Treatment Plan 3

By: MacKenzie McMaster

 29-year-old African American male

Assessment

Patient interview: “I’m due for my cleaning and exam”

Medical/Dental history: Last exam and prophy 12 months ago. Pt taking Insulin,

Humulin, & Lantus for Diabetes Type I. Pt reports last blood sugar was 87 (taken 5 days

ago). Discussed importance of checking blood sugar more frequently. Reports no

known allergies. Chart reports enlarged thyroid from previous visit (still enlarged), pt

states he has followed up with PCP regarding thyroid. Last radiographs made March

2018 (4 BW’s). Pt denied x-rays.

Social history: History of smoking.

Vital signs: 6-26-19 BP: 138/90.

Intra-oral exam: Small bilateral mandibular tori L&R. Blocked duct at #13 vestibule

area. Small frenum tear under tongue R side. Enlarged tonsils. Generalized melanin

pigmentation. Gen pointed contour of interdental papilla. Occlusion class I L&R.

Extra-oral exam: Enlarged thyroid.

Periodontal exam: Generalized 1-3mm probing depths. Localized 4’s and 5’s

throughout (See perio chart) Localized 10mm pocket on MB of #16. Gen bleeding

throughout. Perio case type gen gingivitis with localized areas of slight. Calc class B.

Relate oral changes based on special needs of pt: Due to pt’s diabetes, pt will have

slower healing time with treatment. No concerns with oral effects from Diabetes

medications.

Radiographs: Due to x-rays being just over 15 months old will consider new x-rays at

next visit. Pt low caries risk. Current radiographs show missing teeth: 13, 19, 31.
DH Diagnosis

Level of health:

Relate special needs to diagnosis: Due to diabetes and pts heritage, pt is at higher

risk of slow healing as well as a greater risk for periodontal disease (heritage). Pt is at a

lower risk for caries due to his lack of consumption of sugary foods as well as his

heritage.

Diagnosis: Gen gingivitis with localized areas of slight.

Plan

Consultations Necessary: Recommend pt to pursue OS consult for 3rd molars.

Potentially refer pt to perio for 10mm pocket.

Treatment Goals: Would expect to see improved probing depths with minimal bleeding

post tx. If pt goes forward with extraction of 3 rd molars that will eliminate perio problem

at #16-MB.

Phases of Treatment:

Preliminary phase: Review medical history. Collect data such as probing depths,

radiographs (if needed), and clinical examination. Address patients’ main concerns if

any.

Phase I therapy: Demonstrate plaque present with disclosing solution. Biofilm removal

by polishing. Discuss how to keep plaque levels low (brushing and flossing). Removal of

calculus by hand scaling/cavitron.

Outcomes evaluation of Phase I: Evaluate by probing FM. How is overall gingival

health? Improvement in probing depths? Improvement in BOP? What is the plaque

score? How is patients homecare?

Phase II surgical: FM hand scale/ FM cavitron.

Phase III restorative: No restorative procedures to be completed at this time.

Evaluation of overall outcomes: At this point I will review all the data collected to

determine if the areas of 4-5mm were reduced.

Phase IV maintenance: Assess patients biofilm removal and make changes if

necessary. Pt to be scheduled at a 6 month interval with close monitoring of 4-5 mm

areas for improvement.

Implementation

Consultations: Consultation with OS for 3rds. If pt not willing to get 3rds removed,

potentially refer to perio form tx at #16 MB 10mm pocket.

Instruments used: Ultrasonic scaler, sickle, gracey 1/ 2, gracey 11/12, gracey 13/14,

11/12 explorer, probe, mirror.

Methods: Bass technique, c-wrap method when flossing.

Homecare Aids: Soft bristled toothbrush or electric toothbrush, floss, water pik.

Anesthetic: It pt experiences discomfort, LA could be administered. No

contraindications to LA. I would select 3% carbociane to avoid use of epi.

Prescriptions: Pt could take what he would normally take for a headache if he

experiences discomfort after appt.

Identify alterations to implementation based on special needs: It’s important for the

pt to have a morning appt so that the pts blood sugar levels are stable. Its important to

make sure the pt ate breakfast before their appointment as well as took their directed

amounts of insulin/ diabetes medications. Symptoms of hypoglycemia to watch for:

sweating, shaking, rapid heartbeat.

Evaluation:

Data collected during appointment- Plaque score. Probing depths. EO & IO findings.

Follow up charting: Future visits to show improved probing depths. Would expect to

see less BOP. Improved homecare.

Radiographs: Radiographs show missing teeth: 13, 19, & 31.

OH Behavior changes: Improved oral hygiene by patient and compliance with the

brushing and flossing techniques provided.

References:

Hebl, Lisa. (2019) Dental Hygiene III Class Notes, Kirkwood Community College.

Smith, Jaclyn. (2019) Dental Hygiene III Class Notes, Diabetes at a Glance.

Wilkins, E. M.  (2017). The dental hygiene care plan. Clinical Practice of the Dental

Hygienist. Philadelphia, PA: Wolters Kluwer. 12th Edition. (407-418).