I.

Assessment

a) Patient interview: The patients chief complaint is “I have a broken tooth and my

mouth is always very dry.”

b) Medical/dental history: The patient is a 67 year old male. BP: 135/88, hear rate:

100bpm and respirations: 18 breaths/minute. The patient has type 2 diabetes,

hypertension, early signs of dementia and Parkinsons disease. His medications

are: Lisinopril, Glipizide, Levodopa and Lexapro. Due to his Parkinsons disease

he has tremors in his hands, stiffness in his joints and an impaired balance. He has

early signs of dementia but is still able to function. In the past he’s been told he is

a mouth breather. Last HbA1c reading was a 7.5%. The patient has not seen a

dentist in over 10 years. He says he brushes with a hard bristle toothbrush and

does not floss. He states that he buys his toothpaste on sale so he is not sure if it

contains any fluoride or not. Occasionally he rinses his mouth with hydrogen

peroxide or salt water. Extraoral examination findings were all within normal

limits. Intraoral examination found tenderness in the maxillary left quadrant.

Redness and inflammatory infiltrate present in the region of tooth #12. Attached

gingiva in the maxillary anterior appears pink and stippled but the marginal

gingiva exhibits redness and swelling throughout his mouth.

c) Social history: The patient lost his wife to cancer several years ago and his grown

son lives 1,000 miles away with his family. He still interacts with veteran buddies

who look out for him. He was forced to retire from his factory job 5 years ago due

to his symptoms of Parkinsons disease getting too bad.

d) Vital signs: BP: 135/88; Heart rate: 100bpm; Respirations: 18 breaths/minute

 a) Intra-oral/extra-oral examination: Extra orally; all findings were within normal

limits. Intra orally; reported tenderness in the maxillary left quadrant. Redness

and inflammation was present in the region of tooth #12. Although attached

gingiva in the maxillary anterior region appears pink and stippled, the marginal

gingiva has redness and swelling throughout the mouth.

b) Periodontal examination: Generalized heavy bleeding facial/buccal of entire

mouth with areas of lighter bleeding generalized lingually. 4-7mm probing depths

generalized in the maxillary and 3-4mm in the mandibular. Generalized 1-2mm of

gingival recession.

c) Relate oral changes based on special needs: Due to patients Parkinsons disease,

early stage of dementia and type two diabetes, his oral health will not be as

healthy as someone without these conditions. The Parkinsons disease causes

tremors in his extremities making it very difficult for him to brush and floss his

teeth. He also has early stages of dementia which can cause him to often forget to

take care of or how to take care of his oral health. Type two diabetes makes it

very hard for his mouth to heal from the infections he has going on from not being

able to properly care got his oral hygiene.

d) Radiographs: Panoramic film with four intraoral photographs. Radiographic areas

of carious lesions. Notable areas of generalized demineralization in the intraoral

photos. Notable tooth loss in panoramic image and intraoral photos.

II. DH Diagnosis

a) Level of health: Severe

 b) Relate special needs to diagnosis: Periodontal disease stage: IV grade: C. I put

this patient into this calcification due to the CAL being greater than 5mm in most

areas and because he currently has 19 teeth in his mouth with lots of horizontal

bone loss. We can’t say what his level of bone was 5 years ago, but his bone loss

is at a rapid rate due to his HbA1c being over 7%. Not being able to properly care

for his oral health due to Parkinsons and dementia has led to this diagnosis and

due to type two diabetes it has made it very difficult for his mouth to heal leading

to large areas of bone and tooth loss.

III. Plan

a) Consultations necessary: Comprehensive exam to establish report with new

dentist. Full mouth radiographs taken to have a better understanding of

periodontal disease. Possible consult with a prosthodontist to replace missing

teeth for better everyday living.

b) Treatment goals: Get the patient on a 3 month recall with dentist office for

cleaning appointments. Come up with a great at home care plan with techniques

the patient is able to implement at home. Set up consultation with prosthodontist

to discuss possibly replacing missing teeth.

c) Addresses phases of treatment: 1) comprehensive exam with FMX 2) multiple

SRP visits with dental office 3) consult with prosthodontist

IV. Implementation

a) First appointment we will do a comprehensive examination and take a FMX on

the patient of remaining teeth to be able to properly diagnose his periodontal

disease and treatment plan restorations needed. He will then return to our office
 for any restorations needed and cleaning. I recommend multiple shorter

appointments for this patient due to his Parkinsons disease he will not be able to

comfortably sit through long appointments. Next visit will be right side SRP with

anesthetic, working slowly and taking multiple breaks for the patient. The patient

will then return to the office to finish the left side SRP with anesthetic.

Throughout these appointments we will need to set aside adequate time to do an

extensive at home care routine with the patient. Showing him how he can modify

his at home care so he is able to take proper care of his oral health. I would

recommend patient gets a handle grip for his toothbrush. It will make gripping the

handle with his tremors much easier and have better dexterity for brushing. I

would recommend the same for flossing too. Using floss picks or getting long

handle flossers that can be changed out. He had stated that he has a very dry

mouth, which is due to the medications that he at takes. I would recommend a

Biotine rinse for this patient and stress the importance of drinking lots of water.

Because of the very dry mouth, I would also recommend he has fluoride

treatments to help prevent caries.

b) Identify alterations to implementation based on special needs: I would implement

multiple breaks throughout all appointments due to the Parkinsons disease that

way he can be as comfortable as possible. Also making sure to talk clearly and

slowly due to patient having early stages of dementia that way he can clearly

understand what I am telling him.

V. Evaluation
 a) How will you or how did you evaluate care: Reevaluate BOP and CAL for any

changes. Access biofilm and inflammation to possible adjust OHI.

b) Follow up charting: Perio chart FM to reevaluate probing depths, BOP, CAL and

biofilm

c) Radiographs: FMX with vertical bitewings.

d) Patient OH behavior changes: Make sure he is maintaining good at home care and

make any changes to OHI as needed if he is unable to use the griper for the

toothbrush or the floss picks. After probing reevaluate if there has been any

changes in depths then go from there with adjusting OHI.

VI. 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/
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