Treatment Planning Assignment III Claudia Kinnander

I.Assessment

A. Patient interview: Patient is a 79-year-old African American female. She has not been to the

dentist in several years. The patient chief complaint is “My teeth have not been cleaned in a long time and

are in bad shape.” Patient is curious about a power toothbrush and if a mouth rinse will help reduce

bleeding. The patient brushes pretty hard with a manual toothbrush, she does not floss, and does not know

if she uses a fluoridated toothpaste.

B. Medical/ dental history: the patient had her mandibular right first molar extracted a year ago and

has had no dental treatment since then. The patient has had a hysterectomy when she was 62. The patient

also had a mild stroke four years ago. The patient has to use a cane to help her walk and she sometime has

a shortness of breath when exerting herself. The patient had laser eye surgery on the retina of her right eye

recently. The patient is taking 81mg aspirin, multiple insulin injections, Omeprazole (PrilosecÒ),

Lovastatin (MevacorÒ), Atenolol (TenorminÒ), Ramipril (AltaceÒ), Clopidogrel bisulfate (PlavixÒ),

and Risedronate (ActonelÒ).

C. Implications to treatment: Patient needs a morning appointment. Stroke, Diabetic, Acid reflux,

shortness of breath, use of a cane, and patient is on an anticoagulant.

Medication Use Dental Implications

Aspirin Cardiovascular Increased bleeding due to its effect on hemostasis.

indications

Insulin diabetic Patient needs a morning appointment, make sure patient has eaten normally, and taken
all medication.

Prilosec Acid reflux Taste perversion, dry mouth, esophageal candidiasis, and mucosal atrophy(tongue).

Mevacor cholesterol Asses unusual presentations of muscle weakness or myopathy resulting from lipid therapy.
If patient is having a difficult time brushing teeth and chewing refer back to their physician.

Tenormin Cardiovascular Local anesthetic with a vasoconstrictor can be safely used.

indications

Altace Cardiovascular Patient may experience orthostatic hypotension. Use caution with sudden changes in position.
indications

Plavix anticoagulant Increased bleeding.

 Actonel Osteoporosis Can cause delayed healing especially with oral surgery.

D. Social history: No information available.

E. Vital signs: BP: No information available

F. EO/IO Examination:

1. EO: The patient has a large nevus on the left side of her face. Everything else was WNL

2. IO: Patient’s gingiva has generalized melanin pigmentation, blunted, receded, fibrotic, non-

resilient, and non-stippled. The patient has bilateral mandibular tori. The tori on the

mandibular right side is larger than the tori on the mandibular left side. The patient has

extrinsic staining in the pits and fissures of her posterior teeth. Patient is missing #1, #30,

and 32. The patient also has several amalgam restorations.

G. Periodontal Examination: The patient has a bleeding index of 55%. The patient’s plaque free score is

35%. The patients probing depths are generalized 2-5mm with a localized 6mm on the mesial of #3.

H. Radiographs: Patient has generalized horizontal bone loss.

I. Oral changes based on special needs: Since the patient has had a stroke this can affect her

dexterity making it hard for her to brush and floss. This can cause a build up of plaque which can lead to

gingivitis or periodontal disease if modifications are not made.

II. DH Diagnosis

A. Level of Health: Patient has ADA stage II, grade B, moderate periodontal disease, and

generalized horizontal bone loss.

1. Oral – The patient has ADA stage II, grade B, moderate periodontal disease, and

horizontal bone loss. The patient’s gingiva is blunted, receded, fibrotic, and non-

stippled.

2. Extraoral – Patient has a large nevus on the left side of her face.

3. Systemic – Patient has diabetes. Patient is an ASA III.

 B. Dental Hygiene Diagnosis: Patient has ADA stage II, grade B, moderate periodontal disease, and

generalized horizontal bone loss. Since patient’s hands are weak a modification to OHI is needed

so the patient’s teeth are getting as clean as possible. Since patient is not able to keep their plaque

under control this has contributed to the periodontal disease.

III. Plan

A. Consultation Necessary – Possible consultation with a periodontist if primary dentist thinks it is

necessary. Refer patient to their physician for evaluation because of difficulty brushing their teeth.

