Case Study 31 Dental Treatment Plan:

Addie Bardon, Lauren Cooling, Katie Madsen, Audrey Noonan

I. Assessment
● Patient Interview & Dental History:
○ patient arrived out of breath, and visibly overweight. Patient states he has
○ no dental treatment in 7 years.
○ rarely enough time for oral hygiene
○ uses a hard bristled toothbrush, never flosses and sometimes uses an OTC mouth
rinse.
○ chief complaints are pain and bleeding gums when brushing
● Health History-
○ not regularly seeing a physician, and states he takes Prilosec OTC for frequent
indigestion, as well as 400 mg of Magnesium.
○ excessive thirst and frequent urination during the night, as well as recurrent
dizziness at work
○ family history- mother has diabetes and hyperthyroidism. Father has heart disease
that runs in the family and had a heart attack at age 50. Pt knows the risk of
generational heart disease.
● Social History-
○ high intake of energy drinks and soda
○ no history of smoking
○ stressed with work(assistant manager of paint store) and taking care of his kids
● Vital Signs:
○ BP=138/98
○ Pulse= 110 bpm
○ Respiration=20 bpm
● Intra/Extra Oral Exam:
○ R submandibular lymph nodes palpable (swollen)
○ Small, round, and painful vesicle on labial mucosa of #12 (“been there for a few
days”)
○ Possible abfraction of #3-6
● Periodontal Exam:
○ Max. ant. gingiva is GEN pink and stippled
○ Mand. and post. gingiva GEN red and inflamed
○ Blunted Gingiva between #7-8 and #8-9
○ GEN Recession on maxillary arch (buccal)
○ Mod to Heavy Calc. on Mand anteriors
○ GEN to heavy BOP
 ○ LOC heavy BOP on mand. anterior sextant, mand. R&L. molars
○ Probing depths GEN between 5 and 9 mm. Localized 3-4 mm on Max Right
Quad.
● Radiographs:
○ 20 teeth present
○ #3, 14, 18 and 30 have restorations.
○ Missing - #1, 2, 15, 16, 17, 19, 20, 23, 25, 26, 31 and 32
○ #24 has shifted mesially where #25 and #26 should be
○ Part of #2 broken off

II. Diagnose
● Perio Case Type:
○ Advanced Chronic Periodontitis
● Bleeding Index:
○ 75%
● Calculus:
○ Class D Calculus
● Plaque Score:
○ 65%
● Caries:
○ No caries detected at this time.

III. Plan
● Preliminary Phase
○ Summary of info from assessment
■ Pt. has generalized and heavy bleeding on probing
■ Heavy calculus on mandibular anteriors.
■ Mandibular posterior gingiva is generalized red and inflamed.
■ Generalized recession on maxillary arch.
○ Dental Hygiene diagnostic statements
■ Advanced Chronic Periodontitis
■ Class D Calculus
○ Oral health treatment goals
■ Get patient out of pain
■ Improve overall oral health
■ Address decay, plaque, and calculus issues
■ Develop an oral hygiene routine
■ Get patient to return for recall appointments
 ○ Emergency care
■ Take care of infection in tooth.
● Initial Phase
○ Calculus Control
■ Ultrasonic on all 4 quadrants
○ Dental Biofilm control
■ Ultrasonic debridement.
■ Prophy angle with coarse paste
■ Flossing
■ Toothbrushing
○ Introduction of additional preventative measures
■ Apply fluoride varnish
■ Talk about diet changes (i.e cut down on energy drinks and soft drinks)
● Surgical Phase
○ Consultation with prosthodontics
○ Consultation with periodontics
○ Consultation with endodontics
● Restorative Phase
○ Final restorations (not done by dental hygiene)
○ Fixed/ removable prosthesis (not done by dental hygiene)
● Maintenance/ Recall Phase
○ Appointments for continuing care and education
■ Shoot for a 3 month recall instead of 6 months
○ Refining biofilm control techniques
■ Provide patient with adequate toothbrushing and flossing instructions at
each 3 month appointment.
IV. Implement
● Consultations
○ Prosthodontics for assessment of missing teeth and decayed teeth
○ Periodontics to assess how to improve and treat his periodontitis
○ Oral Surgery to possibly remove the abscess on tooth #30 and any other tooth
extractions
● Instruments used
○ Ultrasonic scaler
○ Hand scalers
○ Explorer
○ Prophy angle
● Methods
○ Homecare
○ Ultrasonic scaling to remove large amount of calculus and plaque
 ○ Hand scaling and root debridement to remove the smaller pieces of calculus and
plaque
○ Explorer to assess calculus after ultrasonic and scaling
○ Prophy angle with course paste to remove extrinsic staining
○ Fluoride to help with teeth sensitivity and cavity prevention
● Homecare Aids
○ Brushing once a day, working up to 2x/day, with a soft bristled toothbrush
○ Flossing either with string floss or a floss pick once/day
○ Use a waterpik or mouthwash to clean out the periodontal pockets
○ Reduce amount of soft drinks and energy drinks consumed per day
○ Drink more water
● Anesthetics
○ Local anesthesia to make scaling more comfortable
● Prescriptions
○ No new prescriptions required

V. Evaluation
● How will you or how did you evaluate care?
○ Evaluate the conditions of the oral cavity and determine proper care based on
conditions.
● Follow up charting
○ Perio charting slightly improved after 3 months of better oral hygiene care at
home.
○ Incipientes have not progressed any further.
● Radiographs
○ Radiographs should be taken at the following appointment.
● Patient OH behavior changes
○ Patient showed improvement at the 3 month follow up appointment.
○ Patient applied changes to brushing and flossing after being given instruction.