ASSESSMENT

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Patient Description and Chief Complaint:

My patient is a 57-year-old Black male. He is married with children and is a barber local

to Jacksonville, NC, he owns the barber shop with two other men. He has been a patient at the

college since 2015 when he came in for a screening appointment and he was last seen April

2021. I contacted the patient from my recall list as a patient for our periodontal probing lab

based off his last classification of a 3CL. When I contacted the patient, his chief complaint was

the buildup of calculus on his teeth, and he realized he was due for a cleaning.

Health History, Medications, and Vital Signs:

The patient is currently working with a physician because he has high blood pressure,

and he is currently taking Hydrochlorothiazide and Amlodipine. Hydrochlorothiazide is a

diuretic that is used to treat hypertension and has a potential adverse effect of hypotension.

Amlodipine is a calcium channel blocker used to treat hypertension that has a potential adverse

effect of gingival hyperplasia.

Vital signs were recorded at every appointment due to him having high blood pressure.

On August 22, 2022, his blood pressure was 140/90, pulse was 57 bpm, and respirations were

15 rpm. The patient stated that this was normal for him and that he’s working with his doctor

to get the best medications for his hypertension. On August 26, 2022, his blood pressure was

134/90. On September 19, 2022, his blood pressure was 142/90. On September 23, 2022, his

blood pressure was 146/86. On September 28, 2022, his blood pressure was 148/86. On

October 5, 2022, his blood pressure was 146/92. On October 19, 2022, his blood pressure was

148/93.

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Dental Exam-Extraoral, Intraoral, and Occlusion:

There were no significant findings during the extraoral exam, findings were within

normal limits with a slight deviation to the right on opening. Fordyce granules were found

during the intraoral exam on the patients’ upper lip at the labial commissures. The patient has

Class I occlusion on the right and left side, an even midline, an overjet of 4 mm, and a moderate

overbite.

Dental Charting:

The patient has two ¾ gold crowns connected on #7 and #8 due to #8 being broken

during a fight, but the tooth is stable. The crowns are not cemented in, and the patient

regularly removes them for eating, cleaning, and sleeping. The patient has no history of decay

or any other existing restorations.

Dental Interview:

The patient stated that he brushes once a day in the morning, every other morning and

will use floss picks occasionally if he has food debris stuck. The patient stated that he is a mouth

breather, he bites his nails occasionally when he is stressed, he does use a toothpick regularly

for clearing food debris and will occasionally have coffee. The patient answered “no” to the

question if he eats candy, however, he later stated that he eats chocolate candy bars at night

before bed most nights of the week. The patient also stated that he has been experiencing

some sensitivity to sweets, but that it is not every encounter.

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Periodontal Charting and Gingival Description:

The patient has localized molar pattern periodontitis. At the initial periodontal exam on

August 26, 2022, the patient had 31 sites of 6 mm and above pocket depth localized to the

molars and 12 sites of 5 mm pocket depth. The patient had one site with 1 mm recession on

#28-F. Class I furcation involvement was present on four teeth and four teeth had Class II

furcation involvement. The mucogingival junction had range of 4 – 7 mm on the maxillary arch

and 3 – 5 mm on the mandibular arch. The patient had no mobility. There were 37 sites of

bleeding on 13 teeth, localized to the molars and the lower anterior.

The gingiva was boggy with swollen margins, the attached gingiva pink and glossy, and

the papillae was blunted, pink, and boggy.

Radiographic Findings:

A set of four horizontal bitewings was taken in April 2021 as post operative bitewings,

the patient was not due for radiographs at the time of treatment. Horizontal bone loss is

present with 50% loss across the mandible. Radiographic calculus is present on #29-D, #21-D,

#20-D, and #14-D.

Plaque Indices:

The first recorded plaque index was taken on September 19, 2022, it was 67%. The

biofilm was generalized around the patient’s entire mouth but concentrated to the facial of the

maxillary arch, lingual of the lower anteriors and all surfaces of the most posterior molars. On

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September 23, 2022, the plaque index was 57% and still generalized, but the biofilm is

concentrated to the facial and lingual of the lower anteriors. The third plaque index recorded at

61% on September 28, 2022, generalized to the entire mouth. On October 5, 2022, the plaque

index was 49%. The biofilm was generalized but less in the lower right quadrant and

concentrated on the lower anteriors and facial surfaces of the molars on the maxillary and

mandibular arch. On October 19, 2022, the plaque index was 52% generalized biofilm.

