I.

Assessment:

 Patient Interview: Patients' gums around the back teeth on the upper right are swollen, bleeding,

and are sore.

 Medical/Dental History: Patient has been hospitalized for these past surgeries: tonsillectomy,

appendectomy, and laser mediated kidney stone ablation. No allergies. Patient is taking the

following medications: hydrochlorothiazide (25mg b.i.d), lisinopril (10mg q.d.), pravastatin

(40mg q.d), metformin (500mg q.d), combined alogliptin and pioglitazone (25mg/ 15mg q.d), and

aspirin (325mg q.d). His HbA1c = 9.3. His parents have a history of type II diabetes with multiple

systemic issues.

Patient’s last dental appointment was 4-5 years ago. Patient was told he has “some” periodontal

disease; was supposed to go back for a deep cleaning but never went. Patient has a history of

orthodontics (age 14-17). Patient uses whatever toothbrush and toothpaste he can find and uses a

round toothpick to remove food impacted between his teeth.

 Implications to treatment of special needs patient: With the patient having diabetes, he needs to

be scheduled for AM appointments to decrease the chances of stress induced hypoglycemia.

 Social History: Works as a full-time IT technician for a large national company. His job requires

that he travels at least 12-14 days per month. Both of his parents are still alive and the patient has

no siblings.

 Vital Signs: BP = 90/140

 Intra-oral/Extra-oral Examination: EO - Right submandibular lymph node is enlarged and easily

palpable. IO - Facial soft tissue associated with the maxillary right molars was spongy, swollen,

and slightly painful to palpation. 

 Periodontal Examination: Patient has generalized very deep pockets in posterior and anterior of

both arches, generalized 5-8mm. Patient has heavy BOP with a bleeding index of 78%.

Interproximal sites between teeth #2-#2 a significant purulence and bleeding was elicited.
 Furcation involvement localized UR, UL, #17, and #30. Plaque score - 70%. Radiographs shows

severe periodontal disease and heavy interproximal calculus.

 Oral changes based on special needs: With the patient taking multiple medications for high blood

pressure, the oral cavity can suffer from xerostomia. Patient is also taking Pravastatin, which is a

medication to tx high cholesterol, can cause difficulty with brushing and chewing so, patient

might have areas of food impaction and inflammation of hard to reach areas.

 Radiographs: PA of maxillary UR #2-4, PA of mandibular LR #32-30, PA of lower right cuspid

area, and VBW of left molar area. 

II. DH Diagnosis:

 Level of Health: Poor. Patient is on 3 different medications for high blood pressure. His blood

pressure reading today was very poor. He also is on a few medications for type II diabetes. His

HbA1c level is high as well. His BMI of 31.9 which is considered obese.

 Relating special needs to his diagnosis (Gingivitis, Periodontal disease, Caries): Pt has advanced

periodontal disease. He has very deep pockets, generalized 4-9mm. His gingiva is very

bulbous/inflamed. Generalized heavy BOP. Generalized Class II furcations on maxillary and

mandibular molars. His radiographs show severe horizontal and vertical bone loss. His intra oral

pictures look like he suffers from xerostomia, which could be a result from his medications.

Xerostomia could cause his periodontal disease to advance more quickly and will also cause an

increase in caries rate.

III. Plan:

 Consultations Necessary: This patient should be referred to a periodontist for his advanced

periodontal disease.
  Treatment goals: We want to improve this patient's overall oral health of his gum tissue and slow

down the progression of his periodontal disease. It is also important for us to improve his at-home

oral healthcare by educating and motivating the patient to take better care of his teeth and overall

health. Patient needs to stop using the round toothpick. 

