I.

Assessment
A. Patient interview
“My teeth are really sensitive and my gums bleed when
I brush my teeth.” Patient brushes with a hard bristled toothbrush and has not
changed it since her last hygiene appointment. She has trouble with flossing and
gives up quickly. She uses a nightly phenol rinse to see if it will decrease her
bleeding.
B. Medical / dental history
She does not receive annual dental examinations and the last dental hygiene
appointment was 9 months ago. Patient has sensitivity to all drinks, especially
high energy drinks. She reports having frequent kidney infections as a young
woman. She has a family history of diabetes, high blood pressure, osteoarthritis
and osteoporosis. Her daily medications include: 81 mg aspirin,
(Hydrochlorothiazide) Microzide®, OTC antihistamines, 1000 mg calcium citrate
and 2000 IU’s Vitamin D.
C. Social History
Patient is a non-smoker and does not drink.
D. Vital Signs
Blood pressure unavailable. Patient is 5’2” and weighs 110 lbs.
E. Intra-oral / extra-oral examination
Intra-oral examination findings include bleeding index of 55% and a plaque free
score of 70%. Gingiva is generalized pink but localized bulbous interdental papilla
between #7 and #8. Gingiva is blunted on the mandibular anteriors. Otherwise
gingiva is pointed. Generalized recession is present throughout. Gingiva is
edematous. Extra-oral examination findings include submandibular, submental
and pre-auricular nodes were palpable and tender. All other assessments
reported within normal limits.
F. Periodontal examination
Generalized 1-3mm probing depths, localized posterior 4-6mm probing depths.
There was bleeding on probing on 55% of the pockets. Class I furcation
involvement on tooth #15 facial, 18 facial and lingual, 19 facial and lingual, 30
facial and lingual and 31 facial and lingual.
G. Radiographs
Generalized horizontal bone loss.
II. DH Diagnosis (Problem identification)
A. Level of health
Patient is in good physical health as evidenced by her BMI and social habits, but
question if she has been sick due to lymphadenopathy. Patient’s oral health
status is poor.
B. Diagnosis
The periodontal case type is generalized moderate chronic periodontitis.
III. Plan
A. Consultations Necessary
 Patient needs to see the dentist for a regular check-up and comprehensive exam.
Specifically assess tooth #21 and #14 for possible decay.
B. Treatment goals
Reduce bleeding and reduce amount of calculus. Decrease inflammation and
maintain or improve probing depths.
C. Addresses phases of treatment
 Preliminary phase – assessment, data collection, no emergency care
needed
 Phase I therapy – dental biofilm control, calculus removal,
comprehensive exam, introduction of additional fluoride in her oral
hygiene regimen is recommended to improve oral health
 Phase II surgical – none
 Phase III restorative – possible restorations determined by dentist’s
comprehensive exam
 Phase IV – 6 month recall for dental prophylaxis
IV. Implementation
Appointment 1: Anesthesia on two quadrants, hand scale two quadrants, have
comprehensive dental exam
Appointment 2: Anesthetize other two quadrants, hand scale two quadrants.
Showed patient bass brushing method and c-wrap flossing, dispense 2
soft bristled tooth brushes, floss aid, consult with dentist about prevident
toothpaste. Suggested that patient begins to use straws when drinking to
help with tooth sensitivity.
V. Evaluation
A. Can evaluate progress at 6 month recall appointment by assessing bleeding on
probing, gingival inflammation, plaque score, gingival health and periodontal status.
B. Perform comprehensive periodontal exam by probing to re-assess periodontal status.
C. Inquire if bite wing radiographs are needed.
D. Follow up with patient about her brushing habits. Follow up to see if the
straws are helping with sensitivity.