planning #2

I. Assessment

a. Patient Interview and Dental History

i. Patient is a 60-year-old Caucasian male. 6ft and 190 pounds

ii. Hard of hearing and wears glasses for reading.
iii. Former smoker, who has taken up sucking on lemon lozenges because
they’ve helped him quit smoking.
iv. Brushes 2-3 times daily with a medium bristled toothbrush and flosses
daily.
v. Has maintained preventive care recommendations for 6-month intervals for
years.
vi. Chief complaint- “last appointment was over six months ago, so I have a
lot of deposit on my teeth and am anxious to have it removed”
b. Health History

i. Has minor vision loss in each eye and minor hearing loss.
ii. Seeing a primary care provider for cluster headaches and high blood
pressure.
iii. Hernia surgery 24 years ago
iv. Takes Amlodipine (Norvasc) and Ramipril (Altace) for treatment of high
blood pressure. Amlodipine can cause gingival hyperplasia. Ramipril can
cause orthostatic hypertension after dental treatment. Use caution when
using local anesthesia for patient on high blood pressure medication. These
medications should not be taken with ibuprofen.
v. Takes Omeprazole (Prilosec) for acid reflux. Omeprazole can cause taste
perversion, dry mouth, mucosal atrophy, and esophageal candidiasis.
vi. Takes ibuprofen for his cluster headaches. Ibuprofen can interfere with
aspirin’s antiplatelet effect, which can prolong bleeding time.
c. Social History
 i. History of smoking
ii. Sales representative for a national company and is on the road a lot, has the
potential to be very stressed with work.
iii. High intake of lemon lozenges.
d. Vital Signs

i. BP= 140/88. Retake and confirm blood pressure, monitor blood pressure
during the appointment, and refer patient to physician for medical
evaluation.
ii. Pulse= 70 bpm
iii. Respiration=12 bpm
e. Intra/ Extra Oral exam

i. Patient has crepitus bilaterally

ii. Reports painful ulcers in mouth that come in numbers and last for 7-14
days, usually on the lips, gingiva, and tongue. None present at the time of
the exam.
iii. Vascular hyperemia above the extracted upper right molar.
f. Periodontal exam

i. Gingiva is GEN pink with localized areas of inflammation on the

mandibular lingual surfaces.
ii. Localized blunting of maxillary and mandibular anterior teeth.
iii. GEN recession on maxillary arch (buccal)
iv. Moderate calculus on lingual surfaces of mandibular anterior teeth.
v. Light BOP
vi. Probing depths between 3-4mm with localized 5-7mm on lingual of tooth
number # 2, 15, 31.
g. Radiographs

i. 25 teeth present
ii. Missing # 1, 3, 14, 16, 17, 19, 32.
iii. Restorations on # 2, 4, 5, 13, 15, 18, 20, 29, 30, 31.
II. Diagnose

a. Perio Case Type

i. Stage III, Grade B.
ii. Moderate Chronic Periodontitis
b. Bleeding Index
i. 20%
c. Calculus
i. Class D
d. Plaque Score
i. 25%
e. Caries
i. No caries detected at this time
 f. Level of Health
i. ASA classification 2
III. Plan

a. Preliminary Phase

i. Summary of info from assessment

1. Patient has light bleeding on probing

2. Heavy calculus on lingual mandibular anteriors
3. Generalized recession on maxillary arch
4. Mandibular lingual gingiva is inflamed.
ii. Dental hygiene diagnostic statements

1. Stage III, grade B.

2. Moderate chronic periodontitis
3. Class D Calculus
iii. Oral health treatment goals
1. Improve overall oral health
2. Address plaque and calculus issues.
iv. Emergency Care
1. None needed
b. Initial Phase

i. Calculus control

1. Ultrasonic on all 4 quadrants, followed by hand scaling if

necessary.
ii. Dental Biofilm control

1. Prophy angle with medium paste

2. Ultrasonic debridement
3. Flossing
4. Toothbrushing
iii. Introduction of additional preventative measures

1. Apply fluoride varnish

2. Talk about diet changes (i.e. cut out lemon lozenges)
c. Surgical phase
i. Consultation with periodontics
d. Restorative phase
i. None needed and this is not done by dental hygiene.
e. Maintenance/ Recall Phase
i. Appointments for continuing care and education
1. Continue 6 month recall visits
ii. Refining biofilm control techniques
 1. Provide patient with adequate toothbrushing and flossing
instructions at each visit.
IV. Implement