 Phases of Treatment:

o Preliminary: Patient first needs to be seen by his physician for his high HbA1c reading

and also for his hypertension. We would not be able to see patient due to his high HbA1c

reading. Refer patient to physician to have right submandibular lymph node checked

because it is enlarged. Also have the dentist do an exam to see if any other areas are of

concern that need to be treated before SRP is performed. Possible new PA of #2-#3 area

because of the purulence and bleeding.

o Initial: SRP performed with the use of local anesthesia.

o Surgical Phase: See periodontist for possible flap surgery or mucogingival surgery. Also

assess to see if any teeth need to be extracted from his advanced periodontal disease. 

o Restorative: If after exam and SRP are completed, have any restorative work completed

that needs to be done.

o Maintenance: 3 month perio maintenance. 

IV. Implementation: 

 Consultations: Suggest purchasing a soft bristled power brush. I think a power brush will be

easier for patient to use and for him to get in hard-to-reach areas. I would also recommend

purchasing a higher concentrated fluoridated toothpaste due to his increase in developing cavities

due to his medications such as Clinpro or Prevident. I would also recommend a waterpik to make

it easier for patient to floss. Review proper brushing and flossing technique with a hand held

mirror. 
  Instruments used: Ultrasonic - blue tip first to remove tenacious calculus then followed by the

straight green tip. Then followed by hand instruments. 

 Methods: Start with ultrasonic scaling instruments followed by hand instruments. Depending how

the appointment went, unsure if I would polish the same day as cleanings depending on how

inflamed/irritated his gum tissues were after the deep cleaning. If polishing is done, I would

recommend medium polish. If severe inflammation/irritation was present, I would skip polishing.

Recommend a fluoride varnish after SRP is all done. 

 Homecare Aids: Power brush and waterpik

 Anesthetic: Administer local anesthesia in the quadrant that we are working on today to keep

patient comfortable. I would use 3% Carbocaine plain once because he does suffer from

hypertension issues, so I want to limit epi and I only need the soft tissues numb, no pulpal.

 Prescriptions: Clinpro/Prevident. Patient states that he will be seeing his primary physician soon

for a medication evaluation so the patient might be getting new medications for his high blood

pressure and diabetes.

 Alterations to implementation based on special needs: Make sure the patient is scheduled in the

morning and that his HbA1c reading is in normal range. Make sure the patient is given frequent

breaks/water breaks due to xerostomia. Make sure to check vitals throughout the appointment due

to poor BP reading. Make sure to have snacks available incase pt gets hypoglycemia. 

V. Evaluation:

 Evaluation of care: Initial assessment of the patients’ needs were correct. Phases of treatment are

set in order of the best way to care for the patient and complete all of the patient’s dental needs.

Based on the patient's health status and health history, we need to reiterate oral hygiene

instructions and the importance of continuation of care. Scaling type was appropriate and calculus

removal was effective with Ultrasonic and Hand Scaler. If polishing is completed, full mouth

plaque removal was effective with the medium polish. Appropriate fluoride treatment was
 planned and completed due to the patient's lack of seeing dentist regularly, high caries risk, and

recession areas.

 Follow up charting: Complete full mouth probing to evaluate if there has been any improvement

of probing depths, make sure periodontal disease isn’t progressing, and if there is any reduction

of BOP.

 Radiographs: Recommend a CMS because there are only 4 other radiographs in the patient's

chart, need more radiographs to be able to see more. CMS with VBWs. 

 Patient OH behavior changes: Patient should be using a soft bristle toothbrush on his power brush

- more specifically that will benefit his oral health instead of “finding whatever is cheapest”. Pt

should be developing a routine with proper brushing and flossing technique. Patient should NOT

be using a round toothpick anymore; the patient should be using his waterpik if he feels like food

is getting trapped. 
 References:

Boyd, L., Mallonee, L., & Wyche, C. (2020). Wilkins’ clinical practice of the dental hygienist (13th ed.). Jones &

Bartlett Learning. 

Wynn, R., Meiller, T., Crossley, H. (Ed.). (2018). Drug information handbook for dentistry (24th ed.). Lexi-Comp

Inc.