Moriah Wallace

GINGIVAL INDEX
PERIODONTAL CARE PLAN
Initial date: September 8, 2016
Gingival Area
M

12

19

25

28

TOTAL: 1.33 (Fair)

Final date: October 28, 2016
Gingival Area
M

12

19

25

28

TOTAL: 0.75 (Good)

Moriah Wallace

PERIODONTAL CARE PLAN

Patient Name:
Date of initial exam: August 25, 2016 (FMX only)

Age:
Date completed: October 28, 2016

1. Medical History: (systemic conditions altering treatment, pre-medication, medical clearance)

explain steps to be taken to minimize or avoid occurrence, effect on dental hygiene diagnosis
and/or care.
This male patient is thirty years old, weighs 220 pounds, and is 5 9. The patients last physical
was three years ago in 2013. It is important for the patient to maintain annual physicals in case
he has any unknown diseases that might affect his overall health. No systemic conditions that
would alter treatment are present. Likewise, the patient does not require any pre-medication or
medical clearance.
Research indicates that there may be a link between periodontitis and cardiovascular disease.
With this said, it is possible that the bacteria and inflammation accompanied with periodontal
disease can increase the risk of heart disease by entering the blood stream. This is why it is
important to note that the patients blood pressure was high at his appointments. At his initial
appointment, his blood pressure read 146/92 which is stage 1 hypertension. However, his blood
pressure decreased to pre-hypertension for the majority of his remaining appointments.
Surprisingly, his blood pressure was the lowest it had been at his last appointment on October 28,
2016. During this appointment, his blood pressure was 118/74. This is why it is important to
consistently check the patients vitals at each and every appointment. Additionally, it is crucial to
remove all plaque biofilm both supragingivally and subgingivally, while halting the progression
of periodontitis to prevent the risk of cardiovascular disease.
Ten milligrams of Trintellix, (a brand new antidepressant) is being taken by the patient once per
day and has the ability to cause xerostomia (dry mouth). Additionally, this medication is
contraindicated with epinephrine. Since this medication can reduce salivary flow, the patient is at
a higher risk for cavities, periodontal disease, sensitive teeth, and receding gums. This is due to
the fact that saliva aids in flushing bacteria out of the oral cavity. Therefore, if saliva is deficient,
the patient should be mindful to drink plenty of water throughout the day, chew sugar free gum,
use saliva substitutes such as biotene, and use a fluoride toothpaste. This aids in removal of
plaque and bacteria so that the oral cavity has a lesser chance of developing these conditions.
The patient confessed to usage of tobacco for the past twenty years. Although he previously
smoked cigarettes, he now chews about half of a can of tobacco per day. This action alone places
the patient at a high risk for progression of periodontal disease and leukoplakia which can lead to
oral cancer. Leukoplakia presents as a white patch that cannot be removed. Also, use of tobacco
products can impair his healing, inflammatory, and immune responses. Additionally, tobacco use
can cause halitosis (bad breath), staining, cavities, and even tooth loss. The patient has
previously attempted to quit twice and is still interested in quitting. In order to assist my patient,
I will educate him on these risks and recommend that he decrease his use to of a can per day.
After a week or so of this habit change, we as a team will attempt to decrease his use to of a
can per day, until eventually he can be tobacco free. I will also recommend that he schedule an

appointment with his healthcare provider to discover additional aid in tobacco cessation. If
practiced regularly, these adjustments could prevent further damage to the oral cavity.
Additionally, alcoholic drinks are consumed about once a month. Although consumption is
infrequent, the risks still remain. This exposure to alcohol increases the patients risk of
developing dry mouth which can also lead to oral cancer and cavities. When informing the
patient of this information, I will suggest frequent sips of water while consuming alcohol so that
the oral cavity is flushed properly of bacteria.
The patient reported that he periodically suffers from sinus problems due to seasonal changes
and treats it with a Z-pack when needed. However, if this medication is used over an extended
period of time or repeatedly, it can possibly result in oral candidiasis. This oral condition is
caused by the fungus known as Candida albicans. This fungal growth can cause pain when
swallowing, bad breath, xerostomia, burning mouth syndrome, and even abnormality of taste.
Overall, the Z-pack could potentially alter the bacteria in the patients mouth, leading to a fungal
growth in the oral cavity.
Chronic pain in the patients shoulders, back, and knees stems from previous years of football
and is also currently work related. However, the patient stated that he does not take medications
for the pain. If the chronic pain is severe enough, it could prevent the patient from practicing
effective oral hygiene when brushing and flossing. This in turn could result in the progression of
periodontal disease if not corrected. Simply put, if the patient is struggling to reach certain areas
when brushing and flossing, bacteria will continue to reside in the sulcus. This will cause the
gums to become more inflamed and can result in further gingival recession and bone loss. To aid
in this situation, I would suggest Tylenol as needed to reduce the pain and ensure proper brushing
and flossing. If the patient is unwilling to try this, my second suggestion would include
purchasing a portable TENS unit. TENS stands for transcutaneous electrical nerve stimulation.
This device contains several adhesive patches that adhere to the areas of pain. Small pulses of
electricity are then released from the device and onto the problem area. This device can be
purchased at Walmart.
Mild acid reflux occurs periodically in the patient. However, he stated that recent improvement
had taken place. If this condition worsens, the acidity could lower the pH in the oral cavity
causing an increased risk for bad breath, cavities, and erosion. It is important that the patient
refrains from spicy/acidic foods, coffee, and alcohol to decrease the occurrences of acid reflux.
2. Dental History: (past dental disease, response to treatment, attitudes, dental I.Q., chief
complaint, present oral hygiene habits, effect on dental hygiene diagnosis and/or care)
The patient stated his chief complaint and reason for visit was that his teeth were messed up.
The patients main concerns include areas of rampant decay and sensitivity. His last dental visit
was in 2011 where he was seen for an abscessed tooth. When I asked the patient as to why he
had not received routine cleanings and dental visits, he explained that he does not currently have
a dentist or dental insurance. Although the patient has had no prior dental diseases, he stated that
he hates the appearance of his teeth and smile. However, he has a positive outlook towards
being treated in the LIT dental hygiene clinic.

His dental I.Q. is fair due to the fact that he was unaware of the risks and consequences that
smoking has on the oral cavity. Additionally, he claimed to only brush his teeth at night and does
not floss. Since the salivary flow decreases at night, it is best to brush before bed. However, it is
still important for the patient to attempt to brush at least twice a day due to his medications and
lifestyle habits. A medium bristle toothbrush is used along with a scrub method for brushing.
This stiff bristled toothbrush has a negative effect of possibly causing tissue trauma and abrasion
on the gingiva. Likewise, the patient uses a scrubbing motion which can also aggravate the
tissue. This not only can cause sensitivity, but can also result in recession. Therefore, I will teach
the patient how to utilize the Bass method with a soft bristled toothbrush. This method ensures a
more thorough cleaning of the gingival sulcus while using circular strokes that are not as
abrasive. Additionally, I will inform the patient on the importance of flossing and how to do so
using the C shape method. This technique will be effective in removing subgingival plaque
that is otherwise difficult to remove by brushing alone. If plaque is not removed it can form into
calculus. This can cause the tissues to become more inflamed, recede, and progress into
periodontitis.
Listerine mouth rinse is used by the patient twice a day, which can also increase the presence of
xerostomia. This is due to the fact that Listerine contains alcohol which produces drying effects
in the oral cavity. The patient stated that he breathes through his mouth at night which can also
produce a dry environment for the oral cavity. Once again, these issues can be approached by
consuming frequent sips of water throughout the day, administering saliva substitutes, and
brushing with fluoride toothpaste. Infrequent dental visits, poor oral hygiene, and low dental I.Q.
are all elements that can progress his state of periodontitis.
Clenching occurs during the day when the patient is angered or stressed. This issue can result in
further bone loss due to the forces applied on the periodontium when the teeth are in occlusion.
For this issue, I would recommend a payment plan so the patient can set aside money for a night
guard. Even though he only claimed to clench during the day, it is wise to recommend one just in
case. A night guard will cushion the forces when clenching so that the pressure is not as intense.
The patient also admits to occasionally chewing on his cheek which can lead to leukoplakia. This
white patch is non-removable and can evolve into oral cancer. It is important for the patient to
abstain from this habit as much as possible since he is already exposed to tobacco use.
Lastly, the patient revealed that he consumed five or more sugars or simple carbohydrates per
day. Exposure to these sugary and starchy foods lowers the patients pH in his oral cavity.
Decreased pH therefore can result in an environment for bacteria to reside. Patient education is
imperative so that the patient is aware of how to counteract those foods with both protein and
calcium. Protein and calcium both share the capability of raising the pH in the oral cavity making
the environment less acidic. This factor decreases the risk for cavities.

