I.

Assessment

o Interview: 38 years old, last dental visit was 7 years ago. Worried about cost. Is
overweight. Reason for visit is teeth pain and bleeding gums.

o Medical History: last Dr. visit was 10 years ago. Has indigestion and self-medicates with
OTC. Family history of diabetes, cardiovascular disease, and hyperthyroidism. Potentially has
undiagnosed diabetes; patient has frequent urination and dizzy spells.

o Vitals: BP: 138/98. Pulse: 110 bpm, respiration: 20 breaths/minute.

o Medications: (OTC) (Omeprazole) Prilosec® and Magnesium 400 mg daily.

§ Brand name: Prilosec

· Generic Name: Omeprazole

· Use: Heartburn

· Effects on Dental Treatment: Dry mouth, esophageal candidiasis,

mucosal atrophy (tongue), and taste perversion

· Effects on Bleeding: N/A

· Effects on Anesthesia: N/A

§ Magnesium 400mg

· Use: Vitamin supplement

· Effect on Dental Treatment: Can potentially interfere with

prescribed antibiotics

· Effects on bleeding: N/A

· Effects on Anesthesia: N/A

o Dental History: Last dental visit was 7 years ago. Uses a hard manual toothbrush when
he remembers. Doesn’t floss and sometimes uses an OTC mouth rinse. He’s lost several teeth to gum
disease. Drinks sugary drinks several times a day.

o Social History: Worried about cost. Has been told he has bad gums by dentists.

o EO/IO: Palpable submandibular lymph nodes on right side. Painful vesicle on labial mucosa
next to #12, small and round that has been there a few days. Gingiva was generalized pink and
stippled in max anterior regions, with localized inflammation on posterior and mandibular areas.
Abfraction on posterior maxillary. Moderate to heavy calculus, heavier on mandibular anterior teeth.
Plaque score: 65%
 o Periodontal exam: Generalized moderate to heavy BOP, heavy localized bleeding in
mandibular anterior sextant, and mandibular posterior molars. Bleeding index: 75%. Probing
depths of 3mm to greater than 10mm, with 0 to 5mm of recession. Mobility and furcation
involvement present.

o Radiographs: #2 still has part of the tooth present. #30 has an abscess at apex of root.
#24 is leaning towards gap where #25 used to be.

II.Diagnosis

Bleeding Index was a 75%

Plaque Score was a 65%

Calculus

Class D Calculus

Perio Case Type

Advanced Chronic Periodontitis

Decay

Generalized decay throughout maxillary and mandibular jaw

Level of Health

The health of this patients oral cavity is overall unhealthy

Periodontal Disease

Stage IV Grade C

III. Plan

o Consultation needed: Oral surgery for #2 and #30. Also will want to refer to primary care
provider for diabetes concerns

o Treatment goals: Reduce inflammation in gums, remove calculus and plaque from teeth,
stop recession and clinical attachment loss, improve homecare, remove #2 root and treat abscess under
#30.

o Phases of treatment

§ Initial: remove accumulated calculus and address surgical concerns. This

should be completed within a few months.

§ Maintenance: Regular appointments every 4 months. Work on home care.

 This should reduce bleeding and inflammation. Goal is in 2 years to have
minimal bleeding and inflammation, to have periodontal exam show either
improvement or no change, and to have a lower plaque score due to improved
home care.

IV. Implementation

Consultation

Consult with oral surgury for tooth #2 extraction. Consult dentist for abscess
under tooth #30, possible antibiotic treatment.

Instruments used

Cavitron, Gracey ½, Gracey 11/12, Gracey 13/14, Nevi, Periodontal Probe

Homecare Aids

Interproximal brush, Super floss, Floss aids

Anesthetic

Possible anesthesia due to gum recession and use of cavitron may cause the
patient discomfort.

Prescriptions

Antibiotic for abscess under tooth #30 also Chlorhexidine for treatment of
periodontal pockets and periodontal disease.

V. Evaluation

How will you or how did you evaluate home care

Patient only brushes when he remembers too. Never flosses and sometimes
uses mouth rinse. Drinks soft and energy drinks several times a day. Has been
told he has bad gums from multiple dentists.

Follow up charting

Follow up with periodontal probing at the next visit to evaluate home care and
progression of periodontal disease. As well as plaque score at next visit and
follow up with pt about brushing and flossing. Talk to pt about how well they are
doing or possible solutions to inconveniences of flossing regularly.
 Radiographs

Radiographs to monitor periodontal disease as well at clearing the abcsess

under tooth #30.

Patient OH behavior changes

Talk with pt about how they are doing with brushing using the BASS method and
flossing regularly. Discuss possible solutions for the inconvenience of flossing
and brushing for 2 mins.

Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2021). Drug information handbook for dentistry:
Including oral medicine for medically compromised patients & specific oral conditions.
Lexicomp/Wolters Kluwer.

Mallonee, L. F., Wyche, C. J., & Boyd, L. D. (2020). Wilkins' clinical practice of the dental hygienist. Jones
and Bartlett Learning.