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frequently.
This patient is considered special needs because he is hearing impaired.
Patient does not use drugs and does not use alcohol excessively.
BP: 110/72
Extra oral exam was within normal limits. Intra oral exam: small cheek bite on the
left buccal mucosa. Exostosis on the mandible. Small bilateral mandibular tori.
Twenty-nine total teeth. Attrition localized to anterior teeth. Generalized light
brown extrinsic stain. Class 2 occlusion on the right and left. Overjet of nine mm.
Moderate overbite.
g. Generalized probing depths less than 4mm.
minor operative, his decay will be restored. The evaluation of overall outcomes
will be evaluating periodontal response to restorations. Phase four is the
maintenance phase. This involves further appointments for continuing care and
supervision as well as reviewing and practicing proper oral hygiene. His level of
bone loss will need to be checked at every appointment to determine the status of
his periodontitis. We need to discuss and review the C shaped method for flossing.
He outright dislikes flossing so I will provide him with samples of interproximal
brushes for the purpose of interproximal cleaning in hopes that he will choose to
do some interproximal cleaning.
d. My role as a hygienist is to provide my patient with the best possible care and
treatment during our appointments. I will accomplish this through OHI, hand
scaling, polishing, and fluoride varnish. My patients role is to comply with OHI
given to him: flossing once daily and brushing with a soft bristled tooth brush
using the BASS brushing method.
4. Implementation
a. Sickle, Gracey , Gracey 11/12, Gracey 13/14, explorer.
b. Hand scaled full mouth, polished full mouth with fine prophy paste, flossed full
mouth, applied fluoride varnish.
c. Homecare aids: floss, floss picks, and interproximal brushes.
d. No anesthesia was given.
e. No prescriptions were written.
5. Evaluation
a. In October 2013, preventive clinic noted his Plaque Index at 1 with slight plaque
on multiple sites. This appointment his plaque score was 32% which is more than
just a slight amount of plaque, as previously noted. Periodontal probing depths
generally remained the same.
b. Since bitewings were completed on 5/30/14, he does not need radiographs at the
next appointment.
c. Sensitivity has decreased very slightly; however, it is still present and bothers
him. There is still heavy bleeding of the gums during treatment. He is using a soft
bristled electric tooth brush and using the BASS brushing method. However, he
still is not compliant with flossing.
References:
Wilkins, Esther. (2013). The dental hygiene care plan. Clinical Practice of the
Dental Hygienist. (351-360).
Crossley, H.L, Meiller, T.F. & Wynn, R.L. (2013). Drug Information Handbook
for Dentistry.