3. Oral Examination: (lesions noted, facial form, habits and awareness, consultation)

Limitation of the patients left TMJ was noted. The patient stated during the appointment that he
experienced trauma from a broken jaw on the left side. This prevented him from being able to
open his jaw entirely for extended periods of time. An enlarged incisive papilla was noted along
with bilateral mandibular tori which are both developmental and atypical only. The left buccal
mucosa revealed an area of scar tissue measuring about 6 mm in diameter which resulted from
the broken jaw incident. The right buccal mucosa contained linea alba which measured about 12
mm in length. This linea alba resulted from the patients natural occlusion, cheek biting, and
clenching. Once again, a night guard would be effective in reducing trauma to the periodontium,
halting the progression of bone loss.
4. Periodontal Examination: (color, contour, texture, consistency, etc.)
a. Case Classification: V
b. Gingival Description:

Periodontal Case Type: II

App't 1: September 8, 2016

Generalized red, festooned architecture was noted on the facials of the mandibular anterior
teeth. These teeth along with the facials of #30, #29, and #28 were recorded as edematous
and spongy. Rolled margins were noted on the facials of #12, #13, #14, #21, #27, #28, #29,
#30, #31. Additionally, bulbous papilla was recorded on the MF of #30, facials of the
mandibular anterior teeth, as well as the DL of #28. No suppuration was present. The
papillary and marginal surface texture was smooth and shiny on the maxillary and
mandibular anterior facials. The attached gingiva was generalized smooth and shiny.
However, the attached gingiva of the maxillary anterior facials was the only area noted with
stippling. These findings are all potential contributors to the presence and progression of
periodontal disease. Rolled, bulbous, festooned, and edematous tissue all result from poor
brushing and flossing. The patient does not floss, but on occasion will use floss picks.
However, these floss aids are not as beneficial in completely removing plaque from the
sulcus.
App't 2: September 23, 2016
The patients periodontal assessment did not change much since no treatment had been
administered at this point. However, the facial of #20 also displayed a rolled margin. All four
quadrants still revealed generalized red festooned architecture along with generalized rolled
margins and bulbous papilla. Both the papillary and attached gingiva were smooth and shiny.
No suppuration was noted.
App't 3: September 30, 2016
Mandibular Right Quadrant:
The mandibular right quadrant was scaled last week on September 23 and showed slightly
decreased redness of the tissues. However, the facials of #27, #28, #29, and #30 still revealed
rolled margins. Even though bulbous papilla was again noted on #25, #26, and #27,
improvement was visible in other areas. Rather than the bulbous papilla being generalized,
this appointment revealed localized bulbous papilla on the facials of the anterior teeth only.

Although the attached gingiva was still generalized smooth and shiny, stippling was noted on
the mandibular anterior facials instead of just the maxillary anterior segment alone. The
patient stated that he had been using the Bass method for brushing and was brushing twice a
day for two minutes each. This proves how removing calculus and plaque buildup can alter
the state of inflammation in the oral cavity. Once again, no suppuration was found. The
architecture in this quadrant was scalloped. However, the anterior facial papilla were
festoons.
Mandibular Left Quadrant:
Since the mandibular left quadrant had not yet been scaled, it still showed festoons and rolled
margins on the facial #20 and #21. Bulbous papilla was still present on the facials of the
anterior teeth. The tissue remained generalized red and the surface texture of the papillary,
marginal, and attached gingiva were all smooth and shiny. No suppuration was found. The
architecture in this quadrant was scalloped. However, the anterior facial papilla were
festoons.
Maxillary Right Quadrant:
The maxillary right quadrant had also not been scaled at this point. This resulted in an
unchanged periodontal assessment. No rolled margins, bulbous papilla, or edematous or
spongy consistencies were noted. This quadrant was simply generalized red, smooth, and
shiny on all tissue surfaces. No suppuration was found.
Maxillary Left Quadrant:
Since the maxillary left quadrant had not yet been scaled, #12, #13, and #14 still displayed
rolled margins. No bulbous papilla was seen and the tissues remained generalized red
throughout the quadrant. The surface texture was generalized smooth and shiny. However,
stippling on the anterior facials of the attached gingiva remained. No suppuration was found.
App't 4: October 6, 2016
Maxillary Right Quadrant:
I scaled the maxillary right quadrant on September 30. The maxillary right quadrant revealed
rolled margins on the facials of #4 and #6 and the linguals of #7 and #8. This development of
rolled margins was new and was not noted at the previous appointments. However, the
patient did confess that he had been struggling with brushing too hard and had rubbed his
gums raw. These aggressive, forceful strokes are most likely the cause of the added
inflammation. During his patient education session, I reminded him of the importance of
brushing with light pressure to avoid tissue trauma. The patient performed the Bass brushing
method in front of the sink and did exceptionally well with his technique and amount of
pressure exerted. Once again, stippling was noted on the maxillary anterior facials. The
marginal tissues were edematous and spongy on the areas with rolled margins. However, this
could once again be due to the tissue trauma caused by aggressive brushing. No suppuration
was found.
Maxillary Left Quadrant:

Since this quadrant had not yet been scaled, the facials of #12, #13, and #14 once again
revealed rolled margins. The linguals of #11 and #14 also displayed rolled margins. Once
again, this added inflammation is most likely due to the patient brushing aggressively. The
rolled margins were edematous and spongy. However, no bulbous papilla was found in this
area. Overall, this quadrant was generalized red and no suppuration was noted. The papillary,
marginal, and attached gingiva were all smooth and shiny. Stippling remained on the anterior
facial segment.
Mandibular Right Quadrant:
The mandibular right quadrant was scaled two weeks ago and had not changed from the
previous appointment dated September 30. The areas with rolled margins and bulbous papilla
still remained the same. Once again, the patient had been brushing his teeth with excessive
force twice a day. This unchanged appearance of his gingiva is due to the patients brushing
technique. Stippling was still noted on the anterior facial segment. The tissues appeared
slightly more red and inflamed from the patient brushing them too hard. Festooned
architecture was seen in the anterior facial papilla.
Mandibular Left Quadrant:
This quadrant had also not been scaled. Therefore, it once again showed festoons and rolled
margins on the facials of #20 and #21. Again, bulbous papilla was noted on the facials of the
anterior teeth. This quadrant was also slightly more red, smooth, and shiny from aggressive
brushing. No suppuration was found. Festooned architecture was only seen in the anterior
facial papilla.
App't 5: October 13, 2016
Mandibular Left Quadrant:
At the last appointment on October 6, the mandibular left quadrant was scaled. The rolled
margins on the facials of #20 and #21 were no longer present. However, a rolled margin on
the lingual of #22 was noted. No suppuration was present and the tissues remained
generalized red. However, the redness was not as vibrant as it was at the previous
appointment. The patient stated that he had been trying to make a conscious effort to brush
with lighter strokes. Although bulbous papilla remained on the facials of #22, #23, and #24,
the inflammation of the papilla had decreased significantly. Stippling was once again noted
on the attached gingiva of the anterior facial portion. Festooned architecture was noted in the
anterior facial papilla.
Mandibular Right Quadrant:
During the initial appointment dated September 8 and the second appointment on September
23, rolled margins were noted on the facials of #27, #28, #29, #30, and #31. On September
30, the rolled margins only included #27, #28, #29, and #30. However, during this
appointment, rolled margins had decreased yet again and now only included the facials of
#27, #28, and #29. Bulbous papilla remained unchanged and was localized to the facials of
#25, #26, and #27. Still, when compared to the first appointment on September 8, this is an
improvement since bulbous papilla initially included #28 and #30. No suppuration was
present in this quadrant. Inflammation in the anterior facial region had decreased

