Special Needs Treatment Plan

Vanessa Chamberlin

Case Study #40

I. Assessment

67 y.o. White male, retired for 5 years from factory job due to Parkinson’s

Disease, widowed, and hasn’t been to the dentist in 10 years. His son lives 1,000

miles away but he has many veteran buddies who he keeps in contact with. Has

Type II Diabetes, hypertension, early Dementia and Parkinson’s Disease. Allergic

to Penicillin. Suffers from hand tremors, stiffness in joints, and impaired balance.

Mild signs of Dementia but still able to function. He is a mouth breather and his

HbA1c at his last check was 7.5%. Medications include: Lisinopril, Glipizide,

Carbidopa/Levodopa, and Escitalopram. BP: 135/88. HR: 100 bpm. Resp:18

breaths/minute. Brushes with a hard bristled toothbrush once daily, doesn’t floss.

Unsure if his toothpaste contains fluoride and rinses his mouth occasionally with

hydrogen peroxide or saltwater. E/O exam: WNL. I/O exam: Tenderness in

maxillary left quad, redness and inflammation present at site #12, attached

gingiva in maxillary anterior region generalized pink and stippled, generalized red

and inflamed marginal gingiva. Bleeding Index: 65%. Plaque Score: 35%.

Probing Depths: 3-7 mm. Class 2 mobility on #3, #10, #11, and #15. Class 1

mobility and exudate evident on # 32. Complaining of a broken tooth and dry

mouth.
Radiograph/Images show

indications of Periodontal Disease due to bone loss including when compared to

charting from PD and CAL. Pt also has generalized recession. Pt’s anterior teeth

show signs of attrition potentially due

to bruxing or clenching. Pt is missing

all posterior teeth except three molars

and three premolars. Heavy staining

present and demineralization present

along the gingival margins of the

maxillary anterior teeth. There is

evidence of decay and a retained root

on the radiograph. Pt has severe

overjet and overbite. Severe Class II

bite. These are potentially

exacerbated by malocclusion due to

missing a large number of teeth.

 II. DH Diagnosis

The patient’s health overall isn’t the best. He does suffer from a handful of things,

though seemingly controlled. His BP, however, is still slightly hypertensive so I

would suggest he see his PCP regarding his Linsinopril and Carbidopa/Levodopa

prescriptions. They may need to be altered slightly. Patient’s Parkinson’s is most

likely contributing to his poor brushing abilities due to his tremors, and his

Diabetes and hypertension is likely contributing to his Periodontal Disease. His

medications, especially his Escitalipram and Carbidopa/Levodopa are most likely

the cause of his dry mouth.

Advanced Chronic Periodontitis, Stage IV, Grade C.

III. Plan

Pt should see his PCP in regards to his blood pressure and possible alterations

of his cardiac medications. Pt should also see Perio to decide alternating

treatment. Pt should see Pros to discuss partial dentures.

Goals: Reduce BOP significantly, figure out why #32 has exudate present/treat it,

get his demineralization treated, discuss replacing missing teeth with upper and

lower partial dentures in order to treat poor occlusion, maintain GM, significantly

improve OH homecare/provide auxiliary aids to allow better grip on his

toothbrush due to stiff joints and get his gingiva back to healthy, pink tissue. Have

the patient increase his brushing, with a soft toothbrush, to twice daily. Get the

patient to floss at least 2-3 times weekly. Have him stop rinsing with hydrogen

peroxide as it may be irritating his already inflamed oral cavity and causing more

dry mouth. Recommend a gingival health toothpaste such as Crest Pro Health
 with fluoride in order to make sure he is receiving fluoride to help with the

demineralization.

IV. Implementation

Create treatment plan, line up referrals, make sure pt is compliant and

understands the treatment that is planned. Full Mouth Debridement then Perio

OR Full Mouth SRP with ultrasonic to remove plaque, debris and bacteria then

hand scale with Gracey scalers. Polish with medium grit prophy paste and apply

a fluoride varnish, focusing to the surfaces along the gingival margin. Potentially

use Oraqix in order to keep the patient comfortable if he is uncomfortable. Have

the pt start brushing with a soft manual toothbrush using the BASS technique

twice daily, increase flossing to 2-3 times weekly using the “c” method and using

a floss aid for a better grip. Have pt start using a toothpaste with fluoride. Provide

the patient with foam grip auxiliary aid in order to ensure the pt can get a better

grip on a small handled toothbrush. Stop hydrogen peroxide rinses and stick to

saltwater rinses. 4-6 week tissue, tooth and compliance check. Future recalls at 3

months between general practice and Perio to keep the patient maintained.

V. Evaluation

Compare gums and teeth before and after the appointment and at recall visits.

Use plaque score, calc detect, perio charting, radiographs, intra and extra oral

exams to do so. Follow up charting, evaluate and compare probing depths, BOP

and recession. Take new radiographs for comparison to previous visits. CMS and

vertical BW’s in order to compare and measure periodontal status and detect
 new decay. Establish patient’s oral health care routine and compare it to

previous visits. Determine if the patient is compliant or not.

References

Boyd, L., Mallonee, L. F., & Wyche, C. J. (2020). Wilkins' Clinical Practice of the Dental

Hygienist. Jones & Bartlett Learning, LLC.

Case Study 40. (2023, June 22). DentalCare.com.

https://www.dentalcare.com/en-us/case-studies/case-study-40