Bleeding Indices:

At the patient’s initial periodontal exam on August 26, 2022, there were recorded 37

sites of bleeding recording meaning a 23% bleeding index. The bleeding was localized to the

molars and lower anterior teeth. At the next appointment on September 19, 2022, the bleeding

index was 19%. There were 30 sites of bleeding localized to the molars and this is expected due

to no debridement has been completed. The third bleeding index was recorded on September

23, 2022, and it was at 17% still localized to the molars. On September 28, 2022, the patient’s

bleeding index was 14%. The bleeding was localized to the molar pattern. The next bleeding

index was 11% recorded on October 5, 2022. On October 19, 2022, the bleeding index was

recorded at 14%. The bleeding was localized in a molar pattern. I believe the incremental

improvements are due to the completion of debridement on the lower right quadrant.

Nutritional Assessment:

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Anesthesia:

No anesthetic was given to the patient during the first appointment of debridement on

September 23, 2022, however, during the second appointment of debridement on September

28, 2022, sensitivity of the patient’s teeth was noted toward the end of the appointment.

Topical was placed before Dr. Gabaree administered 1 cartridge of 4% Septocaine with

epinephrine. He infiltrated #25, #26, and #27.

The next appointment on October 5, 2022, anesthetic was given prior to debridement.

Topical was placed before Dr. Gabaree administered 1 cartridge of 3% Carbocaine for the right

mandibular block. I administered 1 cartridge of 2% Lidocaine with epinephrine for the right

mental block and the long buccal infiltration.

On October 19, 2022, anesthetic was given prior to debridement. Topical was placed

before Dr. Gabaree administered 1 cartridge of 3% Carbocaine for the left mandibular block. I

administered 1 cartridge of 2% Lidocaine with epinephrine for the left mental block and long

buccal infiltration. The patient showed sensitivity after the anesthetic was administered, so I

administered .5 cartridge of 4% Septocaine as an infiltration on #24.

Medical/Dental Referral:

No dental referral was needed. A medical referral was completed on October 5, 2022,

regarding patient’s hypertension. The patient stated that he records his blood pressure at home

and is working with a physician to find the best combination of medications, but a medical

referral was given to the patient.

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Adjunctive Services:

Salivary testing was performed but will not be discussed with patient until the next

appointment on 10-31-22.

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 DIAGNOSIS

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ASA Classification:

My patient is an ASA Type III classification which is a patient with severe systemic

disease, not incapacitating. This is due to the patients poorly controlled hypertension.

AAP Periodontal Case Type:

My patients AAP Periodontal Case Type is a Case type IV, which is advanced

periodontitis. This is due to the patient having 6-8 mm pocket depth and Class II furcation

involvement. He does not have any mobility present.

AAP Classification:

My patients AAP classification is localized molar pattern Stage 3 Grade B. This is due to

6-8 mm pocket depths, Class II furcation involvement, and less than 2 mm of bone loss

occurring over 5 years. It was determined that it is localized due to there being 30 sites with 6

mm or more pocket depth resulting in 19%. 30% or more would be considered generalized.

CCCC Calculus, Stain Classification:

The CCCC Classification of my patient is a 3CL. The patient is a Class 3 because due to 31

sites of 6-8 mm pocket depths. He is in the category of a Class C because he has moderate to

heavy supragingival, and subgingival calculus generalized throughout the mouth. The stain

classification is Class L because there is very light stain present.