B. Treatment goals – Improve home care. (brush teeth using the Bass technique with less pressure

twice a day with a soft bristled electric toothbrush, have patient work their way up to flossing once

a day by having them gradually floss one more day a week than they usually do using a floss aid

because of troubles with dexterity, and instruct patient not to us a mouth rinse that does not contain

alcohol).

C. Addresses phases of treatment

1. Preliminary phase: Assessment and data collection (Ask patient what their chief complaint is.

Record patients medical, dental, and social histories. Complete an IO and EO exams. Record

probing depths for FM.)

2. Phase I Therapy - SRP FM (ultra-sonic and hand scale FM, give local anesthesia if the patient

has sensitivity.), disclose the patients FM, explain to the patient how disclosing works, and

show the patient the plaque that is in their mouth, Give the patient proper OHI instructions

(talk to the patient about why it is important to use a soft toothbrush, demonstrate and have

the patient demonstrate brushing their teeth using a circular motion with light pressure angled

at 45 degrees towards their gums and instruct them to do this for two minutes twice a day,

demonstrate and have the patient demonstrate how to floss their teeth by wiggling the floss

between their teeth through the contacts and wrapping it around each tooth and instruct the

patient to do this once a day, talk to the patient about periodontal disease, recommend an
 electric toothbrush to the patient), apply a fluoride varnish, and give the patient SRP and

fluoride POI.

3. Phase II Surgical – No surgical treatment needed at this time.

4. Phase III Restorative – No restorative treatment needed at this time.

5. Evaluation of overall outcomes: Watch for overhangs, discomfort, and recurrent decay with

the old restorations.

6. Phase IV Maintenance: regular 3-4 month recall appointment to help prevent the progression

of periodontal disease.

IV.Implementation:

A. First appointment: Gathered and recorded dental, medical, and social information. Updated the

health history and medications. AN IO and EO exam were given to check for any abnormalities

and screen for cancer. A periodontal exam of the FM was completed and recorded. A treatment

plan was made and explained to the patient. The patient’s teeth were disclosed, and a plaque score

was recorded. OHI instructions were given based on the plaque score and the patient’s level of

health.

B. Second appointment: Updated health history and medications. An IO and EO exam were done to

observe any abnormalities, screen for cancer, and observe any changes from the first

appointment. Another plaque score was given and recorded to document any improvements or

regressions. Modifications were made to the OHI based off the second plaque score. FM ultra-

sonic and hand scaling were completed. FM prophy was completed with a medium paste due to

the extrinsic stain. A fluoride varnish was applied because of the receded tissue. POI was given to

the patient

C. Alterations to implementation: The patient will need a morning appointment. The patient had a

stroke and needs help with dexterity, so we need to modify the homecare with a soft bristled

power toothbrush and floss aids. Since patient experiences shortness of breath, they may not be

able to lay back all the way. Make sure patient has eaten and taken their medications.
V.Evaluation

A. The care will be evaluated at the patients 3-4 month recall appointments to see if there are

improvements or regressions.

B. Probing will be done at every appointment. Watch #3.

C. If radiographs are needed depending on the patient’s oral health and the age of the last

radiographs. If both the FMS have and batwings have expired the dentist would evaluate the

patient’s oral health. If necessary, the dentist would prescribe any of the following radiographs as

needed FMS, Panorex, or vertical BW (to evaluate bone loss).

D. Patient OHI behavior changes: Instruct the patient to use a soft bristled toothbrush (preferably

electric). Instruct the patient to implement the tooth brushing technique that was shown to them.

Which is small, light circular motions at a 45-degree angle toward the gumline twice a day.

Instruct the patient to use the flossing technique previously demonstrated by wiggling the floss

between the teeth and wrapping the floss around each tooth. Have patient work their way up to

flossing once a day by having them floss once a week and work their way up to once a day by the

next recall appointment. Suggest patient use an alcohol-free mouth rinse.

Case Study Questions: 1.A 2.D 3.A 4.C 5.E 6.D 7.D 8.C 9.E 10.C
 References

Boyd, L., Wilkins, E., Wyche, C. (2017). Clinical practice of the dental hygienist. Philadelphia, PA:

Wolters Kluwer. (12) 395-416.

Crossley, H., Meiller, T., Wynn, R. (2018). Drug information handbook for dentistry including oral

medicine for medically compromised patients & specific oral conditions. Hudson, OH:

Lexicomp. (24).