Treatment Plan #2- Case Study 42

Assessment

 Patient interview

 24 year old African American male

 5’10” and weights 190 lbs – BMI 27.3

 New Patient

 CC: “Gums are sore and bleed sometimes while brushing. Also, the gums are

receding and I think it’s getting worse.”

 Dental History/ Medical History

 Hospitalized for tonsillectomy about age 8.

 Overweight

 Last dental appointment was about a year ago, they took x-rays

 Usually gets his teeth cleaned about once a year

 Has never had a cavity

 Has never been told he has perio disease

 Brushes 1-2x a day using a medium texture brush

 Flosses only if food is caught between teeth

 Doesn’t use any rinses

 Family History

 Family history of severe gum disease

 Both parents are alive and he has an older sister

  Both parents (52) in complete dentures

 Patient’s sister diagnosed with a type of gum disease

 Medications

 No known allergies

 No prescribed medications

 Takes OTC acetaminophen, 500 mg, for occasional headache

 Social History

 Full time graduate student at New Orleans University, working towards an MBA

degree

 Vital Signs

 N/A

 Intra-Oral/Extra-Oral Exam

 WNL, no significant findings

 Gingival tissues

 Red and inflamed though both arches

 Moderate- heavy calc evident on molars

 Generalized recession

 Severe recession with abfractions on #5-6

 Periodontal Examination

 4-10+ mm probing depths

 Heavy BOP generalized- 71%

 Plaque score- 30%

  1-3 mm recession generalized throughout

 Levels of furcations- #1, 2, 3, 5, 12, 14, 15, 16, 19, 30

 Radiographs

o Horizontal bone loss generalized though molars and anteriors

o Furcation involvement listed above

o Vertical bone loss mainly in max. premolar regions

o Radiographic calc

DH Diagnosis (Problem Identification)

 Stage IV, Grade C

 Supra- Mod-heavy

 Sub- Moderate

Plan

 Consults-

o Perio-

 Alternating cleanings

 Bone grafting and gingival grafting if they see fit

 Treatment goals-

o Improvement on BOP 71%

o CAL improvement with bone loss and recession in consideration

o Lighter pressure sulcular brushing with soft bristle toothbrush

o No radiographic calc

o Little to no gingival inflammation

 o More frequent recalls 3-4 months

o Improve plaque score 30%

o Stabilize disease from progressing

 Phases of Treatment-

o Create treatment plan

o Get referrals lined up

o Patient compliance- Make sure the patient understands treatment, necessity of

more frequent visits, importance of proper and effective home care, and

outcomes of poor compliance vs proper compliance.

o SRP involving anesthesia, ultrasonic, and hand scaling.

o 4-6 week teeth and tissue check and homecare check.

o Future visits alternating between perio referral and general office at 3 mo

intervals.

Implementation

 Consults- Perio

 Instruments used- Ultrasonic, hand scalers (sickle, G1/2, G11/12, G13/14) and 11/12

explorer

 Methods- Ultrasonic throughout to flush tissues and furcations, FM hand scaling and

root debridement.

 Homecare aids-

o Switch to a soft bristled toothbrush

o Adding flossing 1x/day minimum to his routine

 o Adding an antiseptic mouth rinse

 Anesthetic- Local and topical

 Prescription(s)- No

Evaluation

 Evaluate care by comparing gum and teeth health of the patient before and after

the appointment, and compare at the next appointment. This can be done with a

plaque score, calculus detection, charting, radiographs, etc.

 Follow up charting- At the next appointment, proceed with follow up charting of

the patients teeth, and compare with the previous visit. Evaluate probe depths,

bleeding, and recession.

 Radiographs- Take new radiographs of the patients teeth, and evaluate and

compare to the previous visit. Monitor bone loss and decay, and note any other

changes.

 Patients OH care- Establish the patient’s oral hygiene care routine, and compare

to previous appointments to determine changes. Evaluate behavioral changes of

the patient regarding at home care.

References

Boyd, L., Mallonee L., & Wyche, C. (2020). Wilkins’ Clinical Practice of the Dental Hygienist.

Jones and Bartlett Learning.

Dental and Oral Health- Case Study 42. DentalCare.com. https://www.dentalcare.com/en-us/ca

se-studies/case-study-42.