Vanessa Chamberlin

Treatment Planning #2

I. Assessment

Patient Interview

● 24 year old African American male.

● Full-time graduate student at NOU, working on MBA.

● Has a sister and parents who are alive and well.

● Chief complaint, “Gums are sore and bleed sometimes while brushing. Also, the gums

are receding on some teeth and I think it’s getting worse.”

Medical/Dental History

● Hospitalized for tonsillectomy at 8y.

● 5’10”, 190lbs, BMI 27.3. -Overweight.

● No allergies.

● No prescribed medications.

● OTC tylenol (acetaminophen) 500mg for occasional headache.

Analgesic- No oral effects, effects on bleeding, anesthetic effects or effects on dental

appointments. Dental use- post operative pain control.

● New patient to this office.

● Last dental appointment ~1 year ago where he had x-rays and a prophy. Has had the

same dentist for as long as he can remember.

● Reports no cavities.

● Pt brushes once or twice daily with fluoride toothpaste.

● Flosses only when food is impacted.

● Uses a medium textured toothbrush.

● No oral rinse used.

 Family History

● Pt reports family history of “severe gum disease.”

● Parents are 52 with full dentures.

● Sister was diagnosed with “some type of gum disease.”

Social History

● No reported alcohol use.

● No reported recreational drug use.

Vital Signs

● No vital signs recorded today. -Needed at every appointment to ensure safety of patient

and compare to previous vitals to aid in the detection of onset health issues.

Intraoral/Extraoral Exam

● No significant findings. All WNL.

Periodontal Examination

● Bleeding Index: 71%

● Plaque score: 30%

● Generalized heavy BOP.

● 3mm - > probing depths.

● Class I and 2 furcations localized to posterior maxillary and mandibular teeth.

● Generalized gingival inflammation.

Radiographs/Images

● X-rays are indicative of severe periodontal disease.

● Photo shows demineralization present on posterior teeth and moderate supragingival

calculus presence on posterior teeth.

II. DH Diagnosis (Problem Identification)

Level of Health

● Overall, the patient's health is good other than being overweight.

Diagnosis

● Advanced Chronic Periodontitis, Stage IV, Grade C, though there is no previous

information for comparison to indefinitely decide grade.

● Calc class C due to moderate supragingival calc and radiographic calc present.

III. Plan

Consultations
 ● Have him consult with his physician regarding his weight.

● Consults- Perio regarding alternating treatment.

Treatment Goals

● BOP minimal to none.

● Maintain GM 1-3mm.

● Improve homecare- Decrease plaque score by increasing flossing and brushing. Change

medium toothbrush to soft. Discuss brushing and flossing techniques.

● More frequent recall visits.

Implementing Phases of Treatment

● Create a treatment plan.

● Line up referrals.

● Patient compliance- Make sure he understands the treatment plan, reason for more

frequent visits, reason for better homecare, outcomes of compliance vs. non-compliance.

● SRP: FM handscale, ultrasonic use on furcation involved areas/posterior teeth with local

anesthesia.

● 4-6 week recall visit for tissue, teeth and compliance check.

● Future recalls at 3 month intervals between perio and general practice.

IV. Implementation

What will happen at the appointments?

● Consult with perio.

● Instruments used- 11/12 explorer,G1/2, G11/12, G13/14 and ultrasonic.

● Ultrasonic use on furcation involved teeth/posteriors. FM hand scaling and root

debridement.

● Homecare aids:

-Switching medium bristled brush to soft bristled to decrease abrasion, discuss a lighter

pressure while brushing.

 -Sending home floss for convenient placement. Recommend Plakers for convenience.

-Stannous fluoride toothpaste.

-OHI: Discuss “c” flossing technique and BASS brushing technique. Have patient

increase brushing to 2x daily and flossing to AT LEAST 1x daily. Ultimately getting him to

2x daily.

● Local anesthesia, topical and injection, for ultrasonic use.

● Prescription of Chlorhexidine for post treatment use to aid in recovery of inflamed gum

tissue.

V. Evaluation

● Compare gums and teeth before and after the appointment and at recall visits. Use

plaque score, calc detect, perio charting, radiographs, intra and extra oral exams.

● Follow up charting, evaluate and compare probing depths, BOP and recession.

● Take new radiographs for comparison to previous visit. CMS and vertical BW’s in order

to compare and measure perio status and detect new decay.

● Establish patient’s oral health care routine and compare to previous visit. Determine if

the patient is compliant or not.

References

Boyd, L. D., Mallonee, L. F., & Wyche, C. J. (2020). Wilkins' Clinical Practice of the Dental

Hygienist. Jones and Bartlett Learning.

Dental and Oral Health- Case Study 42. DentalCare.com.

https://www.dentalcare.com/en-us/case-studies/case-study-42