Michelle Hidalgo

DHYG 1311

Periodontal Care Plan: Treatment Phase

Appointment 1: Friday, September 9, 2016 (8:00-12:00)
A. Plaque Index: Mr. X's plaque index was taken this morning at the start of his treatment
appointment, it was down from a 2.3 to a 2.0. I am happy to see that he has taken an
interest in his dental health and hope to see a further decline in the plaque score.
B. Bleeding Index: Mr. X's bleeding index was taken along with the plaque index and
today it was marked at 10%. It is down from the 16% at the previous appointment 2
weeks ago. Mr. X has taken an interest in his home care, and I look forward to seeing the
progression of his treatment.
C. Gingival Description: At today's appointment the lower right quadrant was treated.
Full periodontal probing was done on teeth 25-31. After using the ultrasonic, the majority
of the calculus was removed and I was able to successfully evaluate the pocket depths of
the LR quadrant. The DL of #31 moved from a 5mm to a 6mm pocket as did the ML #29.
The ML #31, DL #30 deepened to a 5mm from a 4mm as did the DL of #29. The
remainder of the quadrant presents with generalized 4 and 5mm pockets both buccal and
lingual aspects. The CAL in the LR quadrant shows moderate bone/tissue loss, as great as
5mm in lower lingual anterior where he has a great deal of calculus buildup and
recession. My findings today were indicative of what I expected after reviewing his films
and his initial periodontal assessment. His periodontal status is as advanced as I expected.
I discussed with him the importance of his home-care and the impact of how us working
together as a team could successfully halt the progression of his disease. The bacterial
destruction to his tissues has taken a toll and I hope that at his age, we have caught this
and can manage it from here on out.
D. Appointment Notes: Medical/Dental History Updated. Pre-Rinse. Took 3 Retakes
needed for patients FMX series. Intraoral camera was still having issues, so we were
unable to take the intraoral pictures needed today. Plaque and Bleeding Indices were
taken and noted. Plaque score: 2.0; Bleeding score: 10%. Mr. X was given first carpule of
1.7mL Septocaine 4% w/ epi 1:100,000 and we waited approximately 15 minutes for it to
take effect. He was still uncomfortable upon probing and could feel the end of the
explorer when touching the gingiva. Dr. P administered a second carpule of the same
1.7mL Septocaine 4% w/ epi 1:100,000 and after about 10 minutes the patient felt more
numb and was ready to proceed. Nearly halfway through treatment the patient was
feeling me work and was sensitive to the ultrasonic. Dr. P stated he could have no more
anesthetic and we proceeded to use Cetacaine with some success. I used 0.2mL on buccal
gingiva sulcus for treatment. I was unable to complete the treatment on the anterior,
mainly the M of #25 as he was too sensitive. I will attempt to finish when working the
lower left quadrant next week. Full periodontal charting was done on the lower right

quadrant. I was unable to do formal patient education today as we ran out of time due to
anesthesia issues. Chair side, we discussed the importance of brushing both AM and PM,
and how saliva slows down significantly at night. Mr. X has stated that he does not brush
much at night and we discussed this at length today. We discussed the possible tissue
changes we are looking for with removing the calculus below the gums and how
important continued home care and bringing flossing into the picture is. He is currently
trying to quit smoking, I am hopeful this will aid in the healing process as well. I gave
him a printed post op sheet I made and discussed it with him as well. He was told he
could take Tylenol or Advil for discomfort as needed, and use warm salt water rinses or
warm baking soda rinses and not to hesitate to call. LL: Interest.