significantly when compared to the previous appointments. An edematous and spongy

consistency was noted on all areas of rolled margins and bulbous papilla. Stippling was noted
on the attached gingiva in the anterior facial segment. Festooned architecture was visible in
the anterior facial papilla.
Maxillary Left Quadrant:
This quadrant had not been scaled as of yet. With this said, a single rolled margin was noted
on the lingual of #10. This was considered significant improvement because the first three
appointments revealed rolled margins on the facials of #12, #13, and #14. At the fourth
appointment on October 6, the rolled margins included the facials of #12, #13, #14 and the
linguals of #11 and #14. These newly formed rolled margins were due to the patient brushing
aggressively. Although bulbous papilla was never noted at the previous appointments, it was
recorded on the distofacial surfaces of #9, #11, and #12. The patient claimed that he was
attempting to brush with less pressure. However, this quadrant in particular is the patients
only quadrant where no decay is present. With this said, he most likely is brushing this area
the hardest since there is no sensitivity. This could be the reason as to why this quadrant has
not been consistent or improved throughout the appointments. No suppuration was present.
The tissues were edematous and spongy where rolled margins and bulbous papilla were
present. Stippling was still noted in the anterior facial segment of the attached gingiva.
Maxillary Right Quadrant:
On September 8, 23, and 30, no rolled margins or bulbous papilla were noted. However, on
October 6, rolled margins were visually seen on the facials of #4 and #6 as well as the
linguals of #7 and #8. Once again, this new development of edema and spongy consistency
was due to the patient brushing with forceful pressure. Improvement was obvious during this
appointment because no rolled margins were noted. Also, the distofacial of #6 displayed a
remarkably slight bulbous papilla. Swelling on this area had reduced to almost nothing.
Stippling remained on the anterior facial portion of the attached gingiva. No suppuration was
noted.
App't 6: October 28, 2016 (2 Week Appt)
Maxillary Left Quadrant
The maxillary left quadrant was scaled on October 13. During this appointment, the
previously rolled margin on the lingual of #10 was no longer present. The patient stated that
he had been flossing every other day rather than his initial goal of three times per week. Also,
the patient informed me that he had purchased an Oral B power toothbrush which helped him
not use as much pressure when brushing. The once bulbous papilla on the distofacial surfaces
of #9, #11, and #12 was also no longer present. No suppuration was noted. The tissues were
overall much less red and inflamed. There were no edematous or spongy areas in this
quadrant. Once again, stippling was visible in the anterior facial segment of the attached
gingiva. Overall, the architecture was scalloped.
Maxillary Right Quadrant
This quadrant was scaled on September 30, 2016. No rolled margins were seen throughout

this quadrant. The distofacial bulbous papilla on #6 was also no longer present and
suppuration was not present either. The papillary, marginal, and attached gingiva had all
decreased significantly in redness and there were no edematous or spongy areas within this
quadrant. The anterior facial segment of the attached gingiva showed stippling. This quadrant
revealed scalloped architecture.
Mandibular Left Quadrant
This quadrant was scaled on October 6. Initially, the first appointment revealed a rolled
margin on the facial of #21 with bulbous papilla on the facials of the anterior teeth. On
September 30 and October 6, an additional rolled margin was seen on the facial of #20 along
with the bulbous papilla in the anterior segment. However, the appointment dated October 13
revealed only one rolled margin on the lingual of #22. During this appointment, all rolled
margins had vanished. Bulbous papilla was still present on the anterior facial teeth, but had
decreased immensely in swelling. No suppuration was noted and the tissues were less red and
inflamed. The bulbous papilla on the anterior facial section were the only areas that were
edematous and spongy. No suppuration was noted. Stippling was seen on the anterior facial
segment and scalloped architecture was generalized. However, slight festooned architecture
were noted in the anterior facial papilla.
Mandibular Right Quadrant
This quadrant was scald on September 23. During todays appointment, I noticed a slightly
rolled margin on the facial of #30 and the distofacial of #28 and #29. Bulbous papilla was
noted on the anterior facial segment as well as #28 and #29. Stippling was visible on the
anterior facial attached gingiva. Scalloped architecture was generalized. However festooned
architecture was noted on the anterior facial papilla. No suppuration was present. The tissues
were far less red. Areas that were edematous and spongy included the facials of #28, #29, and
#30.
c.Plaque Index:
Appt 1 (September 8, 2016): 2.3 (Fair)
Appt 2 (September 23, 2016): 1.8 (Fair)
Appt 3 (September 30, 2016): 1.16 (Good)
Appt 4 (October 6, 2016): 1.0 (Good)
Appt 5 (October 13, 2016): 0.6 (Good)
Appt 6 (October 28, 2016): 1.0 (Good)
d.

Gingival Index: Initial: 1.33 (Fair)

e.Bleeding Index:
Appt 1 (September 8, 2016): 3.8%
Appt 2 (September 23, 2016): 5.5%
Appt 3 (September 30, 2016): 8.3%
Appt 4 (October 6, 2016): 5.5%
Appt 5 (October 13, 2016): 2.7
Appt 6 (October 28, 2016): 0%

Final: 0.75 (Good)

f. Evaluation of Indices:
1. Initial: September 8, 2016
Slight bleeding on the facials of #5, #15, #26, #29, #30 as well as the lingual of 20 was
recorded during the periodontal examination. This is due to the bacterial plaque
accumulation in the sulcus which has caused inflammation. When buildup of bacteria is
present, the tissues become inflamed which results in bleeding upon probing. This is
correlated with active periodontal disease. Although the patient had areas of rolled
margins, bulbous papilla, and festooned architecture, little bleeding was present due to
the patients use of tobacco. Therefore, even though his tissues were unhealthy, the use
of tobacco halted the bleeding. The patients plaque score was 2.3 which is fair and his
bleeding score was 3.8%. The gingival index was computed to 1.33 which is also fair.
These indices rated as fair reveal that plaque accumulation, inflammation, and
bleeding are all issues that must be improved in order to halt the progression of
periodontal disease.
2. Final: October 28, 2016
As I took the patients bleeding score, and probed during his periodontal examination,
no bleeding occurred. This could be due to the fact that the patient chews tobacco which
masks the presence of bleeding. However, since all quadrants had been cleaned, there
was no longer any plaque and bacteria to inflame the gingiva. Additionally, the patient
admitted to flossing once every other day which plays a major role in halting the
progression of his periodontitis. The patients plaque score was 1.0 which was the goal
that I had set for him to achieve by todays appointment. The patients bleeding score
was 0% which was also a successful goal. Finally, the patients gingival index score was
0.75 which is rated as good. Significant improvement was noted during this
appointment because the patient had managed to obtain his goals while effectively
removing the plaque on his teeth. If maintained, these healthy habits of brushing and
flossing will halt the progression of his periodontitis. Still, it is important that the patient
attempts to terminate his use of tobacco or else his periodontitis could continue to
progress.
g. Periodontal Chart: (Record Baseline and First Re-evaluation data)
1. Baseline: September 8, 2016
A 4 mm probing depth was measured on the facial of #2 M, #4 M , #5 MD, and #15 D.
Additionally, a 5 mm probing depth was measured on the distolingual of #20 and the
facial of #26 D, #29 D, #30 M, and #31 M. The facial of #30 D was the only tooth to
measure a 6 mm probing depth. The patient had 1 mm of recession on the facial of #5,
#12, #23, #24, #25, and #26 as well as the lingual of #4 and #5. The facial of #21, #27,
#28, and #30 had 2 mm of recession while #29 had 3 mm of recession. These probing
depths show where loss of attachment has already taken place. Additionally, recession
has begun to form on various teeth. This being said, it is important for the patient to
practice effective flossing so that the disease progression is halted.

