Megan Devereaux

I. Assessment

A. Patient interview

“I’m here for a cleaning. My tooth on the bottom left hurts.” Patient brushes at

home twice a day with an Oral B electric toothbrush. The patient uses Crest Pro

Health toothpaste in the morning and Prevident-5000 in the evenings. He only

flosses when he has food stuck between his teeth.

B. Medical / dental history

He has been receiving annual cleanings and dental exams for the last 5 years. His

last cleaning was around 1 year ago. Patient has sensitivity to hot and cold food

and beverages. He reports having type 2 diabetes, anxiety and schizophrenia.

Patient reported that his last A1c level was 11.2. His daily medications include:

glipizide, metformin, buspirone and haloperidol. Diabetes makes this patient

more prone to infection, inflammation, and periodontal disease. All four

medications cause xerostomia. Glipizide, metformin and haloperidol may cause

orthostatic hypotension. Metformin also may cause taste perversion.

Haloperidol may cause inflammation. Patient also uses Prevident-5000 which is a

fluoridated toothpaste.

C. Social History

Patient is a non-smoker and does not drink.

D. Vital Signs

Blood pressure was 140/85. Patient is 5’8” and weighs 245 lbs. (BMI = 37.3)
 E. Intra-oral / extra-oral examination

Intra-oral examination findings include bleeding index of 10% and a plaque free

score of 80%. Gingiva is generalized red and recessed. There is generalized

gingival blunting. Intrinsic brown stain due to dysplasia can be found on the

facial side of the maxillary anteriors. Extra-oral examination findings include a

deviation on the right side of the temporomandibular joint. All other

assessments reported within normal limits.

F. Periodontal examination

Generalized 1-3mm probing depths paired with generalized 1-4mm recession

created many periodontal pockets. There was bleeding on probing on 10% of the

pockets. No furcation involvement or mobility was present.

G. Radiographs

4 bite wing images showed generalized horizontal bone loss.

II. DH Diagnosis (Problem identification)

A. Level of health

Patient is in poor physical health as evidenced by his BMI and A1c levels.

Patient’s oral health status is poor.

B. Diagnosis

The periodontal case type is generalized moderate periodontitis.

III. Plan

A. Consultations Necessary

Patient was seen by a dentist for normal check-up. The dentist saw no areas that

required operation. The doctor looked in the lower left area where the patient

felt pain and she indicated that there was nothing wrong with the tooth.

B. Treatment goals

Stop the gum recession and horizontal bone loss. 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, establish flossing routine

 Phase II surgical – none

 Phase III restorative – no restorations needed after comprehensive exam

 Phase IV – 6-month recall for dental prophylaxis

IV. Implementation

Appointment 1: Hand scaled four quadrants. Showed patient bass method brushing and c-wrap

flossing and dispensed soft bristled toothbrush, Crest Pro Health toothpaste,

and floss. Polished and flossed full mouth and gave patient tray fluoride

treatment. 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 plaque score,

gingival health and periodontal status.

B. Perform comprehensive periodontal exam by probing to re-assess periodontal status.

C. Inquire if vertical bite wing radiographs are needed.

D. Follow up with patient about his brushing and flossing habits. Follow up to see if the

straws are helping with sensitivity.

 References

Wilkins, E. M. (2015). Clinical practice of the dental hygienist. Houston, TX: Lippincott Williams
& Wilkins

Jeske, A. H. (2009). Mosby's dental drug reference. Philadelphia, PA: Elsevier Health Sciences.