1.

Assessment

A. Patient interview: chief complaint is the patients gums are sore and bleed

when brushing. His gums are receding and he thinks it's getting worse. He

is a full time student at New Orleans University working towards an MBA

degree.

B. Medical/dental history: Patient is 5’10, weighs 190 lbs and has a BMI of

27.3. He has been hospitalized for a tonsillectomy about 8 years ago. No

allergies and no prescribed medications. He takes 500mg acetaminophen

for occasional headaches. He is a new patient to the dental office and his

last dental appointment was about a year ago. The patient stated that they

took X-rays but he did not have any cavities. He also mentioned that he

has never had a cavity before and that he has never been told that he has

periodontal disease. He typically has his teeth cleaned once a year. He

stated there is a family history of gum disease and both of his parents are

in their 50s with complete dentures. His sister has been diagnosed with

some type of gum disease. The patient brushes once or twice a day with a

fluoride toothpaste. Only flosses when food is caught. Does not use any

mouth rinse and uses a medium brush.

C. Social history: No history of smoking or drinking. Family history of

periodontal disease.

D. Vital signs: Unknown. Patient is 5’10 and weighs 190 lbs. BMI of 27.3,

overweight.

E. Intra/extra oral examination: WNL. No significant findings.

 F. Periodontal examination: Bleeding index was a 71%. Generalized heavy

BOP. No suppuration. Probing depths are all >4mm. Class II furcation on

#1-MB, #2-DL, #2-ML, #3-DL, #3-ML, #3-B, #5-ML, #12-DB, #12-ML,

#14-B, #14-ML, #14-DL, #15-B, #15-ML, #15-DL, #16-ML, #16-DL,

#19-B and #30-B. Class I furcation involvement on #2-B, #19-L and #30-

L. No mobility noted.

G. Radiographs if available: Lower anterior PA’s, 4 Bitewings, and 2 PA’s of

lower right and lower left. #1, 16 and 32 are erupted. #17 is missing.

Localized 75% bone loss #23-26. Generalized bone loss >50% posterior

teeth with multiple areas of furcation involvement. Posterior bone loss is

mainly horizontal. Some vertical bone loss on #30 mesial and distal, #14-

D and #12-D. Radiographic calculus on posterior teeth.

2. DH Diagnosis

A. Level of health: Poor.

B. Diagnosis: Stage IV grade C periodontitis due to > 50 % generalized bone loss

and posterior open bite resulting in masticatory dysfunction. > 5mm CAL,

probing depths > 6mm, vertical bone loss > 3mm, furcation involvement on

multiple teeth, patient is overweight and at risk for diabetes. Grade C because the

destruction exceeds biofilm deposits, and the progression is >1.

3. Plan

A. Consultations necessary: Needs a comprehensive exam first to diagnose and plan

for future visits.

 B. Treatment goals: Stabilize periodontal disease, eliminate BOP, reduce probing

depths and attachment, reduce inflammation, reduce biofilm, reduce size of

gingiva and get back to a healthy normal color.

C. Addresses phases of treatment: 1) comprehensive exam 2) phase 1 SRP 3) phase 2

SRP 4) phase 3 SRP reevaluation.

4. Implementation

A. What will happen at the appointments: 1st appointment comprehensive exam

Recommend SRP all 4 quadrants. Periodontal therapy will need 3 appointments

with local anesthetic. Use Gracey curettes and cavitron for removal of calculus.

Phase 1) SRP UR and LR, phase 2) SRP UL and LL, phase 3) 4-8 week

reevaluation. Prescribe a chlorhexidine rinse, apply stannous fluoride, and Arestin

to control bacteria and biofilm buildup and review OHI.

5. Evaluation

A. How will you or how did you evaluate care: Changes in BOP, CAL, biofilm, and

inflammation. Assess for subgingival calculus and may need to re-instrument and

review OHI.

B. Follow up charting: Full mouth probe, BOP, CAL, biofilm.

C. Radiographs: CMS to check for any residual calculus.

D. Patient OH behavior changes: Check healing and soft tissue response to

instrumentation, changes in probing depth, use of tobacco or control of systemic

diseases, motivation for daily oral self care, mental health issues and stress

impacting self care.

6. Citations
A. Boyd, L.D., Mallonee, L.F., & Wyche, C.J. (2021). Wilkins’ clinical practice of

the dental hygienist. Jones & Bartlett Learning.

B. Clark, S. (2023). 103: Assessment and treatment planning [PowerPoint slides].

Talon.

https://talon.kirkwood.edu/d2l/le/content/179528/viewContent/4918056/View