2. First evaluation: October 28, 2016

The facial of #2 M initially measured a 4 mm probing depth. During this appointment, it
measured a 2 mm probing depth. Additionally, #4 MF went from 4mm to 3mm, #5 M
went from 4mm to 2mm, #5 D went from 4mm to 3mm, and #15 D went from 4mm to
3mm. Likewise, #20 DL, #26 DF, #29 DF, #30 MF, and #31 MF all improved in probing
depths. Initially, these teeth measured at 5mm. However, at this appointment they
decreased down to 3mm. The distofacial of #30 originally measured at 6mm. However,
it now measures at 4mm. The areas of recession remained the same on the facials of #5,
#12, #23, #24, and #25. However, #26 F had 2mm of recession rather than 1mm. Also,
the linguals of #4 and #5 originally had 1mm of recession, but now revealed a tissue
height of 0 on #5 and 1 on #4.The facial of #21 originally had 2mm of recession and
progressed to 3mm of recession. The facial of #27 and #28 had 2mm of recession and
now have 1mm. The facial of #30 remained the same with 2mm of recession.
Additionally, #29 also did not change and had 3mm of recession. These probing depth
and tissue height measurements show that the patient has significantly improved the state
of his periodontitis by brushing twice a day and flossing every other day. By
implementing these oral hygiene habits, the patient managed to decrease his probing
depths considerably.
5. Dental Examination: (caries, attrition, midline position, mal-relation of groups of teeth,
occlusion, abfractions)
The patient has rampant decay on the buccal of #20 and the buccal and cervical of #29.
Rampant, recurrent decay is noted on the lingual of #19, buccal of #18, distobuccal of #2,
and the buccal and cervical of #30. Suspicious areas include the occlusal and facial of #1.
Attrition was also noted on #8, #9, #26, #25, #24, and #23. Overall, the patient had eight
restorations total which heightens his risk even more for caries. This elevated risk for caries
along with the decay already present increases the risk for periodontitis to worsen even more.
The patients right molar occlusion was unclassifiable because tooth #3 was extracted.
However, the right canine, left canine, and left molar were all classed as a class 1 occlusion.
The patient had an overbite of 5 mm, an overjet of 3 mm, and a midline shift of 2 mm to the
right. No cross bites were present. However, an open bite between #7 and #26 and #10 and
#23 were recorded.
6. Treatment Plan: (Include assessment of patient needs and education plan)
App't 1: August 25, 2016
At the first appointment, I reviewed the statement of release, HIPAA, and patient appointment
practice paperwork with the patient along with his medical and dental history. I also took his
vitals and gave him a pre-rinse. Afterward, I took a phosphor plate FMX on him. This is all that
was completed for the first appointment since I had only scheduled him for two hours and was
unaware at the moment that he would be my periodontal patient.
App't 2: September 8, 2016
At the second appointment, I updated the patients medical and dental history, took his vitals,

gave the patient a pre-rinse of mouthwash, conducted a head and neck, intraoral exam,
periodontal assessment, and completed his dental charting with an FMX. The informed consent
and risk assessment were also completed. Additionally, plaque, bleeding, and gingival indices
were also taken. Finally, the appointment was concluded by taking pictures with the intraoral
camera of the patients smile, recession, and decay. Patient education on brushing was very
briefly discussed while waiting to be checked by my professors.
App't 3: September 23, 2016
1. Update patients medical and dental history, take vitals, administer pre-rinse
2. Take patients new plaque and bleeding score
3. Complete first patient education session on plaque and brushing
Long Term Goal: Patient will reduce plaque score by .5 at each visit to obtain a score of
1.0 or less by last appointment.
STG: Patient will define plaque
STG: Patient will discuss importance of brushing and tongue brushing
STG: Patient will use bass method & brush twice a day
During this session, I will review the patients goals with him, making sure he feels they are
reasonable and attainable. I will start by asking him if he can define plaque for me. Then, I will
explain what it is, what it causes, and the importance of removing it through brushing. Also, I
will have my patient education book available to show the patient pictures of plaque. I will
explain the importance of brushing twice daily with the bass method and a soft bristled
toothbrush. I will have the patient demonstrate this brushing technique on a typodont while
explaining the importance of brushing into the sulcus to remove bacteria. After this explanation, I
will watch him brush his teeth in the mirror at the sink. Disclosing solution will be applied after
he brushes to show him the areas that were missed. Tongue brushing will also be discussed in
order to educate the patient on the importance of plaque removal and halitosis. I will briefly
explain topics that will be discussed for the next appointment and ensure the patient that we will
work as a team to achieve these goals.
4. Ultrasonic mandibular right quadrant
5. Complete full periodontal charting on mandibular right quadrant
6. Fine scale mandibular right quadrant
App't 4: September 30, 2016
1. Update patients medical and dental history, take vitals, administer pre-rinse
2. Take patients new plaque and bleeding score
3. Complete second patient education session on flossing and periodontitis
Long Term Goal: Patient will halt progression of periodontitis by last appointment.
STG: Patient will define periodontitis
STG: Patient will explain importance of flossing and C shape flossing technique
STG: Patient will decrease bleeding score by .5 at each appointment by flossing 3 times
per week
First, I will review the previous goals from the first session with the patient and assess how he
did. I will ask him if he remembers what plaque is and the proper brushing technique that we
discussed. During this session, I will review the patients new goals with him, making sure he

feels they are reasonable and attainable. I will ask him if he knows what periodontitis is. I will
then explain exactly what periodontitis is, what it looks like, and what it causes. I will explain
that this disease process is not reversible, but can be halted. I will also explain how to properly
floss using the C shape method on the typodont. The patient will then be asked to demonstrate
this technique on the typodont. After this, I will observe the patient as he flosses in the mirror
over the sink. I will then disclose his teeth to show him any areas he may have missed. I will
briefly explain topics that will be discussed for the next appointment and ensure the patient that
we will work as a team to achieve these goals.
4. Ultrasonic maxillary right quadrant
5. Complete full periodontal charting on maxillary right quadrant
6. Fine scale maxillary right quadrant
App't 5: October 6, 2016
1. Update patients medical and dental history, take vitals, administer pre-rinse
2. Take patients new plaque and bleeding score
3. Complete third patient education on caries
Long Term Goal: Patient will have caries restored by March 2017 (6 Months)
STG: Patient will be able to define caries and what causes it
STG: Patient will save money for caries to be restored
STG: Patient will schedule an appointment to have restorations placed
STG: Reduce sugary/starchy foods from 5 or more daily to 3 per day
First, I will review the previous goals from the second session with the patient and assess how he
did. I will ask him if he remembers what periodontitis is and the proper flossing technique that
we discussed. During this session, I will review the patients new goals with him, making sure he
feels they are reasonable and attainable. I will then ask the patient if he knows what caries is and
how it develops. I will use my patient education book to show the patient what caries looks like,
how it develops, and what it can cause. I will explain that caries is the dental term often used for
cavities and that it starts out as an incipient lesion. I will explain to the patient what an incipient
lesion is and that it can be prevented from progressing to a carious lesion. Additionally, I will
explain how to prevent caries by consuming foods rich in protein and calcium, limiting sugary
and starchy foods, and maintaining adequate oral hygiene. I will explain the importance of eating
sugary/starchy foods all at once rather than throughout the day. I will explain to the patient that
the next session will be chairside and ensure him that we will work as a team to achieve these
goals.
4. Ultrasonic mandibular left quadrant
5. Complete full periodontal charting on mandibular left quadrant
6. Fine scale mandibular left quadrant
App't 6: October 13, 2016
1. Update patients medical and dental history, take vitals, administer pre-rinse
2. Take patients new plaque and bleeding score
3. Patient education chairside on tobacco
Long Term Goal: Patient will quit chewing tobacco by the end of 2016.
STG: Patient will understand tobacco effects on the oral cavity