Appointment 2: Friday, September 16, 2016 (8:00-12:00)

A. Plaque Index: Mr. X's plaque index was taken this morning at the start of his
appointment, it was down from his previous appointment at 2.0 to 1.5. With a decreased
plaque score, his periodontal treatment will likely be successful. The host response and
amount of plaque biofilm play a huge role in how the patient will respond to treatment
and heal. I am extremely happy to see the progress he is making in his home care.
B. Bleeding Index: Mr. X's bleeding index was taken today and is marked at 11%. It was
marked at 10% last week. There was some misunderstanding among the students and
instructors this week about bleeding index and needing to take the entire mouth or just the
index teeth. I believe there may be a discrepancy here. I see a difference in the health of
his tissue and his tissue on the lower right is looking healthier from last visit and is not as
tender to explore around. Even with a discrepancy, Mr. X is getting rid of plaque and
lowering the amount of bacteria, which in turn is lowering both the plaque and bleeding
score. I also would like to take into consideration that he is a smoker and the
vasoconstrictor properties of the nicotine. This could be disguising some of the gingival
bleeding.
C. Gingival Description: At today's appointment the lower left quadrant was treated. Full
periodontal probing was done on teeth #18-24. Mr. X has generalized 4 and 5 mm
pockets on the LL quadrant. After ultrasonic treatment was performed, and the heavy
calculus was removed, I was able to easier access the pockets and get more accurate
readings. The 4mm pockets on the DB of #18 and 19 moved to 5mm. The LR quadrant
presents as a much healthier looking tissue today, although it is not the firm, pink, tight
tissue that we are looking for, it is significantly healthier looking than the previous week.
The tissue around the buccal of the molars was much less red and less rolled and
inflamed. The tissue on the linguals of the anterior teeth #25-28 was firm and tight, no
rolling of the margins and pink. It is slightly bulbous, but not longer rolled, there is a
flatness in the shape of the papillae of his lower anterior between #25-23 where there is
significant recession on both the facial and lingual surfaces. I was certainly encouraged to
see the progress in a short week.
D. Appointment Notes: Medical/Dental History Updated. Pre-Rinse. Took 6 Intra Oral

pictures for patient education use and Bleeding Indices were taken and noted. Plaque
score: 1.5; Bleeding score: 11%. Mr. X was given 1 carpule of 4% Septocaine w/ epi
1:100,000 followed by 2% lidocaine w/ epi 1:100,00 on the lower left quadrant as well as
1/3 of a carpule of Septocaine as an infiltration on the lower anterior buccal. After about
8 minutes, the patient was fully numbed and we were able to start treatment. This weeks
anesthetic technique and and combination of Septocaine and lidocaine worked well for
Mr. X. He was extremely comfortable throughout the majority of the procedure. I was
able to complete treatment on the lower anterior and have the LR checked by 2
instructors. LL was ultrasonic treated and hand scaled as well as full periodontal probed.
Formal patient education session was done today.
Patient Eduction Session 1: Today, I introduced the 4 LTGs for the patient, including
lowering plaque score to 0, halting periodontitis, having the caries repaired, and tobacco
cessation. During todays session, we discussed what plaque is and that is has to be
mechanically removed by a toothbrush daily as well as by a professional. I explained the
detrimental effects of plaque, hardening into calculus if not removed daily, and what
happens if it stays for a long period of time and creates the periodontal pockets. We
discussed the importance of night brushing and then went over brushing technique, both
on the typodont and at the sink. Patient was disclosed and shown what he missed. We
reviewed the session today as well as what will be introduced next week. The patient
responded well, I believe he is interested in trying and knows the shape his mouth is in.
He seems willing to try and I am seeing progress in the numbers on his plaque scores and
bleeding scores as well as clinical exams. LL: Involved

Appointment 3: Friday, September 23, 2016 (8:00-12:00)

A. Plaque Index: Mr. X's plaque index was taken today at the start of his appointment, it
was down even farther from last week to a 1.1. This is great improvement and progress
for my patient. I know some of this is that we have cleaned 2 quadrants, but I am seeing a
decrease in the areas of plaque on the index teeth. I am extremely encouraged as I am
fully aware of the host response and what the amount of plaque biofilm can do to the
treatment of periodontitis. If I can continue to encourage him to get his plaque score
down, WE can be successful in halting the progression of his disease.
B. Bleeding Index: Mr. X's bleeding index was taken today on the index teeth and was
down to 10% from 11% last week. I believe there is room for improvement, but I do see
visible progress in the healing of his tissues. I'm hopeful we will continue to move
forward. He is a smoker and I do believe this plays a role in the lack of bleeding, he does
have a decrease in plaque, but there is still inflammation and I believe the smoking is
hiding this.
C. Gingival Description: At today's appointment the upper right quadrant was treated.
Full periodontal probing was done on teeth #2-8. The MB #2, 3 both moved to 5mm from
4mm after ultrasonic treatment was done and heavy calculus was removed and there is a
5mm pocket on the DB of #3. The DL #3 moved to a 6mm pocket from a 5mm. Overall,
there are generalized 4-5 mm pockets on the UR quadrant with the localized 6mm. This