a. Consultations
i. Periodontics to assess how to improve and treat his periodontitis.
b. Instruments used

i. Ultrasonic scaler
ii. Hand scalers
iii. Explorer
iv. Prophy angle
c. Methods

i. Homecare
ii. Ultrasonic scaling to remove large calculus
iii. Hand scaling to remove smaller deposits
iv. Explorer to assess effectiveness of calculus removal
v. Prophy angle with medium paste to remove plaque
vi. Fluoride to help with cavity prevention and teeth sensitivity
d. Homecare aids

i. Drink more water

ii. Purchase a power toothbrush
iii. Use a proxabrush between posterior teeth
iv. Use a toothpaste with stannous fluoride.
v. Use mouthwash to clean out periodontal pockets.
e. Anesthetics

i. Local anesthesia for # 2 and 31 to making scaling more comfortable.

f. Prescriptions

i. None needed
V. Evaluation

a. How will you or how did you evaluate care?

i. Evaluate oral cavity and determine proper care based on conditions

b. Follow up charting

i. Perio charting improving after 6 months of better oral hygiene care.

c. Radiographic

i. Bitewings should be taken at following appointment

d. Patient OHI behavior changes

i. Patient applied changes to brushing and flossing after being given

instructions
ii. Patient is utilizing power brush and proxabrush correctly.
 1. If anesthesia were to be required to debride the teeth with furcations and deeper
pockets, what would be the best choice of an anesthetic agent for this patient,
taking into consideration, his medical history?

A. Lidocaine HCL 2% with epinephrine 1:100,000

B. Articaine  HCL 4% without epinephrine
C. Prilocaine HCL 4% Plain
D. Bupivicaine HCL 0.5% with epinephrine 1:200,000

2. Taking into consideration, the patient’s clinical, radiographic and historical

findings, how would you classify his periodontal condition based on the 2018 AAP
Classification of Periodontal and Peri-Implant Diseases?

A. Stage II, Grade B

B. Stage III, Grade B
C. Stage III, Grade C
D. Stage IV, Grade B

3. Given the patient’s blood pressure reading, how would you classify it based on the
new AHA/ACC Guidelines?

A. Normal
B. Elevated
C. Stage 1
D. Stage 2

4. Of the medications that the patient is currently taking, which might be

responsible for his current blood pressure reading?

A. Prilosec should not be taken with Amlodipine

B. Motrin should not be taken with Prilosec
C. Amlodipine and Ramipril should not be taken with Ibuprofen
D. Ramipril and Amlodipine should not be taken together

5. Given the amount of deposit, pocket depths, and bleeding index, what would be
the best approach for a dental hygiene care plan?

A. Quadrant scaling with local anesthesia, using both ultrasonics and hand instruments,
polishing of the teeth
B. Ultrasonic scaling throughout the mouth, followed by some hand scaling if necessary,
selective polishing
C. Hand scaling of all areas of the mouth, polishing of all teeth and topical fluoride application
D. Local anesthesia for #2 & # 31, ultrasonic scaling of all areas of the mouth followed by hand
scaling if necessary
 6. Upon observing the patient’s study models, how would you BEST describe the
patient's centric occlusion?

A. Open bite
B. Overjet
C. End-to-end
D. Crossbite

7. The posterior bitewing radiographs on the right side demonstrate a technique

error due to:

A. Insufficient vertical angulation

B. Excessive vertical angulation
C. Film packet placement
D. Horizontal angulation of the cone

8. The facial characteristics at the gingival margins observed on both teeth #8 and
#9 are most likely due to what?

A. Bruxism habit
B. Sucking on acidic lozenges
C. Clenching habit
D. Scrub brushing

9. The patient indicated that he has been getting recurrent painful ulcers in his
mouth since he quit smoking, what do you suspect these ulcers might be?

A. Herpetic lesions
B. Traumatic ulcers
C. Apthous ulcers
D. Acid reflux

10. After discussing his brushing and flossing technique with him, what other home
care recommendations would you make for him?

A. Purchase a power toothbrush; use a toothpaste with stannous fluoride; use a proxabrush
between the posterior teeth
B. Use an air flosser; sodium fluoride toothpaste; and an alcohol-based mouthrinse
C. Switch to a soft bristled toothbrush; a desensitizing toothpaste; and use a toothpick in the
deeper pockets and furcations
D. Use a stannous fluoride toothpaste; an essential oils mouthrinse; and a floss threader