STG: Patient will reduce chewing tobacco from can to can per day and then can
until goal is reached.
STG: Patient will schedule appointment with healthcare provider to discuss tobacco
cessation.
During this session, I will review the patients new goals with him, making sure he feels they are
reasonable and attainable. I will ask the patient if he can name any side effects and risks
associated with tobacco use. I will then explain the side effects and risks associated with tobacco
use. I will inform the patient that tobacco use can cause his state of periodontitis to progress
faster, resulting in greater bone loss. I will also explain to the patient that tobacco use typically
results in decreased bleeding and inflammation so it appears the mouth is somewhat healthy. The
patient will be informed that this is all the more reason to maintain regular dental visits for
cleanings and oral cancer screenings. Additionally, tobacco use could be the reason for several of
his restorations experiencing recurrent decay. I will use my patient education book to show the
patient pictures of what could occur in his mouth if tobacco cessation does not take place. I will
then thank the patient for his time and as if he has any questions regarding all of his goals. As
always, I will ensure the patient that we will work as a team to achieve these goals.
4. Ultrasonic maxillary left quadrant
5. Complete full periodontal charting on maxillary left quadrant
6. Fine scale maxillary left quadrant
App't 7: October 28, 2016
1. Update patients medical and dental history, take vitals, administer pre-rinse
2. Take patients new plaque and bleeding score along with gingival index
3. I will perform patient education chairside over previous topics. I will ask if he has any
questions and assess if he has attained any of his goals. If any goals are not attained, I will
modify them to meet his needs.
This appointment will take place two weeks after all scaling is complete. During this
appointment, I will re-scale any newly formed calculus on all quadrants, plaque free the patient,
and perform a post-periodontal evaluation. After this is completed, I will place Arestin in areas
with 5 mm probing depths or more. Afterward, I will administer a fluoride treatment to the
patient and discuss scheduling an appointment for the following semester. Once again, I will
remind the patient of the importance of adequate oral hygiene and tobacco cessation.
7. Radiographic Findings: (crown root ratio, root form, condition of interproximal bony
crests, thickened lamina dura, calculus, and root resorption)
The patient had mild horizontal bone loss on the upper right teeth including #s 4 and #5.
Tooth #12 in the upper left also showed mild horizontal bone loss. The lower left quadrant
consisted of mild horizontal bone loss in #21, and #20, while the lower anterior portion
showed the same bone loss in #24, #23, and #22. Additionally, the lower right quadrant
revealed mild horizontal bone loss in the entire quadrant.
Calculus was also noted in several areas. The upper anterior portion revealed calculus on the
distal of #7. Likewise, lower anterior portion contained calculus on #25 M, #24 D, and #23.
The lower right quadrant revealed calculus on #28 D, #29 M and D, #30 D, and #31 M. Last,

#21 M in the lower left also displayed calculus deposits. Dental caries were noted on #2, #20,
#19, #18, #29, and #30.
8. Journal Notes: (Record in detail the treatment provided, oral hygiene education, patient
response, complications, improvements, diet recommendations, learning level, progress
towards short and long term goals, expectations, etc.) The progress notes should be written
by appointment date.
August 25, 2016
During this initial appointment, the only treatment rendered was the patients medical and
dental history, vitals, pre-rinse, and a phosphor plate FMX survey. The patient was eager to
receive a dental cleaning and stated that it had been five years since his last dental visit. The
patient also admitted that his gums bled slightly when he brushed his teeth. I informed him
that it was important to take a full mouth x-ray since it had been several years since his last
cleaning. I also advised him that since his gums bled easily while brushing, an FMX survey
was important in assessing his periodontal condition to see if any bone loss was present. The
patient had several areas of rampant decay which was another reason an FMX was crucial. I
explained that this survey allowed the dentist to assess how far reaching the decay was into
the enamel, dentin, and pulp. The patient seemed interested and was very concerned about
the numerous areas of decay in his mouth. However, he still thought that the teeth with
rampant decay did not need to be extracted since there was minimal pain. The patients
learning level for this appointment was unaware because he lacked the knowledge about
caries and the risks associated with them. No complications were noted at this appointment.
September 8, 2016
This second appointment included updating the patients medical and dental history, prerinse, head and neck exam, intraoral exam, periodontal assessment and screening, dental
charting with an FMX, informed consent, and risk assessment. A plaque, bleeding, and
gingival index was also taken along with a few intraoral camera pictures of the patients
recession and decay. The patient had a plaque score of 2.3, a bleeding score of 3.8%, and a
gingival index of 1.33. These indices were rated as fair. However, I told my patient not to be
discouraged because these numbers could improve by simply brushing and flossing. As the
dentist assessed the patients dental charting, he recommended that the patient seek
immediate treatment for his decay. The dentist went on to suggest treatment at dental schools
since it is less expensive. Upon his screening, I explained to the patient that he qualified to be
my periodontal patient. I explained that this was a time consuming commitment, but that it
reaped great benefits for his oral health. He agreed and was both eager and excited to begin
treatment. I briefly educated the patient on brushing since I knew that I would further explain
this subject at the next appointment. While taking the patients plaque score, I asked how
often he brushed his teeth. The patient said that he only brushed with a medium bristle
toothbrush once a day, which was at night. I explained that although it was highly beneficial
to brush at night, it would be to the patients advantage to brush twice daily in order to lower
his plaque score. I also explained how the plaque score measures the amount of plaque on the
patients teeth and how this accumulation of bacteria causes inflammation of the gums. The
patient was somewhat familiar with what plaque was. However, he did not know that it was
considered a bacteria. The patient had a learning level of being aware of the importance of
brushing. Still, brushing was a potential complication because it required a habit and lifestyle

change that the patient had not adequately practiced twice a day. Regardless, the patient had a
positive response and said that he was really going to try to improve his brushing because he
wanted to improve his oral health.
September 23, 2016
At this appointment, I updated the patients medical and dental history, administered a prerinse, took the patients plaque and bleeding score, taught patient education on plaque and
brushing, and ultrasonic scaled, periodontal charted, and fine scaled the mandibular right
quadrant. Additionally, the dentist administered one cartridge of 3% Mepivacaine without
epinephrine for patient comfort while using the ultrasonic. At this appointment, the patient
had a plaque score of 1.8 which was still considered fair and a bleeding score of 5.5%.
However, the plaque score did decrease and the patient stated that he had been trying to brush
more often. I praised him for his effort and told him to keep up the good work! Although it
appeared that the bleeding score increased, it in fact did not. This is due to the fact that all
teeth were assessed at the initial appointment, whereas only six teeth were assessed at this
appointment.
At the beginning of the patient education session, I read over all of the patients long term
and short term goals and made sure he felt they were reasonable and attainable. He stated that
the only goal he felt would be difficult to achieve in the amount of time given was tobacco
cessation. I told him that I understood and that we would alter the goal together. Additionally,
the patient requested a print out of all of his long term and short term goals at the next
appointment. He truly was motivated and wanted a visual so that he could put these actions
into practice. After this, I asked the patient if he knew what plaque was. The patient described
it as the gross stuff on your teeth. I agreed and explained how it is a bacteria that forms
when sugary and starchy foods are left on the teeth. I also told the patient that it can only be
removed by brushing and flossing. However, if plaque is not removed, it can harden into
calculus which can only be removed during a routine cleaning. I expressed how it can cause
bad breath, inflammation and bleeding of the gums, periodontitis, and cavities. I stressed the
importance of prevention by brushing twice a day for two minutes each with a soft bristle
toothbrush.
After explaining all of these things, I taught the patient how to brush his teeth using the
bass method. This method consists of holding the toothbrush at a 45 degree angle to the
teeth while utilizing circular strokes into the gums to disrupt the plaque within the sulcus. I
explained how this method is less abrasive to the tissues than the scrubbing technique he
currently practiced. I then had the patient demonstrate the bass method on a typodont.
Afterward, I disclosed his teeth and had him practice this method in front of a mirror on
himself as I corrected him. I also taught the patient the importance and technique of tongue
brushing and how it fights bad breath. I explained that the tongue is the perfect environment
for bacteria to reside because it is moist, warm, and has a rough surface for the bacteria to
adhere. The patient seemed very interested throughout the appointment and stated that he had
never heard of the bass method. He also admitted that he had never thought of disrupting the
plaque in the space sulcus with a toothbrush. As I watched him practice the bass method in
the mirror, I could see that he was struggling. I assured him that this was okay and that just
like anything else, it would take practice. This complication was due in particular to the

