Treatment Plan

Jessica Heberlie, Caitlin Jamison, Allie Erickson,

Rebecca Mullet
I. ASSESSMENT
A. Patient Interview
1. Chief Complaint: “I am way overdue for my dental check-up.”
2. Complains of a burning, dry mouth
3. Brushes twice a day with a medium bristles toothbrush
4. Pt. does not floss unless food is trapped
5. Mouthwash Pt. is using gives him a burning sensation
B. Medical/Dental History
1. Medical History: Pt. reports a history of cigar smoking,
hypothyroidism, Parkinson’s disease, frequent bronchitis, GERD
and occasional angina. Five years ago he had a basal cell
carcinoma removed from under his right eye.
2. Medications:
a) (Simvastatin) Zocor®: used to treat hyperlipidemias. May
cause unusual muscle weakness such as the patient having
a difficult time brushing their teeth or weakness with
chewing, no effects on bleeding or local anesthetic.
b) (Metoprolol succinate) Toprol®: used to treat angina, heart
failure and hypertension. The prolonged use of NSAIDS can
reduce the effect of this medication, no effects on bleeding
or local anesthetic.
c) (Levothyroxine) Synthroid®: used for hypothyroidism, no
effects on dental treatment, bleeding or local anesthetic.
d) (Lisinopril) Zestril®: used as treatment/management of acute
myocardial infarction, heart failure and hypertension. Can
cause orthostatic hypotension, no effects on bleeding or
local anesthetic.
e) (Levodopa) Sinemet®: used for the treatment of Parkinson
disease. Can cause xerostomia, taste alterations, orthostatic
hypotension, no effects on bleeding or local anesthetic.
f) 81 mg aspirin: Could be used for temporary pain relief or to
reduce the risk of vascular indications. Can cause increased
bleeding and hemorrhage, no effects on local anesthetic.
3. Dental History: In previous years Pt. received regular dental care
and was on a 6 mo. recall appointment interval.
C. Social History
1. Smoked cigars weekly for 20 years and now smokes 1 pack of
cigarettes weekly
2. Retired life insurance salesman
D. Vital Signs
1. BP 138/88 - will monitor during treatment
E. Extra Oral Exam
1. Pt had clicking and popping noted in bilateral TMJ
2. Mild and inconsistent facial tremors occurred
 3. Areas of tenderness were noted in the submental, submandibular
and deep cervical chain nodes
F. Intra Oral Exam
1. Stain: med-heavy with calc deposits
2. Generalized plaque and BOP
3. 55% bleeding index
4. Overjet
5. Generalized pale, bulbous, rolled, spongy, edematous, inflamed
gingiva; with localized blunting in interproximal areas of 8/9, 10/11,
24/25
G. Periodontal Exam
1. Generalized 4-6mm probing depths, localized 7mm depths,
bleeding upon probing, class I mobility on tooth #9
H. Radiographs (if available)
1. Consult Periodontics to look at 7mm pockets on #30, #25, #9
2. Consult Prosthodontics for a possible implant or bridge for #19
3. Vertical bone loss present, horizontal bone loss in posterior

II. DH DIAGNOSIS
A. Level of Health
1. Pt has a BMI of 30.4, putting him in the ‘obese’ catagory. His blood
pressure is considered hypertensive.
B. Diagnosis
1. Generalized Moderate Chronic Periodontitis
2. Localized advanced chronic periodontitis - #9 (Class I mobility)
3. Generalized Gingivitis