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 TREATMENT PLAN

Date of Service ADA Clinical Plan OHI/ Home Care Plan/ Post-Op

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 Codes instructions if needed
8-22-22 D0120 Appointment 1
Record vitals and review medical
history
EO/IO exam
Dental charting
8-26-22 Record vitals and review medical
history
Periodontal charting
9-19-22 D1330 Appointment 2 Biofilm tree, the relationship between
D0350 Record vitals and review medical biofilm, gingivitis, and periodontitis
D0417 history Explained to patient how uncontrolled
Intraoral photos high blood pressure with the combination
Complete periodontal charting of biofilm and bacteria can result in
Salivary testing inflammation of the gums and lead to
Plaque index gingivitis which will cause periodontitis
Complete oral hygiene instruction when left untreated
Discussed the effects of medications on
oral health
Tell, show, do modified bass
toothbrushing method 2x/ daily for 2 min
Tell, show, do C shaped flossing 1x/daily
Recommended a power toothbrush
9-23-22 D4342 Appointment 3
Record vitals and review medical
history
Plaque index
Bleeding index
Cavitron/ Handscale #23 and #24
9-28-22 D4341 Appointment 4 Review biofilm tree
Record vitals and review medical Rev modified bass2x/daily for 2 min
history Rev C shaped flossing
Plaque index Recommended and demonstrated C
Bleeding index shaped flossing using floss picks
Apply topical and administer
anesthetic, infiltrate
Cavitron / Handscale LRQ
10-5-22 D4341 Appointment 5 Review biofilm tree
Record vitals and review medical Rev modified bass 2x/daily for 2 min
history Rev C shaped flossing
Medical Referral indicated for high Recommended a water flosser
blood pressure Encouraged brushing at least 1x/daily at
Plaque index night

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 Bleeding index
Apply topical and administer
anesthetic, mental block, mand block,
long buccal infiltration
Cavitron/ Handscale LRQ
10-19-22 D4341 Appointment 6 Review biofilm tree
Record vitals and review medical Rev modified bass 2x/daily for 2 min
history Rev C shaped flossing 1x/daily
Plaque index Explained importance of brushing 2x/daily
Bleeding index
Apply topical and administer
anesthetic, mental block, mand block,
long buccal infiltration
Cavitron/ Handscale LLQ
Flush LRQ
10-31-22 D4341 Appointment 7 Review biofilm tree
Record vitals and review medical Rev modified bass 2x/daily for 2 min
history Rev C shaped flossing 1x/daily
Plaque index Discuss test results of salivary testing
Bleeding index
Cavitron/ Handscale URQ and ULQ
Flush LLQ and LRQ
11-2-22 D9995 Appointment 8 Review 5-day food diary nutritional
Teledentistry: Nutritional counseling counseling with patient
11-9-22 D0350 Appointment 9 Review biofilm tree
D0274 Record vitals and review medical Rev modified bass 2x/daily for 2 min
D4381 history Rev C shaped flossing 1x/daily
D1206 Post operative bitewings Post operative instructions for Arestin
Intraoral photos Post operative instructions for Fluoride
Plaque index
Bleeding index
Air polish all quadrants
Place Arestin
Fluoride varnish
11-28-22 D0170 Appointment 10 Review Oral Hygiene Instruction
Re-evaluation
Record vitals and review medical
history
Cursory EO/IO exam
Periodontal charting
Plaque index and review OHI
Flush all quads
Air polish

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 Set re-care interval to 3-month
periodontal maintenance due to
periodontal status and medications

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 IMPLEMENTATION

Patient Questions:

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 During the thorough oral hygiene instruction at the patients third appointment, he

asked me how the medications he is taking for his high blood pressure affect his mouth. I

explained to the patient that the one of the medications he is taking, amlodipine, can cause

gingival hyperplasia, which is a condition where the gums can become swollen and overgrow.

When the gums become swollen a pseudo pocket can form and can trap more bacteria. When

the bacteria are left undisturbed under the gum line, they can colonize and cause an infection

that will break down the bone and supporting tissues of your teeth, which is called

periodontitis.

Treatment Plan Modifications:

Modifications did have to be made to the treatment plan. The first four appointments

went as planned. The initial visit was to complete paperwork, begin assessment through the

intraoral/ extraoral exam and dental charting to be able to bring the patient back for the

periodontal probing lab which was the second appointment. The third appointment I took

intraoral photos, completed my periodontal exam, completed salivary testing, completed oral

hygiene instruction competency, and did calculus detection on the lower right quadrant to

prepare for his fourth appointment, our “C” calculus lab. For his fifth appointment, it was

planned to be another “C” calculus lab, but that was canceled. So, I shifted the treatment plan

and I had planned to ultrasonic scale the lower right quadrant for a competency, and I did,

however, I did not complete the lower right quadrant due to incorrect calibration of the

Cavitron unit and the patient’s sensitivity without local anesthetic. Dr. Gabaree did administer

local anesthetic, but I did not have enough time to complete scaling.