circular motions. Since the patient had not used these motions before, it felt weird to him.
This patient education session resulted in a learning level of self-interest because the patient
showed a mild inclination to act. Although he was eager to improve the health of his teeth
and tissues, he admitted that the bass method of brushing was going to take some getting
used to. I ended the appointment by cleaning the mandibular right quadrant and recording a
periodontal chart on that quadrant. The long term goal for this patient education session was
that the patient would reduce his plaque score by .5 at each appointment to obtain a score of
1.0 or less by his last appointment. I advised the patient that this goal would be achieved by
obtaining three short term goals. The short term goals are like baby steps. These goals stated
that the patient would define plaque, discuss the importance of brushing and tongue brushing,
and use the bass method and brush twice a day. I explained to the patient that I expected his
plaque score to decrease by .5 at the next visit if he brushed how I instructed him to. I also
explained that this should somewhat decrease his bleeding score as well.
September 30, 2016
At this appointment, I updated the patients medical and dental history, administered a prerinse, took the patients plaque and bleeding score, taught patient education on periodontitis
and flossing, and ultrasonic scaled, periodontal charted, and fine scaled the maxillary right
quadrant. The patient requested no local anesthetic for this appointment and the future
remaining appointments. The plaque score was 1.16 which is rated as good. I praised the
patient for exceeding his long term goal of reducing his plaque score by .5 at each visit.
Additionally, the patient attained his short term goal of being able to define plaque. The
patient also attained his second short term goal of describing how brushing is important in
removing plaque on the surfaces of the teeth and beneath the gums. However, the third short
term goal of brushing twice a day was not attained. Although the patient was still brushing
once a day, he did use the bass method. I encouraged him and explained that improvement
was still made!
I explained that although the patients bleeding score slightly increased to 8.3%, it was only
one additional tooth that bled at this appointment. I reminded the patient to continue brushing
in order to reduce this score as well.
Once again, at the beginning of the patient education session, I read over all of the patients
long term and short term goals and made sure he felt they were reasonable and attainable. I
gave the patient a print out of all of his long term and short term goals per his request. The
patient expressed that he still felt comfortable with the goals I set for him and stated that he
was still thinking about a time goal for tobacco cessation. This particular patient education
session had a long term goal of halting the progression of periodontitis by the last
appointment. I explained that this would be attained by three short term goals. These goals
included defining periodontitis, explaining the importance of flossing and using the C
shape flossing technique, and decreasing his bleeding score by .5 at each visit by flossing
three times per week. I told the patient that I expected both brushing and flossing to greatly
reduce his plaque and bleeding scores. I also added that flossing consistently will halt the
progression of periodontitis.

I began this session by asking the patient if he had ever heard of periodontitis or if he knew
what it was. The patient said that he had not heard of this disease state before. I then began to
explain how it begins as gingivitis which is an inflammation of the gums. I told the patient
that gingivitis can be reversed by simply brushing and flossing, but that periodontitis is
irreversible. I also reminded the patient about how the plaque on and in between the teeth is a
bacteria which is what causes the gums to become inflamed. I informed the patient that when
plaque hardens into calculus and is not removed, it can cause recession and bone loss. I
expressed how periodontitis is bone loss and loss of attachment. Some of the symptoms I
addressed were recession, bleeding gums, bone loss, and sensitivity. I explained how this
disease is treated by scaling off the calculus during a routine dental cleaning. Still, if the
patient does not implement active brushing and flossing, tooth loss can potentially occur.
Although this disease cannot be reversed, I told the patient that it could be halted by brushing
twice a day for two minutes and flossing once a day. However, since the patient has never
flossed with regular floss, I set a goal for him to begin flossing three times per week.
Next, I educated the patient on flossing. The patient stated that he only used floss picks
periodically. I gave him a visual description by telling him to imagine his fingers stuck
together and not being able to separate them. I then told him to imagine sticking that same
hand in a jar of honey. I asked if when he pulled his hand out of the jar and separated his
fingers if there would be honey in between his fingers. The patient replied, yes! I explained
how this visual is no different from when we eat. Although our teeth are touching, food and
debris can still get stuck in between those spaces. I also described and explained the different
types of floss to the patient. Waxed, unwaxed, and waxed dental tape floss were all explained
along with each of their pros and cons. Next, I taught the patient how to floss by first
obtaining about 18 inches of floss. I then instructed him to wrap the majority of floss around
the middle finger of his dominant hand and the remaining floss around the middle finger of
his non-dominant hand. I explained how the index fingers and thumbs of both hands are used
to push the floss down into the sulcus or space between the teeth. I demonstrated this method
on a typodont and emphasized the importance of using a c shape hug around each tooth. I
also explained the importance of going up and down five times to ensure that a greater
surface area is being cleaned. The risk factors of not flossing include inflammation, bleeding
gums, and cavities.
The learning level for this session was unaware because the patient had never heard of
periodontitis and also had never flossed with anything other than a floss pick. The patient
also stated that he had never heard of periodontitis and was unaware of this disease.
However, he seemed thoroughly disgusted and fearful of periodontitis when I showed him
pictures of extreme cases in my patient education flip book. The patient stated that it would
be a difficult habit change, but that he really did want to start flossing. I ended the
appointment by cleaning the maxillary right quadrant and recording a periodontal chart on
that quadrant.
October 6, 2016

At this appointment, I updated the patients medical and dental history, administered a prerinse, took the patients plaque and bleeding score, taught patient education on caries and
fluoride, and ultrasonic scaled, periodontal charted, and fine scaled the mandibular left
quadrant. The patient had a plaque score of 1.0 which is rated as good. However, he did not
meet his goal of reducing his place score by .5. Still, I told the patient that it did decrease and
that I was proud of him for brushing. Once again, the patient attained the goal of defining
plaque and discussing the importance of brushing and tongue brushing. I asked the patient if
he felt confident with brushing and flossing. The patient stated that he had been brushing
twice a day with the bass method for the past week and attained his short term goal from his
first appointment. However, the patient stated that he was brushing really hard and admitted
to brushing his gums raw. The patient complained of pain when rinsing with his Listerine
at home. This discomfort was due to the tissue trauma caused by his forceful strokes. The
patients reasoning for this action was that he felt if he brushed harder, he was removing
more plaque. I reminded the patient of the importance of brushing with light strokes to avoid
tissue trauma. I also recommended that he purchase a power toothbrush in hopes that he
would let the toothbrush do the work rather than bearing down on his tissues. The patient
stated that he was working on not being so aggressive.
Also, the patient stated that flossing was still somewhat of a struggle. Since he had never
flossed with regular floss, he was struggling with holding the floss properly and pushing it
down into the interproximal spaces. Regardless, the patient surpassed his goal of reducing his
bleeding score by .5 at each visit. The bleeding score for this appointment was 5.5% and had
lowered back to the same score on September 23. On the other hand, the patient did not attain
his short term goal of defining periodontitis. I reminded him that it is loss of attachment and
bone loss. Although he struggled with flossing correctly, he did achieve his goal of
explaining the importance of flossing.
At the beginning of this patient education session, I read over all of the patients long term
and short term goals and made sure he felt they were reasonable and attainable. The patient
expressed that he still felt comfortable with the goals I set for him. He also stated that he was
going to try to quit chewing tobacco by the end of the year in December. I and my professor
expressed how proud we were of him. However, I told him that I knew this was difficult and
that if he failed in achieving this goal to not get discouraged.
I began by teaching caries and asked the patient if he had ever heard this word. The patient
replied, no. I then told him how caries is just the dental term for cavities. I explained that
caries is a bacterial infection that occurs when acid attacks the tooth. I stated that bacteria
eats the sugars and carbohydrates consumed by the patient which produces an acidic
environment. I also explained how early signs of cavities may appear as a white spot on the
tooth which is called an incipient lesion. I told the patient that this is reversible with fluoride.
However, if not used, it could progress into an overt lesion which is irreversible. This overt
lesion is a cavity. I then gave the patient a printed list of cariogenic and non-cariogenic foods.
I informed the patient that whenever sugary, starchy, or acidic foods and drinks are
consumed, the pH in the mouth is lowered and becomes acidic. I then asked if he had heard
of demineralization or remineralization. The patient said that he had not. I explained that
demineralization is a loss of minerals and remineralization is the opposite. This environment

