Treatment Plan Assignment #2

Morgen Greif

1. Assessment (preliminary phase)

a. Patient interview (chief complaint): patient reports that her bottom teeth seem to be getting

longer while her gums are disappearing.

b. Medical history: diagnosed with type 2 diabetes and hypertension 10 years ago – both

controlled with medication, sees physician annually, measure glucose daily, most recent

HbA1c was 6%. History of surgery: hysterectomy 12 years ago.

c. Tx Modifications: Medications - (Nisoldipine) Sular®, (Metformin hydrochloride)

Glucophage® and 81 mg aspirin.

i. (Nisoldipine) Sular® - be aware of light headedness and dizziness after pt. is lying in

the chair

ii. (Metformin hydrochloride) Glucophage® - may cause dizziness and other

symptoms, consult with doctor before surgery as may be directed to stop taking

medication for a period of time

iii. 81 mg aspirin – may cause bleeding implications with clotting, be aware of other

drugs combined with aspirin and their effects

d. Vital signs: BP 125/78, Pulse 68 BPM, Respiration 19 breaths/minute

e. Dental history: has received dental care throughout life. In the last 5 years, pt. has had

several extractions due to periodontal disease, been on periodontal maintenance program

since then. Pt. uses hard bristle, manual toothbrush. “Scrubs” twice daily. Pt. is concerned

with gums receding even more if she uses electric toothbrush. Pt. finds flossing difficult and

only flosses when food is stuck. Occasional use of alcohol-based mouth rinse for breath

odor.
 f. Social history: pt. is elementary school teacher who loves her career, no children of her

own. Pt. considers herself to be in good physical condition, plays tennis twice a week with

her husband.

g. Extraoral exam: submandibular nodes on right side were tender and slightly enlarged. All

other EO finding were within normal limits.

h. Intraoral exam: Submandibular and submental nodes on right side were tender. All other IO

findings were within normal limits. Gingival tissue: pale with no redness, gingival margins

rolled on several teeth, localized inflammation on posterior molar facial and lingual

margins, interdental papillae had some redness and bulbousness.

i. Periodontal Exam: Some bleeding on probing. Furcation involvement on teeth #19 and #30.

Light staining on mandibular anterior teeth. Generalized recession (2-4mm) on all facial

surfaces. Plaque score 15%. Bleeding index 12%.

j. Radiographs: Full mouth series present. Radiographic calculus detected between teeth #4

and #5, distal of #8, and mesial of #22. Generalized horizontal bone loss detected. Possible

root resorption on tooth #2 and #4.

2. DH Diagnosis

a. Level of Health: Patients overall health is fair.

i. Pt. presents has type 2 diabetes and hypertension, but both are controlled with

medication. She sees her physician and measures her glucose levels daily.

ii. Would need to look further into the swollen lymph nodes with more questioning,

refer pt. to get them looked at by physician.

iii. Medications: (Nisoldipine) Sular® for hypertension, (Metformin hydrochloride)

Glucophage® for high blood sugar, 81 mg aspirin

1. With these meds, watch for dizziness upon sitting patient up in chair, check

blood sugar before treatment, and excessive bleeding may be possible.

 iv. Pt. states she is in good health, physical activity twice per week

b. Diagnosis: Moderate - Chronic Periodontitis, generalized Class: C Stage: III Grade: B

i. Probing depths: Majority of the probing depths range from 2-4 but some localized 5,

6, 7, and 8s.

ii. Horizontal bone loss present.

iii. Moderate calculus deposits. Radiographic calculus detected between teeth #4 and

#5, distal of #8, and mesial of #22.

iv. Furcation involvement on tooth #19 (F2) and #30 (F3).

v. Generalized recession on facial surfaces of 2-4 mm.

vi. Potentially 5 teeth lost due to periodontitis.

vii. Pt. is diabetic with HbA1c 6%.

3. Plan

a. Consultations: No known consultations necessary

b. Treatment goals: OHI focusing on bass method of brushing and creating a flossing routine

at home, inform about electric toothbrushes and address concerns, suggest floss picks if the

string floss is too difficult, recommend a tongue scraper for breath odor, scaling/polishing

to remove calculus.

c. Phases of treatment:

i. Preliminary phase

1. Patient is worried about her teeth looking longer and gums disappearing –

recession of gum tissue

2. Oral health goals: stop recession, remove plaque and calculus

3. Pt has no emergency needs to address

a. Be aware of dizziness upon standing, possible increased bleeding,

and make sure blood glucose levels are WNL.

 ii. Phase I therapy

1. Ask questions about why it is difficult for the patient and offer alternatives

(floss picks). Suggest a flossing routine (pt. flosses every Sunday and

Wednesday night to form the habit)

2. Show patient bass technique. Explain how “scrubbing method” could be

causing recession. Recommend soft bristle toothbrush. Answer questions

about electric toothbrushes.

3. Introduce pt. to fluoridated toothpaste if not already using.

4. Scaling to remove plaque and calculus – 4 quadrants.

5. Polish pt.’s teeth with fine prophy paste.

iii. Outcomes evaluation of phase I

1. Review pt.’s participation

2. Probe - check inflammation status

3. Measure dental biofilm levels

iv. Phase II surgical: not needed

v. Phase III restorative: not needed

vi. Evaluation of overall outcomes

1. Oral response to scaling and polishing

vii. Phase IV maintenance

1. Re-evaluation every 4 months

2. Refining biofilm control techniques as needed

4. Implementation

a. 1st appointment

i. Take blood pressure

ii. Go through medications, health, and dental history

 iii. Perform intraoral and extraoral exam

iv. Periodontal exam

v. Calculus detection

vi. No surgical needed

b. 2nd appointment

i. Take blood pressure

ii. Confirm no changes in medical history, intraoral and extraoral exam

iii. Remove calculus using hand scaling and ultrasonic scaler on 4 quadrants

iv. Polish with fine prophy paste

v. Floss

vi. Apply fluoride varnish

vii. Recommend patient a soft bristle toothbrush with bass method instruction, flossing

instruction, and implement flossing routine

viii. Possible auxiliary aid (such as floss picks) may be easier for patient, recommend

tongue scraper for breath odor

ix. Next visit: recall appointment, vertical bitewings to check bone level

5. Evaluation

a. Ultrasonic and hand scaling in all 4 quadrants was appropriate for our patient due to

moderate calculus and furcation involvement.

b. Plaque removal was effective by using an ultrasonic, prophy angle, and floss.

c. Fluoride varnish was appropriate choice due to her periodontal status and restorations.

d. Pt.’s oral health should improve because patient came in with a concern and is motivated to

fix it. With the OHI given, we should see improvements going forward.

e. The patient will be on a 4 month recall due to periodontal status until improvements are

seen and measured.

 f. Everything documented in the appointment (oral exam booklet, periodontal chart, note,

etc.) should be completed and updated upon end of the appointment.

g. On the radiographs, we saw horizontal bone loss and calculus deposits. We will take

vertical bitewings next appointment to check bone level.

h. Follow up with checking patient’s previously swollen lymph nodes. Did pt. go to physician

as recommended? If still present, make it clear that it is very important to see physician for

this.

Resources

Wilkins, E. M., & Wyche, C. J. (2013). Clinical practice of the dental hygienist. Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins.

Wynn, R. L., Meiller, T. F., & Crossley, H. L. (2003). Drug information handbook for dentistry: Oral
medicine for medically-compromised patients & specific oral conditions. Hudson, Ohio: Lexi-
Comp.