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 At the sixth appointment I had planned to ultrasonic the lower left quadrant, but I had

to administer anesthetic and complete the lower right quad as well as my competency. I had to

shift the rest of the treatment plan to accommodate finishing the lower right quad.

Debridement Notes:

The first quadrant I scaled was the lower right which had 3 mm pockets in the anterior

and 3-4 mm pockets in the posterior with 5 sites that had 5-6 mm pockets. The calculus was

tenacious and was moderate to heavy supragingival and subgingival. I started with my orange

ultrasonic insert to do a full debridement of the entire quadrant. Then, I went in with my hand

instruments to do a fine scale of the remaining deposits. I used a combination of instruments

including the McCaul, posterior Graceys, Gracey ½, Nebraska and the Nevi 4. Most of the

bleeding was localized to the anterior teeth.

The next quadrant scaled was the lower left quad. This quadrant had 8 sites of 6-8 mm

pocket depths in the posterior and 2-3 mm pockets in the anterior with one 4 mm pocket

interproximal of #24 and #25. There was moderate to heavy tenacious calculus subgingival and

supragingival. I began with my orange insert again to debride the quadrant and went back to

fine scale the remaining deposits. In this quad I used the McCaul, posterior Graceys, Gracey 1/2,

and Nevi 4. There was Class I and Class II furcation involvement in this quad, so I used the

posterior Graceys in those areas. The distal of #19 had a large “hump” of calculus that was deep

and tenacious that I used my posterior Gracey and McCaul to remove. There was heavy

bleeding on the anterior teeth and on #17 and #19. Scaling this quadrant was more challenging

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due to the deep pocket depths in the posterior teeth in comparison to the lower right

quadrant.

The patient did show sensitivity prior to local anesthetic, specifically in the lower

anterior teeth, but was more comfortable after anesthetic was administered. The IsoDry was

used in every quadrant with the Cavitron. The patient has an extremely strong tongue, so the

IsoDry was required to retract as well as provide water control and help keep his mouth open

for the extended periods of time. The patient has never complained of discomfort; however, I

could tell he enjoyed taking frequent breaks from the IsoDry. The patient has been extremely

understanding and cooperative during treatment and has never complained.

Educational Notes:

During the initial oral hygiene instruction, the patient stated that he was brushing once

a day, in the morning, every other day with a manual toothbrush and flossing with a floss pick

occasionally when he had food debris stuck. The original plaque index and amount of calculus

present reflected that as well.

I demonstrated the Modified Bass toothbrushing method due to the deep pocket depths

he had and instructed him to use this technique twice a day, in the morning and before bed at

night, for two minutes. I explained to the patient that angling the bristles toward the gumline

disrupts the bacteria and allows it to be rinsed away when you incorporate a roll away from the

gums after vibrating the bristles. I recommended an electric toothbrush to the patient as they

can be more effective and have built in timers to allow the patient to dedicate 30 secs to a

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quadrant, ensuring he gets every surface. The patient has good dexterity and motivation to try

the technique.

I also demonstrated “C” shaped flossing using traditional string floss and instructed him

to do this once a day before bed. The patient had good dexterity using the floss correctly but

did not have great motivation to incorporate this daily with string floss. Considering that the

patient currently used floss picks to remove food debris, I demonstrated how to manipulate the

floss pick into a “C” shape. I did show and explain that the floss pick would not let him get as

deep into the pocket as he could with the string floss.

A water flosser was recommended for the patient if he was noncompliant with flossing

regularly. I explained to the patient that a water flosser does not replace traditional flossing but

will help with areas of deeper pockets and flushing bacteria from the gumline.

The patient was very interested in the relationship of bacteria and biofilm to the disease

progression and even stated that no one had previously told him that. He seemed motivated to

make the changes, but throughout the rest of the appointments it appeared no changes had

been made due to the consistency in plaque index over the appointments and buildup of

calculus in areas that had been debrided previously. The patient stated that he is still brushing

once daily and not flossing daily. I stressed the importance of brushing twice daily and most

importantly, at night before bed. I also stressed regular re-care and periodontal maintenance

appointments to prevent further progression of the disease.

The patient has no decay or history of decay, so no additional restorative treatment is

needed.

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