causes a breakdown of the enamel (demineralization) which strips the enamel of calcium and
phosphorus. I explained that cariogenic foods can cause cavities when left on the teeth.
However, the non-cariogenic foods like dairy and protein raise the pH in the oral cavity and
remineralize the teeth by adding calcium, phosphorus, and other minerals back into the
enamel. This action makes the teeth harder and stronger rather than the weak, brittle state
during demineralization. I also advised the patient that some medications can cause
xerostomia or dry mouth which can also cause caries. This is because there is less saliva to
keep the oral cavity flushed of bacteria. I reviewed different prevention techniques such as
limiting sugary, starchy, acidic foods and drinks, using anti-cavity toothpastes and rinses,
brushing and flossing, and utilizing a fluoride rinse. I explained that if not treated, caries can
reach the pulp which can lead to an abscess. This is treated with a root canal and crown. I
also recommended certain diet modification habits in order to prevent caries. I showed the
patient the list I printed for him. I then explained that since dairy and protein raise the pH, to
drink a glass of milk or eat a few cheese cubes after consuming a dessert or a bag of chips. I
explained the importance of consuming foods with dairy at the end of a meal so that the
ending pH is not acidic.
I then began to teach about fluoride. The patient also had not heard of this mineral. I
explained that it was a mineral that is sometimes present in drinking water, toothpaste, rinses,
etc. I further explained that it too aids in remineralization by adding calcium and phosphorus
back into the enamel. Fluoride builds the enamel up while strengthening and hardening this
tooth structure. I explained that our clinic has fluoride in the form of a gel and varnish. I
informed the patient that it is important not to eat, drink, brush, floss, or rinse for thirty
minutes after the gel is applied to ensure that it stays on the teeth for an adequate amount of
time. Additionally, the patient cannot eat or drink anything crunchy, hot, sticky, or alcoholic
for 4-6 hours after the varnish is applied. This is because these food items can knock off the
varnish, melt it off, or dissolve it. I also stated that this is the only time the patient should not
brush his teeth before bed because the fluoride should remain on his teeth for as long as
possible that night.
The learning level for this session was unaware because the patient had not heard of fluoride
and also was unaware of the causes and risks of caries. I told the patient that for his long term
goal, I would like to see his caries restored by March 2017 (6 months). I expressed that this
could be achieved by defining caries and its cause, saving money for the caries to be restored,
scheduling an appointment to have the restorations placed, and reducing his sugary and
starchy foods from 5 or more daily to 3 per day.
October 13, 2016
At this appointment, I updated the patients medical and dental history, administered a prerinse, took the patients plaque and bleeding score, taught patient education on tobacco, and
ultrasonic scaled, periodontal charted, and fine scaled the maxillary left quadrant. The patient
had a plaque score of 0.6 which is rated as good and a bleeding score of 2.7%. The patient
lowered his plaque score by .4 rather than .5, but still greatly reduced his score! Also, his
bleeding score improved as well. The patient attained all of his goals from his first
appointment and was able to define plaque, discuss the importance of brushing and tongue

brushing, brush twice a day with the bass method. Once again, the patient also attained his
goals of defining periodontitis, explaining the importance of flossing, and decreasing his
bleeding score by .5 at each visit by flossing three times per week. At the final appointment, I
will assess if the patients long term goal of halting periodontitis has been achieved. The
patient was also able to define caries and what caused it. However, he had not been able to
start saving for them to be restored, scheduled an appointment , or reduced his intake of
sugary and starchy foods. I encouraged him that these short term goals would not happen
overnight and to take one day at a time.
Once again, at the beginning of this patient education session, I read over all of the patients
long term and short term goals and made sure he still felt comfortable with them. The patient
expressed that he felt as though he was doing well with them and wanted to continue his
newly formed habits. I praised him for making such drastic changes and for staying
committed to them. I then began to discuss the effects and risks of tobacco chairside with my
patient. I explained how tobacco can cause halitosis (bad breath), tooth staining, increased
build-up of plaque and calculus, xerostomia (dry mouth), increased bone loss, and can also
increase the risk of oral cancer. I informed my patient that xerostomia alone can cause the
oral cavity to become dry which prevents the flow of saliva from flushing the oral cavity out.
This allows food, liquids, and tobacco to remain in the oral cavity for an extended period of
time which leads to bad breath, staining, and plaque and calculus build up. I reminded the
patient that when calculus builds up over time, it can cause inflammation and recession of the
gums. If the calculus remains on the tooth surfaces long enough it can cause further damage
of bone loss. I also explained that since he chews tobacco, his state of periodontitis could
progress if tobacco cessation does not occur. Studies have shown smoking as a risk factor of
the onset and progression of periodontal disease. I reviewed the patients long term goal of
tobacco cessation by the end of the year. I also reminded him that this could be accomplished
by understanding the effects of tobacco on the oral cavity, reducing chewing tobacco from
can to can per day and then can until the goal is reached. Finally, the patient would
schedule an appointment with his healthcare provider to discuss different options for tobacco
cession.
The patients learning level during this appointment was unaware because he did not know
the true effects that tobacco had on the mouth. The patient was unaware that it caused bad
breath, plaque, calculus, and much more. The patient truly desires to quit, but is concerned
that he will fail again. I advised him to keep trying no matter what! The patient also
mentioned that he was interested in buying a power toothbrush. During his previous
appointment, I had recommended this. I stated that I believed that was a good idea and to
give it a try! The patient also stated that he was going to try to start flossing everyday by his
next appointment.
October 28, 2016
This final appointment was scheduled two weeks after the patients last scaling appointment.
At this appointment, I updated the patients medical and dental history, administered a prerinse, took the patients plaque, bleeding, and gingival indices, and taught patient education
on Arestin. I also performed post calculus and post periodontal charting as well as plaque

free. I then placed Arestin on #31 ML and #17 DF and DL and provided the patient with a
fluoride gel treatment of 2.0% sodium fluoride. The patient had a plaque score of 1.0 and a
bleeding score of 0%. Likewise, the gingival index was 0.75 and was now rated as good. I
explained to the patient that although his plaque score increased by .4, it was still good. This
is because he reached his long term goal of obtaining a plaque score of 1.0 or less by his last
appointment. I assured the patient not to be discouraged because some plaque over time is
inevitable which is why it is important to maintain routine dental cleanings. I also told the
patient that his gingival index improved from 1.33 to 0.75. I explained that there was no
bleeding and that this was due to the patient flossing regularly. The patient was still able to
address his short term goals of defining plaque, discussing the importance of brushing, and
using the bass method while brushing twice a day. I praised my patient for reaching his goal
of brushing twice a day with a soft bristle toothbrush. In fact, during this appointment, my
patient informed me that he took my professors advice and purchased a power toothbrush. He
stated that he didnt feel as though he was cleaning his teeth as well with it. I asked if this
was because he couldnt use as much forceful pressure and he said, yes. I assured him that
the toothbrush was indeed doing its job and that it was good that it prevented him from
exerting aggressive strokes. Also, the patient achieved his second long term goal of halting
the progression of his periodontitis by the last appointment. The patient once again met his
short term goals of defining periodontitis, explaining the importance of flossing with a C
shape technique, and decreasing his bleeding score by .5 at each appointment by flossing
three times per week. In fact, the patient informed me that he was now flossing once every
other day. I was beyond excited to hear of this improvement and praised my patient for going
above and beyond his goal attainment. I told my patient that it was very evident that he had
been flossing and brushing properly because his gums were far less inflamed. The patient is
still working towards reaching his long term goal of having his caries restored. Still, he
maintained his goals of defining caries and its causes and saving money for the caries to be
restored. However, the patient has not yet been able to schedule an appointment to have the
restorations placed, nor has he reduced his intake of sugary/starchy foods from 5 to 3 per day.
I reminded the patient of the effects these foods have on the oral cavity, but also let him know
that this is a difficult habit to alter and that it was okay! The patient is still working on
obtaining his goal of tobacco cessation by the end of the year. The patient listed some effects
of tobacco on the oral cavity, but was still struggling to reduce his use of it in his short term
goals. As of today, the patient had not yet scheduled an appointment with his healthcare
provider to discuss tobacco cessation.
As I began to teach the patient about Arestin, I explained that it is an antibiotic which helps
kill the bacteria within the pockets. I explained to the patient how it releases slowly over the
course of 14 days. Therefore, it is important to wait at least 10 days before flossing so that
the antibiotic is not removed. I also informed my patient to wait 12 hours before brushing so
that the Arestin placed below the gumline would not be disrupted. Additionally, I informed
my patient to avoid eating hard, crunchy, or sticky foods for one week. I explained how these
foods can knock the Arestin off or adhere to it. Also, I advised my patient not to touch the
areas for one week aside from regular brushing. The patients learning level for this
appointment was unaware because he had never heard of Arestin or minocycline
hydrochloride. Prior to this appointment, the patient admitted that he did not know anything
like this existed. Still, his response was positive and he was intrigued to learn about this

