Kileigh Reed

Treatment Plan #2

I.

● Patient interview: Patient states that he knows he has a lot of deposit on his teeth and he is

anxious to get it removed.

● Medical/Dental History: It has been over 6 months since his last dental appointment. He has been

following 6-month maintenance intervals for years. He states he brushes 2-3 times a day and he

flosses daily. He has minor vision loss in each eye and minor hearing loss. He goes to a physician

for his cluster headaches and high blood pressure. He had a hernia surgery 24 years ago and has

not had any issues since. The patient is currently taking Amlodipine, Ramipril, Omeprazole, and

OTC ibuprofen for his cluster headaches.

● Social History: Patient is a sales representative and is on the road a lot, he used to be a smoker but

has quit and now instead of smoking he sucks on lemon lozenges, they are what helped him quit

smoking. He is married and has adult children who live in another state.

● Vital Signs: BP 140/88. Pulse: 70 bpm. Respiration 12 breaths/minute.

● Extraoral/Intraoral Examination: EO- Crepitus bilaterally, everything else was WNL. IO-

Circumferential redness in the mucosa above tooth #3 that was extracted, the dentist took a look

and indicated it was most likely a vascular hyperemia. Generalized pink gingiva, with localized

areas of inflammation, particularly on mandibular lingual surfaces. There is visible supra calculus

on the lingual surfaces of the mandibular anterior teeth. From the photos tooth #11 has possible

caries on the facial surface, class I furcation on #30.

● Periodontal Examination: Patient has generalized pockets depths of 1-4mm. With localized 8mm

to the DF of #2, 7mm to the DL and ML of #2, 6mm to the BL of #31, and 5mm to the BF of #31.

Bleeding index 20%. Plaque score 25%.

 ● Radiographs: An FMS, generalized bone loss, no large carious lesions.
II.

● Level of Health: For the most part healthy, the patient is 6’ tall and weighs 190. He is taking

Amlodipine and Ramipril to control his high blood pressure and says he takes ibuprofen to

control his headaches, have patient talk to his physician about taking those medications together

and see if the doctor has any recommendations about that.

● Diagnosis: Pt has periodontal disease due to his probing depths and his bone loss, the

inflammation of the gingiva, and his recession.

III.

● Consultations Necessary: He should be referred to a periodontist to have him take a look at his

recession, bone loss, and his deep probing depths.

● Treatment Goals: We want to remove all of the patient's calculus to be able to start healing his

gum tissue and see if we can get some of his deep pocket depths to go down.

● Phases of treatment:

○ Preliminary- Have the doctor take a look at tooth #11 and see if he would need it restored,

also have him look at tooth #2 to check out those deep periodontal pockets.

○ Initial- Scaling and root planing to remove bacterial plaque biofilm and calculus.

○ Surgical Phase- See periodontist for a possible gum graft for recession or bone graft for his

bone loss.

○ Restorative- Have any final restorations completed and any fixed or removable

prosthodontics made.

○ Maintenance- 3-month maintenance to check his probing depths and bone level to make

sure nothing has gotten worse.

IV.
● Consultation: Have him continue brushing 2-3 times a day but switch to a soft bristle toothbrush,

recommend switching to an electric toothbrush, have him keep using the fluoridated toothpaste.

Make sure the pt is brushing in a circular motion with the toothbrush angled towards the gum line

instead of using a vertical and horizontal motion, make sure the patient is not scrubbing hard.

Have the patient continue flossing once a day. Stress to the patient about paying more attention to

brushing and flossing behind his lower anterior teeth. Have patient try to cut back with the lemon

lozenges or tell him to swish water or brush right after he has one of them to try and get a lot of

the sugar out of his mouth.

● Instruments Used: Ultrasonic FM, followed by hand scaling FM, complete FM polish using a

medium prophy paste, floss FM, and place topical fluoride on FM at the end of the appointment.

● Anesthetic: Possible anesthetic use for teeth #2 and #31, if he is sensitive in any other areas

consider using it in those areas too.

● Prescriptions: Talk to doctor about possibly prescribing Metronidazole (Flagyl) to help with his

periodontal disease by stopping the growth of certain bacteria. V.

● Evaluation of Care: Initial assessment of the patients needs were correct. The phases of treatment

are set in order for the best way to care for the patient to try and improve his dental issues. Oral

Hygiene instructions were given to try and help improve his plaque and calculus build up between

his appointments. Scaling type was appropriate and effective, due to using the ultrasonic on the

lingual of mandibular anteriors for the large buildup of calculus, followed by FM hand scaling, all

calculus was removed. All plaque was removed by polishing FM with a rubber cup prophy.

Appropriate fluoride treatment was used to help with the possible areas for decay in his mouth.

● Follow up charting: Probe FM to see if any of his probing depths have improved.
 ● Radiographs: Recommend 4 BWs at next recall appointment due to the date not being known on

his last FMS, and to monitor his bone loss.

● Patient OH Behavior Changes: See if the patient has switched to an electric toothbrush/soft

bristled toothbrush, have the patient show you how he is brushing to see if his technique has

changed. Follow up and see if has started rinsing his mouth out with water or brushing after he

has his lemon lozenges.

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.