Treatment Plan #1 Assignment

Heather
Wilhelmi

Due April 7, 2015

Dana Arenas
Sarah Moore

1. Assessment
a. 21 white female
b. Regular dental hygiene checkups until last year, medical recent
mono, insomnia, panic attacks
c. Social drinker, poor diet
d. Temp 100.7, Pulse 90, Resp. 18, BP 108/68
e. Bilateral, palpable, tender cervical submandibular lymph nodes,
fetid breath, and dry mouth
f. Perio exam 3-4 mm pocket depths
g. Anterior Periapical radiographs no bone loss, no calculus, no
cysts or pathologies

2. Diagnosis
Advanced Nug
Level health Fair (Mono, current fever, predisposing factors stress,
illness, smoking, hygiene (not flossing and late on 6 mo apt), nutrition)
Prognosis - Fair
3. Plan
A. Consult dentist for restorations of caries, and for a prescription for
chlorehexadine. If patient interested consult for smoking cessation.
B. Treatment goal is to eliminate ANUG through reducing risk factors
and increasing the patients oral hygiene knowledge thus lessening
the pain, bleeding, and improve E
C. Treatment Phases:
a. Remove Plaque with ultrasonic and hand scaler
i. split into separate appointments if necessary
ii. coordinate with Dentist for restorations
iii. utilize anesthesia for patient comfort if needed
iv. evaluate progression, make changes as needed at each
appointment
v. instruct on homecare with prescription for chlorhexidine
also to be assessed at each appointment and changed if
needed

b. During the separated appointments:

i. evaluate diet and discuss changes
ii. talk about smoking cessation
iii. give tips for helping with xerostomia and bad taste
**Be sure to focus on one thing at a time. Dont try to
fix it all at once.
4. Implementation
Remove plaque using ultrasonic and hand scaler. May need to split
appointments and scale in sections using anesthesia. Coordinate the
appointments with the dentist to have caries restored. At the first
appointment instruct the patient on brushing and flossing techniques.
Brush with a soft toothbrush angled toward the gingiva in small circular
motions. Use chlorhexidine to brush and rinse one time in the morning
and again after her last daily meal. Floss by sawing it through the
contacts and wrapping around the tooth to not injure the gingiva or
cause pain. Discuss nutrition and how this can be changed to help her
oral health. Give her information for smoking cessation programs and
motivate/encourage her. Since she complains of xerostomia and bad
taste explain that is caused by the medicine, lunesta. Give her tips to
help with that such as rinsing with H20 after meals and chewing trident
with xylitol. Explain the relationship of the acid in mouth and saliva
and how water and gum helps combat this. At follow up appointments
assess home care, smoking habit, nutritional diet and xerostomia
improvement. After all cleaning complete allow tissue to heal for
several weeks then have her return to assess the treatment
effectiveness and health of tissue, polish, and apply fluoride. Schedule
a 6 month appointment recall. Refer her to using a toothpaste such as
crest pro-health and if prefers using a mouth rinse recommend using
one without alcohol so it is less abrasive and irritating to the gingiva.
5. Evaluation
To evaluate the SRP done in this appt. I will use floss and an explorer to
make sure all of the sub calculus has been removed. Then using air to
ensure all supra calculus has been removed. Most care will be reevaluated at next visit. Todays visit is baseline for future. This
patients inflammation and bleeding will need to be assessed at next
visit to determine if care plan needs modification. She needs to be on
6 mo. Recall and care will be evaluated by comparing perio chart from
today and the one done in 6 months. BOP will need to be checked for
improvement. Redo radiographs in 1 year or as dentist prescribes for
comparison. Radiographs today are blurry, but doesnt appear to show
periodontitis. If patient improves home care her gingival health/ANUG

should improve. Documentation of gingival of gingival description will

be critical for this patient to assessing elimination of ANUG.
Document the medications and other health concerns as they have
contributed to her overall health. Her smoking habits and OH details
should be reviewed and documented at future visits.