Jessica Fox

L. Assessment - Preliminary phase

a. Patient lnterview
i. "l would like my teeth cleaned. I want to get my dental care under
control"
b. MedicaUDental History
i. Medication
1. Albuterol- Oral effects; Xerostomia
2. Alprazolam - Oral effects; Significant xerostomia and salivary
changes
3. Symbicort - Oral effects; Xerostomia and localized Candida or
Aspergillus infection.
ii. Does not receive annual dental exams. Last appointment was
approximately 11 years ago. Flosses rarely. Brushes one time per week'
Only receiving fluoride in drinking water. Currently using non-fluoridated
toothpaste as he feels fluoride lowers lQ level.
iii, Asthma, chronic bronchitis, gout, sleep apnea,.xerostomia (from
CPAP/medications).
c. Social HistorY
i. Heavy snacker - Consumes a frozen pizza as a typical snack
d. Vital Signs
i. BP 150/90 - Consulted for ok to treat. Patient *425#' lnstructor gave ok
to treat.
e. lntra/Extra Oral Exam
i. TMJ - deviates upon closure. Minimal popping associated bilaterally. No
pain associated,
ii. ChaPPed LiPs
iii. Dry mouth - seen bilaterally on cheeks. Has a cheek bite look.
iv. Tongue - Tan coating Present
v. Mandible - Bilateraltori present
vi. Extrinsic staining - Light yellow
vii. Color of Gingiva - generalized red
viii. Contour of lnterdental Papilla - localized blunted and bulbous in the
posterior. Localized pointed and normal in the anterior.
ix. Contour of Marginal Gingiva - Generalized knife-edged. Localized rolled
in the posterior.
x. Consistency of Gingiva - Localized firm and resilient in the anterior'
Localized spongy and edematous in the posterior.
xi. Texture of Gingiva - Generalized stippled
xii. BOP - Spontaneous
f. Periodontal exam
i. Generalized 2-4 mm probing depth
ii. Localized 5 mm on mesiofacial of tooth #6 and distofacial of tooth #3
B. Radiographs
 i.
Generalized horizontal bone loss
2. DH Diagnosis - Phase 1
a. Level of Health
i. Patient is in fair-poor health. Physically capable of good OHl, but Lacks
knowledge and motivation to make and implement appropriate
homecare.
ii. Orally - Generalized gingivitis, localized slight in posterior. Class B
calcu lus.
b. Diagnosis
i. Generalized Gingivitis. Localized Slight (posterior)
3. Plan
a. Consultation - No need for consult at this time - No need for phase 2 at this
time.
i. Previous filling on tooth #30 done the morning of the cleaning.
b. Treatment Goals
i. Less calculus, less BOP, Better OHI- Educate patient about his levelof
dental health and options to improve it. Develop new routine of using
new Oral B brush once daily along with a fluoridated toothpaste. Better
nutrition - eliminate frozen pizzas as snacks, drink more water and eat
more protein and green veggies. Maintain perio case type.
c. Address phase of treatment
i. Listed throughout plan
4. Implementation * One DHYG appointment needed.
a. Consultatircns, instruments used, homecare aids, anesthetic, prescriptions
i. No consultation needed at this time.
ii. Probed FM with UNC 12 probe. Ultrasoniced FM, followed by hand
scaling FM with Sracey curettes (L12, tt/12, L3/!4],, sickle (H5/33), LtlL2
explorer. Followed hand scaling with slow speed prophy angle and
medium paste, Applied fluoride varnish to FM.
iii. Dispensed floss reacher (pt, had difficulty reaching the posterior teeth
when flossing). Also dispensed floss pick and fluoride toothpaste.
5. Evaluation - Phase 4
a. How will you evaluate care?
i. Gingival bleeding decreased, gingival inflammation reduced, healthier
gingiva present.
b. Follow up charting
i. Perio chart - Probing depths maintained
c. Radiographs
i. Bitewing Radiographs
t, Bone loss maintained
2. CMS and Pan just done L month ago, so will need to wait until 1
year recall appointment to evaluate radiographs.
d. Pt. OHI behavior changes
i. Plaque score improved
 ii. Utilized recommended aids (Oral B brush used at least l time per day,
Floss reacher, Floss pick, and fluoride paste).
iii. Pt demonstrates appropriate use of aids.
e. References
i. Wynn, R. (2017). Drug information handbook for dentistry. Wolters
Kluwer.
ii. Wilkins, E. (2017). Clinical practice of the dental hygienist. Philadelphia,
PA. Wolters Kluwer.
 Jts'*no

Grading Criteria 0 7 2 J
Not Beginning- Developing- Accomplished-
Present Understood, Understaod, Understood,
fncludedt Included, hduded,
Covered Covererl Covered AII
Few Some
L Assessesment
patient interview 0 I 1 3
medical/dental 0 1 1 3
histogy
j
social history 0 7 3
1 3
vital signs 0 1
inh'a-oraUextra-omi 0 1 1 J
examination
,,
periodontal 0 1 3
examination
radiographs 0 I 2 3
if available
il. DH Diagnosis (Problem
fdentification)
Level of Hea1th 0 I 2
,}
3
Diagnosis 0 1 3
(seleets one)
Gingivitis
Periodontal Disease
Caries
III. Plan
Consultations Necessary 0 1 2 3
Treatment Goals 0 I 2 3

Addresses Phases of Treattnent 0 1 2 J

fV. Implementation
(narrative section) 0 1 2 J
Consultations, Instruments used
Methods, Homecale Aids
Anesthetic, Prescriptions
V. Evaluation
How will you orhow did you 0 1 "} 3
evaluate care
Follow up charfing 0 I 2 3

Radiograplis 0 1 , 3
n J
Patient OH behavior changes 0 1 L

Other Items
References 0 1 , 3
t
Spelling/Grammar 0 1 \\
By due date 0 1 1
I
3'
Total
i
\
Final Score !
l1 60