tooth also has an peri-apical pathology on the palatal root, and also has had previous
endodontic treatment. Mr. X has some significant recession on the UR premolar, canine
area, as well as class V decay on 6,7,8. This leads to higher numbers on the CAL, as
much as 6mm on the facial. Both the LR and LL quadrants are continuing to heal nicely.
The LL has much less inflammation than that of last weeks appointment, as well as the
lower anterior. The bulbous nature of the papillae between #24-20 have been reduced.
The rolling of the margins in the posterior region in the molars on the buccal has also
been reduced. The LR is maintaining the appearance of last weeks description. The color
is the same, the redness is not what is was initially, but we have not achieved the healthy
pink color. I believe this is due to the smoking and lack of flossing regularly and still not
perfected brushing technique. These issues were stressed today.
D. Appointment Notes: Medical/Dental History Updated. Pre-Rinse. Plaque score and
bleeding score taken and noted. Plaque score: 1.1; bleeding score: 10%. Mr. X was given
3.4mL of Septocaine was administered on the UR quadrant and was successful for
treatment. The complication we ran into at this appointment with anesthesia was that he
metabolized it rather quickly and I chose to get up in the middle of treatment to do patient
education because there were so many of us needing to use the rooms. I had previous
experience with Septocaine and it usually lasts, I did not expect it to wear off as fast as it
did. After returning from patient ed, Mr. X was only numb on his skin tissue on his face,
the teeth and oral tissues were no longer numb. Mr. X was a fantastic patient getting
through the last bit of his appointment. Ultrasonic and hand-scaling was done. I was
unable to ultrasonic on the facials of #6,7,8 due to the amount of decay. I struggled even
with hand-scaling because he was so sensitive as a result of the decay and decalcification.
The severe sensitivity resulted in the decision to place 5% NSF varnish over the upper
anterior in hopes of aiding in a reduction of sensitivity for the next treatment. Post
fluoride instructions were given to Mr. X. It was stressed not to eat crunchy, sticky foods,
no hot beverages or alcohol for 4-6 hours. Also not to brush until the next morning.
Patient Education Session 2: During our patient education session today, we reviewed the
previous LTG, I asked if he had any issues with brushing, any questions regarding plaque
or the technique taught. None were stated. Today, I introduced LTG #2, halting
periodontitis. I explained that we want healthy, firm, pink tissue. We want to lower his
bleeding score by 4% at each appointment, we want to learn proper flossing techniques
and the importance of flossing, as well as get him flossing regularly. Mr. X was taught
that periodontitis is the progression of gingivitis, it is bone/tissue loss and these can NOT
be re grown, Mr. X was shown recession on his intra oral photos. We discussed flossing
and the importance, that if no flossing is done, he misses 40% of his tooth structure when
cleaning! We then went over technique, even discussing floss picks, because he likes
these and if that is what I can get him to use, I am willing to at least teach him to use
them correctly. Mr. X was disclosed at the sink and allowed to floss using the new
technique he was taught and see how to get off the plaque still on his teeth. Overall, the
session went well and we agree that we can start towards flossing a few times a week and
work towards a daily goal next semester. LL: involved.

