DIAGNOSIS

Copy of Dental Hygiene Diagnosis

Systemic health:
Ø Controlled hypothyroidism
Ø Controlled GERG
Ø Smoker
Oral health:
Ø Lack preventive dental care
Ø Chronic periodontitis
Ø Genialized erosion from GERD
EO/IO:
Ø Bilateral severe linea alba
Oral Hygiene:
Ø Generalized heavy plaque
Intra-oral lesion
The lesion was found out by the DH student upon IO exam. Pt was not aware the
duration of the lesion and had no symptoms.
■ Shape: round
■ Size: 4mmX5mm
■ Color: purple
■ Consistency: soft
■ Texture: smooth
■ Location: Right buccal mucosa
■ Duration: unknown
■ Sensation: asymptomatic
■ History: patient is a smoker and grinder
■ Refer: not indicated
■ Differential diagnosis:
■ Hematoma from occlusal trauma
■ Oral Nevi
Intra-oral lesion follow up

■ The lesion disappeared at the next appointment.

■ Informed patient the lesion has been healed.
■ DDS performed enameloplasty (D9971) on several sharp cusps that
may contribute to the occlusal trauma.
■ Patient has been smoking for over 30 years. Given the risk factor
for oral cancer, advised patient to do intra-oral self-exam once a
month, including the floor of the mouth and the lateral side of the
tongue in addition to the semi-annual routine dental care.
 Check T3/T4/TSH every six months to monitor thyroid hormone.

Tobacco cessation consultation to help patient to quit smoking.

Methods Nutrition counselling to help patient get balanced diet.

Used to Full mouth SRP to treat periodontitis.

Achieve Full mouth air polishing to remove stains from cigarette.

Goals and
Outcomes Composite filling on #30 and #31 buccal pit.

Oral hygiene home care instructions to help patient improve

biofilm removal at home, including perio-aid and waterpik.

Perio-maintenance every three month to reduce inflammation and

slow down the progression of periodontitis.
Caries

Past
•Patient does not remember caries history. Two bridges
clinically presented in patient’s mouth. The upper bridge is
from #10-#12 and the lower bridge is from #18-#20. Patient
reported loss of #11 and #19 possibly due to trauma.
Current
•#30 and #31 buccal pit caries detected.
Fluoride Sources
This Photo by Unknown Author is licensed under CC BY-NC-ND

Current
•Patient lives in a fluoridated area.
•Patient uses OTC fluoridated toothpaste.
Goal
•Continue the same fluoride intake. Patient is not at
high risk for caries.
Risk Assessment

■ Patient is at high risk to

periodontal disease due to
smoking, lack of professional
cleaning and lack of dental
knowledge.
■ Patient is at low risk to cavity due
to genetic factors, low-sugar diet,
access to fluoride from water and
toothpaste.
Methods of Evaluating
Success
■ How do you know your goals were met?
1. Compare the pre and post pocket depth, BOP, and
gingival description.
2. Compare the amount of cigarette patient smokes a
day before and after tobacco cessation counseling.
3. Compare the daily plaque control before and after
home care instructions.
■ How will you measure if goals were met?
1. Tissue re-evaluation: gingival description and
probing
2. Plaque index