III. PLAN
A. Consultations Necessary
1. Restorative work on #3 and #31 with DDS
2. Perio consult
a) #9 mobility
b) Generalized moderate chronic periodontitis, localized
advanced chronic periodontitis.
3. Potential pros consult for missing #19
a) Bridge or implant
4. Potential ortho consult for overjet of maxillary arch
5. TMJ specialist for popping and clicking of both sides
B. Treatment Goals
1. Plaque control
a) Increase the plaque-free score
 2. Gingiva
a) Reduce redness - move toward pink and healthy, More firm
and less spongy, Less bulbous and rolled
3. Establish a habit of flossing once/day with C shape
4. Establish a habit of using the BASS method with soft toothbrush,
emphasizing on 45 degree angulation toward the gumline
C. Phases of Treatment (Wilkins pg. 409)
1. Preliminary
a) Gather pt data
(1) Medical and dental history
b) Appears there is no immediate need for emergency care
2. Phase I
a) Preform plaque score and utilize this teaching tool for OHI
on the pt
b) Ultrasonic and hand scale to remove calc
c) Set pt up for appointment with DDS for restorative work on
#3 and #31
3. Outcomes of Phase I
a) Probe full mouth
b) Chart the description of the gingiva from first and second
appointment
c) Redisclose at second appointment and perform plaque score
(1) Use this as teaching moment for OHI
4. Phase II
a) Set pt up with perio consult
(1) #9 mobility
(2) Generalized moderate chronic and localized
advanced chronic pt
b) Set pt up with pros consult
(1) Potential implant #19
5. Phase III
a) Set up pt with pros consult
(1) Potential bridge for #19
6. Evaluation of Overall Outcomes
a) Check and chart the gum tissue around the restorations on
#3 and #31, #9 if perio was done, #19 if pros was done
(1) Probe depths
7. Phase IV maintenance
a) Perio pt should be on a 3 month recall
b) Keep teaching OHI to pt
IV. IMPLEMENTATION
A. Scaling Type: Ultrasonic and hand scale 4 quadrants
B. Plaque removal: Tooth brush, floss and a prophy angle (cup/brush)
C. Fluoride: Varnish
D. Auxiliary Procedures: Local anesthesia may need to be administered if
there is too much sensitivity when scaling with deep probing depths
E. OHI: Teach and demonstrate the BASS brushing technique, being sure to
use small circular motions with the tooth brush at at a 45 degree angle to
the gumline and turning the tooth brush vertical when brushing “behind his
front teeth.” Demonstrate the c-wrap method of flossing to ensure that the
floss is going under the gingiva along the tooth surface, and recommend
that he gets into a routine of flossing at least once a day. A good starting
goal is flossing 3 or 4 times a week and then work up to daily flossing.
F. Homecare:
1. Soft manual toothbrush using BASS technique twice per day
2. Floss using c-wrap technique at least once per day
3. Use a water irrigator to ensure the debridement of materials from
the deep pockets
4. Use a non-alcoholic mouth rinse that contains fluoride to help
eliminate the burning that he is having with his current rinse
5. Incorporate Biotene products into his daily routine to help with the
discomfort of his dry mouth - recommend xylitol gum to help with
dry mouth
6. Taking a wash rag to palate after smoking
7. Stimulate gingiva using a rubber tip stimulator
V. EVALUATION
A. How will you or how did you evaluate care
1. Ultrasonic and hand scale and check with an explorer when
finished
2. Follow up with pt to see when they have scheduled the consults
a) Restorative work on #3 and #31, Perio for mobility #9,
Potential pros for missing #19, Ortho for overjet, TMJ
specialist for popping and clicking
B. Follow up charting
1. Disclose and perform another plaque score
2. Probe full mouth
3. Redo bleeding index
4. Redo extraoral exam
a) check for lymphadenopathy in submental, submandibular,
and deep cervical chain
b) Ask if seen PCP for this if inflammation is still present
 5. Redo intraoral exam
C. Radiographs
1. Take radiographs as prescribed by DDS
a) Check bone loss levels
D. Patient OH behavior changes
1. Saw a decrease in redness within 6 weeks
2. Staining is lessened but still present after 6 weeks
3. Want to see the patient develop a habit of flossing with C shape
once a day.
4. Expect the patient to be using a soft toothbrush and the BASS
method
5. Expect to see the patient using alcohol-free mouthrinse with
fluoride
6. Expect to see the patient using Biotene products to help with dry
mouth

Wilkins, E., (2017). Clinical practice of the dental hygienist (12th ed.). Philadelphia, PA:
Wolters Kluwer.

Crossley, H., Meiller, T., Wynn, R. (2018). Drug information handbook for dentistry
including oral medicine for medically compromised patients and specific oral
conditions (24th ed.). Hudson, OH: Lexicomp.

Case Study 6 - Questions

1. E
2. B
3. D
4. B
5. E
6. D
7. D
8. D
9. D
10. C