Appointment 4: Friday, October 14, 2016 (8:00-12:00)

A. Plaque Index: Mr. X's plaque index was taken today and was recorded at 1.3. It is up
from 1.1, 3 weeks ago at his previous appointment. This shows me that I need to spend
some time discussing brushing and flossing again with him during our next patient
education session. This may be a good opportunity to explain to him the host immune
response to him. Mr. X is a very intelligent man and knows the shape his mouth is in, I
believe on some level if the correct information is given, he can take the knowledge an
apply it for lifelong benefit.
B. Bleeding Index: Mr. X's bleeding index was recorded today at 2%. This is down
significantly from the 10% 3 weeks ago. I am extremely encouraged, but also perplexed
as to why. I see a plaque score up and a bleeding score down. I know he is a smoker, and
I am positive this is the reason behind the lowered bleeding score. Mr. X has been
brushing, but evidence in his oral cavity does not show that he is brushing and flossing as
well as stated.
C.Gingival Description: At today's appointment the upper left quadrant was treated. After
ultrasonic scaling, I was able to better access the periodontal pockets for more accurate
readings. I recorded readings deeper on the DB #14 and MB #15, that went from a 4mm
to a 5mm pocket, also DL of #14 went from a 4mm to a 5mm pocket as well. He has
generalized 3 and 4 mm pockets on the UL quadrant. There is also several places of
recession, mostly on the U/Ant, due to the class V decay. I have also charted 2 and 3 mm
recession on #12 and 13, respectively. There is no recession on the lingual. The CAL
suggests on the upper posterior of the left he has some localized 4mm loss of attachment.
This loss of attachment has been explained to Mr. X as something we don't regrow. Tissue
that has been lost, we don't get to grow back, but we can get it to a maintainable state. My
hope is for Mr. X to understand and take seriously the state his mouth is in. Periodontally,
he will loose his teeth if he continues down this path. I was disappointed to see the state
of the remaining quadrants. The tissue was more inflamed than at the previous
appointment, the bulbous papillae are not quite where they were in the beginning, but
there is definite inflammation present. I feel his is not being as diligent in his home-care
as he is stating. I am discouraged with what I am seeing. We took a few weeks break due
to some scheduling conflicts and I am seeing regression. I had to do some spot checks
from the previous appointments and had to rescale because of the grainy calculus that had
built up in 3 short weeks. I will take into consideration the quick amount of time that he
builds up calculus and the lack of diligent home care not yet achieved, and consider a 3
month recall at this point. This was discussed today with Mr. X. In my professional
opinion it is for his benefit.
D. Appointment Notes: Medical/Dental History Updated. Pre-Rinse. Plaque Score and
Bleeding score taken and recorded. Plaque Score: 1.3, Bleeding Score: 2%.

Mr. X was given 1.12mL of Septocaine 4% with epi 1:100,000 initially for us to start
treatment. This worked well for the posterior molars and pre-molars. He needed
additional anesthetic and requested palatal injection for the remainder of the procedure.
Dr. N administered 1.12mL of lidocaine 2% with epi 1:100,000, GP, ASA, and MSA.
This was a great deal of help and allowed us to move much further along in treatment. I
was still unable to finish him without the need of a final injection, Dr. N gave him another
1.7mL of Septocaine -PSA, MSA, ASA; as well as the remainder .56mL of lidocaine-NP.
The UL quadrant was ultrasonic scaled with the universal and slimline tips. I full perio
probed the entire quadrant and then began hand scaling. Mr. X did well through the
ultrasonic scaling, the hand scaling, we struggle though, especially on the upper anterior
where the class V decay and decalcification is. Mr. X stated that the fluoride treatment
done 3 weeks ago did not leave any positive results, but we will try again today and hope
for results after another treatment for his last appointment. Due to the amount of time it
took to get though the scaling and probing and anesthesia difficulties, we were unable to
get to the final formal patient education session. It was approved to do at the post calculus
appointment. We did discuss the diligence he needs to have with brushing and flossing
and how his tissue in other areas have look better. He stated that it feels better to brush
and floss now. I am trying to encourage him to continue to use regular floss. 5% NSF
Varnish was applied to the recession and Class V decayed areas today and he was given
instructions not to eat crunchy or sticky foods for 4-6 hours as well as no hot drinks or
alcohol for the same time. He was advised not to brush until that evening. LL:
Involvement