subject.
The patients ending gingival statement was slight generalized periodontitis with slight
bleeding. Although the patient did not bleed upon probing, he did slightly bleed during
scaling.
9. Prognosis: (Based on attitude, age, number of teeth, systemic background, malocclusion,
tooth morphology, periodontal examination, recare availability)
The prognosis for this patient has positive inclinations. First off, the patient is 30 years old
and therefore has a greater chance of improving his health because he still has the motor
skills to practice effective oral hygiene habits. In total, the patient has 30 teeth. However,
seven of those teeth have areas of rampant decay and one additional tooth has just begun to
form decay as well. The decay is a result of several years of previous drug use. Additionally,
the patient has used tobacco for about 20 years. These areas of decay raise a concern in
prognosis because the damage has already been done. The patient will most likely need
several root canals and/or implants to replace the decayed areas. If these areas are not tended
to, the state of periodontitis could progress further, resulting in greater bone loss.
Systemically speaking, the patient has no conditions that altered treatment or that would
affect the prognosis. However, the patient does have a form of malocclusion which is
recognized as an open bite between #7 and #26 and #10 and #23. This open bite can cause
further clenching and grinding on the back teeth which can increase the painful effects of
TMJ disorders. This act of clenching and grinding could also cause further progression of
periodontitis due to the forces applied. The patients tooth morphology was difficult to assess
because of the rampant decay that was present on several occlusal areas of the teeth.
Additionally, the patient had several metal fillings, and various crowns which also made it
difficult to determine. Regardless of this patients numerous areas of decay, his periodontal
examination proved that it is possible to halt the progression of periodontitis in spite of the
numerous factors fighting against him. During his periodontal examination, I noted how the
only rolled margin was on the facial of #30. This was an immense improvement since the
first appointment consisted of 8 teeth with rolled margins. The initial appointment also
showed 8 teeth with bulbous papilla. This number did not change. However, the bulbous
papilla were far less inflamed compared to the first appointment. The papillary, marginal, and
attached gingiva had greatly reduced in redness and scalloped architecture was more
common. This results in a positive prognosis because the patient was able to halt the
progression of his periodontitis. The patient stated that he wanted to continue these habits for
as long as possible which also aids in a positive prognosis. I place this patient on a 3 month
recall due to his periodontitis. The patient agreed and reminded me that he owns his own
business, so scheduling appointments shouldnt be a problem.
10. Supportive Therapy: Suggestions to patient regarding re-evaluation, referral, and recall
schedule. (Note: Include date of recall appointment below.)
During my final appointment, I suggested that a re-evaluation would be beneficial in the
Spring semester. During this appointment, I will re-evaluate his oral health by assessing his
gingival and periodontal condition. I explained that I would re-scale the newly formed

calculus, perform a new periodontal examination and periodontal charting, and place Arestin
in areas with 5mm probing depths or greater. I would also perform polish the patients teeth
and provide a fluoride treatment. I suggested that the patient continue his attempts of
reaching his goal of having his caries restored. On September 8, the dentist in the clinic
referred the patient to different dental schools in Houston, TX to receive treatment for his
decay. These areas included teeth #1, #2, #18, #19, #20, #21, #29, and #30. The dentist
suggested this hoping it might be more affordable for the patient. Due to the patients
periodontitis, I suggested a three month recall schedule. The patient agreed and was eager to
form this new habit of receiving routine dental cleanings. I told the patient that I would be
seeing him again in late January 2017. I explained that maintaining routine dental cleanings
such as this would ensure healthy tissues and teeth.
11. Assessment of Changes: (including plaque control, bleeding tendency, gingival health,
probing depths)
The patients initial plaque score was 2.3 which is considered fair. Throughout the course
of his treatment, it decreased due to the patient brushing more frequently. The second
appointment revealed a plaque score of 1.8. On September 30, the plaque score reduced to
1.16. October 6, showed a plaque score of 1.0 and October 13 revealed a score of 0.6.
Finally, his final appointment ended in a plaque score of 1.0. The patient reduced the
amount of plaque on his teeth by brushing twice a day for two minutes while utilizing the
Bass method. These circular strokes into the gingival sulcus disrupted and removed the
plaque significantly over time.
The patients bleeding score also reduced considerably. During his initial appointment, the
bleeding score was 3.8%, the second appointment was 5.5%. Although it appears that the
bleeding score increases, it is not. This is because the initial appointment evaluated all of the
patients teeth. However, the remaining appointments only evaluated six indicator teeth. On
September 30, the bleeding score was 8.3% and therefore slightly increased. However, on
October 6, it reduced back down to 5.5%. At the October 13 appointment, the bleeding score
reduced again to 2.7%. Finally, the last appointment on October 28, revealed no bleeding
upon probing which produced a bleeding score of 0%. Prior to the patients first
appointment, the patient only flossed with floss picks periodically. However, during his
treatment, the patient began to floss three times per week. By the patients final
appointment, he had been flossing once every other day. This action alone greatly reduced
his bleeding and inflammation.
Overall, the patients gingival health was initially red, edematous, spongy, and inflamed.
However, throughout the course of his treatment, I was able to witness the inflammation
lessen with each appointment. Initially, rolled margins were noted on the facials of #12, #13,
#14, #21, #27, #28, #29, #30, #31. Additionally, bulbous papilla was recorded on the MF of
#30, facials of the mandibular anterior teeth, as well as the DL of #28. Nevertheless, by the
final appointment, rolled margins were only noted on the facial of #28, #29, and #30. This
resulted in a reduction of rolled margins from 9 teeth to 3 teeth. Likewise, bulbous papilla
was still present on the mandibular anterior facials along with #28 and #29.

The facial of #2 M initially measured a 4 mm probing depth. During this appointment, it

measured a 2 mm probing depth. Additionally, #4 MF went from 4mm to 3mm, #5 M
went from 4mm to 2mm, #5 D went from 4mm to 3mm, and #15 D went from 4mm to
3mm. Likewise, #20 DL, #26 DF, #29 DF, #30 MF, and #31 MF all improved in probing
depths. Initially, these teeth measured at 5mm. However, at this appointment they
decreased down to 3mm. The distofacial of #30 originally measured at 6mm. However,
it now measures at 4mm.
12. Patient Attitudes and Cooperation:
Throughout treatment, the patient exhibited a constant state of positivity and willingness to
learn. From the beginning, the patient was determined to make a change regarding the health
of his oral cavity. He always presented a positive attitude and was willing to cooperate in
every single way possible. This patient cooperated by being punctual to all appointments,
taking his time at the clinic seriously, assessing his goals and implementing them in his daily
routine, and was mindful of my time and what I needed to accomplish that day to ensure that
he received adequate care and treatment. The patients mental and emotional status was
stable and consistent. He exhibited a composed temperament and was not anxious or fearful
of any dental treatment. He always remained respectful and treated me and my instructors
with the utmost regard. The patient was truly enthusiastic about receiving a complete dental
cleaning. He even admitted to me that he had gone to work and was showing everyone his
teeth. He was impressed by how much cleaner they appeared and felt and was proud of the
work that I had accomplished. Although the patient was required to have several
appointments, he stated that he did not mind because he knew I was taking my time and
doing a good job.
13. Personal Evaluation/Reaction to Experience:
Although this care plan has been both challenging and time consuming, it has truly been an
incredible learning experience. I venture to say that this is the most beneficial project I have
completed thus far in the program. I say this because I was able to see the changes made
firsthand. I was most impressed by the changes noted in the periodontal examination and
periodontal charting. Its one thing to learn the facts in a lecture setting. However, its
completely different to actually see these facts transition from words in a textbook to a real,
visual, and tangible situation. I was amazed at how the patients pocket depths decreased in
millimeters. I was also fascinated to see the gingiva alter from red and inflamed to nearly
pink and close to normal. Overall, this has been a great learning experience for myself and
my patient.